Every finding on record at Restoracy of Whitestown, The

Based on observations, interviews, and record reviews, the facility failed to ensure residents were afforded privacy during medical assessments and personal care for 5 of 5 residents reviewed for privacy (Residents 3, 8, 28, 65, and 25). Findings include:1. On 2/10/26 at 11:40 a.m., the Physician Assistant (PA) approached Resident 3 while she was asleep in a chair in a common area. Without ensuring the resident was awake, without requesting permission, and without providing privacy, the PA pulled the collar of the resident's shirt to the side to assess bruising on the resident's left shoulder. The assessment occurred in a common area where privacy was not provided. On 2/10/26 at 11:43 a.m., PA approached Resident 8 in the main activity room, where other residents were present, and asked the resident about her pain level. Resident 8 indicated, her pain was really bad. The PA then assessed the resident by checking her pulse and visually examining her physical condition while she remained in the main activity room, without offering or providing privacy. 2. On 2/11/26 at 10:57 a.m., the PA was asked to assess Resident 28's leg for a suspected rash. The PA approached the resident in the main activity room, where six other residents were present, and without asking if the resident would like privacy or relocating the resident to a private area, pulled up the resident's pant leg and examined and palpated the resident's skin. On 2/11/26 at 10:58 a.m., the PA then approached Resident 3, who was asleep in her chair in the common area, and pulled the collar of her shirt to the side to assess bruising without waking the resident, requesting permission, or providing privacy. 3. On 2/11/26 at 11:03 a.m., Certified Nursing Assistant (CNA) 7 approached Resident 65 in the main activity room. Without offering privacy or relocating the resident, she wiped the shirt sleeves of the resident's sweater, (which was soiled with spilled food crumbs and wet from excessive drool that dripped from her mouth). She continued to wipe down her face and hands, then removed the Resident's sweater by pulling it up and over her head, which in turn, pulled the back of her shirt up exposing the sides of her breast and briefs sticking out from her pants. 4. On 2/12/26 at 12:16 p.m., Licensed Practical Nurse (LPN) 8 and CNA 6 stood in the dining room where multiple residents were gathered as they waited on lunch and discussed resident weights. At one point, CNA 6 indicated, the weight on the new guy, in the presence of other residents, without ensuring privacy of resident health information. On 2/13/26 at 10:30 a.m., the above observations were shared with the Director of Nursing (DON) who indicated even in Memory Care, staff should strive to ensure residents were at least offered privacy before exams and not discuss medical records/conditions in front of other residents. 5. During an observation, on 2/10/26 at 12:00 p.m., the Physician's Assistant (PA) assessed Resident 25 in the dining room. There were seven other residents, and two visitors, present at the time of the assessment. The PA touched Resident 25's lower legs, and stated, You feel a little swollen, can I see your feet? The PA placed a stethoscope on the resident's back and chest. Resident 25's record was reviewed on 2/11/26 at 12:28 p.m. Diagnoses on the resident's profile included, but were not limited to, Alzheimer's disease (a progressive, irreversible brain disorder that destroys memory and thinking skills) unspecified. A nurse's note, dated 2/10/26, indicated the resident was evaluated by the PA for increased weight and swelling to the lower extremities. On 2/12/26 at 2:50 p.m., the DON provided a copy of current facility policy titled, Resident Rights, dated 5/20/2020. The policy indicated, .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to. t. Privacy and confidentiality.

Based on observation, interview, and record review, the facility failed to ensure a resident with dementia (Resident 37) received person-centered care and services to honor Resident 37's expressed preference to leave the dining room table for 1 of 3 residents reviewed for dementia care. Findings include: Throughout the survey period, Resident 37 was observed to be pleasantly confused, non-verbal, and independent in her activity pursuits which mostly consisted of independently ambulating in her wheelchair up and down the hallway outside of her room. She was also observed to prefer sitting away from the dining room table, and watching her peers, staff, and visitors instead of participating or engaging with them. During a continuous observation on 2/12/26, from 12:20 p.m., until 12:50 p.m., the following was observed: Resident 37 and ten of her peers were observed gathered in the dining room while they waited for lunch. Resident 37 was observed to exhibit behaviors consistent with attempting to leave the dining room table and relocate herself independently in her wheelchair, back to the hallway, or away from the gathered crowd. Resident 37 pushed herself backwards, turned around, and wheeled away from the group back into the hallway outside of her room. Certified Nursing Assistant (CNA) 7 went to Resident 37 and returned her to the table, at which time, Resident 37 immediately began trying to remove herself from the table again. This continued for several minutes as she repeatedly attempted to leave the table by maneuvering her wheelchair away, but CNA 7 continued to relocate the Resident back to the table. At one point, Resident 36 appeared to become irritated with Resident 37 and indicated to her, you need to stay here, you don't want to leave this place. Resident 36 used Resident 37's wheelchair arm rest to jerk her back to the table. As Resident 36 continued to encourage Resident 37 to stay at the table, CNA 7 indicated her thanks to Resident 36 for trying to keep Resident 37 at the table. When Resident 37 went to move away from the table on another attempt, Resident 36 put her hand over Resident 37's arms and pulled her back to the table, which prompted Resident 50 to reach over and shoo away Resident 36's touch and indicated, Don't pull on her like that, you're going to hurt her arm. Resident 36 let go, and Resident 37 left the table. CNA 7 returned Resident 37 to the table. Then proceeded to stand in the resident's path, blocking her from being able to get in between the table and the kitchen island. CNA 7 indicated, you can't get past me [name] I know you can't move me. CNA 7 stood, blocking the residents path for several minutes as she flipped through TV channels. As soon as CNA 7 moved, Resident 37 immediately left the area and went back to the hallway outside of her room. CNA 6 returned Resident 37 back to the table, and when Resident 37 attempted to leave the table, CNA 6 also physically blocked Resident 37's path. Throughout these observations, Resident 37 consistently demonstrated her preference to leave the dining room table. Staff repeatedly physically blocked her exit, allowed another resident to physically handle and redirect her, and did not implement person-centered dementia care approaches to accommodate her expressed preference to be away from the dining table. On 2/13/26 at 10:30 a.m., the above observations were shared with the Director of Nursing (DON) who indicated she would review the resident's care plans and record, but staff should not allow other residents to intervene with redirection and should not force a resident to be at the table if it was their desire to leave. On 2/12/26 at 1:00 p.m., Resident 37's record was reviewed. She was a long term care resident who resided in a secure memory care house. She had diagnoses of dementia and anxiety. An annual Minimum Data Set (MDS) assessment, dated 11/24/25, indicated she was severely cognitively impaired. Resident 37's comprehensive care plans were reviewed and lacked person-centered interventions to address her preference for being away from the dining room table, or individual approaches to offer when she was exhibiting signs of anxiousness or anxiety. The record lacked documentation of staff attempts to intervene or address her peers from redirecting her to prevent resident-to-resident altercations. On 2/13/26 at 11:05 a.m., the DON provided a copy of current but undated facility policy titled, Dementia- Clinical Protocol. The policy indicated, .for the individual with confirmed dementia, the IDT [interdisciplinary team] will identify a resident-centered care plan to maximize remaining function and quality of life. Direct care staff will support the resident in initiating and completing activities and tasks of daily living. Bathing, dressing, mealtimes, and therapeutic and recreational activities will be supervised and supported throughout the day as needed. 3.1-37

Based on observations, interview and record review, the facility failed to ensure staff performed appropriate hand hygiene and used infection control practices between resident contact and during resident assessments. This deficient practice had the potential to affect 3 of 3 residents randomly observed, (Residents 28, 3 and 65). Findings include: On 2/11/26 at 10:57 a.m., the Physician's Assistant (PA) was asked to assess Resident 28's leg for a suspected rash. The PA examined the resident's leg by pulling up the resident's pant leg and palpating the resident's skin without performing hand hygiene or wearing gloves.On 2/11/26 at 10:58 a.m., immediately after touching Resident 28, the PA approached Resident 3 and touched the resident's clothing and skin to assess bruising without performing hand hygiene between residents.On 2/11/26 at 10:59 a.m., immediately after contact with Resident 3, the PA approached Resident 65 and wiped the resident's nose and mouth with a tissue without performing hand hygiene between residents.On 2/11/26 at 11:03 a.m., Certified Nursing Assistant (CNA) 7 used a wet washcloth to wipe off Resident 65's soiled sweater (which had bits of food crumbs and spots of wetness from her excessive drooling). She first wiped off the sleeves of the sweater, then using the soiled cloth, wiped off the resident's hands, then moved to her face.On 2/13/26 at 10:30 a.m., the above observations were shared with he Director of Nursing (DON) who indicated, it was best practice to perform hand hygiene in-between resident contact. On 2/12/26 at 2:50 p.m., the DON provided a copy of current facility policy titled, Handwashing/Hand Hygiene, dated 5/20/2020. The policy indicated, .use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations.before and after direct contact with residents. 3.1-18(l)

Based on observation, interview, and record review, the facility failed to ensure sufficient staff were available to answer and address the root cause needs/requests of residents without having to wait for long periods of time for 4 of 5 residents reviewed for call light response times (Residents 38, 18, 13 and 1). Findings include: 1. During a continuous observation on 10/30/23 from 4:00 p.m., until 4:55 p.m., the following was observed: At 4:00 p.m., Resident 38 was observed in bed. He indicated he wanted to get out of bed because he did not like to lay in bed for long periods of time. He was laid down after lunch around 1:30 p.m. and had put his call light on about ten till 4:00, the girl came and said she would be right back, but he was still waiting. His call light was observed off at that time, and with his permission it was placed on again. Resident 38 indicated he often waited a long time to get up, because he needed two people and the Hoyer lift, plus when they were finally able to come, he would need to be cleaned up before he could be gotten out of bed. At 4:13 p.m., certified nursing aide (CNA) 20 entered Resident 38's room and turned off his call light. He indicated he wanted to get up and she explained she needed to find someone else to help her get him up as he required the use of the Hoyer lift. At 4:21 p.m. the call light was pressed again. At 4:31 p.m., the Minimum Data Set Coordinator (MDSC) entered the room and indicated the CNAs were helping another resident but would be with him as soon as possible. She indicated, ideally, she would like a resident's needs/wants to be able to get up as soon as possible upon request but not have to wait longer than 10-15 minutes. At 4:34 p.m., CNA 20 and 21 entered the room with the Hoyer lift to get Resident 38 up. Before he could be transferred back into his chair the aids performed incontinent care. At 4:51 p.m., Resident 38 was positioned in his Hoyer sling in the bed and at 4:55 p.m., he was finally up and seated in his wheelchair. During an interview on 10/20/23 at 4:40 p.m., CNAs 20 and 21 indicated it was hard to get to everyone who needed help in a timely manner because each person that required the Hoyer needed both CNAs at the same time. Taking care of incontinent needs also added to other resident's wait times and even though there was a nurse or medication aid (QMA) they were often busy passing medications or doing treatments, or their other responsibilities too. During an interview on 10/30/23 at 5:01 p.m., the Director of Nursing (DON) indicated, there was not specific policy for call light response time, but her expectation was no one should wait longer than 15 minutes excluding emergency situations. Resident 38's call light response record was provided by the DON on 11/1/23 at 4:47 p.m. and reviewed at that time. The corresponding activation times for the above observation were as follows: On 10/30/23 he activated his call light at 3:49:42 p.m. The light was deactivated at 3:57 p.m. (8 min. 16 sec.) he activated the light a second time at 4:02:31 p.m. and was deactivated at 4:11:11 p.m. (8 min 40 sec.). The light was activated a third time at 4:21:49 p.m. and was deactivated 4:33:26 p.m. (11 min. 37 sec.). The average call light response time for these three activations was 9 minute and 31 seconds. However, from the initial activation at 3:49:42 p.m., until 4:33:26 p.m., a total of 44 minutes had surpassed. His call light device log was further reviewed to reveal the following (to include but was not limited to): a. On 10/25/23 he activated his call light at 10:16:03 p.m. It was deactivated at 10:25:41 p.m. (9 min. 38 sec.). He activated the light 3 minutes later at 10:28:51 p.m. It was deactivated at 10:28:54 p.m., (4 sec.) and activated for a third time at 10:28:55 p.m. and deactivated at 10:42:18 p.m. (13 min. 24 sec.). the average response time for these three activations was 7 min and 42 seconds. However, from the initial activation at 10:16:03 p.m. until 10:42:18 p.m., 26 minutes and 15 seconds had surpassed. b. On 10/18/23 between 8:58:38 p.m. until 11:14:02 p.m., he activated his call light 9 times. The average response time for those 9 activations was 10 minutes and 6 seconds. However, from the initial activation at 8:58 p.m. until the final activation at 11:14 p.m., 2 hours and 16 minutes had surpassed. 2. On 10/31/23 at 11:10 a.m., Resident 13 was observed in his room seated in an electronic wheelchair. Resident 13 indicated he did not want to complain to get anyone in trouble, but he found that he did often wait a long time, mostly in the mornings before he was able to get up for the day. The aide usually wanted everyone to go to bed soon after dinner, and even though he did not want to go to sleep that early, he wanted to make things easier for the staff, so he agreed to lay down early and watch TV until he was ready for sleep. That just meant, but the time morning came, he was ready and anxious to get out of bed. He required two staff members and the Hoyer lift to get into his chair since he was not able to stand or walk. Resident 13 indicated when he put his light on they always came right away that was not the problem. But they would turn the light off, and sometimes forget to come back, or got caught up with someone else that needed them, so it took a long time to actually get out of bed. On 11/1/23 at 4:47 p.m., the DON provided copies of Resident 13's call light response log. a. On 10/6/23 he activated his Bath Device at 8:09:19 a.m. It was deactivated at 8:13:31 a.m. (4 min. 12 sec.) He activated it a second time 9:00:38 a.m. and it was deactivated at 9:01:35 a.m. (57 sec.) The average response time for those two activations was 2 minutes and 32 seconds. However, from the initial activation to the final deactivation, 52 minutes had surpassed. b. On 10/23/23 he activated his Bed Device at 7:00:35 a.m. It was deactivated at 7:02:22 a.m. (1 min. 47 sec.) He activated the light a second time at 7:35:48 a.m. and it was deactivated at 7:37:07 a.m. (1 min and 19 sec.) The average response time for these two activations was 1 minute and 33 seconds. However, from the initial activation at 7:00:35 a.m., until 7:37:07 a.m., approximately 36 minutes had surpassed. On 10/25/23 he activated his Bed Device at 7:27:28 a.m. It was deactivated at 7:36:18 a.m. He activated the light a second time at 8:00:05 a.m., and it was deactivated at 8:07:06 am. The average call light response time for these two activations were 7 minutes and 55 seconds. However, from 7:27 a.m. until 8:07 a.m., approximately 39 minutes had surpassed. 3. During an interview on 11/3/23 at 10:44 a.m., Resident 18 indicated she required the use of a Hoyer lift and two staff members to get up and get into her specialty wheelchair and get her positioning device placed. Staff were very responsive to answering the call lights, but they came in, turned it off and promised to come right back. Sometimes that happened, but most times it did not, especially on the weekends. She would need to put the light on a couple time for reminders until she was actually able to get what she needed. On 11/1/23 at 4:47 p.m., the DON provided copies of Resident 18's call light response log. a. On 10/2/23 she activated her Bath Device at 12:35:41 p.m., and it was deactivated at 12:36:24 p.m. (43 sec.) She activated the device a second time, two minutes later at 12:38:00 p.m. and it was deactivated at 12:41:11 p.m. (3 min. 11 sec.). She activated the device a third time at 12:56:13 p.m. and it was deactivated at 1:11:56 p.m. (15 min 43 seconds. The average response time for these three activations was 6 minutes and 35 seconds. However, from the initial activation at 12:35 p.m., until the final activation at 1:11 p.m., approximately 36 minutes had surpassed. b. On 10/8/23 she activated her Bath Device at 1:02:59 p.m., and it was deactivated at 1:04:34 p.m., (1 min. 35 sec.) She activated it a second time at 1:19:22 p.m. and it was deactivated at 1:27:46 p.m. (8 min. 24 sec.). The average response time for these two activations was 3 minutes and 19 seconds. However, from the initial activation until the final activation, approximately 25 minutes had surpassed. 4. During an interview on 11/03/23 10:50 a.m., the Resident Council President, Resident 1, indicated she did not have an issues with call light wait times per say as she and the staff had a pretty good routine. However, on behalf of the Resident Council, call light wait times were often complained about, especially on the weekends when they often had agency staff cover shifts who were not familiar with the resident routines. Response to the resident council grievance was usually a printed report for the specific residents with concerns that showed their wait times were not actually that long. At that time, she gave permission to review the Resident Council Meeting Minutes for supportive documentation of call light response times. On 11/3/23 at 11:00 a.m., the Resident Council Meeting Minutes were reviewed and revealed the following: A Resident Council Grievance Form, dated 11/29/22, for a specific Resident who complained of call light response times. The action taken indicated, .call light response times were pulled. Average time is 3 minutes and 34 seconds The resident's corresponding call light device activity report was attached and reviewed: Bath Device: a. On 11/24/23, the call light was activated at 3:32:11 a.m., deactivated at 11:32:50 a.m. (39 sec.). It was activated a second time at 3:44:56 a.m., and deactivated at 3:45:28. For those two activations, the averaged call light response time was only 35 seconds. However, from the initial activation at 3:32:11 a.m., until the final deactivation at 3:45:28 a.m., a total of 13 minutes and 17 seconds had surpassed. b. On 11/24/23, the call light was activated at 12:23:37 p.m., and deactivated at 11:29:06 p.m. (5 min. 29 sec.). the light was activated a second time at 12:44:55 p.m. and deactivated at 12:54:27 p.m. (9 min and 32 sec.). for those two activations the average response time was 7 minutes and 30 seconds. However, from the initial activation at 12:23:37 p.m. until the final activation at 12:54:27 p.m., 30 minutes and 50 seconds had surpassed. c. On 11/25/23, the call light was activated at 3:33:25 p.m. and deactivated at 3:48:13 p.m. (14 min. 38 sec.) the light was immediately activated a second time at 3:48:13 p.m. and deactivated at 3:52:58 p.m. (4 min. 45 sec.). The light was activated a third time at 3:59:06 p.m., and deactivated at 4:00:19 p.m., (1 min 13 sec.) The average call light response time for these three activations was 6 min. and 52 seconds. However, from the initial activation at 3:33:35 p.m. until 4:00:19 p.m., 26 minutes and 44 seconds had surpassed. The Resident Council met on 7/28/23. Five Residents and 1 family representative were present. New Business Stated: . a few complained that evening and weekend staff will come in and turn off the light and say, 'I will be right back' and a lot of the time they didn't come back There was no documentation of actions taken to resolve the concern. The Resident Council met on 8/24/23. Four Residents attended. The Old/Resolved issues was left blank. New Business Stated: .weekends are slower to answer lights . still say 'I'll be right back' and didn't come back There was no documentation of actions taken to resolve the concern. 5. Grievances logs were reviewed and revealed: A. An individual grievance form was filled out for a resident who complained of call light response times. The Grievance was dated 11/29/22. B. An individual grievance form was filled out for a resident who complained of call light response times. The Grievance was dated 7/21/23 at 9:00 a.m., Nature of Concern: Resident complain call light response times in the evening. The Department Head review and action taken: Call light times pulled. Longest call light time was 13 minutes during mealtime. Average call time is approximately 4 minutes. Educated resident of call light times. [The resident] requested new CNAs for evening. Educated resident that is not a feasible request .Comments: Resident continued to request for new staff. Denies any poor customer service but does not want to wait when call light is pressed. Education provided to resident, stated understanding. The resident's corresponding call light device activity report was attached and reviewed: Bed Device: On 7/20/23 the call light was activated at 11:14:55 p.m., deactivated at 11:16:05 p.m. (1 min., 10 sec.) activated a second time at 11:22:06 p.m., deactivated at 11:22:15 p.m. (9 seconds), and activated a third time at 11:32:43 p.m., deactivated at 11:33:36 p.m. (53 seconds). For these three activations, the call light response time was 44 seconds. However, from the initial activation at 11:14:44, until the final activation at 11:33:36, a total of 17 minutes and 41 seconds had surpassed. Bath Device: On 7/20/23 the call light was activated at 9:31:24 p.m., deactivated at 9:38:55 p.m. (7 min., 31 sec.), activated a second time at 9:53:05 p.m., and deactivated at 9:55:44 p.m. For these to activations, the call light response time was 5 min. 5 seconds. However, from the initial activation at 9:31:24 p.m. until the final deactivation at 9:55:44 p.m., a total of 24 minutes and 20 seconds had surpassed. During an interview on 11/3/23 at 11:13 a.m., with the Executive Director, DON, and ADON present, the call light response procedure was reviewed. The DON and ED indicated the facilities call light response times were far above industry standards, and while there was no disagreement about the average response time, root cause/tasks/requests/needs of the residents were that lights were being responded to but turned off and then often forgotten. The DON indicated when there were grievances related to call lights they could pull the report logs and compare the house cameras, however the cameras had been broken for several weeks and determining the root cause response times were impossible at that time. The ED indicated the response times proved staff were going into the rooms to turn the lights off and at least let the resident know where they were and how long to expect them to come back. There was no policy, but the DON and ED indicated it was preferable for residents not to wait longer than 15 minutes, or 30 maximum, emergencies excluded. 3.1-17(b)

Based on observation, interview, and record review, the facility failed to ensure a resident, (Resident 18) who required the use of a posture support harness/mobility device received routine and ongoing assessments and monitoring of the device to prevent the potential for accidents for 1 of 2 residents reviewed for positioning. Findings include: On 10/31/23 at 1:29 p.m., Resident 18 was observed. She was seated in an electric wheelchair with an adjustable harnessed strap buckled across her sternum. On 11/1/23 at 11:17 a.m., Resident 18's medical record was reviewed. She was aa long term care resident with diagnoses which included, but were not limited to, multiple sclerosis, history of stroke and muscle spasms. An Occupation Therapy (OT) Discharge summary indicated Resident 18 had received treatment and services between 9/23/22 and 12/15/22. During that time, she received a new harness for her wheelchair. New harness equipment ordered and tilt chair modified by power mobility company with assistance from OT to facilitate. At the time of her discharge on 12/15/22, she still required partial to moderate assistance to put on the harness . assist to don [put on] harness, able to operate power mobility once hoyered and positioned in chair She had a physician's order, dated 4/4/23, which indicated, may use positioning strap to chest due to poor trunk control related to multiple sclerosis. The physician's order lacked specific/special instructions which may need consideration upon placement, duration of use, and removal of the device. She had a comprehensive care plan, initiated 4/9/21 and revised on 8/16/23. The care plan indicated Resident 18 had an Activities of Daily Living (ADL) self-care performance deficit related to multiple sclerosis. An intervention for the use of her positioning strap was not included on her plan of care until 4/5/23 (approximately 4 months after it had been installed). On 11/2/23 at 9:00 a.m., the Director of Nursing (DON) provided a copy of the harness' manufacture's instructions titled, H-Style Shoulder Harness, dated 2020. The instructions indicated, .Caution: whenever an anterior trunk support is used, a properly adjusted pelvic support should also be worn to prevent sliding . because of the risk of choking, it is dangerous to use this product without stabilizing the pelvis- always use with a properly fitted pelvic support belt . this harness must be properly fitted to support the user's trunk and shoulders without causing injury. Have your seating specialist demonstrate its proper adjustment and use. A Harness that is too tight can restrict respiration and increase pressure across the shoulders and chest. A harness that is too loose can allow the user to slip down and may create a risk of strangulation. Accidental release of this shoulder harness can allow the use to fall forward. A user's inability to self-release can be hazardous if the user slips down or is strapped in the chair in an emergency. As with any new seating support, this product may change the way a person sits. Users must continue to practice regular pressure relief activities and skin integrity checks, not only where this product contacts the use but also in primary pressure-bearing areas such as the sacrum, legs and buttocks . Periodic Safety and Performance Checks: to ensure user safety, this product must be checked periodically for function and signs of wear. If the product does not function correctly or if significant wear is found in the buckles, mounting points, webbing, padding or stiches, stop using it Although Resident 18 received weekly skin checks, the templated form did not include person-centered/individualized areas of inspection related to the use of her harness. Resident 18's comprehensive care plan lacked implementation/revision of a plan of care to routinely, and appropriately assess the need, appropriateness, installation, functioning and/or integrity of her positioning harness. The record lacked documentation of nursing staff education/in-serving for the placement, positioning, functioning and/or routine/ongoing monitoring/assessment of the device. During an interview on 11/2/23 at 10:43 a.m., the Director of Therapy indicated, Resident 18 was unable to put on or release her harness, and that she required staff to ensure it was placed properly. During an interview on 11/3/23 at 10:44 a.m., Resident 18 indicated, she was unable to put on or take off her positioning harness because of her multiple sclerosis. She indicated she relied ono nursing staff to put it on. The aides were the ones who strapped her in after they got her in her chair each day. Resident 18 indicated she assumed the staff had been educated on how to put it on properly and hoped that it was placed correctly each day. On 11/2/23 at 9:00 a.m., the DON provided a copy of current facility policy titled, Assistive Devices and Equipment, dated 5/20/20. The policy indicated, The Restoracy provides, maintains, trains and supervised the use of assistive devices and equipment for residents . devices and equipment will be maintained on schedule and according to manufacturer's instructions. Defective or worn devices will be discarded or repaired. Staff will be required to demonstrate competency in the use of devices and equipment and be available to assist and supervise residents as needed On 11/2/23 at 11:51 a.m., the Assistant DON (ADON) provided a copy of current, but undated facility policy titled, Care Plans, Comprehensive Person-Centered. The policy indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . The comprehensive, person-centered care plan will: include measurable objectives and timeframes, describe the services that are to be furnished . care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making 3.1-45

Based on observation, interview, and record review, the facility failed to ensure a resident's enteral tube feeding formulas and water containers were labeled according to policy for 1 of 1 resident reviewed for tube feeding (Resident 19). Findings include: On 10/30/23 at 10:03 a.m., Resident 19 was observed in bed, a tube feeding bag and water bag were observed hanging from an IV (intravenous) pole. Neither bag had labels and no hand writing was observed. The kangaroo pump indicated 40 milliliters (mL) per hour. On 10/30/23 at 2:26 p.m., Resident 19's tubing feeding formula and water bags had a information written on the bags in ink. It indicated 10/30/23, 12 a.m., with illegible initials. On 10/31/23 at 9:13 a.m., the enteral feeding formula bag was labeled as Jevity 1.5, 10/30, 2100. The water bag was not labeled. On 10/31/23 at 9:47 a.m., Registered Nurse (RN) 8 indicated the enteral feeding formula and the water bag should always be labeled. On 11/1/23 at 9:27 a.m., Resident 19's record was reviewed. Her diagnoses included, but were not limited to, dementia, anxiety, severe protein calorie malnutrition, dysphagia (difficulty swallowing), hemiplegia (partial paralysis), aphasia (difficulty communicating), acute respiratory failure with hypoxia (limited oxygen reaching the tissues, and encephalopathy (function of the brain of affected). Her physician's orders indicated to change the feeding administration set (tubing) daily and label the formula container, syringe and administration set with resident's name, date, time, and nurse's initials on every night shift, starting on 9/28/2023. A nutrition care plan, dated 10/20/23, indicated Resident 19 had a potential or actual nutritional problem related to a history of requiring a g-tube to meet nutritional and hydration needs. Resident 19 had a history of fair by mouth intakes, dysphagia secondary to cerebral vascular accident (CVA), dementia, with severe protein calorie malnutrition. A Registered Dietitian (RD) progress note, dated 5/5/23, indicated Resident 19 was downgraded to a mechanical soft diet related to pocketing foods and for safety. She was assisted at meals per staff. Resident 19 had a significant change on 6/4/23. She returned from a local hospital with a g-tube in place with an abdominal binder to help prevent her from pulling at it On 11/1/23 at 2:47 p.m., the Director of Nursing (DON) indicated an enteral feeding bag and the water should have been labeled with rate, date, time, and initials. She indicated item 2 on the policy, titled, Enteral Feedings - Safety Precautions, was addressing the bags of enteral nutrition and water. A current policy, titled, Enteral Feedings Safety Precautions, dated 5/20/20, was provided by the DON on 11/1/23 at 1:10 p.m. A review of the policy indicated, .On the formula label document initials, date and time the formula was hung, and initial that the label was checked against the order 3.1-44(a)(2)

Based on observation, interview and record review, the facility failed to ensure a resident was not accidently given the wrong medication to prevent the potential for a significant medication error for 1 of 4 residents reviewed for accidents, (Resident 8). Findings include: On 10/30/23 at 11:14 a.m., Resident 8 was observed in her home's activity room. She was working on a table puzzle and agreed to an interview at that time. Resident 8 indicated she had never had a concern or issue until last week when she was mistakenly given another resident's medication. There had been an agency nurse on the weekend who must not have known the residents very well. That morning she had come to give Resident 8 her morning medication and after she had swallowed the cup of pills, she noticed the incorrect room number written on the cup. Resident 8 had received Resident 18's medications. Resident 8 indicated she used to live in the room where Resident 18 was now, and perhaps that was how the mix-up occurred. She did not remember much of the rest of the day, she felt dizzy and very tired and thought the medications must have interacted with whatever she regularly took. That's my biggest fear, it frightens me to think what could have happened or if it might happen again. I never used to have to check my cups, but every cup of medicine I get now, I double and triple check it is the right room number. On 11/1/23 at 9:27 a.m., Resident 8's medical record was reviewed. She was a long-term care resident with diagnose which included, but were not limited to, hypertensive heart (high blood pressure) and chronic kidney disease with heart failure, type II diabetes, major depressive disorder, and other seizures and narcolepsy without cataplexy. Resident 8's prescription medications were reviewed and revealed she received the following: Four medication with black-box warnings: a. sertraline: antidepressant medication b. diclofenac: a topical anti-inflammatory medication c. lisinopril: a high blood pressure medication d. Hydrocodone-acetaminophen: a narcotic pain medication Two controlled substances: a. Hydrocodone-acetaminophen b. armodafinil: a stimulant medication used to treat narcolepsy She also received 7 units of insulin daily, with 3 units before each meal for diabetes, a 10 milligram (mg) diuretic medication and additional blood pressure medications. Resident 18's prescription medications were reviewed and revealed she received the following: Six medications with black-box warning: a. hydrocodone-acetaminophen): a narcotic pain medication b. voltaren: a topical anti-inflammatory medication c. metformin: an anti-diabetic medication d. Trulicity: an anti-diabetic medication e. lisinopril f. bupropion: an anti-depressant medication Two controlled substances: a. the hydrocodone b. Lyrica: a nerve pain medication She also received additional anti-diabetic medications and blood pressure mediations. A Nurse Practitioner (NP) progress note dated 10/19/23 at 10:53 a.m., indicated Resident 8 had been seen by the NP for an acute visit for follow up related to the titration of her high blood pressure medication and heart failure. Her blood pressures that morning were within normal limits following the increase of her hydralazine, however, some high SBP (systolic blood pressure, the top number) with significant fluctuations of BP noted on chart review. An NP progress note dated effective on 10/20/23 at 10:56 a.m., but was recorded late on 10/25/23 at 10:56 a.m., indicated, Resident 8's SBP remained elevated with intermittent normal ranges and significant fluctuations. The hydralazine was increased to three times a day with blood pressure checks prior to each administration. A nursing progress note dated 10/21/23 at 12:33 p.m., indicated, Resident 8 was inadvertently given medication that was not prescribed. The NP was notified, and her medications were reviewed. The NP gave instructions to monitor the resident and notify of adverse reactions. A nursing progress note dated 10/21/23 at 8:52 p.m., indicated, Resident 8 refused to take her evening medications as she stated that she did not want anything to happen to her. Her blood sugar, after her evening meal was 82, staff would continue to monitor for hyper/hypoglycemia. On 11/1/23 at 4:00 p.m., the Executive Director, (ED) provided a copy of the medication error investigation which had been conducted and was reviewed with no concern. Prior to the survey, staff were educated on safe medication administration procedures and a system was implemented to monitor for the deficient practice. Therefore, the deficient practice was corrected on 10/23/23, prior to the start of the survey, and was Past Noncompliance. 3.1-48(c)(2)

Based on observation and interview, the facility failed to date medications and destroy expired medications for 3 residents in 2 of 5 resident houses (Residents 44, 54, and 22). Findings include: 1. During an observation on 10/31/23 at 10:06 a.m., Resident 44 had a bottle of lorazepam 2mg/ml in house 5's refrigerator. The bottle was opened with no date to identify when it was opened. The pharmacy sent the bottle on 8/28/23. 2. During an observation on 10/31/23 at 10:08 a.m., Resident 54 had a bottle of lorazepam 2mg/ml in house 5's refrigerator. The bottle was illegible. His name was written on the bottle. There was no date to indicate when it was opened. 3. During an observation on 10/31/23 at 10:10 a.m., Resident 22 had a bottle of lorazepam 2mg/ml in house 5's refrigerator. The bottle was opened with no date to indicate when it was opened. The pharmacy sent the bottle on 3/13/23. 4. During an observation on 10/31/23 at 10:15 a.m., a vial of tuberculin serum was lying in the refrigerator of house 6 with no date to indicate when it was opened. During an interview with the DON (Director of Nursing) on 11/1/23 at 10:30 a.m., she indicated lorazepam was good for 30 days after opening. A policy titled, Medication Storage Policy, with a date of 5/20/20 was provided by the DON on 11/1/23 at 11:05 a.m., it indicated, .Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from stock and disposed of according to policy from medication disposal . 3.1-25(j) 3.1-25(m) 3.1-25(n)

Based on observation, interview, and record review, the facility failed to post accurate staffing daily for 4 of 6 homes at the facility. Findings include: On 8/1/22 at 9:45 a.m., during an initial tour of building 4, the staff posting was observed on the bookshelf in a clear plastic frame. The posting was dated 7/13/22. It indicated Building 4 had 1 Nurse, and 2 Certified Nursing Assistants (CNA) for day shift and evening shift. Night shift was 1 nurse 1 CNA. On 8/1/22 at 10:41 a.m., during an initial tour of building 3, a clear plastic frame was observed on the bookcase. The frame was empty. No nursing hours were posted in building 3. On 8/1/22 at 11:34 a.m., the Staffing Coordinator (SC) was observed as he posted the daily staffing for building 3. The posting indicated 1 Nurse and 2 CNA, for day shift. On 8/1/22 at 11:35 a.m., during an interview, the SC indicated the nurse was shared between two buildings. Building 3 and 4 had the same nurse (for the 8-hour shift). The staffing sheet for each of the two buildings showed 1 nurse, but it was the same nurse. He did not know how to show a nurse was shared between two buildings, on the posting. The posting showed the number of people assigned to the building, not the amount of hours. On 8/2/22 at 3:11 p.m., the facility assessment was reviewed along with the nurse staffing schedule and daily posting for one month. The facility assessment indicated, Days [shift] Licensed Practical Nurse (LPN), Unit 1 - 8 hours, Unit 2- 12 hours, Unit 3- 4 hours, Unit 4- 4 hours, Unit 5- 4 hours, Unit 6- 4 hours, total nurses 36 hours (Day shift). The daily staffing assessment sheets indicated Day shift Home 3, 8/1/22 daily through 8/4/22 LPN 23, CNA 25 and CNA 26. The daily staffing assessment sheets indicated Day shift Home 4, 8/1/22 daily through 8/4/22 LPN 23, CNA 27 and CNA 28. On 8/3/22 at 9:05 a.m., the Director of Nursing (DON) provided a current policy, dated 5/27/20, titled, Posting Direct Care Daily Staffing Numbers. This policy indicated, Restoracy will post in each home, daily for each shift, the number of nursing personnel responsible for providing direct care to residents .the actual time worked during that shift for each category and type of nursing staff .when computing hours of direct care staff working split shifts, count only the total number of hours the individual is actually scheduled to work for the shift information being posted (example : you are posting data for the Day Shift. A CNA reports to work and is scheduled to work four (4) hours on the Day Shift and four (4) hours on the Evening Shift. In computing the number of hours worked for that shift, count only four (4) hours scheduled for Day Shift and the remaining four (4) hours on the Evening Shift

Based on observation, interview, and record review, the facility failed to ensure appropriate PPE (personal protective equipment) was utilized correctly during resident care in a COVID-19 positive (Red) Room for 1 of 1 resident COVID-19 positive (Resident 54) and appropriate PPE in resident areas for 2 of 6 home buildings (Residents 7, 219, 16, 32, 28, and 30). The facility failed to ensure hand washing was completed at appropriately during medication administration for 3 of 3 random residents observed during medication administration (Resident 36, 48, and 5). Findings include: 1. On 8/1/22 at 10:00 a.m., upon initial entrance into Home 3, there was a sign posted on the front door which indicated there was a COVID-19 positive resident in the house and gave instructions to keep masks pulled up and on at all times. During an interview on 8/1/22 at 10:02 a.m., the Staffing Coordinator indicated there was one COVID-19 positive resident in Home 3. Resident 54 had tested positive on 7/31/22 after a potential exposure from a positive staff member and was in droplet isolation. In Home 3, on 8/1/22 at 10:13 a.m., Licensed Practical Nurse (LPN) 23 was observed as she exited Resident 7's room. Her surgical mask was pulled down below her chin. She pulled her mask back up at the nurses' cart. In Home 2, on 8/1/22 at 11:07 a.m., a visiting lab technician approached a room with a yellow stop sign which indicated droplet isolation precautions. Certified Nursing Assistant (CNA) 6 informed the lab tech to place on PPE as a precaution as the resident was in isolation due to being a new admission. The Lab tech donned all the appropriate PPE except she placed a new N95 face mask overtop of the surgical mask, which was already in place, therefore a proper seal was not created. In Home 2, on 8/1/22 at 11:24 a.m., the lab tech who had completed a lab draw in a yellow isolation room, entered Resident 219's room (a green room) and completed a blood draw. In Home 2, on 8/1/22 at 12:45 p.m., LPN 35 was observed at the nurses' cart which was located in the central common area by the dining room. A Physical Therapist (PT) 36 approached her cart and requested a second step PPD ([CONDITION(S)] skin test) and a COVID-19 test. After completing the PPD skin test, LPN 35 placed on gloves and performed a nasal swab on PT 36. She did not don a face shield, or any additional PPE. There were two unidentified residents at the dining room table. 2. In Home 3, on 8/2/22 at 10:13 a.m., LPN 23 was observed in Resident 16's room. Her mask was pulled down below her chin as she and the resident spoke. In Home 3, on 8/2/22 at 2:39 p.m., a pair of goggles was observed on the PPE bin outside of Resident 54's room. At that time, LPN 23 indicated CNA 26 was in Resident 54's room providing resident care. When asked if the CNA's PPE could be observed, LPN 23 knocked on and cracked open Resident 54's door. CNA 26 was not observed to have eye protection in place at that time. During an interview on 8/2/22 at 2:40 p.m., LPN 23 indicated staff were supposed to wear eye protection in droplet precaution isolation rooms. 3. In Home 3, on 8/3/22 at 9:45 a.m., the Staffing Coordinator approached Resident 54's room. He indicated he needed to hand off supplies to the nurse who was proving resident care at that time. When asked if the nurses' PPE could be observed, he knocked on and cracked open the door to give LPN 23 supplies. At that time, LPN 23 was observed wearing an N95 face mask, but the bottom strap hung lose below her chin. When LPN 23 exited Resident 54's room a surgical mask was observed under her N95 so that a proper seal was not created. Additionally, she removed the N95 mask, which had been used in the COVID-19 positive room and discarded it in the open trash can at the kitchen counter. Residents 32, 28 and 30 were seated in the dining room near the trash can. During an interview on 8/3/22 at 11:03 a.m., the above observations were shared with the DON. She indicated staff should always keep their masks up in place, especially in house 3 since there was a COVID-19 positive resident. Staff should also not perform COVID-19 nasal swabs in resident common areas, they could be performed in the front office building or in House medication rooms. When performing the COVID-19 test swabs, staff should wear eye protection in case of splash. PPE should be doffed in the isolation rooms and left in trash cans inside the rooms until it could be safely removed. Finally, it was expected that resident care or services should be performed in green rooms first, then yellow, and red rooms last to reduce the chance of spreading COVID. On 8/4/22 at 9:07 a.m., the DON provided a Copy of current facility competency validation titled, Personal Protective Equipment (PPE) Competency Validation. The Validation for donning and doffing PPE required, while donning a mask/respirator staff should secure ties/elastic bands at middle of the head and neck, and goggles should be in place. When doffing, staff should discard PPE in a waste container. 4. During a random medication administration on 8/3/22 at 4:06 p.m., Qualified Medication Aide (QMA) 12 was observed popping pills from the blister package into her hands for Resident 36. She put them into the medication cup and Resident 36 was observed to swallow them. a. [MEDICATION(S)] (antihypertension) 12.5 milligrams (mg) b. [MEDICATION(S)] (anticonvulsant) 140 mg On 8/3/22 at 4:09 p.m., QMA 12 did not wash or gel her hands before she prepared medications for Resident 48. She dropped the pills into her hand and put them into the medication cup. a. [MEDICATION(S)] (antibiotic) 250 mg, b. [MEDICATION(S)] (hormone) 3 mg, c. [MEDICATION(S)] (antidiabetic) 500 mg d. [MEDICATION(S)] (antipsychotic) e. Tylenol Arthritis Pain ER (Extended Release) 650 mg She provided the medication to Resident 48 in the dining room. Two unidentified residents were sitting with her. Resident 36 touched her hand. On 8/3/22 at 4:22 p.m., QMA 12 indicated since Resident 36 touched her hand, she needed to hand wash. She turned the water faucet off with her bare hands and dried with a paper towel. On 8/3/22 at 4:25 p.m., QMA 12 provided Resident 5 with an unidentified medication. She was observed to wash her hands afterward. She turned the water faucet off with her bare hands and dried with a paper towel. During an interview, on 8/3/22 at 4:23 p.m., QMA 12 indicated she should not have put pills into her hand, then place them in the medication cup them in the medication cup and she should have washed her hands between each resident. During an interview, on 8/2/22 at 3:11 p.m., the Director of Nursing (DON) indicated the staff should have washed their hands for 20 seconds, dried them with paper towel, then got a new paper towel to turn off the water after their hands are dried. A current policy, titled, Handwashing/Hand Hygiene, with no date, was provided by the DON on 8/2/22 at 3:54 p.m. A review of the policy indicated, .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . A current policy, titled, Medication Administration General Guidelines Policy, dated 5/27/20, was provided by the DON on 8/4/22 at 9:40 a.m. A review of the policy indicated, .The facility will provide appropriate care and services to manage the resident's medication regimen to avoid unnecessary medications and minimize negative outcomes .Alcohol gel may be used between resident when passing oral medications 3.1-18(b)(1)

Based on observation, interview, and record review, the facility failed to ensure an advanced directive was charted according to the resident's preference for 1 of 16 residents reviewed for advanced directives (Resident 39). Findings include: On 8/2/22 at 12:51 p.m., Resident 39's record was reviewed. He was admitted on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 39's code care plan, dated 10/22/21, indicated his preference was Do Not Resuscitate (DNR). Resident 39's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It was signed by the resident and his POA (Power of Attorney). Resident 39's physician code order, dated 6/4/22, indicated his advanced directive was a full code. On 8/2/22, Resident 39's physician's code order was changed to DNR. During an interview, on 8/2/22 at 2:55 p.m., the Director of Nursing (DON) reviewed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Her expectation was for the nursing staff was to recognize the inconsistencies in the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A current policy, titled, Advance Directives, with no date, was provided by the Social Services Director (SSD) on 8/3/22 at 3:38 p.m. A review of the policy indicated, .The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive 3.1-4(f)(4)(A)(ii)

Based on observation, record review, and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was coded correctly for 2 of 20 residents reviewed for MDS assessments (Residents 17 and 32). Findings include: 1. On 8/03/22 at 3:25 p.m., the medical record was reviewed for Resident 17. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/1/22 the Director of Nursing (DON) provided a second facility resident matrix which indicated Corrected at the top right-hand corner. This matrix did not indicate Resident 17 had a Pre-admission Screening and Resident Review (PASARR) Level II assessment. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . may have manic episodes. monitor for compulsiveness, and excessive euphoric behaviors. may be tearful at times. does occasionally refuse medications. document each incident in nursing note with interventions attempted and effectiveness. A review of the annual Minimum Data Set (MDS) assessment, dated 2/18/22, indicated Resident 17 did not have a PASAR Level II. A PASAR Level II, dated 3/10/21, was scanned into the medical record documents. It indicated a Level II was required but the resident did not require specialized services. On 8/3/22 at 10:16 a.m., during an interview, the MDS coordinator indicated Resident 17 did have a PASAR Level II in her medical record. Her last annual MDS assessment had been coded wrong. 2. On 8/03/22 at 12:37 p.m., the medical record was reviewed for Resident 32. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/1/22 the Director of Nursing (DON) provided a second facility resident matrix which indicated Corrected at the top right-hand corner. The matrix did not indicate Resident 32 was on hospice services. A physician order, dated 7/30/20, indicated hospice. A review of the quarterly MDS assessment, dated 6/7/22, did not indicate Resident 32 was on hospice. On 8/3/22 at 10:16 a.m., during an interview, the MDS coordinator indicated Resident 32's MDS assessment was coded wrong. She had been on hospice since 2020. On 8/4/22 at 9:40 a.m., the DON provided a current policy, dated October 2019, titled, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual. This policy indicated .if an error is discovered in a record that has already been accepted by the QIES ASAP system, implement procedures for either modification or inactivation of the information in the system 3.1-31(c)(1)

Based on observations, interviews, and record review, the facility failed to ensure a resident who was hard of hearing (HOH) had a baseline care plan to address his specific needs for 1 of 1 residents reviewed for hearing and vision (Resident 217). Findings include: On 81/22 at 11:55 a.m., Licensed Practical Nurse (LPN) 35 asked Certified Nursing Assistant (CNA) 6 how Resident 217 transferred because she needed to assist him to the restroom. CNA 6 indicated to LPN 35, he was a 1-person assist, but the only way he could hear was if he could read your lips. Resident 217 was not wearing hearing aids at that time. During an interview on 8/1/22 at 12:03 p.m., CNA 6 indicated Resident 217 was very hard of hearing and needed his hearing aids in. He was confused and asked a lot of questions, then would forget the answers. On 8/1/22 at 3:45 p.m., Certified Nursing Assistant (CNA) 6 knocked on Resident 217's room and asked him if he could leave the room so she could clean the floor. Resident 217 indicated, What? I can't hear you. CNA 6 pointed toward the direction of the door and assisted him out of the room. Resident 217 asked, What am I supposed to do? CNA 6 indicated, just wait there for a minute so I can clean your room. Resident 217 shrugged and began to roll away. He was not observed to wear hearing aids at this time. During an interview on 8/2/22 at 9:25 a.m., Resident 217 was observed as he laid in his bed. He was very hard of hearing. Questions were typed on a laptop computer using extra-large bold letters and read aloud slowly. Resident 217 was able to read along and hear enough to answer simple yes or no questions. He indicated he did not know where his hearing aids were. He did not know if he was supposed to be in bed, or if he was going to go home. Resident 217 pointed at the computer, smiling, and repeated, that's neat, where did you get that? Can I have one? During an interview on 8/2/22 at 10:05 a.m., CNA 6 indicated it was hard for him to understand, he was confused, and very hard of hearing. He was supposed to wear hearing aids, but she did not know where they were. Resident 217 continued to call out, Hey! Come here a minute! On 8/3/22 at 10:12 a.m., Resident 217 was observed at the dining room table. He indicated, Hey! When I get done eating, what do I do? LPN 38 indicated, You can lay down if you want. Resident 217, I can't hear you. LPN 38 repeated herself, several times, louder each time, but Resident 217 continued to shake his head and indicated, he could not hear her. LPN 38 patted his back and indicated, I know. When he finished eating, he asked, are you going to put me to bed? LPN 38 told him yes, but he replied, I can't hear you. LPN 38 removed him from the dining room table and assisted him to his room. Resident 217 was not observed to have hearing aids in at this time. During an interview on 8/4/22 from 9:17 a.m., Speech Therapist (ST) 39 indicated, Resident 217 did have a pair of hearing aids that made it a little easier to communicate with him, but they had not been charged last night so they had just been placed on the charger. Even with his hearing aids in, he was still confused, and it was hard to know what he wanted to do. On 8/5/22 at 12:00 p.m., an interview was conducted with the Activity Director (ED) and Executive Director (ED). The AD indicated Resident 217 was very hard of hearing. As for his hearing aids, she had never seen him wearing any, and did not know if he had a pair or used them. It was hard to communicate with him because of his hearing loss and confusion, and she had not tried any other types of communication methods such as a communication board, white board, or visual cue cards. During an interview on 8/5/22 at 12:36 p.m., the Social Service Director (SSD) indicated each department head was responsible for filling out their corresponding section of the Baseline Care plan. The Baseline Care Plan was usually initiated by the admitting nurse, and then filled out by the appropriate staff. The purpose of the Baseline Care Plan was to identify and capture the most important things required for initial care upon a new resident's admission, so it was important to be filled out entirely and as accurately as possible. On 8/5/22 at 11:57 a.m., Resident 217's medical record was reviewed. He admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He had a current physician order, dated 7/21/22, which indicated, Nurse to ensure resident's hearing aids are charging at night and ensure they are in his ears every day. His admission Minimum Data Set (MDS) assessment, dated 7/22/22, indicated he was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 8. He was moderately hard of hearing with the assistance of hearing aids and required extensive assistance with his ADLS (activities of daily living). A Baseline Care plan was initiated on 7/15/22 and closed on 7/25/22. Section C for Vision and Hearing was blank and did not indicate that Resident 217 was hard of hearing and required the assistance of hearing aid assistive devices. On 8/5/22 at 3:00 p.m., the Director of Nursing provided a copy of current facility policy titled, Care Plans- Baseline, dated 5/27/20. The policy indicated, . A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission . the interdisciplinary team will review the healthcare practitioner's orders (e.g. dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs including but not limited to . physician orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation, interview, and record review, the facility failed to ensure a resident with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: 1. During an interview on 8/4/22 at 10:27 a.m., Licensed Practical Nurse (LPN) 23 indicated, Resident 46 was a brittle and unpredictable diabetic. Her blood sugar readings did fluctuate a lot so the nurses did regular blood sugar checks via her Libre device. She was on a sliding scale for insulin and did not always follow her diet. On 8/4/22 at 1:30 p.m., Resident 46 was observed as she sat in her wheelchair in her room. Resident 46 indicated she had been having trouble getting her blood sugars under control but they were working on it. She used to get her finger pricked so many times a day the ends of her fingers were sore, so she was happy to have a new monitoring device. She pointed to the Libre device which was located on her left upper arm. Resident 46 indicated she thought the biggest issue for her was her diet. For example, that morning she had been given oatmeal with brown sugar which would raise her blood sugar. She used to only take a pill for her diabetes but was recently put on insulin too so it was taking some time to get adjusted. On 8/5/22 at 11:58 a.m., Resident 46's medical record was reviewed. She admitted to the facility on [DATE] with current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 46's comprehensive care plans were reviewed and lacked documentation of a plan to manage her diabetes. A Progress Note, dated 6/3/22 at 10:41 a.m., indicated Resident 46 had emesis (vomit) at 7 a.m., per off going nurse. Her vitals were taken and an Accu-check was done. Her blood sugar (BS) was 568 which was treated with new physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A follow up progress note, dated 6/3/22 at 1:47 p.m., indicated Resident 46 was more responsive, and her blood sugar had come down to 330 and treated per her sliding scale instructions. She was given soup and crackers for lunch. A Progress Note, dated 6/5/22 at 12:28 p.m., indicated Resident 46's BS was 382. The on-call physician was notified and instructed to use of her sliding scale. [MEDICATION(S)] (insulin medication) 8 units was given at this time. A Progress Note, dated 6/5/22 at 4:20 p.m., indicated her BS was 339. The on-call physician gave orders to change physician notification parameters for if her BS was greater than 350. A Progress Note, dated 6/6/22 at 11:25 a.m., indicated the Interdisciplinary team (IDT) met to discuss Resident 46's antibiotic orders. After Resident 46 had an episode of vomiting, change in mental status, and her BS was found to be 568 on 6/3/22. The Nurse Practitioner (NP) ordered labs, urine, IV fluids, and intramuscular (IM) injection of [MEDICATION(S)] due to acute change. Urine was negative and white blood cell count (WBC) was not elevated. She was diagnosed with [CONDITION(S)] and acute kidney injury (AKI). Her repeat labs were redrawn 6/6/22 and no further antibiotic had been ordered. Endocrinology would follow up as well. A Progress Note, dated 6/6/22 at 1:50 p.m., indicated the IDT team also met to discuss a new diabetic ulcer on Resident 46's right heel. Her blood sugars had been elevated due to her recent illness. BS readings have ranged from over 300, at times over 500. The NP ordered insulin based on glucose results. Resident 46 also had 3 doses of IM [MEDICATION(S)] and 2 liters (L) of fluids for hydration. Additional labs were obtained that morning and were pending. New order was obtained for right foot/heel wound, paint with [MEDICATION(S)] and allow to dry prior to applying non-skids socks- no shoes and heel protection boots were to be worn in bed. A Progress Note, dated 7/10/22 at 2:47 p.m. indicated Resident 46 was noted to be diaphoretic (clammy/sweaty), her Accucheck reading was 66. She was given 120 milliliters of juice at that time and would be rechecked in 15 minutes. On 7/10/22 at 3:05 p.m., Resident 46's BS was rechecked and at 100, with a note that the MD would be notified of the low reading. A Progress Note, dated 7/11/22 at 4:17 p.m., indicated the Residents BS was checked and read 46. She was clammy and even though her eyes were open, she was unable to respond. She was given orange juice then the MD was notified who gave new orders to give 1 injection of [MEDICATION(S)] (a hormone that your pancreas makes to help regulate your BS). Additionally, her lunchtime insulin orders were discontinued, and her dinner insulin was held. Resident 46 was responding better and able to communicate per her norm. A Progress Note, dated 7/12/22 at 5:10 p.m., indicated Resident's BS was 82 at 7 a.m., BS at noon were documented and her medication and [MEDICATION(S)] were held per MD order. A Progress Note, dated 7/23/22 at 12:23 p.m., indicated Resident 46's Accucheck was 423. The on-call physician was notified and gave instructions to give morning diabetic meds and scheduled lunch insulin then recheck in one hour. On 7/23/22 at 2:05 p.m., her BS was down to 387, and the on-call physician was notified. A Progress Note, dated 7/24/22 at 7:15 a.m., indicated Resident 46's Accucheck was 46 at the beginning of the shift. She was given orange juice and crackers, then was conversing with staff and denied symptoms. The on-call physician was notified and gave instructions to recheck in 30 minutes. A Progress Note, dated 7/24/22 at 7:50 a.m., indicated Resident 46's BS was rechecked and read 60. The on-call physician was notified and gave instructions to hold her morning [MEDICATION(S)] and call back with Accucheck results when she was finished with breakfast. A Progress Note, dated 7/24/22 at 10:00 a.m., indicated Resident 46 had finished eating breakfast and her Accucheck was 289. The on-call physician was notified and gave new orders to hold [MEDICATION(S)] and Trajenta. A Progress Note, dated 7/31/22 at 2:05 p.m., indicated Resident 46 refused her scheduled [MEDICATION(S)], the on-call physician was notified and gave no new orders. Resident 46 had a baseline A1C lab draw on 2/25/22 after her admission. The results were 6.5 (hemoglobin A1C or HbA1c test is a blood test that measures your average blood sugar levels over the past 3 months). On 6/9/22 her A1c was re-checked and had increased to 10.8. Normal ranges should be between 4.1-6.1 During an interview on 8/5/22 at 9:50 a.m., the Director of Nursing (DON) indicated she had looked at Resident 46's record and also found that there was no diabetic management care plan or physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON indicated nurses had all been in-serviced on the use of the Freestyle Libre system but she did not see a physician order. The DON provided a copy of a new care plan she developed earlier that morning for Resident 46's diabetes management. 2. During an observation of Resident 43 on 8/1/22 at 11:52 a.m., she was observed sitting up in her room in a recliner. She did not have a bed in her room. She indicated that she preferred to sleep in her chair to help with pain and breathing. In the corner of her room two upright green oxygen tanks along with an oxygen concentrator were observed. A reusable container filled with a water and nasal cannula tubing were attached to the concentrator. The tubing and container of water lacked a date. On 8/2/22 at 10:52 a.m., Resident 43 was observed with the oxygen concentrator in her room connected to a reusable container filled with water and attached to nasal cannula tubing. The tubing and container of water was undated. During an interview with Resident 43 on 8/2/22 at 10:55 a.m., she indicated that she had the oxygen in her room for her to use if she needed it. She recently had pneumonia and had shortness of breath at times. Resident 43's record was reviewed on 8/03/22 02:28 p.m. Resident 43 had the following diagnoses, including but not limited to [CONDITION(S)], type 2 diabetes mellitus, mild cognitive impairment, chronic kidney disease, cardiomegaly, [CONDITION(S)], hypertension, [CONDITION(S)] pectoris (chest pain), unspecified [CONDITION(S)] and chronic pain. A review of Resident 43 record included orders for hospice to evaluate and treat. No orders were documented for oxygen on the Medication Administration Record. A review of the hospice admission record revealed orders for oxygen on 6/12/22. The order read oxygen at 3 liters per minute per nasal cannula as needed for shortness of breath and comfort; apply oxygen per nasal cannula at 0.5-5 liters per minute for dyspnea (difficulty breathing) or shortness of breath, may titrate as needed for comfort. Resident 43's care plans were reviewed. Resident 43 lacked a care plan to address hospice orders for oxygen as needed for shortness of breath and comfort. On 8/4/22 at 1:23 p.m., the Executive Director (ED) provided a copy of current facility policy titled, Resident Care Plan, dated 5/27/20. The policy indicated .The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident 3.1-35(a)

Based on observation, interview, and record review, the facility failed to ensure comprehensive care plans were revised for 4 of 20 residents reviewed for care plan timing and revision (Residents 43, 56, 13, and 21). Findings include: 1. During an observation on 8/1/22 at 11:52 a.m., Resident 43 was sitting up in her room in a recliner. She did not have a bed in her room. She indicated that she preferred to sleep in her chair to help with pain and breathing. During a record review on 8/3/22 at 2:28 p.m., Resident 43 had the following diagnoses, which included, but were not limited to [CONDITION(S)], type 2 diabetes mellitus, mild cognitive impairment, chronic kidney disease, cardiomegaly, [CONDITION(S)], hypertension, [CONDITION(S)] pectoris (chest pain), unspecified [CONDITION(S)] and chronic pain. A care plan, dated 3/18/22, indicated Resident 43 used transfer rails to enable resident with turning and repositioning in bed with a goal that Resident 43 would continue to utilize transfer rail to enable bed mobility/transfers and not sustain any injury from the transfer rail. Interventions included complete side rail assessment on admission and for significant changes in condition; and encourage and assist as needed with using the transfer rail for mobility. During an interview on 8/4/22 at 2:12 p.m., the DON (Director of Nursing) and MDS (Minimum Data Set) Coordinator were present. Resident 43's care plans were reviewed. The DON and MDS Coordinator indicated the care plans should have been updated. 2. During an observation on 8/1/22 at 11:31 a.m., Resident 56 was observed sitting in his recliner in his room. He did not have a bed in his room. During a record review on 8/4/22 at 10:26 a.m., Resident 56 had the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 4/19/21, indicated Resident 56 used transfer rails on the bed to enable turning and repositioning in bed with a goal that Resident 56 will continue to utilize rail to enable bed mobility/transfer and not sustain any injury from the transfer rail through. Interventions included complete side rail assessment on admission and for significant changes in condition; and encourage and assist as needed with using the transfer rail with mobility. Resident 56 had a comprehensive care plan, dated 4/27/21, with a problem that Resident 56 used an antidepressant medication, [MEDICATION(S)], as an appetite stimulant related to severe protein malnutrition with a goal that Resident 56 will be free of discomfort or adverse reaction related to antidepressant therapy. Interventions included administer antidepressant medication as ordered by physician, monitor document side effects and effectiveness every shift, educate the resident/family/caregivers about risks, benefits, and the side effects and/or toxic symptoms of [MEDICATION(S)], and monitor/document/report as needed adverse reaction to antidepressant therapy. [MEDICATION(S)] was not listed on Resident 56's physician orders. During an interview on 8/4/22 at 2:12 p.m., the DON (Director of Nursing) and MDS (Minimum Data Set) Coordinator were present. Resident 53's care plans were reviewed, and the DON and MDS Coordinator indicated the care plans should have been updated. 3. During an observation on 8/1/22 at 1:05 p.m., a urinary bag was attached to the frame of Resident 13's bedframe. The contents of the bag were observed. A dignity bag was not observed in place at that time. The bag was on the side of the bed facing the entrance to Resident 13's room. During an observation on 8/3/22 at 10:00 a.m., a urinary bag was observed attached to the frame of Resident 13's bed on the side of the entrance to room and was inside a blue dignity bag. During a comprehensive record review on 8/2/22 at 2:41 p.m., Resident 13 had that following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Orders for an indwelling catheter included: On 4/25/22, change foley catheter monthly on the 25th of each month and as needed at bedtime every month staring on the 25th for dislodgement or occlusion, foley 18 French, 30 cc (cubic centimeters) as needed for dislodgement or occlusion. On 3/28/22 flush foley catheter with 50 millimeters of sterile water every day and evening shift for patency. On 2/25/22 empty contents of catheter drainage bag. On 2/5/22 monitor catheter signs and symptoms monitoring: dysuria (painful urination), pain and infection. Review of Resident 13's care plans revealed a care plan, dated 6/30/21, with a problem that Resident 13 has a condom catheter due to [CONDITION(S)] with a goal that the resident would not show signs or symptoms of urinary tract infection. Interventions included check tubing for kink each shift, monitor for signs and symptoms of discomfort on urination, monitor, document for pain/discomfort due to catheter, monitor/record/report to MD for signs and symptoms of [CONDITION(S)] (urinary tract infection), position catheter bag and tubing below the level of the bladder and away from the entrance of the room door, and cover drainage bag with dignity bag. During an interview with the DON (Director of Nursing), ADON (Assistant Director of Nursing) and MDS (Minimum Data Set) Coordinator on 8/4/22 at 3:00 p.m., they indicated that Resident 13's indwelling catheter was removed, and he currently had a condom catheter. The DON indicated that Resident 13 went between an indwelling and condom catheter. During a chart review on 8/5/22 at 2:50 p.m., Resident 13 continued to have orders for an indwelling 18 French, 30 milliliters catheter. 4. During an observation and interview on 8/1/22 at 11:17 a.m., Resident 21 indicated he had oxygen because he cannot breathe without it. He was observed to have an oxygen concentrator in his room connected to a reusable container of water with tubing inserted into his nares. The flow rate of the concentrator was set to 6 liters per minute. The water container and tubing were undated. Resident 21 reported that he was receiving hospice care. During an observation on 8/2/22 at 11:20 a.m., Resident 21 had oxygen tubing in his nares. The oxygen concentrator was set to 6 liters per minute. A reusable container of water was connected to the concentrator and tubing. The tubing and water container were undated. During a comprehensive record review, Resident 21 had the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 21 had an order, dated 6/27/22, for oxygen continuously via nasal cannula or mask to keep oxygen saturation 90% or greater every shift for [CONDITION(S)] (chronic obstructive respiratory disease). Resident 21 had orders to receive hospice services. Resident 21's care plan, dated 2/19/22, indicated Resident 21 had [CONDITION(S)] (chronic obstructive pulmonary disease) with potential for complications/exacerbation. The care plan lacked documentation of the use of oxygen as an intervention. Resident 21's record lacked a care plan indicating he had a hospice provider service. During an interview on 8/4/22 at 2:12 p.m., the DON (Director of Nursing) and MDS (Minimum Data Set) Coordinator indicated Resident 21's care plans should have been updated and implemented. A policy titled, Resident Care Plan, was provided by the ED (Executive Director) on 8/4/22 at 1:23 p.m., indicated .The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident .Changes in the resident's condition must be reported to the MDS Assessment Coordinator so that a review of the resident's assessment and care plan can be made 3.1-35(c)(1)

Based on observation, interview, and record review, the facility failed to ensure a resident who was hard of hearing (HOH) had his hearing aids in place as ordered to promote his functional hearing ability for 1 of 1 residents reviewed for hearing and vision (Resident 217). Findings include: On 81/22 at 11:55 a.m., Licensed Practical Nurse (LPN) 35 asked Certified Nursing Assistant (CNA) 6 how Resident 217 transferred because she needed to assist him to the restroom. CNA 6 indicated to LPN 35 he was a 1-person assist, but the only way he could hear was if he could read your lips. Resident 217 was not wearing hearing aids at that time. During an interview on 8/1/22 at 12:03 p.m., CNA 6 indicated Resident 217 was very hard of hearing and needed his hearing aids in. He was confused and asked a lot of questions, then would forget the answers. On 8/1/22 at 3:45 p.m., CNA 6 knocked on Resident 217's room and asked him if he could leave the room so she could clean the floor. Resident 217 indicated, What? I can't hear you. CNA 6 pointed toward the direction of the door and assisted him out of the room. Resident 217 asked, What am I supposed to do? CNA 6 indicated, just wait there for a minute so I can clean your room. Resident 217 shrugged and began to roll away. He was not observed to wear hearing aids at this time. During an interview on 8/2/22 at 9:25 a.m., Resident 217 was observed as he laid in his bed. He was very hard of hearing. Resident 217 was able to read along with questions typed on a laptop with extra-large bold type and was able to hear enough to answer simple yes/no questions. He did not know where his hearing aids were. He did not know if he was supposed to be in bed, or if he was going to go home. Resident 217 pointed at the computer, smiling, and repeated, that's neat, where did you get that? Can I have one? During an interview on 8/2/22 at 10:05 a.m., CNA 6 indicated it was hard for Resident 217 to understand, he was confused and very hard of hearing, he was supposed to have hearing aids in, but she did not know where they were. Resident 217 continued to call out, Hey! Come here a minute! On 8/3/22 at 10:12 a.m., Resident 217 was observed at the dining room table. He indicated, Hey! When I get done eating, what do I do? LPN 38 indicated, You can lay down if you want. Resident 217, I can't hear you. LPN 38 repeated herself, several times, louder each time, but Resident 217 continued to shake his head and indicated he could not hear her. LPN 38 patted his back and indicated, I know. When he finished eating, he asked, are you going to put me to bed? LPN 38 told him yes, but he replied, I can't hear you. LPN 38 removed him from the dining room table and assisted him to his room. Resident 217 was not observed to have hearing aids in at this time. During an interview on 8/4/22 from 9:17 a.m., Speech Therapist (ST) 39 indicated Resident 217 did have a pair of hearing aids that made it a little easier to communicate with him, but they had not been charged last night so they had just been placed on the charger now. Even with his hearing aids in he was still pretty confused, and it was hard to know what he wanted to do. On 8/5/22 at 12:00 p.m., an interview was conducted with the Activity Director (ED) and Executive Director (ED). The AD indicated Resident 217 was very hard of hearing. As for his hearing aids, she had never seen him wearing any and did not know if he had a pair or used them. It was hard to communicate with him because of his hearing loss and confusion, and she had not tried any other types of communication methods such as a communication board, white board, or visual cue-cards. On 8/5/22 at 11:57 a.m., Resident 217's medical record was reviewed. He admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He had a current physician order, dated 7/21/22, which indicated, Nurse to ensure resident's hearing aids are charging at night and ensure they are in his ears every day. His admission Minimum Data Set (MDS) assessment was dated 7/22/22 and indicated he was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 8. He was moderately hard of hearing with the assistance of hearing aids and required extensive assistance with his activities of daily living (ADLs). He had a comprehensive care plan, dated 7/25/22, which indicated he had impaired cognitive function due to his dementia. Interventions for this plan of care included ask yes/no questions in order to determine his needs and cue, reorient, and supervise as needed. He had a comprehensive care plan, dated 7/28/22, indicated he had a communication problem related to his hearing deficit. Interventions for this plan of care included staff were to anticipate and meet his needs, be conscious of resident position when in groups, activities, dining room to promote proper communication with others and to allow adequate time to respond, repeat if necessary, do not rush, request clarification from the resident to ensure understanding, face when speaking, make eye contact, turn off TV/audio to reduce environmental noise, ask yes/no questions if appropriate use simple, brief consistent words/cues. Use alternative communication tools as needed. The care plan record lacked documentation of Resident 217's use of hearing aids. An initial Activities Review, dated 7/17/22, included a section titled, Limitation/Special Needs and was checked no, for the question, should activities be modified to accommodate hearing deficit. An acute Medical Doctor (MD) progress note was dated 8/2/22 and indicated .He is extremely hard of hearing On 8/4/22 at 9:40 a.m., the Director of Nursing provided a copy of current facility policy titled, quality of Life- Dignity, dated 5/27/20. The policy indicated, .Each resident shall be care for in a manner that promotes and enhances quality of life, dignity, respect and individuality . treated with dignity means the resident will assisted in maintaining and enhancing his or her self-esteem and self-worth . staff shall treat cognitively impaired residents with dignity and sensitivity; for example: addressing the underlying motives or root causes for behaviors 3.1-39(a)

Based on observation, interview, and record review, the facility failed to provide one on one activities for residents unable to participate in group activities for 2 of 2 residents reviewed for one on one activities (Residents 28 and 32), and failed to provide group and individual activities which provided meaningful stimulation and were patterned for interests and hobbies for 2 of 6 facility buildings (Residents 30 and 46). Findings include: 1. On 8/1/22 at 11:08 a.m., during a random observation Resident 28 was seated at the dining room table. Certified Nurse Aid (CNA) 25 was seated across the table looking at her phone. The resident was staring ahead. The television was positioned up high on the wall, above the fireplace. The resident did not appear to notice the television and she never looked up. The resident was confused and disoriented. She did not converse or respond to questions appropriately. On 8/2/22 at 9:31 a.m., during a random observation, Resident 28 was seated at the table. She had just finished breakfast. She stared straight ahead and looked down. The television was on, but she did not look up. On 8/3/22 at 1:41 p.m., the medical record was reviewed for Resident 28. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A current care plan indicated Resident 28 had a communication problem related to dementia. She was rarely understood and rarely understood others. Another current Care Plan indicated Resident 28 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits and physical limitations related to dementia. The goal indicated Resident 28 would participate in activities of choice 3 to 5 times weekly by next review date. She would join her housemates thru the day watching game shows and movies. She also engaged with the cook playing balloon toss. Interventions were for all staff to converse with her while providing care, encourage ongoing family involvement, and invite the resident's family to attend porch visits. Staff were to ensure that the activities the resident was attending were: Compatible with physical and mental capabilities; Compatible with known interests and preferences; Adapted as needed (such as large print, holders if resident lacks hand strength, task segmentation); Compatible with individual needs and abilities; and Age appropriate. Resident 28 needed assistance with ADLs as required during the activity. Resident 28 needed assistance/escort to activity functions. Resident preferred activities which did not involve overly demanding cognitive tasks. Engage in simple, structured activities such as music, sensory stimulation. Preferred activities were attending church services in the house and playing balloon toss. 2. On 8/1/22 at 11:20 a.m., during a random observation, Resident 32 was seated at the dining room in front of the television, in her Broda (specialized high back wheelchair) chair. She occasional glanced upward but did not engage in watching the television show. The resident was confused and disoriented. She did not converse or respond to questions appropriately. On 8/2/22 at 9:21 a.m., during a random dining observation, Resident 32 was seated at the dining room in front of the television, in her Broda (specialized high back wheelchair) chair. She occasional glanced up at the television. The television was on. On 8/3/22 at 12:37 p.m., the medical record was reviewed for Resident 32. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A current Care Plan indicated Resident 32 had impaired visual function related to low vision diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She did follow movement with her eyes. A current activity care plan indicated the resident had a low participation in group activity. She enjoyed music, watching TV, religious activities and snacks. The resident also enjoyed being read to and going outside when it is nice out. The goal indicated the resident would engage in one-on-one activities 2 x [times] a week such as being read to, listening to music and or having snacks. The interventions were during one-on-one visits offer to read devotions, poems and or short stories. During one-on-one visits play music or show musical programs on the TV. Give positive affirmations for engaging in one-on-one activities. Provide one-on-one activity twice a week. Another Current Care Plan indicated the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits. The goal indicated Resident 32 would attend activities 1 to 3 times weekly through the next review date. The interventions listed were for All staff to converse with [resident] while providing care. Encourage ongoing family involvement. Invite her family to attend porch visits. Ensure that the activities [resident] is attending are: Compatible with physical and mental capabilities; Compatible with known interests and preferences; Adapted as needed (such as large print, holders if resident lacks hand strength, task segmentation), Compatible with individual needs and abilities; and Age appropriate. [Resident] needs assistance with ADLs as required during the activity. [Resident] needs assistance/escort to activity functions. 3. On 8/1/22 at 11:30 a.m., the activity calendar was observed by the visitor's entry door, Building 3. All morning activities were television or video application channels from 9:30 a.m. to 1:00 p.m. 2:00 p.m. Craft 3:00 p.m. Porch time and water plants 4:00 p.m. Puzzle time 6:00 p.m. Here comes the Boom comedy on a video application channel On 8/2/22 at 9:22 a.m., during a random observation, the television was on a criminal show with fighting and action. On 8/2/22 at 9:38 a.m., the television channel was changed by an unidentified Certified Nurse Assistant (CNA) to a western. On 8/2/22 at 9:44 a.m., a review of the activity calendar showed Chair Exercises on a video application channel for 9:30 a.m., coloring pages at 10:15 a.m., and an older sitcom on a video application channel at 11:30 a.m. On 8/3/22 at 11:15 a.m., during an interview with the Director of Nursing (DON) she indicated the Activity Coordinator (AC) arrived at work at 7:00 a.m. each day. The CNAs were responsible to change the channels on the televisions to be sure they agreed with the activity calendar. The AC did a hands-on activity in each home every day. On 8/3/22 at 1:53 p.m., during a random observation in Building 3, a nature show was on the television. The activity calendar indicated you tube TV - TV trivia. The Calendar indicated AC in the building at 2:00 p.m. CNA 26 was observed trying to put the common room television on for a movie scheduled at 2:00 p.m. A bag of store-bought popcorn was on the kitchen counter. There were 2 residents in the common area (Residents 30 and 46). All other residents were in their rooms. No one was observed going to the rooms to invite the residents to the activity. On 8/3/22 at 2:02 p.m., during a random observation in Building 4, the activity calendar indicated Popcorn and a movie at 1:00 p.m. The AC was in this house at 1:00 p.m. daily per the printed calendar. Two unidentified residents were seated at the dining room table painting with CNA 27. One unidentified resident was eating lunch at the table. No other residents were present in the communal area. On 8/3/22 at 11:54 a.m., during an interview, the AC indicated she had worked at the facility since August of 2020. She was initially a cook. She had a certification for activities completed in July of last year. The calendar was a little bit different for each home, based on interest and ability. The CNAs were supposed to turn on the television shows. Each calendar designated when the AC was in that building each day. She did not have one on one activities. Unfortunately, she was not able to do one on ones with residents with having to manage activities of all 6 buildings. Residents 28 and 32 were able to participate in some activities such as church service, even if they could not actively participate in activities they were present when other residents were participating. Sometimes the aids took them outside. The cook in that building was really good with the residents and sometimes did some things with them. On 8/4/22 at 9:06 a.m., the DON provided a current policy, dated 5/27/20, titled, Activities Program Policy. This policy indicated, To support our vision of enjoying each day, connecting with others and balancing meaningful homelife tasks with leisure pursuits, the Restoracy offers daily activity programs .An assessment of each resident's interests, hobbies, and preferred patterns of activity will be completed as part of the process, with each comprehensive Minimum Data Set (MDS) assessment, and periodically updated as part of the care planning process. Activity options will be offered in consideration of the individual cognitive level based on the [NAME] Cognitive Level Stage (ACLS) or other assessments, with the goal of matching best ability to function with just right challenges and personal preferences. Residents, including those unable to leave their rooms, may choose to take part in a variety of activities 3.1-33(a)

Based on observation, interview, and record review, the facility failed to ensure residents with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: 1. During an interview on [DATE] at 10:27 a.m., Licensed Practical Nurse (LPN) 23 indicated Resident 46 was a brittle and unpredictable diabetic. Her blood sugar readings did fluctuate a lot, so the nurses did regular blood sugar checks via her Libre (brand name/subcutaneous glucose monitoring device). She was on a sliding scale for insulin and did not always follow her diet. On [DATE] at 1:30 p.m., Resident 46 was observed as she sat in her wheelchair in her room. Resident 46 indicated she had been having trouble getting her blood sugars under control but they were working on it. She used to get her finger pricked so many times a day the ends of her fingers were sore, so she was happy to have a new monitoring device. She motioned to the Libre which was located on her left upper arm. Resident 46 indicated she thought the biggest issue for her was her diet, for example that morning she had been given oatmeal with brown sugar, which would raise her blood sugar. She used to only take a pill for her diabetes but was recently put on insulin too, so it was taking some time to get adjusted. On [DATE] at 11:58 a.m., Resident 46's medical record was reviewed. She admitted to the facility on [DATE] with current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She had a current physician order to complete Accuchecks each morning and evening with instructions to contact the doctor if her blood sugar (BS) was below 70 or greater than 350. There was no physician's order for the Freestyle Libre blood glucose monitoring device. Resident 46's nursing progress notes were reviewed and revealed the following: On [DATE] at 10:41 a.m., Resident 46 had emesis (vomit) at 7 a.m., per off going nurse. Her vitals were taken, and an Accu-check was done. Her blood sugar was 568 which was treated with new physician orders of a one time injection of [MEDICATION(S)] (an antibiotic), IV (intravenous) fluids, and her sliding scale insulin. A follow up progress note, dated [DATE] at 1:47 p.m., indicated Resident 46 was more responsive and her blood sugar had come down to 330 and treated per her sliding scale instructions. She was given soup and crackers for lunch. On [DATE] at 12:28 p.m., Resident 46's BS was 382. The on-call physician was notified and instructed use of her sliding scale. [MEDICATION(S)] (insulin medication) 8 units were given at this time. On [DATE] at 4:20 p.m., her BS was 339. The on-call physician gave orders to change physician notification parameters for if her BS was greater than 350. On [DATE] at 11:25 a.m., the Interdisciplinary Team (IDT) met to discuss Resident 46's antibiotic orders. After Resident 46 had an episode of vomiting, change in mental status, and her BS was found to be 568 on [DATE]. She was diagnosed with [CONDITION(S)] and AKI (acute kidney injury). Her repeat labs were redrawn [DATE] and no further antibiotic had been ordered. Endocrinology would follow up as well. On [DATE] at 1:50 p.m., the IDT team also met to discuss a new diabetic ulcer on Resident 46's right heel. Her blood sugars had been elevated due to her recent illness. BS readings have ranged from over 300, at times over 500. The NP has ordered insulin based on glucose results. On [DATE] at 2:47 p.m. Resident 46 was noted to be diaphoretic (clammy/sweaty), her Accucheck reading was 66. She was given 120cc of juice at that time and would be rechecked in 15 minutes. On [DATE] at 3:05 p.m., Resident 46's BS was rechecked and down to 100, with a note that the MD would be notified of the low reading. On [DATE] at 4:17 p.m., the Residents BS was checked and read 46. She was clammy and even though her eyes were open, she was unable to respond. She was given orange juice then the MD was notified who gave new orders to give 1 injection of [MEDICATION(S)] (a hormone that your pancreas makes to help regulate your BS). Additionally, her lunchtime insulin orders were discontinued, and her dinner insulin was held. Resident 46 was responding better and able to communicate per her norm. On [DATE] at 5:10 p.m., Resident's BS was 82 at 7 a.m., BS at noon were documented and her medication and [MEDICATION(S)] were held per MD order. On [DATE] at 12:23 p.m., Resident 46's Accucheck was 423. The on-call physician was notified and gave instructions to give morning diabetic meds and scheduled lunch insulin then recheck in one hour. On [DATE] at 2:05 p.m., her BS was down to 387, and the on-call physician was notified. On [DATE] at 7:15 a.m., Resident 46's Accucheck was 46 at the beginning of the shift. She was given orange juice and crackers, then was conversing with staff and denied symptoms. The on-call physician was notified and gave instructions to recheck in 30 minutes. On [DATE] at 7:50 a.m., Her BS was rechecked and read 60. The on-call physician was notified and gave instructions to hold her morning [MEDICATION(S)] and call back with Accucheck results when she was finished with breakfast. On [DATE] at 10:00 a.m., Resident 46 had finished eating breakfast and her Accucheck was 289. The on-call physician was notified and gave new orders to hold [MEDICATION(S)] and Trajenta. On [DATE] at 2:05 p.m., Resident 46 refused her scheduled [MEDICATION(S)], the on-call physician was notified and gave no new orders. Resident 46 had a baseline A1C lab draw on [DATE] after her admission. The results were 6.5 (hemoglobin A1C or HbA1C test is a blood test that measures your average blood sugar levels over the past 3 months). On [DATE] her A1C was re-checked and had increased to 10.8. Normal ranges should be between 4.,d+[DATE].1 During an interview on [DATE] at 9:50 a.m., the Director of Nursing (DON) indicated she had looked at Resident 46's record and also found that there was no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON indicated nurses had all been in-serviced on the use of the Freestyle Libre system, but she did not see a physician order. 2. On [DATE] at 10:29 a.m., during an observation and interview, Resident 40 indicated the facility did not treat her blood sugars correctly. They kept changing her insulin and they did not listen to her. I'm in my right mind and handled it for years. A beeping noise was heard coming from a small monitoring device on the resident's over bed table. The resident indicated she had a reader on her arm for her blood sugar monitor. She picked up the monitor and held it to her left upper arm. The monitor registered 270 (high blood sugar). The facility monitored her blood sugars at certain times, but she liked to keep up with it herself. On [DATE] at 2:15 p.m., Resident 40's medical record was reviewed. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's order, dated [DATE], indicated ACCU CHECK [a type of finger stick blood sugar monitoring] in the morning for DM [diabetes] AND in the evening for dm [diabetes]AND in the afternoon for dm [diabetes] AND at bedtime for dm [diabetes]. The blood sugar readings were recorded on the resident record as indicated. There was no order for a Free Style Libre monitoring device. There was no order to assess the device or change the subcutaneous patch on the resident's arm. There were no assessments in the record of the site itself. On [DATE] at 3:11 p.m., during an interview, the Director of Nursing (DON) indicated Resident 40 had a Free Style Libre. It had to be changed out every 14 days. The nurse should have been assessing the site daily and there should have been a care plan in place. The assessment and site change should have been documented in the medical record. On [DATE] at 9:10 a.m., the DON provided a copy of current facility policy titled, Continuous Glucose monitoring Policy, dated [DATE]. The policy indicated, Residents will have glucose monitoring performed by a licensed nurse or qualified medication aide within the home. The preferred method of glucose monitoring is by use of a continuous glucose monitor 3.,d+[DATE](a)

Based on observation, interview, and record review, the facility failed to ensure a treatment cart was locked when a nurse was not present for 1 of 1 random observation, and ensure medications were not left at the bedside for residents without a self-administer order and evaluation for 2 of 5 residents reviewed for medication administration (Residents 26 and 267). Findings include: 1. On 8/1/22 at 9:45 a.m., during an initial tour and observation in Building 4, the treatment cart was observed unlocked. A bottle of COVID-19 liquid antigen was on top of the cart. There were 4 residents at a table in front of the treatment cart. An unidentified Certified Nurse Assistant (CNA) was observed as she walked around the common area doing an activity with the residents. She came and went from the area and was not with the residents at all times. A visitor entered and sat with the residents as they completed a snowman craft. On 8/1/22 at 10:10 a.m., during a continuous observation the treatment cart remained unlocked. A visitor and 4 residents remained at the table approximately 4 feet away. There were no staff present at this time. On 8/1/22 at 10:27 a.m., Licensed Practical Nurse (LPN)23 entered the building. She indicated she was responsible for the residents in buildings 3 and 4. She had been building 3. The treatment cart should not have been unlocked. It must have been left open from night shift. 2. On 8/1/22 at 10:14 a.m., during the initial tour and observation of building 4, Resident 26 had a bottle of [MEDICATION(S)] nasal spray on her overbed table. The order indicated [MEDICATION(S)] Allergy Relief Suspension ([MEDICATION(S)]), 1 spray in both nostrils in the morning for allergies AND 1 spray in both nostrils at bedtime for allergies. On 8/3/22 at 9:52 a.m., Resident 4's medical record was reviewed and lacked documentation of a physician order and/or an assessment of her ability to self-administer her medication. 3. On 8/4/22 at 8:51 a.m., during a medication pass observation, Licensed Practical Nurse (LPN) 24 was observed as she prepared medications at the medication cart for Resident 267. She verified the physician's order and placed the resident's eight oral medications in a pill cup. Then she removed three inhalers from the medication and took them, along with the cup of prepared oral medications and a cup of applesauce to the resident's room. Resident 267 was observed seated in a chair at her bedside. The over the bed table was in front of her. LPN 24 greeted the resident and placed the cup of pills, applesauce and inhalers on the over bed table, in front of the resident. She indicated to the resident to take her pills and not forget her inhalers. She would be back later to get her inhalers (to put back in storage). The nurse left the room before the resident took her medication or inhalers. On 8/4/22 at 9:08 a.m., during an interview, LPN 24 indicated Resident 267 got anxious if you watched her take her medications. She did not have an order to self-administer but she could write an order if she needed to. A resident who self-administered their own medications had to have an evaluation and order to do so. On 8/3/22 at 9:05 a.m., the Director of Nursing (DON) provided a current policy, dated 5/27/20, titled, Security of Medication Cart. This policy indicated .Medication carts must be securely locked at all times when out of the nurse's view On 8/3/22 at 9:05 a.m., the DON provided a current policy, dated 5/27/20, titled Medication Administration General Guidelines Policy. This policy indicated, .The facility will provide appropriate care and services to manage the resident's medication regimen to avoid unnecessary medications and minimize negative outcomes. The licensed nurse and or QMA [Qualified Medication Aid] shall administer each resident's medications in accordance with the physician's order and the resident's plan of care .Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with self-administration medication policy of the facility 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident's personal preference for catheter supplies was honored and failed to ensure the catheter bag and tubing was not in contact with the floor, in order to reduce the potential for infections for a resident with a history of urinary tract infections (UITs) for 1 of 3 residents reviewed for catheters/UTIs (Resident 222). Findings include: On 8/1/22 at 12:11 p.m., Resident 222 was observed as he sat in his wheelchair in his room. Upon entrance into his room, his catheter drainage bag and tubing were observed on the floor. When asked about his catheter, Resident 222 picked up the bag, pointed to the clip, and indicated they must have forgotten to clip it somewhere and he attempted to hang the bag on the side of his wheelchair (WC), but it slid off. Resident 222 placed his drainage bag on top of his bed. The nurse was called for assistance. Licensed Practical Nurse (LPN) 35 entered the room and indicated his catheter bag should be attached and kept off the floor at all times to reduce the potential for infections or contamination. When she picked the drainage bag off the bed and stood beside him to look for a place to secure the bag, the bag was above the level of the bladder. As she passed the bag from one hand to the other it swung the tubing, with urine visible in the line, above the level of his bladder. On 8/2/22 at 9:38 a.m., Resident 222 was observed at the dining room table where he finished his morning coffee. At this time, his catheter tubing was noted to touch the floor. There was a moderate amount of light yellow and cloudy urine observed in the tubing. During an interview on 8/2/22 at 9:45 a.m., Resident 222 indicated he had his catheter for a while now and had some problems with UTIs before. At this time, the Staffing Coordinator indicated he was ready to help Resident 222 get his new catheter in place. On 8/2/22 at 9:59 a.m., the Staffing Coordinator exited Resident 222's room. Resident 222 was wearing a pair of shorts and a new leg drainage bag was observed in place secured to his right leg, just above his knee. Resident 222 indicated he had just been told earlier that morning that he was supposed to wear a leg bag when he came out of his room. Resident 222 did not like the leg bag style, because it irritated and scratched his skin, but since it was facility policy, he agreed to put it on. During an interview on 8/2/22 at 10:02 a.m., the Staffing Coordinator indicated, Resident 222 was supposed to have a leg bag on earlier, but he did not want it. The Staffing Coordinator had gone in to remind him he was supposed to have a leg bag on to come out of the room and Resident 222 changed his mind and agreed to wear it. On 8/2/22 at 2:52 p.m., Resident 222 was observed as he was assisted out of his room and down to the therapy room. He was wearing shorts, so that his catheter drainage leg-bag was visible above his right knee. The drainage bag was approximately 1/4 full of clear yellow urine. On 8/3/22 at 9:32 a.m., Resident 222 was observed in his wheelchair in his room as he worked on a crossword puzzle. His leg bag had been removed and replaced with a drainage bag that hung under his seat. He indicated he did not know why they kept going back and forth about it. The tubing of the catheter was observed to hang lose and looped as it rested on the floor. There was a moderate amount of yellow cloudy urine with sediment visible in the tubing. On 8/4/22 at 8:43 a.m., Resident 222 was observed sitting in his wheelchair at the dining room table as he ate breakfast. His catheter drainage tube hung lose and rested on the floor. There was a moderate amount of yellow cloudy urine with sediment visible in the tubing. On 8/4/22 at 9:26 a.m., Resident 222 was assisted to the therapy gym. His catheter tubing dragged on the ground as he was rolled in his wheelchair. At the conclusion of his therapy session 8/4/22 at 10:08 a.m., Resident 222 was assisted back to the dining room table. A greater length of his catheter tubing now hung lose on the ground and rested on the floor. There was a moderate amount of yellow cloudy urine with sediment visible in the tubing. During a follow up interview on 8/4/22 at 2:05 p.m., the Staffing Coordinator indicated the facility should always honor resident preference for catheter supplies. If a resident did not want to wear a leg bag, then they should not have to, and the bag as well as the tubing should always remain off the floor. On 8/4/22 at 2:00 p.m., Resident 222's medical record was reviewed. He had recently admitted to the facility in July of 2022 with active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent comprehensive assessment was an admission Minimum Data Set (MDS) assessment dated [DATE]. The MDS indicated Resident 222 was moderately cognitively impaired with Brief Interview for Mental Status (BIMS) score of 10 and had no behaviors (including rejection of care) in the last 7 days. A Urinalysis lab was completed on 7/18/22. His urine color was turbid and positive for Citrobacter Freundii, a species of bacteria. A Nurse Practitioner visit note, dated 7/26/22, indicated Resident 222 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing progress note, dated 7/28/22 at 3:02 p.m., indicated Resident 222 was having intermittent confusion and continued to hallucinate off and on. The Nurse Practitioner (NP) had discontinued [MEDICATION(S)] and started an antibiotic for chronic [CONDITION(S)]. A nursing progress note, dated 8/2/22 at 9:39 a.m., indicated, Tried to put leg bag on resident. He refused stating he didn't like leg bag due to comfort. Resident 222 had a comprehensive care plan for his suprapubic catheter with interventions which included but were not limited to position catheter bag and tubing below the level of the bladder and cover the drainage bag with a dignity bag. On 8/4/22 at 9:40 a.m., the Director of Nursing (DON) provided a copy of current facility policy titled, Management of Indwelling Urinary Catheter, dated 5/27/20. The policy indicated, .indwelling urinary catheter should not be changed routinely. Catheters should only be changed for a. obstruction b. catheter is leaking, c. physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Be sure tubing is not kinked, twisted, obstructed, or caught. Keep drainage bag off the floor. Tubing should be secured with a securement device 3.1-41(a)(2)