Every finding on record at Riveroaks Health Campus

Based on interview and record review, the facility failed to ensure the physician was notified during a change in condition for 1 of 1 residents reviewed for closed records. (Resident 57)Finding includes: On 12/16/25 at 2:23 P.M., Resident 57's clinical record was reviewed. Resident 57 was admitted on [DATE]. Diagnoses included, but were not limited to, encephalopathy. The most recent admission Minimum Data Set (MDS) Assessment, dated 9/10/25, indicated Resident 57 was cognitively intact. Physician orders included, but were not limited to: lactulose solution 45mL (milliliters) oral three times a day; Start date 9/12/25 The electronic medication administration record (eMAR) indicated the following dates Resident 57 refused lactulose medication:10/3/25 12:21 P.M.10/4/25 11:55 A.M.10/8/25 8:26 A.M.10/8/25 12:20 P.M.10/10/25 3:42 P.M.10/10/25 6:48 P.M.10/11/25 7:31 A.M. The clinical record lacked physician notification of refusal of medications for the above attempted medication administrations. A physician note, dated 10/10/25, indicated resident does take medicines and has been using lactulose. During an interview on 12/19/25 at 1:15 P.M., Clinical Registered Nurse 3 indicated staff had previously contacted the physician when Resident 57 was refusing medications but did not contact the physician each time. On 12/22/25 at 9:43 A.M., the Administrator provided a policy titled Self Determination of Care, dated 5/16, that indicated Should a resident refuse his/her medications service recommendation, appropriate documentation relative to this decision shall be recorded in the resident's EMR. Documentation pertaining to a resident's care decision shall include, as a minimum: Open a self determination of care observation form in the electronic health record . b. The resident's response and reasons for denial . f. the date and time the physician was notified as well as the physician's response. 3.1-5(a)(2)

Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) Assessments were completed accurately for 1 of 4 residents reviewed for pressure ulcers and 2 of 5 residents reviewed for unnecessary medications. (Resident 4, Resident 3, and Resident 42)Findings include: 1. On 12/16/25 at 10:33 A.M., Resident 4's clinical record was reviewed. Resident 4 was admitted on [DATE]. Diagnoses included, but were not limited to, generalized anxiety disorder. The most recent Annual Minimum Data Set (MDS) Assessment, dated 9/19/25, indicated Resident 4 was cognitively impaired and received antianxiety medication during the 7-day lookback period. Physician orders included, but were not limited to: lorazepam (antianxiety medication) tablet 0.5 mg (milligrams) one tablet oral at bedtime; Start date 12/12/24 The electronic Medication Administration Record (eMAR) from 9/13/25 to 9/19/25 was reviewed. The resident received lorazepam 0.5 mg seven out of seven days. 2. On 12/16/25 at 2:03 P.M., Resident 3's clinical record was reviewed. Diagnoses included, but were not limited to, anxiety disorder. The most current Significant Change Minimum Data Set (MDS) Assessment, dated 10/4/25, indicated Resident 3 was cognitively intact, received an anticonvulsant medication, and did not receive an antianxiety medication during the 7-day lookback period. Physician orders included, but were not limited to:clonazepam (an antianxiety medication) 0.5 milligrams (mg) - Give one tablet by mouth four times a day for anxiety, dated 9/28/25. Pharmacological classifications listed for this medication were antianxiety, hypnotic, and anticonvulsant. The electronic Medication Administration Record (eMAR) from 9/30/25 to 10/4/25 was reviewed. Resident 3 received clonazepam 0.5 mg seven out of seven days. 3. On 12/16/25 at 1:28 P.M., Resident 42's clinical record was reviewed. Diagnoses included, but were not limited to, anxiety disorder. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 10/31/25, indicated Resident 42 had severe cognitive impairment, received an anticonvulsant medication, and did not receive an antianxiety medication during the 7-day lookback period. Physician orders included, but were not limited to:clonazepam (an antianxiety medication) 0.5 milligram (mg) tablet - Give 0.25 mg by mouth twice a day for anxiety, dated 6/17/25 and discontinued on 12/16/25. Pharmacological classifications listed for this medication were antianxiety, hypnotic, and anticonvulsant. The electronic Medication Administration Record (eMAR) from 10/25/25 to 10/31/25 was reviewed—resident 42 received clonazepam 0.25 mg seven out of seven days. During an interview on 12/19/25 at 9:04 A.M., MDS Coordinator 5 indicated that clonazepam was coded as an anticonvulsant. During an interview on 12/19/25 at 10:15 A.M., MDS Coordinator 5 indicated she was not aware that clonazepam was also classified as an antianxiety medication and a hypnotic medication. She indicated medications should be coded for all pharmacological classifications on the MDS Assessment. She indicated that she used the facility's charting system drug classifications for coding medications. At that time, she indicated the facility followed guidelines set in the Resident Assessment Instrument (RAI) Manual. On 12/19/25 at 10:27 A.M., the RAI Manual, dated October 2024, was reviewed. It indicated Medications that have more than one therapeutic category and/or pharmacological classification should be coded in all categories/classifications assigned to the medication, regardless of how it is being used.

Based on interview and record review, the facility failed to develop a comprehensive care plan for 1 of 5 residents reviewed for medications. (Resident 3) A resident receiving a long-term prophylactic antibiotic did not have a care plan in place to address the antibiotic medication.Finding includes: On 12/16/25 at 2:03 P.M., Resident 3's clinical record was reviewed. Diagnoses included, but were not limited to, hypertensive chronic kidney disease and urinary retention. The most current Significant Change Minimum Data Set (MDS) Assessment, dated 10/4/25, indicated Resident 3 was cognitively intact and received an antibiotic medication during the 7-day lookback period. Physician orders included, but were not limited to:ciprofloxacin (an antibiotic medication) 250 milligram (mg) - Give one tablet by mouth once a day on the 24th of the month, dated 9/30/25ciprofloxacin 500 mg tablet - Give one tablet by mouth twice a day, dated 9/28/25 and discontinued on 9/30/25ciprofloxacin 500 mg tablet - Give one tablet by mouth twice a day, dated 9/30/25 and discontinued on 10/2/25A care conference was completed on 10/24/25 with Resident 3's family member in attendance. Care plans were reviewed.The clinical record lacked a care plan related to the long-term use of an antibiotic.During an interview on 12/19/25 at 9:06 A.M., the Director of Nursing (DON) indicated that residents who received an antibiotic would also have a care plan that addressed the antibiotic.During an interview on 12/19/25 at 10:25 A.M., the DON indicated that there was not a care plan in place in the clinical record that addressed Resident 3's antibiotic medication prior to 12/19/25.On 12/22/25 at 9:43 A.M., the Administrator provided a current Comprehensive Care Plan Guideline policy, dated 5/22/18, that indicated Should new identified areas of concern arise during the resident's stay, they should be addressed on the care plan . Address problems that become ongoing or chronic with a new comprehensive care plan . Comprehensive care plans need to remain accurate and current .3.1-35(a)3.1-35(b)(1)

Based on interview and record review, the facility failed to ensure care plan interventions were revised following a fall for 1 of 4 residents reviewed for falls. (Resident 12) A resident's care plan was not updated with a new intervention after a fall.Finding includes:On 12/16/25 at 12:55 P.M., Resident 12's clinical record was reviewed. Diagnoses included, but were not limited to, Parkinson's disease and dementia. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 11/20/25, indicated Resident 12 had mild cognitive impairment, required substantial to maximal assistance of staff (staff does more than half of the effort) with toileting and transferring, and had two or more falls without injury since the prior assessment. A care plan conference was completed on 12/3/25 with Resident 12's representative attending via phone call. Care plans were reviewed.A risk for falling care plan, initiated 1/2/25, included, but was not limited to, the following interventions:Therapy evaluation and treatment as needed, dated 1/2/25Ensure Dycem (a non-slip pad) is in place in wheelchair, dated 1/3/25Staff to assist resident to bed after p.m. meals, dated 2/10/25Dycem placed to wheelchair and staff to ensure placement and replace as needed, dated 6/3/25Therapy referral, dated 7/15/25Staff to assist resident to bed after supper if resident declines to stay in common area, dated 10/27/25An Occurrence clinical note, dated 1/2/25 at 9:59 A.M., indicated Resident 12 had an unwitnessed fall in her room while attempting to pick items up off the floor. Ensure Dycem is in place in wheelchair was added to the care plan on 1/3/25.A nursing progress note, dated 2/7/25 at 9:43 P.M., indicated Resident 12 had an unwitnessed fall in the common area while attempting to stand unassisted. Staff to assist resident to bed after p.m. meal was added to the care plan on 2/10/25.An Occurrence clinical note, dated 6/2/25 at 3:10 P.M., indicated Resident 12 had an unwitnessed fall in her room while attempting to pick an item up off the floor. Dycem placed to wheelchair and staff to ensure placement and replace as needed was added to the care plan on 6/3/25.A nursing progress note, dated 7/13/25 at 6:28 P.M., indicated Resident 12 had an unwitnessed fall in her room while attempting to walk unassisted. Therapy referral was added to the care plan on 7/15/25.A therapy referral report, initiated 7/14/25 and completed by therapy staff on 7/15/25, indicated that therapy was not recommended at that time.The clinical record did not indicate that the Interdisciplinary Team (IDT) met to follow up on the therapy report or that another relevant intervention was implemented following Resident 12's fall on 7/13/25.An Occurrence clinical note, dated 10/25/25 at 5:22 P.M., indicated that Resident 12 and an unwitnessed fall while attempting to self-transfer from her wheelchair to her bed. Staff to assist resident to bed after supper if resident declines to stay in common area was added to the care plan on 10/27/25.During an interview on 12/19/25 at 9:06 A.M., the Director of Nursing (DON) indicated that after a resident sustained a fall, the IDT would review the fall and initiate a new intervention appropriate to the situation.During an interview on 12/19/25 at 10:55 A.M., Clinical Registered Nurse (RN) 3 indicated that if an intervention such as a therapy referral did not end up being appropriate for the resident, a new intervention would be added to the care plan depending on the situation. After the therapy evaluation on 7/15/25 determined Resident 12 was not a candidate for therapy at that time, nothing else was added to the care plan.On 12/22/25 at 9:43 A.M., the Administrator provided a current Fall Management Program Guidelines policy, last reviewed on 11/19/25, that indicated Should the resident experience a fall the attending nurse shall complete .interventions to reduce risk of repeat episode and a review by the IDT to evaluate .appropriateness of the interventions . The resident care plan should be updated to reflect any new or change in interventions.On 12/22/25 at 9:43 A.M., the Administrator provided a current Comprehensive Care Plan Guideline policy, dated 5/22/18, that indicated Comprehensive care plans need to remain accurate and current. New interventions will be added and updated during or directly following CCM meeting.3.1-35(b)(1)

Based on interview and record review, the facility failed to ensure residents were monitored for side effects of high-risk medications for 1 of 5 residents reviewed for medications. (Resident 3) A resident was not monitored for side effects of antibiotic, antiplatelet, diuretic, and antianxiety medications.Finding includes:On 12/16/25 at 12:03 P.M., Resident 3's clinical record was reviewed. Diagnoses included, but were not limited to, hypertensive chronic kidney disease, urinary retention, congestive heart failure, and anxiety disorder. The most current Significant Change Minimum Data Set (MDS) Assessment, dated 10/4/25, indicated Resident 3 was cognitively intact and received an antibiotic, diuretic, antiplatelet, and anticonvulsant medication and did not receive an antianxiety medication during the 7-day look back period.A care conference was completed on 10/24/25 with the resident's family member in attendance. Care plans were reviewed.The clinical record included, but were not limited to, the following care plans:Resident receives diuretic medication related to congestive heart failure, dated 6/6/25Resident is at risk for excessive bleeding and bruising related to medications, dated 6/6/25Resident has diagnosis of anxiety and demonstrated the following symptoms: fidgeting about, talking quickly, undecisive, dated 9/28/25Physician orders included, but were not limited to:aspirin (an antiplatelet medication) 81 milligrams (mg) chewable tablet - Give one tablet by mouth once a day, dated 9/28/25ciprofloxacin (an antibiotic medication) 250 mg tablet - Give one tablet by mouth once a day on the 24th of the month, dated 9/30/25furosemide (a diuretic medication) 20 mg table - Give one tablet by mouth once a day, dated 9/28/25clonazepam (an antianxiety medication) 0.5 mg tablet - Give one tablet by mouth four times a day, dated 9/28/25The clinical record lacked monitoring orders for side effects of the antiplatelet, antibiotic, diuretic, and antianxiety medication.During an interview on 12/19/25 at 9:04 A.M., MDS Coordinator 5 indicated that she coded the clonazepam as an anticonvulsant.During an interview on 12/19/25 at 9:06 A.M., the Director of Nursing (DON) indicated that when a resident was prescribed a high-risk medication, they also got an order to monitor for side effects of that medication. During an interview on 12/19/25 15 10:15 A.M., MDS Coordinator 5 indicated that she was unaware that clonazepam was also an antianxiety medication.During an interview on 12/19/25 at 10:25 A.M., the DON indicated that there was not a monitoring order for the antibiotic or the antiplatelet. Nursing staff monitored the side effects of the antianxiety medication with the anticonvulsant monitoring order. The diuretic medication was monitored through an intervention in the care plan.During an interview on 12/19/25 at 11:23 A.M., Registered Nurse (RN) 16 indicated that they monitored side effects of medication by using the monitoring orders and that they were not sure how to access the care plan. They indicated since there was not an antianxiety monitoring order for the clonazepam, she would use the hypnotic medication monitoring order to monitor for side effects of that medication.During an interview on 12/22/25 at 10:28 A.M., Clinical RN 3 indicated that there were some important side effects listed in the antianxiety monitoring order that were not listed in the anticonvulsant monitoring order such as sedation, vomiting, confusion, headache, and skin rash, and that the anticonvulsant monitoring order would not be completely appropriate for monitoring for side effects of clonazepam.On 12/22/25 at 10:34 A.M., Clinical RN 3 provided a current Specific Medication Administration Procedures policy, revised 11/2018, that indicated Obtain and record any vital signs or other monitoring parameters ordered or deemed necessary prior to medication administration . Monitor for side effects of adverse drug reactions immediately after administration and throughout each shift . Monitoring of side effects of medication-related problems occurs continually, but particularly after medication administration .3.1-48(a)(3)

Based on interview and record review, the facility failed to ensure documentation was complete or accurate for 1 of 3 residents reviewed for closed records. (Resident 57) Finding includes: On 12/16/25 at 2:23 P.M., Resident 57's clinical record was reviewed. Resident 57 was admitted on [DATE]. Diagnoses included, but were not limited to, encephalopathy. The most recent admission Minimum Data Set (MDS) Assessment, dated 9/10/25, indicated Resident 57 was cognitively intact. Physician orders included, but were not limited to: lactulose solution 45mL oral three times a day; Start date 9/12/25 The electronic medication administration record (eMAR) indicated the following dates lactulose medication was recorded as unavailable:10/1/25 11:07 A.M.10/1/25 6:48 P.M.10/6/25 8:35 P.M.10/7/25 7:51 A.M.10/7/25 11:22 A.M.10/7/25 7:45 P.M. During an interview on 12/9/25 at 10:28 A.M., the Director of Nursing indicated staff could not remember Resident 57's lactulose medication being unavailable, and believe the missed medication administrations were documented in error. On 12/22/25 at 9:43 A.M., the Administrator provided a policy titled Medication Orders, dated 11/18, that indicated The prescriber is contacted by the facility personnel for direction when delivery of a medication will be delayed or the medication is not or will not be available. 3.1-50(a)(2)

Based on interview and record review, the facility failed to ensure designation of a certified Infection Preventionist (IP). The IP had not received specialized training in infection prevention and control when starting as the IP. This had the potential to affect 56 of 56 residents residing in the facility. Finding includes: On 10/4/24 at 9:38 A.M., the Assistant Director of Nursing (ADON) indicated that she was currently responsible for the infection prevention and control program in the facility. She indicated she was able to dedicate approximately 5-10 hours per week on the infection control program. On 10/4/24 at 11:25 A.M., the ADON's employee record was reviewed. The ADON had begun the role as IP on 6/4/24, prior to obtaining her IP certification on 6/17/24. On 7/17/24 the ADON was promoted from IP to ADON. The lack of a dedicated Infection Preventionist resulted in Enhanced Barrier Precautions not being implemented. Cross Reference F880. On 10/4/24 at 12:25 P.M., the Administrator provided a document titled Infection Prevention and Control Program, dated 11/10/17, that indicated the campus shall designate a member of the clinical team to monitor the campus infection prevention and control program.

Based on observation, record review, and interview, the facility failed to implement infection control practices for 6 of 6 residents reviewed for EBP (Enhanced Barrier Precautions). Signs were not posted, orders were not initiated, and gowns were not worn during high contact activities. (Resident T, Resident S, Resident D, Resident L, Resident W, Resident V) Findings included: 1. On 9/30/24 at 1:48 P.M., during a random observation there was no EBP sign on Resident L's door. On 10/1/24 at 9:00 A.M., during a random observation there was no EBP sign on Resident L's door. On 10/02/24 at 10:28 A.M., during a random observation there was no EBP sign on Resident L's door. On 10/2/24 at 10:11 A.M., Resident L's clinical record was reviewed. The diagnoses included, but were not limited to, anemia, COPD (Chronic Obstructive Pulmonary Disease), and generalized edema. Current Physician included but were not limited to: - Staff to use enhanced barrier precautions, wearing a gown and gloves at minimum during high-contact care activities twice a day, initiated 9/28/24. The Care Plans included, but were not limited to: Enhanced barrier protocol initiated on 9/30/24. The goal was to minimize the transmission of infection from wound by utilizing EBP. Interventions included, but were not limited to: Utilize gown and gloves per EBP policy during wound care/dressing changes, initiated on 9/30/24. 48147 2. On 9/30/24 at 9:45 A.M., Resident W's door was observed without an EBP sign on the door. During a confidential interview during the survey from 9/30/24 to 10/4/24, it was indicated that staff do not wear gowns while providing care for Resident W. On 10/2/24 at 8:49 A.M., Resident W's clinical record was reviewed. The diagnoses included, but were not limited to, neuromuscular dysfunction of bladder and malignant neoplasm of colon. The most current Quarterly Minimum Data Set (MDS) assessment, dated 7/10/24, indicated Resident W was not assessed for cognitive ability due to rarely or never being understood, was dependent on staff for toileting, and had a feeding tube and an indwelling urinary catheter. Physician orders included, but were not limited to: - Resident requires EBP during high-contact care related to presence of indwelling catheter, dated 5/1/24. - Staff to use EBP, wearing a gown and gloves at minimum during high-contact care activities due to indwelling catheter and g-tube, dated 8/28/24. An EBP care plan, dated 5/1/24, included an intervention to utilize gown and gloves per EBP policy during high contact Activities of Daily Living (ADL) care and during linen changes. 3. On 9/30/24 at 11:50 A.M., Resident V's door was observed without an EBP sign on the door. On 10/2/24 at 6:56 A.M., Resident V indicated that the sign was not there before that morning and was not sure why it was hung up. On 10/1/24 at 2:33 P.M., Resident V's clinical record was reviewed. The diagnosis included, but was not limited to, pressure ulcer of left buttock. The most current Quarterly MDS assessment, dated 7/12/24, indicated Resident V was cognitively intact and had one stage four pressure ulcer. Current physician orders included, but were not limited to: - Staff to use EBP, wearing a gown and gloves at minimum during high-contact care activities, dated 10/1/24. The clinical record lacked physician orders for EBP prior to 10/1/24. A current EBP care plan, dated 5/1/24, included an intervention to utilize gown and gloves per EBP policy during high-contact care related to presence of wound with dressing change and colostomy. 50827 4. On 9/30/24 at 9:40 A.M., staff was observed to be transferring Resident D. Resident had a urinary catheter at that time. No enhanced barrier precaution sign was observed and staff were not wearing protective gowns. During an observation on 9/30/24 at 2:40 P.M., a staff member was observed assisting Resident D transferring to bed. Resident D was observed to have a urinary catheter. There was no enhanced barrier precaution sign in Resident D's room or on the door and the staff member was not wearing a gown. On 10/1/24 at 3:00 P.M. Resident D's clinical record was reviewed and indicated they had diagnoses that included, but were not limited to facial/skull fracture, subdural hemorrhage (type of brain bleed), and subarachnoid hemorrhage (type of brain bleed). Resident D's clinical record lacked an order for enhanced barrier precautions. On 10/1/24 at 3:40 P.M., an enhanced barrier precaution sign was observed on Resident D's door. Regional Support 27 indicated the precaution was most likely due to a wound because the resident did not have a catheter. On 10/1/24 at 4:45 P.M. the ADON indicated that Resident D was on enhanced barrier precautions due to having a catheter. 5. During an observation on 9/30/24 at 10:43 A.M., there was not an enhanced barrier precaution sign in Resident S's room or on the door and no cart containing gowns or gloves near Resident S's room. On 10/2/24 at 12:59 P.M., Resident S's clinical record was reviewed. The diagnosis included, but was not limited to, dementia. The most recent Quarterly MDS assessment, dated 9/20/24, indicated Resident S was severely cognitively impaired, required substantial assistance (staff does more than half the help) for toileting, bathing, and transfers, and had an unhealed wound. Physician orders included, but were not limited to: - Staff to use enhanced barrier precautions wearing a gown and gloves at minimum during high-contact care activities, started on 10/1/24. 6. During an observation on 9/30/24 at 10:48 A.M., there was not an enhanced barrier precaution sign in Resident T's room or on the door and no cart containing gowns or gloves near Resident T's room. On 10/2/24 at 9:53 A.M., Resident T's clinical record was reviewed. The diagnosis included, but was not limited to, obstructive and reflux uropathy. The most recent Quarterly MDS assessment, dated 7/30/24, indicated Resident T was cognitively intact, required substantial assistance (staff does more than half the help) for bathing, toileting, and transfers, and had a urinary catheter. Physician orders included, but were not limited to: - Staff to use enhanced barrier precautions wearing a gown and gloves at minimum during high-contact care activities, started on 10/1/24. During an interview on 10/4/24 at 9:38 A.M., Regional Clinical Support 29 indicated resident's were missing enhanced barrier precautions and orders because the facility was not consistent. On 10/3/24 at 12:00 P.M., the Administrator provided a document titled Enhanced Barrier Precautions (EBP) Standard Operating Procedure, dated 4/1/24, that indicated EBP would be in place during high-contact care activities for residents with the following conditions, all residents with chronic wounds, including, but not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers and all residents with indwelling medical devices. Personal protective equipment (PPE) should be used even if blood and body fluid exposure is not anticipated. At minimum staff shall wear gloves and gowns during high-contact activities. This citation related to complaint IN00440076. 3.1-18(b)(1)

Based on interview and record review, the facility failed to ensure a notice of transfer was completed for 1 of 4 residents reviewed for hospital transfers. (Resident 21) Finding includes: On 10/2/24 at 10:34 A.M., Resident 21's clinical record was reviewed. The diagnosis included, but was not limited, to encephalopathy. The most recent Quarterly MDS (Minimum Data Set) assessment, dated 8/28/24, indicated Resident 21 was moderately cognitively intact. A nursing progress note, dated 8/16/24 at 2:04 P.M., indicated Resident 21 had returned from the dentist after oral surgery. On 10/3/24 at 1:51 P.M., Regional Support 27 provided transfer discharge paperwork sent with Resident 21 to his appointment on 8/16/24. Notice of Transfer or Discharge and Notice of Transfer Discharge Request for Hearing were blank and did not include any resident information or reason for transfer. On 10/4/24 at 11:23 A.M., Regional Support 27 provided a document titled Guidelines for Transfer and Discharge, dated 5/3/17, that indicated to record the reason for, the effective date of transfer or discharge, and the location to which the resident is being transferred or discharged in the medical record and on a discharge form. 3.1-12(a)(6)(A)(i)

Based on observation, record review, and interview, the facility failed to ensure a newly admitted resident had immediate orders for an indwelling urinary catheter for 1 of 1 residents reviewed for urinary catheters. (Resident D) Findings include: On 9/30/24 at 9:40 A.M., staff was observed to be transferring Resident D. Resident D was observed to have a urinary catheter at that time. On 10/1/24 at 3:00 P.M., Resident D's clinical record was reviewed. The diagnoses included, but were not limited to, facial/skull fracture, subdural hemorrhage (type of brain bleed), and subarachnoid hemorrhage (type of brain bleed). Resident D was admitted [DATE] Resident D's clinical record lacked orders for an indwelling urinary catheter and/or catheter care. On 10/3/24 at 10:30 A.M., Resident D's clinical record was reviewed. A Nursing Assessment, dated 10/2/24 at 12:37 A.M., indicated Resident D did not have an indwelling urinary catheter. On 10/3/23 at 12:39 P.M., Regional Support RN indicated catheters would have been assessed upon the initial admission nursing assessment. The orders and care plans were not always put in immediately as the facility allowed time for physician's to assess medical indication for the catheter. A policy provided by the Administrator on 10/3/24 at 12:00 P.M., on indwelling catheter use indicated a resident who enters the campus with an indwelling urinary catheter, or subsequently receives one is assessed for removal as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary. 3.1-30(a)

Based on record review and interview, the facility failed to ensure care plans were revised quarterly for 1 of 5 residents reviewed for unnecessary medications. (Resident 36) Findings include: On 10/2/24 at 1:04 P.M., Resident 36's clinical record was reviewed. The diagnoses included, but were not limited to, major depressive disorder, restlessness and agitation, and mild cognitive impairment. The current Annual MDS (Minimum Data Set) assessment, dated 9/18/24, indicated Resident 36 was mildly cognitively impaired and did not receive hypnotic medications during the assessment period. The record lacked an order for a hypnotic medication. A current care plan for psychotropic drug use indicated the resident was at risk for adverse consequences related to receiving a hypnotic medication for insomnia, initiated 11/6/23. During an interview on 10/3/24 at 9:18 A.M., the MDS Coordinator indicated when a medication was discontinued the care plan needed to be updated. On 10/4/24 at 11:23 A.M., the Regional Support Nurse provided a current policy Comprehensive Care Plan Guidelines revised 12/31/18. The policy indicated . the purpose of the comprehensive care plan was to ensure appropriateness of services and communication that will meet the resident's needs, severity/stability of conditions .in accordance with state and federal guidelines .comprehensive care plans should be reviewed no less than quarterly and revised to reflect changes in the resident's condition as they occur. 3.1-35(d)(2)(B)

Based on interview, observation, and record review, the facility failed to ensure professional standards of practice were implemented for a PICC (Peripherally Inserted Central Catheter) for 1 of 1 residents reviewed for a PICC line. Physician orders were not followed and a care plan was not developed. (Resident T) Finding includes: During an interview on 9/30/24 at 10:50 A.M., Resident T indicated he had a PICC line for a while but was unsure why he had it. Resident T pulled back the sleeve of his shirt and revealed a PICC on the right side of his chest. The insertion site of the catheter was distal to the right subclavian and appeared to be in the location of a central venous catheter. On 10/2/24 at 9:53 A.M., Resident T's clinical record was reviewed. The diagnoses included, but were not limited to, bacteremia and diabetes mellitus. The most recent Quarterly MDS (Minimum Data Set) assessment, dated 7/30/24, indicated Resident T was cognitively intact and did not have IV (intravenous) access. Physician orders included, but were not limited to: - Change end caps every 96 hours every four days, start date 7/28/23. - Monitor IV site for signs/symptoms of infiltration twice a day, start date 7/28/23. - PICC line flush five mL (milliters) of normal saline every 12 hours, start date 7/28/23. - PICC dressing change every five days, measure external catheter length, enter in measurement note once a day every five days, start date 11/14/23. The clinical record lacked care plans related to IV/PICC. A nursing progress note, dated 7/28/23 at 5:00 P.M., indicated Resident T returned to the facility from the hospital with a PICC line placed centrally to right clavicle. A nursing progress note, dated 9/8/23 at 1:18 P.M., indicated a call was made to infectious disease regarding future lab work and if the line was to remain in place. No further labs were needed, and the physician indicated the facility could remove the line per infectious disease. A nursing progress note, dated 9/27/24 at 2:04 P.M., indicated Resident T's suture site on PICC line was red, warm, and purulent drainage noted. A nursing progress note, dated 9/30/24 at 4:55 P.M., indicated the nurse attempted to remove the PICC line and met resistance when removing line. A nursing progress note, dated 9/30/24 at 5:16 P.M., indicated the physician was notified with order to arrange an appointment with the hospital for PICC line removal. During an observation on 10/3/24 at 10:38 A.M., Resident T's PICC line insertion site and suture sites were observed to be red. During an interview on 10/3/24 at 1:33 P.M., the DON and Clinical Support 25 indicated Resident T received the PICC line July 2023 for osteomylitis. They indicated a PICC line was typically removed after the course of antibiotics were finished. Resident T should have been marked as having IV access on the MDS assessment and should have had a care plan for the PICC line. During an interview on 10/4/24 at 11:35 A.M., Regional Clinical Support 29 stated there was no documentation of Resident T's refusal to remove the PICC line, education provided after a refusal of removal, or why the physician order to remove the PICC line was not followed. On 10/3/24 at 11:59 A.M., a policy related to IV care and a PICC line care skills check off were requested and were not provided. 3.1-47(a)(2)

Based on observation, interview, and record review, the facility failed to ensure residents were free of a medication error rate greater than 5 percent for 2 of 35 opportunities, resulting in a medication error rate of 5.71 percent. (Resident W) Finding includes: On 10/2/24 at 7:02 A.M., Registered Nurse (RN) 17 was observed administering medication to Resident W. Two and a half milliliters of liquid famotidine (antacid medication) mixed with water was administered via the resident's gastric tube. Carboxymethylcellulose (eye lubricant) eye drops were administered to each of the resident's eyes. RN 17 lifted the upper eyelids with a gloved finger and dropped one drop onto each eye. On 10/2/24 at 8:07 A.M., Resident W's clinical record was reviewed. The diagnoses included, but were not limited to, malignant neoplasm of colon and chronic duodenal ulcer with hemorrhage. The most current Quarterly Minimum Data Set (MDS) assessment, dated 7/10/24, indicated Resident W was not assessed for cognitive ability due to rarely or never being understood and had a feeding tube. Physician orders included, but were not limited to: - Famotidine suspension for reconstitution 40 milligrams (mg)/5 milliliters (ml) - Give 2.5 ml by gastric tube twice a day, dated 8/28/24 and discontinued on 9/24/24. - Lubricant Eye Drops (carboxymethylcellulose sodium) 0.5 percent, give one drop per eye for dry eyes four times a day as needed, dated 9/25/23. A progress note, dated 9/24/24 at 1:34 A.M., indicated that the physician discontinued the famotidine. On 10/3/24 at 11:22 A.M., RN 23 indicated eye drops are administered by pulling down on the lower eyelid and dropping the medication in the pouch in the lower eyelid. At that time, she indicated discontinued medications were removed from the cart and destroyed. On 10/3/24 at 1:34 P.M., the Director of Nursing indicated Resident W's liquid famotidine was discontinued on 9/24/24. On 10/3/24 at 10:53 A.M., Regional Support 27 provided a current Specific Medication Administration Procedures: Eye Drop Administration policy, revised 11/2018, that indicated With a gloved finger, gently pull down lower eyelid to form pouch, while instructing resident to look up . Hold inverted medication bottle between the thumb and index finger, and press gently to instill prescribed number of drops into pouch near outer corner of eye. On 10/4/24 at 12:15 P.M., Regional Support 25 provided a current Disposal of Medications and Medication-Related Supplies policy, revised 11/2018, that indicated Medications are removed from the medication cart or active supply upon receipt of an order to discontinue. 3.1-48(c)(1)

Based on record review and interview, the facility failed to ensure clinical records were accurate and complete for 1 of 1 residents reviewed for falls. Neurological checks were not documented. (Resident 36) Findings include: On 10/2/24 at 1:04 P.M., Resident 36's clinical record was reviewed. The diagnoses included, but were not limited to, unsteadiness on feet, abnormalities of gait and mobility, and history of falling. The current Annual MDS (Minimum Data Set) assessment, dated 9/18/24, indicated Resident 36 was mildly cognitively impaired. Resident 36 needed substantial assistance with transfer and hygiene and had recent falls. An Event Report from an unwitnessed fall on 7/31/24, indicated Resident 36 did not have neurological checks documented after the fall. An Event Report from an unwitnessed fall on 8/11/24, indicated Resident 36 did not have neurological checks documented after the fall. An Event Report from an unwitnessed fall on 8/25/24, indicated Resident 36 did not have neurological checks documented after the fall. During an interview on 10/4/24 at 10:21 A.M., the Regional Support Nurse indicated there were no neurological checks documented after 11:15 A.M. on 7/31/24. There were no order sets initiated for neurological checks initiated for falls on 7/31/24, 8/11/24, and 8/25/24. On 10/4/24 at 11:23 A.M., the Regional Support Nurse provided a current policy Guidelines for Neurological Checks, revised 12/31/23. The policy indicated .neuro-checks for 24 hours should be completed within the Fall Event Form . 3.1-50(a)(1) 3.1-50(a)(2)

Based on observation, interview, and record review, the facility failed to provide assistance with bathing and oral hygiene for 4 of 7 residents reviewed for activities of daily living (ADLs). Residents did not receive a complete bed bath, shower, and/or daily oral hygiene according to the plan of care and residents preferences. (Resident F, Resident G, Resident H, Resident J) Findings include: 1. During an observation on 5/16/24 at 10:20 A.M., Resident F was sitting up in his room, dressed, with his hair combed back. His hair appeared to be oily. During record review on 5/16/24 at 11:00 A.M., Resident F's diagnoses included, but were not limited to, heart failure, kidney failure, reduced mobility, and weakness. Resident F's most recent Admission MDS (Minimum Data Set) assessment, dated 5/8/24, indicated that the resident had moderate cognitive impairment, required an assistive device including a walker or wheelchair for mobility, was dependent for oral hygiene and bathing. Resident F's care plan included, but was not limited to, showers on Wednesdays and Saturdays (first shift) (initiated 5/1/24), Resident has potential for mouth pain due to: natural teeth - offer and provide mouth care as needed (initiated 5/3/24). Resident F's documented bathing and provided mouth care reviewed from the admitted [DATE] through 5/16/25 included no documented showers or complete bed baths and no documentation of daily mouth care. 2. During record review on 5/16/24 at 12:00 P.M., Resident G's diagnoses included, but were not limited to, pulmonary disease, obesity, and obstructive and reflux uropathy. Resident G's most recent Admission MDS assessment, dated 5/9/24, indicated that the resident had severe cognitive impairment and was dependent for oral hygiene, toileting, and bathing. Resident G's care plan included, but was not limited to, showers on Wednesdays and Saturdays (second shift) (initiated 5/6/24), Resident has potential for mouth pain due to: wears upper dentures - offer and provide mouth care as needed (initiated 5/6/24). Resident G's documented bathing and provided mouth care reviewed from the admitted [DATE] through 5/10/25 (discharge date ) included no documented showers or complete bed baths and no documentation of daily mouth care. 3. During record review on 5/17/24 at 10:30 A.M., Resident H's diagnoses included, but were not limited to, neurocognitive disorder, dementia, altered mental status, polyneuropathy, and repeated falls. Resident H's most recent Admission MDS assessment, dated 4/23/24, indicated that the resident had severe cognitive impairment, used a walker or wheelchair for mobility and was dependent for oral hygiene and bathing. Resident H's care plan included, but was not limited to, showers on Wednesdays and Saturdays (second shift), Resident has potential for mouth pain - offer and provide mouth care as needed. Resident H's documented bathing and provided mouth care reviewed from the admitted [DATE] through 5/16/24 included showers on 4/22/24, 4/27/24, and 5/9/24. No documentation of daily mouth care was found in Resident G's record. 4. During an observation and interview on 5/17/24 at 12:09 P.M., Resident J was sitting up in her room dressed. Resident J's hair appeared to be uncombed. Resident J indicated that she required assistance from staff to stand up and to bathe and that she is not provided at least two showers or complete bed baths per week. During record review on 5/17/24 at 12:30 P.M., Resident J's diagnoses included, but were not limited to, acute kidney failure, heart failure, diabetes, and chronic pain. Resident J's most recent Admission MDS assessment, dated 4/30/24, indicated that the resident had no cognitive impairment, used a walker or wheelchair for mobility, and was dependent for bathing. Resident J's care plan included, but was not limited to, showers on Mondays and Thursdays (second shift). Resident J's documented bathing reviewed from 4/23/24 through 5/16/24 included one shower on 4/30/24. 5. During a review of the facility's grievance log on 5/16/24 at 11:45 A.M., the following grievances were made: - On 3/29/24 - [Resident] having issues with nursing not coming to help her with showers and toileting in a reasonable amount of time . - On 4/9/24 - [Resident] is very tearful. Had shower today but was not offered her razor to shave and has facial hair. - On 4/21/24 - .[Resident] is only being [sic] receiving his showers per his requests. - On 5/5/24 - States that [Resident] is not getting showers. Wants showers on (Monday/Thursday) evenings. During an interview on 5/16/24 at 9:25 P.M., CNA 4 indicated that staff are not always able to provide a complete bed bath or shower in the evenings on a resident's scheduled shower day due to being short-staffed. During an interview on 5/17/24 at 11:40 A.M., RN 5 indicated that staff should document provided oral care in the point of care charting system. On 5/17/24 at 3:20 P.M., the Administrator supplied a facility policy titled, Guidelines for Bathing Preference, dated 12/31/22. The policy included, .4. Bathing shall occur at least twice a week unless resident preference states otherwise. On 5/17/24 at 3:45 P.M., the Administrator supplied a facility policy titled, Nursing ADL Documentation Guidelines, dated 12/31/23. The policy included, .2. ADL services will be conducted and documented by the CNA each shift at the 'point of care' or as reasonably possible after care . This citation relates to Complaint IN00434456. 3.1-38(b)(1) 3.1-38(b)(2)

Based on observation, interview, and record review, the facility failed to ensure sufficient nursing staff was provided to maintain residents quality of life and to ensure residents' activities of daily living (ADL's) were completed for 2 of 2 days during the survey. Findings include: On 5/16/24 at 10:00 a.m., the Facility Census Form indicated there were 57 residents residing on the health center. 1. During the survey from 5/16/24 through 5/17/24, the following interviews were conducted. - The staff could use more help. - Call lights take a long time to be answered and it was frustrating. - Waiting 20 minutes for call lights to be answered. - The facility is short staffed. - It was difficult to complete tasks for residents due to staffing. - She needed staff assistance to stand up out of her chair and that staff hardly answered her call light at all. She may have to wait up to an hour or hour and a half to have a call light answered. One night shift she turned her light on at 2:45 A.M. and staff didn't come until 5:00 A.M. Staff had told her when answering her light that they only had two CNA's for 50 people. She didn't receive her showers. Sometimes the supper trays are still in the resident room in the morning. 2. During a review of the facility's grievance log on 5/16/24 at 11:45 A.M., the following grievances were made: - On 3/27/24 - Angry about call light/waiting. - On 3/27/24 - Upset about call light/waiting, waiting for an extended period of time. - On 4/2/24 - Upset about call light/waiting, stated she had a long wait time for call light during evening supper time hours. - On 4/4/24 - Upset about call light/waiting - Resident stated that on Monday night she had to wait too long for staff to answer the call light. When they finally came, she was wet from urine. She was continent but when she had to wait and just needed stand by assist to ambulate to the bathroom, she had an accident. - On 4/2/24 - Angry about call light/waiting - CNA staff left the floor. - On 4/4/24 - Upset about call light/waiting - light was not answered timely on evening shift. - On 4/9/24 - Angry about call light/waiting. - On 4/21/24 - Upset about call light/waiting. - On 4/21/24 - Upset about not having enough help. - On 4/21/24 - Upset about not having enough staff. - On 4/23/24 - Upset about call light/waiting - Resident had to wait long time on someone to answer light for assistance with using restroom. - On 5/3/24 - Upset about call light/waiting - Resident ended up toileting self because no one answered the call light. - On 5/3/24 - Concerned about call light/waiting - Had issues over the weekend with call light not being answered. On 5/16/24 at 8:50 P.M., two licensed nursing staff and three CNAs were working on the 100, 200, and 300 halls. A stack of resident meal trays were on the nursing station desk between the 100 and 200 halls containing dirty dishes and food scraps left over from supper that evening. On 5/16/24 at 8:55 P.M., the 300 hall was observed to have a nurse passing medications from a medication cart and no CNA was observed. A push cart was left in the hall containing three left over supper trays with dirty dishes and food scraps. Rooms 313, 317, 318, 322, and 323 had call lights on. On 5/16/24 at 9:00 P.M., Resident B was observed lying in bed with a bed side table extended out over her lap with a dirty dishes and a plate of leftovers resting on the table. Resident B indicated the plate was from the supper meal. On 5/16/24 at 9:03 P.M., room [ROOM NUMBER] turned their call light on. At 9:04 P.M., CNA 4 was observed on the 300 hall and entered room [ROOM NUMBER]. At 9:14 P.M., CNA 4 was observed to enter room [ROOM NUMBER]. Call lights in Rooms 315, 317, 322, and 323 were still on. On 5/16/24 at 9:25 P.M., CNA 4 indicated that most evening shifts are scheduled with one CNA per hall and two nurses. CNA 4 indicated the goal was to have two CNAs per hall. CNA 4 indicated that the 200 hall had several resident that required an assist of two staff with mechanical lifts for transfers and that she had just came from helping on the 200 hall when she saw the residents lights on the 300 hall. 3. On 5/17/24 at 2:30 P.M., a review of the facility's list of residents requiring two assist or greater for transfers indicated that 8 of 24 residents on the 100 hall needed 2 assist, 7 of 15 residents on the 200 hall required 2 assist, and 4 of 18 resident required 2 assist on the 300 hall. 4. On 5/17/24 at 3:15 P.M., during a review of daily posted staffing from 5/5/24 through 5/15/24 included the following staffing patterns: (Licensed nursing staff worked 12 hour shifts) 5/5/24 - Day shift - 3 licensed nursing staff, 6 nurse aides Evening shift - 3 nurse aides Night shift - 1 licensed nursing staff, 2 nurse aides 5/6/24 - Day shift - 1 licensed nursing staff, 8 nurse aides Evening shift - 4 nurse aides Night shift - 1 licensed nursing staff, 4 nurse aides 5/7/24 - Day shift - 3 licensed nursing staff, 10 nurse aides Evening shift - 4 nurse aides Night shift - 1 licensed nursing staff, 3 nurse aides 5/8/24 - Day shift - 4 licensed nursing staff, 11 nurse aides Evening shift - 4 nurse aides Night shift - 3 licensed nursing staff, 3 nurse aides 5/9/24 - Day shift - 3 licensed nursing staff, 12 nurse aides Evening shift - 6 nurse aides Night shift - 2 licensed nursing staff, 5 nurse aides 5/10/24 - Day shift - 2 licensed nursing staff, 9 nurse aides Evening shift - 7 nurse aides Night shift - 1 licensed nursing staff, 2 nurse aides 5/11/24 - Day shift - 3 licensed nursing staff, 10 nurse aides Evening shift - 2 nurse aides Night shift - 1 licensed nursing staff, 3 nurse aides 5/12/24 - Day shift - 3 licensed nursing staff, 11 nurse aides Evening shift - 2 nurse aides Night shift - 1 licensed nursing staff, 3 nurse aides 5/13/24 - Day shift - 3 licensed nursing staff, 9 nurse aides Evening shift - 5 nurse aides Night shift - 2 licensed nursing staff, 3 nurse aides 5/14/24 - Day shift - 4.5 licensed nursing staff, 9 nurse aides Evening shift - 7 nurse aides Night shift - 2 licensed nursing staff, 3 nurse aides 5/15/24 - Day shift - 4 licensed nursing staff, 9 nurse aides Evening shift - 7 nurse aides Night shift - 1 licensed nursing staff, 2 nurse aides 5. The lack of sufficient nursing staff resulted in the lack of ADL services provided including bathing and oral care. Cross reference F677. On 5/17/23 at 3:45 P.M., the Administrator supplied a facility policy titled, Scheduling Standards Policy, dated 1/2024. The policy included, Each schedule should be developed and planned to ensure adequate staffing levels to meet resident needs, to manage staff efficiently, to align the schedule with a census adjusted staffing budget, and to improve employee engagement and retention . Schedules should be developed in a manner that promotes efficient staffing in each Health Campus area for all shifts, weekdays, and weekends . This citation relates to Complaint IN00434456. 3.1-17(a)

Based on observation, interview, and record review, the facility failed to provide assistance with bathing for 3 of 4 residents reviewed for activities of daily living (ADLs). Residents did not receive bathing according to their plan of care or resident preferences. (Resident F, Resident G, Resident H) Findings include: 1. During a review of facility grievances on 9/11/23 at 10:30 A.M., Resident F had submitted a grievance on 9/5/23 that she had not received showers. During an observation on 9/12/23 at 10:00 A.M., Resident F was sitting up in their room wearing a night gown. During record review on 9/12/23 at 12:45 P.M., Resident F's diagnoses included, but were not limited to, chronic pain, muscle weakness, unsteadiness on feet, and lack of coordination. Resident F's most recent quarterly MDS (Minimal Data Set) assessment, dated 6/21/23, included that the resident had severe cognitive impairment, required limited assistance with transfers, and physical help in part of bathing. Resident F's care plan included, but was not limited to: Resident requires staff assistance to complete ADL tasks completely and safely (revised 6/23/23). Resident to receive showers on Tuesday and Friday evenings. During review of Resident F's documented bathing from 8/13/23 thru 9/11/23, the following showers/complete bed baths were provided, 9/8/23 (Shower). The record indicated 7 out of 8 showers/complete bed baths were not completed. 2. During an observation and interview on 9/12/23 at 9:45 A.M., Resident G was sitting up in her room. Resident G indicated that she did not always receive her scheduled shower. During record review on 9/12/23 at 12:30 P.M., Resident G's diagnoses included, but were not limited to, heart failure, hemiplegia and hemiparesis affect right dominant side, chronic obstructive pulmonary disease (COPD), and morbid obesity. Resident G's most recent admission MDS assessment, dated 7/28/23, indicated the resident was cognitively intact, required extensive assistance with transfers and bed mobility, and was totally dependent with bathing. Resident G's care plan included, but was not limited to: Resident requires staff assistance to complete ADL tasks completely and safely (revised 7/26/23). Resident to receive showers on Wednesday and Saturday during day shift. During review of Resident G's documented bathing from 8/12/23 thru 9/11/23, the following showers/complete bed baths were provided; 8/12/23 (complete bed bath) and 8/24/23 (shower). The record indicated 7 out of 9 showers/complete bed baths were not completed. 3. During an observation on 9/12/23 at 8:40 A.M., Resident H was sitting up in a recliner in their room sleeping. During record review on 9/11/23 at 11:00 A.M., Resident H's diagnoses included, but were not limited to, fracture of left patella, anemia, muscle weakness, unsteadiness on feet, and lack of coordination. Resident H's most recent admission MDS assessment, dated 6/30/23, indicated the resident's cognition was moderately impaired, required extensive assistance with transfers and bed mobility, and required physical help in part of bathing. Resident H's care plan included but was not limited to; resident requires staff assistance to complete ADL tasks completely and safely (started 6/27/23). Resident to receive showers on Wednesday and Saturday during day shift. During review of Resident H's documented bathing from 6/29/23 thru 9/11/23, the following showers/complete bed baths were provided; 7/1/23 (complete bed bath), 7/8/23 (complete bed bath), 7/12/23 (completed bed bath), 7/15/23 (complete bed bath), 7/29/23 (complete bed bath), 8/12/23 (complete bed bath), and 8/18/23 (complete bed bath). The record indicated 14 out of 21 showers/complete bed baths were not completed. During an interview on 9/12/23 at 9:00 A.M., the Administrator indicated that staff document bathing in point of care (POC) charting and do not use paper shower sheets. During an interview on 9/12/23 at 9:15 A.M., CNA 2 indicated that staff document in the kiosk anytime bathing is done. Residents should receive a partial bath every morning, and at least 2 bed baths or showers per week or according to the shower schedule. CNA 2 indicated staff would document if a resident was refusing their bathing and that she was unsure what the documentation other bath was referring to, but that it likely means a partial bath was given and not documented correctly. During an interview on 9/12/23 at 1:50 P.M., the Administrator indicated the documentation other bath should be considered a shower. During an interview on 9/12/23 at 2:00 P.M., CNA 4 indicated she documented other bath when a resident was washed up while on the commode. On 9/12/23 at 12:00 P.M., the Administrator supplied a facility policy titled, Nursing ADL Documentation Guidelines, dated 12/31/22. The policy included, .2. ADL services will be conducted and documented by the CNA each shift at the 'point of care' or as reasonably possible after care . This Federal tag relates to Complaints IN00416620 and IN00417115. 3.1-38(b)(2)

Based on observation, interview, and record review, the facility failed to ensure oxygen services were provided according to physician orders for 1 of 2 residents reviewed for respiratory care. A resident's humidification bottle was not filled with water. (Resident 34) Finding includes: On 7/24/23 at 8:35 A.M., Resident 34's oxygen concentrator was observed to have no water in the humidification bottle. On 7/25/23 at 9:02 A.M., Resident 34's oxygen concentrator was observed to have no water in the humidification bottle. At that time, the resident indicated she was unsure if it was ever filled with water. On 7/25/23 at 9:51 A.M., Resident 34's clinical record was reviewed. Resident 34's diagnoses included, but were not limited to, acute respiratory failure with hypoxia (low levels of oxygen in body tissue) and COPD (chronic obstructive pulmonary disease). The most recent quarterly MDS (Minimum Data Set) assessment, dated 6/20/23, indicated Resident 34 was cognitively intact, required extensive assistance of 2 staff for transfers and bed mobility, and was on oxygen. Current physician orders included, but were not limited to: - Oxygen at 2L (liters) per nasal cannula continuous, dated 5/30/23. - Add water to humidifier Q (every) HS (night) at bedtime, dated 6/1/23. Current care plans included, but were not limited to: Potential for complications, functional and cognitive status decline related to respiratory disease that included the intervention, but was not limited to, administer oxygen per orders, dated 5/1/21. On 7/26/23 at 8:57 A.M., Resident 34's oxygen concentrator was observed to have no water in the humidification bottle. At that time, RN (Registered Nurse) 5 indicated the oxygen concentrator was supposed to be filled with distilled water nightly by night shift staff. On 7/26/23 at 2:20 P.M., a current Administration of Oxygen policy, dated 12/31/22, indicated be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through. 3.1-47(a)(6)

Based on observation and interview, the facility failed to store medications in a safe manner for 2 of 3 medication carts and 1 of 1 medication rooms. Narcotic medications not locked, loose pills were in the medication carts, the refrigerator was not within the temperature range, and resident money was stored in the medication carts. (Medication Room, 200 Hall Medication Cart, 300 Hall Medication Cart) Findings include: 1. During an interview with LPN (Licensed Practical Nurse) 9 and observation on 7/24/23 at 8:30 A.M., the medicine refrigerator on the skilled unit was found to have 2 permanently affixed drawers inside that were unlocked. One drawer contained full bottles of liquid morphine sulfate (an opiod pain medication), 30 ml (milliliters) each, labeled for Resident 20 (unopened), Resident 30 (unopened) and Resident 37 (opened). The other drawer contained liquid Lorazepam (an anti-anxiety medication) for Resident 30 (unopened) and Ativan (an anti-anxiety medication) for Resident 27 (unopened). The thermometer in the medicine refrigerator was observed to be 49 degrees F (Fahrenheit). LPN 9 indicated the temperature should be between 36 degrees F and 46 degrees F. During an interview with the DON on 7/24/23 at 8:55 A.M., she indicated the key to the locked narcotic/anxiolytic drawers in the medication room had broken off, so the drawers were unlocked. 2. On 7/26/23 at 10:30 A.M., during an observation of the medication administration with RN 13 on the 200 hall, there were 4 loose pills in the top drawer of the medicine cart - 1 round brown pill, 1 small round pink pill, 1 small round white pill, and 1 oblong white pill. 3. On 7/26/23 at 11:00 A.M., during an observation of medication administration on the 300 hall with RN 14, there were 26 dollars in cash in the bottom of the drawer. There was a 20 dollar bill, which RN 14 indicated had been found in a resident's room and the staff were not sure whose it was. There was a bundle of six, one dollar bills wrapped with a rubber band and a note around it with a resident's name. RN 14 indicated the resident was on the Assisted Living Unit now. During an interview on 7/26/23 at 12:38 P.M., the Business Office Manager indicated that when money was found, the staff were supposed to give it to their supervisor, who took it to the business office. If they knew who it belonged to, they return it. If not, they kept the money for 30 days and if not claimed they donated it to the activities fund. 3.1-25(m) 3.1-25(n)

Based on observation and interview, the facility failed to ensure that waste was properly contained in dumpster's with lids covered for 1 of 1 garbage storage areas observed. Findings include: On 7/23/23 at 9:05 A.M., the garbage storage area was observed with the Food Service Director. There were 2 dumpsters. One was open, surrounded by trash on the ground, 1 large smashed cardboard box was under it, and 3 old mattresses with tears in their coverings were piled on top of each other beside it. The Food Service Director indicated it would be cleaned up. The policy for the garbage storage area was requested and not received. 3.1-21(i)(5)

Based on observation, interview and record review, the facility failed to ensure residents were assessed for and treated for [REDACTED]. The residents indicated they were always in pain. (Residents #26, #38) Findings include: 1. On 6/13/13 at 9:50 a.m., Resident #26 was observed to be very stiff and have a pained facial expression. He indicated he hurt all the time. He indicated he had discomfort 24 hours a day, mostly in his back and legs. On 6/14/13 at 12:31 p.m., Resident #26 was in the dining room for lunch. He indicated he was "just accustomed to having pain." On 6/17/13 at 9:35 a.m., the resident indicated he "lives with pain." Always hurting, takes 3 pain pills a day, or he thinks it would be worse. Thinks they've done all they can. Just "doesn't enjoy anything much anymore. Just existing." Resident #26's clinical record was reviewed on 6/17/13 at 9:48 a.m. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessments dated 11/7/12, 2/5/13, and 4/23/13 indicated no pain. The MDS dated [DATE] indicated the resident was on a scheduled pain medication, had occasional pain with no effect on sleep or activities of daily living, and the pain was mild. A Monthly Nursing Assessment and Data Collection tool, dated 5/24/13, indicated the resident exhibited little interest in doing things. The pain assessment on the monthly summary was not completed; it only indicated the resident was on a scheduled pain regime. None of the questions about frequency, intensity, interference with sleep or daily activities were answered. A 4/7/13 Monthly Summary also failed to address pain, only indicating the resident was on a scheduled pain regime. The resident had care plans for Alteration in Comfort related to arthritis, and for chronic pain, both initiated 11/8/12 and reviewed 5/15/13. Interventions included, but were not limited to, the following: Vitamin/mineral supplements Assist with activities of daily living Encourage consume diet Monitor for signs/symptoms of pain, swelling, redness Notify MD of changes... Pain meds per order Encourage exercise Handle gently... Position for comfort. Monitor and report to nurse, signs/symptoms of pain, worsening pain Report changes in location/type/frequency/intensity Provide comfort measures, relaxation techniques, repositioning... Administer, monitor effectiveness and for side effects from routine and as needed pain medication... Notify the resident's physician if they do not state/demonstrate relief or reduction of pain after one hour or receiving the first intervention. The resident had physician's orders [REDACTED]. On 6/17/13 at 10:20 a.m., LPN #2 was interviewed regarding pain assessments. She indicated if the resident was on daily charting, they would assess pain daily. Otherwise, pain was addressed on the monthly assessment. She also indicated they asked residents during medication pass if they were in pain. She indicated Resident #26 did have complaints of pain, especially with any movement. He "has arthritis" and had pain in his knees and back. There was no indication the resident had a comprehensive assessment of his pain and care provided to address the on-going pain. 2. During interview, on 6/13/13 at 9:28 a.m., Resident #38 indicated she had back pain. She indicated she had scoliosis, had a back brace she wore all the time, and wore pain patches all the time, but continued to have pain. She indicated she had falls recently. Resident #38's clinical record was reviewed on 6/14/13 at 11:22 a.m. The resident's Minimum Data Set (MDS) assessment, dated 3/19/13, indicated she had occasional mild pain. The record indicated the resident had experienced two falls as follows: 5/6/13 at 9:00 p.m., and 5/10/13 at 6:20 p.m. She complained of back and neck pain after the falls. A computerized tomography (CT) scan of the cervical spine was done on 5/13/13 and indicated the following impression: "There is severe intervertebral disc space narrowing at the C5-6 level, with mild retrolisthesis. Also severe intervertebral disc degeneration at the C6-7 level." "Multilevel degeneration, as above, negative for acute posttraumatic cervical osseous injury." A Monthly Summary, dated 5/25/13 at 10:00 a.m., included a pain assessment. The assessment indicated the resident was on scheduled pain regime, experienced moderate pain at an intensity of 6 to 8 out of 10, and vocalized pain in her back. Resident #38 had care plans for alteration in comfort related to arthritis, and for pain, dated 4/1/13. Goals included, but were not limited to, "pain/discomfort will be controlled..." "Resident will state/demonstrate relief or reduction in pain within one hour after receiving interventions." Interventions included, but were not limited to, the following: Vitamin/mineral supplements per orders Encourage to consume 70% of diet Assist with activities of daily living as needed Monitor for signs/symptoms of pain Notify MD of changes as needed Pain meds per order Encourage exercise balanced with rest and weight reduction to affected joints if needed... Report changes in pain location, type frequency intensity to physician Administer, monitor effectiveness and for side effects from routine and as needed pain medication. physician's orders [REDACTED]. [MEDICATION NAME] 325 milligrams, two tablets by mouth three times a day. [MEDICATION NAME] (narcotic pain medication) patch 100 micrograms per hour plus [MEDICATION NAME] 25 micrograms per hour to total 125 micrograms per hour. On 6/14/13 at 11:45 a.m., Resident #38 was seated in the dining room. There was obvious curvature of her spine. She indicated she hurt all the time when up. she had a recent fall and "hurts all over." She indicated one leg was worse with "sciatic rheumatism." Did indicate some relief when she laid down. At that time, while up, the pain was rated at a level 8 out of 10. On 6/14/13 at 12:23 p.m., the resident still in the dining room awaiting lunch. Her head was down and she was holding her neck. There was no indication the effectiveness of the resident's pain regime was being assessed, with on-going pain at levels of 6 to 8 out of 10. 3. The policy and procedure for "Guidelines for Pain Assessment and Management" (no date) was provided by the Administrator on 6/21/13 at 10:40 a.m. The purpose of the policy was "to ensure each resident's pain including its origin, location, severity, alleviating and exacerbating factors, current treatment and response to treatment will be assessed/reassessed and documented according to the needs of each individual." The procedure included, but was not limited to, the following: "Assessment of resident pain should be completed as part of the Admission Nursing Assessment...Ongoing assessment will be documented on the Monthly Nursing Summary..." "The assessment should include self report of pain or for those cognitively impaired and unable to self-report level of pain the assessor shall observe the resident..." "Initiate a Plan of care related to chronic, acute or breakthrough pain." "If there is a change in pain indicators or verbalizations from resident, a pain circumstance form will be completed to indicate changes and care plan update..." "Implement the care plan approaches to assist with pain management." "Evaluate the effectiveness of pain management interventions and modify as indicated." 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure each resident was free from unnecessary drugs, for 2 of 10 residents reviewed for unnecessary drugs, in that one resident (Resident #104) was on multiple psychoactive medications without indications for their use and/or monitoring, and one resident (Resident #16) was given a non-steroidal anti-[MEDICAL CONDITION] medication with a history of [MEDICAL CONDITION]. Resident #16 was admitted to the hospital with [REDACTED]. Resident #104, #16 Findings include: 1. On 6/14/13 at 3:30 p.m., Resident #16 was observed being prepared to be transported to the hospital. The Assistant Director of Nursing indicated the resident was being transferred due to reporting she was having bloody bowel movements. Resident #16's clinical record was reviewed on 6/17/13 at 9:00 a.m. The resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A physician's progress note, dated 5/18/13, indicated the resident's abdomen had mild tenderness mostly on the right side. He indicated the resident wasn't having significant abdominal pain. She was having neck pain and headaches. He opted to start her on [MEDICATION NAME] (non-steroidal anti-[MEDICAL CONDITION] medication) for the neck pain. The physician ordered [MEDICATION NAME] 15 milligrams by mouth daily with food, on 5/15/13, due to cervical spine [MEDICAL CONDITION] joint disease. The recapitulation of physician's orders [REDACTED]. The resident had a care plan, dated 1/26/13 and reviewed 4/2/13, for being at risk for bleeding due to a history of gastro-intestinal bleeding and hemorrhoids. Goals included being free from signs and symptoms of bleeding and hematocrit and hemoglobin levels at acceptable range. Interventions included, but were not limited to, assessing for signs of bleeding, and reporting to the physician any abnormal bleeding. Nurses' notes, dated 6/14/13 at 2:25 p.m., indicated the following, "Resident has been having rectal bleeding since this a.m. Resident notified this nurse @ 11:30 a.m. Stated she had been having problems since early morning. Stated she had been passing clots along with blood. Also has abd (abdominal) pain occurring. Received order from Dr. (name) to send to (name of hospital) ER (emergency room )." Unit Manager #1 was interviewed on 6/19/13 at 10:25 a.m. She indicated she thought the resident was put on the [MEDICATION NAME] for arthritic pain. At 10:45 a.m., Unit Manager #1 indicated she had been told the resident was scoped at the hospital and diagnosed with [REDACTED]. The Director of Nurses provided a copy of the Colonoscopy Procedure report, dated 6/18/13, on 6/20/13 at 4:00 p.m. The report indicated the preoperative [DIAGNOSES REDACTED]. The postoperative [DIAGNOSES REDACTED]. The details of the scope indicated "...Large inflamed, external hemorrhoids are present. Multiple diverticula are noted in the left colon. Blood is present in [MEDICATION NAME] and left colon..." The 2010 Nursing Spectrum Drug Handbook was reviewed on 6/21/13 at 12:05 p.m. Regarding [MEDICATION NAME] ([MEDICATION NAME]), there was a "Boxed Warning." The warning included, but was not limited to, the following: "Drug increases risk of serious GI (gastrointestinal) adverse events, including bleeding, ulcers, and stomach or intestinal perforation. These events can occur at any time during use and without warning. Elderly patients are at greater risk." "Interactions Drug-drug...Aspirin: increased [MEDICATION NAME] blood level, increased risk of toxicity." 2. Resident #104 was observed sitting in a recliner reading the paper on 06/12/13 at 11:50 a.m. The clinical record of Resident #104 was reviewed on 06/18/13 at 12:11 p.m. The record indicated Resident #104 was admitted on [DATE] with [DIAGNOSES REDACTED]. The admission MDS (Minimum Data Set Assessment), dated 03/14/13, indicated Resident #104 experienced mild cognitive impairment. A hospital history and physical, dated 03/04/13, indicated Resident #104 worked part-time on a farm prior to hip surgery. The May 2013 Physician order [REDACTED]. [MEDICATION NAME] (antianxiety medication) 0.5 mg (milligrams) tid (three times daily) for anxiety was started on 03/13/13, [MEDICATION NAME] (pain medication) 37.5 mg two tablets po tid for pain was started on 3/13/13, [MEDICATION NAME] (antianxiety medication) was revised from 50 mg to 100 mg at hs (bedtime) with food for depression on 04/06/13, and [MEDICATION NAME] (antipsychotic medication) 0.25 mg bid (twice daily) was started on 04/20/13 for a behavioral disorder, The Behavior Symptoms Detail Report from 03/07/13 through 04/06/13 lacked any documentation of behaviors. The Nurse's Notes from 03/07/13 through 06/19/13 lacked any documentation of anxiety, pain, behaviors, or depression. A Mental Health Wellness Circumstance, Assessment and Inter-(sic), dated 03/08/13, indicated Resident #104 had an episode of verbally yelling out with mood swings with the following signs of depression: anxious, irritable, persistent anger, change in mood. The monitoring tool indicated no further behavior episodes occurred during the next 72 hours. A Mental Health Wellness Circumstance, Assessment and Inter-(sic), dated 03/13/13, indicated Resident #104 had a verbal episode of mood swings and repetitive verbalization with the following signs of depression: anxious, irritable, persistent anger. The monitoring tool indicated the behavior recurred once during the first 24 hours, but was successfully re-directed. The monitoring tool further indicated the behavior did not recur in the next 48 hours. A Skilled Nursing Assessment and Data Collection, dated 03/28/13, indicated Resident #104 had no mood or behavior issues. A Skilled Nursing Assessment and Data Collection, dated 03/31/13, indicated Resident #104 had no mood or behavior issues. A Skilled Nursing Assessment and Data Collection, dated 04/05/13, indicated Resident #104 had no mood or behavior issues. A Skilled Nursing Assessment and Data Collection, dated 04/07/13, indicated Resident #104 had no mood or behavior issues. A Mental Health Wellness Circumstance, Assessment and Inter-(sic), dated 04/20/13, indicated Resident #104 experienced the following signs of depression: anxious, irritable, and persistent anger. The monitoring tool indicated no further behaviors occurred in the following 72 hours. The Hospital Aftercare Instructions dated 06/18/13 included, but was not limited to, a recommendation for "review and minimize ...medication..." and [DIAGNOSES REDACTED]. During an interview on 06/19/13 at 11:35 a.m., UM (Unit manager) #1 indicated there was no documentation of why the medications were started or changed. UM #1 further indicated, at that time, documentation in the clinical record was lacking and had been an issue for some time. During an interview on 06/19/13 at 10:45 a.m., the Director of Health Services (DHS) indicated Resident #104 had experienced behavior problems since admission to the facility. 3.1-48(a)(3) 3.1-48(a)(4) 3.1-48(a)(6) 3.1-48(b)(1) 3.1-48(b)(2)

Based on observation, record review and interview, the facility failed to ensure 1 of 1 resident with a pressure sore, in the sample of 15, did not develop a pressure sore under an immobilizer. (Resident #17) Finding includes: 1. During the initial tour, on 4/4/11 at 10:25 a.m., the Medical Record Clerk (MRC), an LPN, indicated that resident #17 had a wound on the lower leg that had been caused by a splint. The MRC indicated the resident currently had a wound vac to the area. The clinical record for Resident #17 was reviewed on 4/5/11 at 2:15 p.m. The record contained documentation of Resident #17 having been admitted to the facility on [DATE]. The record contained [DIAGNOSES REDACTED]. The admission physician's orders [REDACTED]. "weekly skin assessment 0= no skin impairment, 1= new area of skin impairment-see skin sheet, 2= existing area of skin impairment-see skin sheet." "(R) (right) knee immobilizer @ all x's (times) remove for bathing and skin care 6a- 6p and 6p to 6a." The Assessment Review and Considerations, dated 1/25/11, identified the resident had the following risk factors the could contribute to skin breakdown: "mobility impairment, lack of sensation/response to pain, past history and medical diagnosis." The Medication Record, dated 2/1-2/28/11, had documentation of staff initials that the knee immobilizer had been removed for bathing and skin care. The initials were placed in boxes for day shift, 6a- 6p, and night shift, 6p to 6a from 2/1-19/11. The weekly skin assessment had been identified by blocked off dates of 2/7/11 and 2/14/11. There were no initials to indicate the weekly skin assessment had been conducted on either of these dates The record contained a Skin Impairment Circumstance, Assessment and Interventions form, dated 2/13/11. The form indicated, on 2/13/11 at 1920 (7:20 p.m.), an unstageable pressure area had been noted on the resident's right posterior calf. The area was measured as length 8.7 cm (centimeters) width 2.3 cm depth blank. On 3/24/11 and 4/4/11, the resident was seen at a wound care center. The history and physical, dated 3/24/11, contained the following documentation: "...comes in today for a chief complaint of a right posterior calf wound. She states that has been there approximately 2 months." The measurements were length 65 mm (millimeters) (6.5. centimeters) width 22 mm ( 2.2 cm) and depth 3 mm( .3 cm). On 4/4/11, the wound clinic added a wound vac to be used on the area. On 4/5/11 at 3:05 p.m., the record was reviewed with the Director of Nurses and the Medical Records Clerk (MRC). The MRC was unable to locate any additional information about the removal of the splint and the assessment of the area. On 4/5/11 at 3:25 p.m., the MRC provided a copy of the Certified Nursing Assistant assignment sheet in use at the time the open area was observed. The assignment sheet identified that the immobilizer was to be in place at all times without any instructions to remove it. The area was observed on 4/8/11 at 9:00 a.m. The wound vac was removed and the area was observed to be clean with red granulation tissue and a small amount of yellow slough. On 4/8/11 at 11:30 a.m.. the DON provided the current copy of the facility guidelines for cast, splint and brace care (no date). The interventions for the brace/splint use included but were not limited to: "Follow physicians order for removal of splints and braces, if physician orders [REDACTED].." 3.1-40(a)