Every finding on record at Waters of Greencastle, The

Based on observation, record review, and interview, the facility failed to supervise and ensure the safety of a resident with dementia residing on the locked dementia unit when an exit glass door and an outside courtyard gate were left open by a contractor and the resident eloped from the facility and fell into a ditch for 1 of 3 residents reviewed for accidents (Resident B). The immediate jeopardy began on 6/2/26 at 1:58 p.m., when Resident B was observed via video footage exiting the gate from the locked unit courtyard. She continued across the parking lot into a grassy field. She walked at a rapid pace, carrying a blanket in front of her. She walked approximately 100 yards and veered towards the road and was observed falling on her face in a ditch. She was observed trying to get up and falling again. She was on the ground for 13 minutes before a hospital staff member approached her, but she was unable to stand. He indicated she was about 2 1/2 to 3 feet from the road between the facility and the hospital. Facility staff were seen arriving to assist the resident after the hospital staff member left to get assistance. The Director of Nursing, Regional Nurse Consultant, and Regional Director of Operations were notified of the Immediate Jeopardy on 6/16/26 at 3:02 p.m. The immediate jeopardy was removed on 6/16/26, but the noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include:Observation of a surveillance video, provided by an acute care hospital on 6/15/26 at 10:55 a.m., included the following: Resident B exited the facility's locked courtyard gate at 1:58 p.m. on 6/2/26, and walked across the facility's parking lot towards a grassy area. She continued to walk across a rolling, grassy area at a rapid pace and was carrying a blanket. After going approximately 100 yards, the resident turned toward the road and fell at 2:00 p.m., face first, into a ditch. She attempted to get up, was unable to do so, and again fell forward. The resident sat up, appearing close to the edge of the road. Approximately six vehicles were seen driving down the road during this time. A beige SUV stopped on the opposite side of the road and a hospital employee can be viewed reaching Resident B at 2:11 p.m. At 2:14 p.m., a silver SUV arrived and stopped on the same side as the resident. At 2:17 p.m., other staff members crossed the grassy area and arrived. Resident B was placed in the silver SUV and at 2:20 p.m., and the silver SUV pulled away. According to the website Accuweather at https://www.accuweather.com/en/us/greencastle/46135/june-weather/332953, accessed on 6/18/26 at 6:58 a.m., the temperature in the afternoon on 6/2/26 was 78 degrees Fahrenheit (F). A clinical record review for Resident B was completed on 6/15/26 at 12:49 p.m. Diagnoses included vascular dementia (a decline in thinking and memory skills caused by conditions that block or reduce blood flow to the brain) and anxiety disorder (chronic, exaggerated worry about everyday events that is difficult to control). The resident admitted to the locked Memory Care unit on 6/1/26. An admission Wandering Risk Scale, completed 6/1/26 at 4:35 p.m., indicated the resident was at moderate risk for wandering. The resident was ambulatory and had a medical diagnosis of dementia. An admission Baseline Care Plan Assessment, completed on 6/1/26 at 4:38 p.m., indicated the resident was a risk for elopement. Interventions included to monitor doors when staff and visitors come and go, and if wandering in potentially unsafe areas, to redirect to safer area. An Activity admission Evaluation, dated 6/1/26 at 2:16 p.m., indicated Resident B had poor short- and long-term memory, and used nonsensical/slurred speech. She was ambulatory. A nursing progress note, dated 6/2/26 at 3:00 p.m., included the Administrator had spoken to Resident B's spouse making him aware that the resident had followed a contractor out of the memory care courtyard door, and that she had stumbled in the grass before staff could reach her. She had a small scratch on her nose from her glasses. Facility staff brought her back into the building and she was resting. During an interview on 6/15/26 at 10:50 a.m., an employee of an acute care hospital indicated he received a call at 2:10 p.m. from someone parked in the hospital parking lot. The caller told him there was a lady on the side of the road across the street from the hospital who appeared to be unable to get up. The hospital employee went out to the parking lot and walked toward the road and could see an SUV pull up and stop. Upon going across the street, he saw Resident B laying on her side by the road. When he spoke to her she looked at him but did not respond. The man sitting in the SUV indicated to him that he had called someone for help. The employee then returned to the hospital to get help, and when he returned, others were observed with the lady and waved him away, indicating they were helping her. During an interview on 6/15/26 at 1:37 p.m., the Administrator indicated Resident B had exited the building through the glass, double doors at the end of the hallway into the courtyard. The outside courtyard gate had been open so the contractor could go back and forth to an outside vehicle with supplies to fix the air conditioning unit. The glass, double doors must not have latched when the contractor had last exited the building. Resident B walked across the parking lot into the grassy area and fell. During an telephone interview on 6/16/26 at 11:15 a.m., Dietary Aide 9 indicated he was seated in his car during his lunch break and noticed the resident lying on the ground. He immediately called the facility and reported that the resident was on the ground. During a telephone interview on 6/16/26 at 12:59 p.m., CNA 4 indicated she had gotten off work and was driving towards the main entrance of the hospital parking lot. She saw a dietary aide parked on the road and Resident B lying in the ditch across the street from where he was parked. She got out of her car and went to the resident. The employee in the other car had indicated he called the facility to report the resident lying next to the road. She remained with the resident until other staff arrived. She had fallen in a small ditch by the road about halfway between the facility and the hospital in a grassy area, about 100 yards from the facility. She was approximately 2 1/2 to 3 feet from the edge of the road. When she approached Resident B, she was lying on her side, curled up with a blanket, holding her glasses in her hand. She had a scratch on her nose. Other facility staff arrived and they assessed Resident B, then helped her get on her feet. She walked with assistance to CNA 4's car and was helped into the passenger seat. CNA 4 then drove her to the front entrance of the building where other staff assisted her into the building. She appeared to be walking without any visible issues. During an interview on 6/17/26 at 10:22 a.m., CNA 6 indicated she was working on the memory care unit on 6/2/26, and saw Resident B walking up and down the hallways holding a blanket around 1:30 p.m. CNA 6 had clocked out and was talking to another resident's family member in front of the facility outside the entrance doors. The Administrator, DON and QMA/Scheduler ran out of the front doors of the facility. CNA 6 and CNA 8 followed them, thinking someone needed help. They walked across the grassy area to the side of the building, to about 100 yards, and she observed Resident B on the ground with another CNA. She seemed alert and awake and did not appear to be crying. She had a mark on her nose and was holding a blanket tightly. They stood her up and assisted her to CNA 4's car that was parked on the road. She only had socks on her feet. CNA 6 felt at that point, Resident B appeared confused and tearful. CNA 6 went back to the front entrance and when Resident B arrived, she gave her a hug and she was taken back to the unit. CNA 6 indicated the resident's gait was at her normal and she lacked any appearance of being in pain. During an interview on 6/17/26 at 10:57 a.m., CNA 8 indicated she went out to the grassy field when other staff were observed headed that way. She observed Resident B holding a blanket and sitting on the ground. She had a little blood on her nose. She observed the resident when she was walking to the car and again when she was walking into the facility and had not noticed the resident having any discomfort or change in her usual gait. A current facility policy, undated, titled, Policy and Procedure Regarding Missing Residents and Elopement, provided by the Regional Nurse Consultant on 6/17/26 at 12:48 p.m., included the following: .Prevention of Missing Residents and Elopements 1. Environmental.At no time will any door alarm or personal safety device be deactivated without continual direct visit supervision of the exit(s). The immediate jeopardy that began on 6/2/26 was removed on 6/16/26 when the facility implemented a systemic plan that included the following actions: conducted a facility wide audit of all resident risk assessments for elopement risk and update of elopement binders. All resident care plans were reviewed. Alarms for all locations were checked daily and logged beginning June 2026 for magnetic locks, wandering system alarms, door station alarms, and remote alarms. Skin assessments were completed for all memory care residents. Education was provided to all nursing staff on elopement policy and procedures. Pre and Post tests completed for all staff with infrequently scheduled employees flagged for education and testing prior to working in the facility. The noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the facility's need for continued monitoring. This citation relates to Intakes 3041631 and 3042609. 410 IAC (Indiana Administrative Code) 16.2-3.1-45(a)(2)

Based on observation, record review, and interview, the facility Administrator and Director of Nursing (DON) failed to communicate accurate information, complete accurate documentation, and pressured facility staff to provide false statements for an elopement from the memory care unit for 1 of 5 residents reviewed for accidents (Resident B). This deficiency had the potential to affect 68 of 68 residents residing at the facility who were overseen by the Administrator and DON.Findings include:During an interview on 6/15/26 at 12:29 p.m., Resident B's spouse indicated he had been caring for his wife at home and was very sad he had to make the decision to place her in a safer environment due to her dementia. His wife was admitted to the facility on [DATE]. He received a call from the Administrator around 3:00 p.m. on 6/2/26. She indicated Resident B had a little incident when she followed a contractor out of the memory care doors and had fallen in a grassy area. She indicated she was okay. Before going into a care plan meeting on 6/8/26, the Hospice Nurse told him Resident B had fallen outside the courtyard gates and across the parking lot in a grassy area. During the meeting, he was not told she was beyond the locked gates when she fell. During the meeting, he asked to see the incident report for the fall outside. The Administrator indicated she would let him see the nurses' notes. He had not heard anything further and had stopped trying to get information from her. After the meeting, he went over to the acute care hospital across the road from the facility because he felt like something was not right. He asked to speak to someone about an incident that had occurred on 6/2/26. A hospital employee asked if he was referring to information about the woman who fell. The hospital employee showed him where she was found, about 100 yards from the facility. The employee believed she was outside for at least 15 minutes before being placed in a vehicle and taken back to the facility. He was not allowed to see the video footage from the hospital surveillance cameras. The administrator had stopped contacting him or responding to his questions. He will be transferring her to another facility this afternoon (6/15/26).A clinical record review for Resident B was completed on 6/15/26 at 12:49 p.m. Diagnoses included vascular dementia (a decline in thinking and memory skills caused by conditions that block or reduce blood flow to the brain) and anxiety disorder (chronic, exaggerated worry about everyday events that is difficult to control). The resident admitted to the locked Memory Care unit on 6/1/26.An admission Wandering Risk Scale, completed 6/1/26 at 4:35 p.m., indicated the resident was at moderate risk for wandering. The resident was ambulatory and had a medical diagnosis of dementia.An admission Baseline Care Plan Assessment, completed on 6/1/26 at 4:38 p.m., indicated the resident was a risk for elopement. Interventions included to monitor doors when staff and visitors come and go, and if wandering in potentially unsafe areas, to redirect to safer area.An Activity admission Evaluation, dated 6/1/26 at 2:16 p.m., indicated Resident B had poor short- and long-term memory, and used nonsensical/slurred speech. She was ambulatory.A nursing progress note, dated 6/2/26 at 3:00 p.m., included the Administrator had spoken to Resident B's spouse making him aware that the resident had followed a contractor out of the memory care courtyard door, and that she had stumbled in the grass before staff could reach her. She had a small scratch on her nose from her glasses. Facility staff brought her back into the building and she was resting.A Care Plan Meeting Progress note, dated 6/8/26, included that Resident B's spouse had asked for details about Resident B's second fall. The Administrator indicated that she had informed him previously and that Resident B had followed a facility contractor outside of the building. The facility staff had eyes on her the entire time and had her back into the building within a few minutes. During an interview on 6/15/26 at 1:37 p.m., the Administrator indicated the reason Resident B's elopement was not reported to the State Agency was because the resident had not left the property, and there had been a staff person who had eyes on her the entire time. She had gotten out of the locked glass, double doors due to them not being completely closed after maintenance had exited. The outside gate had been open so the contractor could go back and forth to an outside HVAC unit and his truck. Resident B must have followed them out to the courtyard and then out of the opened gate. Resident B had crossed over the parking lot into the grass. Dietary Aide 9 saw her fall on her left knee and rolled onto her right side. Since Dietary Aide 9 had eyes on her from the time she exited the gate and fell in the grass, this was not considered a reportable elopement. Dietary Aide 9 had called the facility when she fell to let them know she was outside. During an observation on 6/15/26 at 1:56 p.m., accompanied by the Administrator, the potential route taken by Resident B was observed. The resident had exited through glass, double doors at the end of the men's hall on the memory care unit, into the gated courtyard. The Administrator indicated the gate was open at the time of her elopement, and she went through them. The resident then walked across a single row parking lot onto a grassy area. The Administrator indicated the resident was found lying on the grass approximately 25 yards from the courtyard gate. The Administrator indicated when the dietary aide called the facility, they immediately went to the resident and brought her back into the facility in an employee's vehicle to the main entrance. During an interview on 6/16/26 at 9:45 a.m., the DON indicated she was sitting in the Administrator's office on 6/2/26 when they received a call that Resident B had been found outside at 2:10 p.m. They immediately went outside to where the resident was lying in the grass and found CNA 4 sitting with Resident B in the grassy area beyond the parking lot. She had a small scratch on her nose and was holding her glasses in her left hand. CNA 4's vehicle was parked on the road by the entrance. The resident was helped to her feet and assisted into the CNA's vehicle and taken to the front entrance of the facility. She walked into the facility without any distress noted. During an observation on 6/16/26 at 10:00 a.m., the DON indicated the resident had been found in the grassy area across the parking lot. The area she indicated was a little further out and closer to the road than previously observed with the Administrator. She indicated where CNA 4's vehicle was parked and that the staff had assisted the resident to the car. The path to the car was observed to have a ditch prior to reaching the street. The DON indicated that the resident had no problem walking through the ditch to get to the vehicle. The resident was then driven to the facility entrance and walked back to the memory care unit for further assessment.During an interview on 6/16/26 at 9:42 a.m. CNA 8 indicated she had gone out to her car sometime after 2:00 p.m. on 6/2/26. She had noticed people in the grass just off to the side of the building and began to move that way. The Administrator waved her off and said that no further help was needed. That was all she could remember. She had observed Resident B wandering up and down the halls carrying a blanket around 1:30 p.m. in the memory care unit prior to her elopement.During an interview on 6/16/26 at 12:41 p.m., Dietary Aide 9 indicated he was sitting in his car after 2:00 p.m. on 6/2/26. He saw the courtyard gate open and Resident B walked out. He thought at first it was a family member because she walked toward the cars. He watched her cross the parking lot into the grassy area. He drove his car towards the exit and tried to talk to her. She lowered herself to one knee and leaned down. Another employee came out of the facility and drove to the resident in her vehicle. She was only there for about a minute and a half before staff arrived and took her back into the facility. At no time was she out of his sight. Observation of a surveillance video, provided by an acute care hospital on 6/15/26 at 10:55 a.m., included the following: Resident B exited the facility's locked courtyard gate at 1:58 p.m. on 6/2/26, and walked across the facility's parking lot towards a grassy area. She continued to walk across a rolling, grassy area at a rapid pace and was carrying a blanket. After going approximately 100 yards, the resident turned toward the road and fell at 2:00 p.m., face first, into a ditch. She attempted to get up, was unable to do so, and again fell forward. The resident sat up, appearing close to the edge of the road. Approximately six vehicles were seen driving down the road during this time. A beige SUV stopped on the opposite side of the road and a hospital employee can be viewed reaching Resident B at 2:11 p.m. At 2:14 p.m., a silver SUV arrived and stopped on the same side as the resident. At 2:17 p.m., other staff members crossed the grassy area and arrived. Resident B was placed in the silver SUV and at 2:20 p.m., and the silver SUV pulled away.During a telephone interview on 6/16/26 at 10:22 p.m., the Hospice Nurse indicated the Administrator had called her on 6/4/26 and apologized for not having contacted her regarding the fall outside of the facility on 6/2/26. The Administrator told her that Resident B had followed a contractor out to the courtyard and fell in the grass. Then on 6/7/26, a facility CNA approached her and said they were not being honest about the resident's fall outside the building. During the care plan meeting, Resident B's spouse asked the Administrator where she had been found when she got out of the building. The Administrator said she tumbled in the grass in the courtyard, then clarified it was the grassy area just outside the courtyard, then clarified again, that it was in the grassy area across the parking lot. At the end of the care plan meeting, the Hospice Executive Director, who was attending via telephone, asked the Administrator if she had reported the elopement to the State Agency. The Administrator indicated it was not reported because, according to policy, it was not an elopement if eyes were on the resident at all times. The Hospice Executive Director indicated she would be submitting a report regarding Resident B's elopement. The Administrator became very upset and began to yell at the phone and at the Hospice Nurse, This is the last time [Hospice Provider] is going to f--- me over! The Hospice Nurse indicated she had been advocating for her resident and her spouse, because the truth was not being shared.During a telephone interview on 6/16/26 at 12:59 p.m., CNA 4 indicated she had gotten off work and when she turned out of the parking lot, she observed another employee's vehicle parked on the side of the road. She parked her car facing the other direction and got out of her car. Resident B was lying on the grass halfway between the hospital and the facility. She was 2 to 3 feet off the road, lying on her side curled up with a blanket and holding her glasses. She had left the facility a little after 2:10 to 2:15 pm. The Administrator, DON and a few other employees arrived just as two men from the hospital arrived. The Administrator waived them off and said no help was needed. The staff were told by the Administrator what to say and what not to say about where Resident B was found and if she was supervised. The staff feared the Administrator and of repercussion if they did not cooperate.During an interview on 6/17/26 at 10:22 a.m. CNA 6 indicated she did not answer the phone when her phone rang for an interview because she did not want to be vague. She was working on the memory care unit on 6/2/26. She observed Resident B walking down the hallways holding a blanket around 1:30 p.m. She was going out to her car around 2:10 p.m. after clocking out and was talking to another resident's spouse outside the front doors. The Administrator, DON, and the QMA/Scheduler ran out the door. She followed them and when they reached Resident B, she was lying on the grass near the road. She was further away from the facility than had been originally indicated. The staff was talking to her. She had blood on her nose and was holding her blanket tightly. They stood her up and she walked to CNA 4's car with assistance. She seemed upset with tears in her eyes and appeared confused. She only had socks on her feet. They took her back to the unit. CNA 6 indicated she stayed on the unit to complete a head count of the memory care residents. On 6/10/26, the Administrator had pulled her into her office and told her she would be interviewed soon by the Indiana Department of Health (IDOH). The Administrator suggested she not share during the interview that she had gone to the outdoor scene and indicated that the Administrator had waved her off. She asked her not to share where Resident B was found. She indicated they were going to tell IDOH that she was closer to the building. On 6/15/26 at 3:00 p.m., she received a call from the Administrator and the DON. The Administrator indicated that IDOH was about to call and asked what her answers to questions were going to be, like, did you see the contractor, what time had you checked/changed Resident B, when was the last time you saw Resident B in the hallway,' then reviewed answers to questions about where Resident B was found. She had me rehearse my answers. She reviewed the questions again after talking about the answers that should be given. During an interview on 6/17/26 at 10:57 a.m., CNA 8 indicated her written statement was true and written to be very basic, not detailed. She had gone out with the group when they came out of the building quickly and headed to the grassy field next to the parking lot. They walked quite aways from the facility through the grass to an area close to the road. She noticed Resident B had some blood on her nose and was hugging her blanket as staff talked to her. After Resident B was returned by CNA 4's vehicle, she went to the memory care unit to help complete a head count of all the locked unit residents. She got a call from the Administrator and DON on 6/15/26. The Administrator asked her not to say she had gone out to where Resident B was and to say she was waved off and to be vague if asked about the location Resident B was found. She had felt pressured by the Administrator to say what she requested and felt like she would be getting people in trouble if she didn't. She tried to just leave things out when completing her statement and interview.During an interview on 6/18/26 at 12:10 p.m., Dietary Aide 9 indicated he had not provided an accurate account of what occurred on 6/2/26. He indicated he had been approached by the Administrator after the elopement and it was suggested that he had eyes on Resident B when she left the building and that he witnessed her fall. The timeline was suggested and he felt pressured to cooperate because he did not want anyone to get in trouble. The truth was he pulled out of the facility parking lot (unable to recall a time) and passed by Resident B who was seated on the side of the road pretty far from the facility. He turned his vehicle around and parked across the street from where she was lying. A hospital employee walked up at the same time and went over to the resident. Dietary Aide 9 called the facility and reported where Resident B was lying in the ditch. Shortly after calling, the hospital employee indicated he was going to get help, and then CNA 4 pulled up on the other side of the road and parked. She got out of her car and went to Resident B. I left at that time. I had not seen Resident B exit the courtyard gate and had not witnessed her fall.The Administrator and DON were unavailable for a follow-up interview due to being placed on suspension during an investigation into the elopement and misinformation provided to corporate and IDOH.A current facility policy, effective 1/1/24, titled, Employee Handbook, provided by the Regional Operations Manager on 6/18/26 at 9:43 a.m., included the following: Anti-Bullying/Abuse Conduct Prevention Policy.All employees (including managers) are expected to conduct themselves in a manner that demonstrates professional conduct and mutual respect for others. Managers must make every reasonable effort to establish and maintain a workplace free of bullying and abusive conduct.A current Job Description, revised 8/21/23, titled, Administrator, provided by the Regional Nurse on 6/18/26 at 11:33 a.m., included the following: Position Summary .the Administrator leads and directs the overall operations of the facility in accordance with resident needs, government regulations and company policies so as to maintain quality care for the residents.Essential Job Functions A. Role Responsibilities:.Maintain a working knowledge and insure compliance with all governmental regulations and company Quality Assurance Standards. Monitor employee relations practices of key staff to ensure compliance with employment laws and company policies. Promote practices that maintain high morale and staff retention, including effective communication, prompt problem resolution and positive reinforcement.Cross reference F689 and F9999.This citation relates to Intakes 3041631 and 3042609.410 IAC (Indiana Administrative Code) 16.2-3.1-13(r)(1)410 IAC (Indiana Administrative Code) 16.2-3.1-13(r)(2)

Based on observation, interview, and record review, the facility failed to ensure beard restraints were worn appropriately and hand hygiene was performed after staff touched their face during 5 of 5 kitchen observations. This deficient practice had the potential to affect 68 of 68 residents who ate meals from the kitchen. Findings include: 1. During a kitchen observation, on 12/1/25 at 10:05 a.m., [NAME] 7 was observed in the food preparation area, stirring a pot on the stove and preparing other food. At the same time, [NAME] 7 was observed with a full beard and mustache. [NAME] 7 had a beard restraint in place, but it only covered a small area of the beard on his chin, leaving the mustache and sides of the face open. [NAME] 7 was wearing gloves but touched his face and nose several times with his forearm and wrist area of the glove. [NAME] 7 did not wash his hands after touching his face and nose and continued to prepare food. 2. During a lunch service observation, on 12/1/25 at 12:03 p.m., [NAME] 7 was observed serving food from the steam table in the main dining room. The beard restraint remained covering a small area of the beard on his chin, leaving the mustache and sides of the face open. [NAME] 7 was wearing gloves and wiped his nose on the back of his glove/hand three times during the meal service. [NAME] 7 did not change gloves or wash his hands after wiping his nose. 3. During a kitchen observation, on 12/3/25 at 10:12 a.m., [NAME] 7 was observed putting food in the oven. [NAME] 7 was wearing a new style beard cover which covered the sides of his face better, however, the mustache was still uncovered. 4. During a kitchen observation, on 12/3/25 at 10:43 a.m., [NAME] 7 was observed preparing the pureed lunch. [NAME] 7's mustache remained uncovered by the beard restraint during the food preparation. At the same time, Dietary Aide 10 was observed in the food preparation area with a full beard and mustache. He was wearing a beard restraint, but the mustache was uncovered. 5. During a kitchen observation, on 12/3/25 at 11:16 a.m., [NAME] 7 was observed checking the temperature of the food on the steam table. [NAME] 7's mustache remained uncovered by the beard restraint. At the same time, Dietary Aide 8 was observed putting away boxes in the walk in freezer and preparing silverware near the steam table. Dietary Aide 8 had a full beard and mustache and wore a beard restraint. The beard restraint was pulled up over Dietary Aide 8's mustache, but there was significant beard growth outside of the beard cover on the bottom of his chin and neck. [NAME] 9 was observed in the food preparation area near the stove top. [NAME] 9 had a small amount of unshaved beard/mustache growth. He was not wearing a beard cover. Dietary Aide 10 was observed putting away boxes in the walk in freezer. Dietary Aide 10's mustache remained uncovered by the beard restraint. During an interview, on 12/3/25 at 1:13 p.m., the Regional Dietary Director indicated employees' mustaches and beards needed to be completely covered. She acknowledged some of the employees had not covered their beards and mustaches completely, and she had talked with them about this. Hand hygiene should have been performed if employees touched their face or noses. On 12/3/25 at 1:45 p.m., the Regional Dietary Director provided an undated document titled, Hair Restraints., and indicated it was the policy currently being used by the facility. The policy indicated, .Policy: Food & nutrition services employees shall wear hair restraints and beard guards.Procedure.Beard guards or masks will be worn as indicated. On 12/3/25 at 1:45 p.m., the Regional Dietary Director provided an undated document titled, Use of Disposable Gloves, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy: Vinyl or latex gloves will be worn when handling foods that will not be further cooked to help ensure microorganisms are not transferred from food handler's hands to the food product being served. Procedure: 1. Hands are to be washed upon entering the kitchen and before putting on gloves.3. Anytime a gloved hand touches a contaminated surface, the glove must be changed, for example: a. After coughing or sneezing into hands or touching hair or face. This citation is related to Intake 2575446. 3.1-21(i)(3)

Based on record review and interview, the facility failed to obtain consent for treatment of psychotropic medications for 4 of 5 residents reviewed for unnecessary medications. (Residents 7, 8, 27, and 22). Findings include:1. On 12/3/25 at 10:25 a.m., the medical record of Resident 7 was reviewed. The resident was admitted to the facility on [DATE]. admission diagnoses included, but were not limited to, dementia (the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), hypertension (high blood pressure) and depression (an illness characterized by persistent sadness and a loss of interest in activities that you normally enjoy, accompanied by an inability to carry out daily activities, for at least two weeks). The record did not indicate the resident had any related heart conditions. An admission Minimum Data Set (MDS) assessment, dated 4/2/25, indicated the resident was cognitively impaired and required extensive assistance with activities of daily care needs. A physician order, dated 5/31/25, indicated to administer one tablet orally of Zoloft (Sertraline HCl) 50 milligrams (mg) for depression. A physician order, dated 9/5/25, indicated to administer Seroquel (quetiapine fumarate) 150 mg by mouth two times a day for psychosis. A physician order, dated 10/15/25, indicated to administer divalproex sodium delayed release sprinkle 125 mg by mouth one time a day for mania. The record indicated that a psychotropic medication (any psychoactive drug that affects the brain's chemical makeup to treat mental and emotional disorders) had been ordered by the physician and a consent to administer the zoloft, quetiapine, divalproex sodium had not been obtained from the responsible party. Review of the psychotropic medication consents indicated an assessment was completed on 5/5/25. 2. On 12/3/25 at 11:30 a.m., medical record of Resident 8 was reviewed. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, dementia (the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), hypertension (high blood pressure), anxiety (a feeling of fear, dread, and uneasiness. It might cause you to sweat, feel restless and tense, and have a rapid heartbeat. It can be a normal reaction to stress), and depression (an illness characterized by persistent sadness and a loss of interest in activities that you normally enjoy, accompanied by an inability to carry out daily activities, for at least two weeks). A quarterly MDS assessment, dated 9/8/25, indicated the resident was cognitively impaired and required extensive assistance with activities of daily living. A physician order, dated 12/3/25, indicated to administer 1 tablet orally of Zoloft tablet 50 mg (Sertraline HCl) one time a day for depression. A physician order, dated 9/5/25, indicated to administer Seroquel (Quetiapine Fumarate) 150 mg by mouth two times a day for psychosis. A physician order, dated 10/10/25, indicated to administer 2 capsules orally of divalproex sodium delayed release sprinkle 125 mg one time a day for mania. A physician order, dated 10/15/25, indicated to administer 1 capsule orally of divalproex sodium delayed release sprinkle 125 mg (Divalproex Sodium) one time a day for mania. Review of the psychotropic consents indicated an assessment was completed on 5/30/25, 6/2/25 and 8/29/25. The documentation lacked evidence of notification to obtain consent from the responsible party. On 12/3/25 at 11:15 a.m., during an interview the Director of Nursing (DON) indicated the nurse who was to obtain consent for the psychotropic medications was to sign and have the MDS nurse verify education and consent was obtained. She indicated the facility identified this was not being completed and the second nurse did not verify. 3. Resident 27's record was reviewed on 12/4/25 at 11:40 a.m. The profile indicated the residents' diagnoses included, but were not limited to, major depressive disorder (a mood disorder characterized by persistent feelings of sadness and a loss of interest in activities, which interfere with daily life for at least two weeks), psychotic disorder with delusions (a mental health condition where a person holds firm, false beliefs that aren't based in reality), and Parkinson's psychosis (a non-motor symptom of Parkinson's disease that causes a break with reality, leading to seeing/hearing things not there, and/or fixed, irrational beliefs, like paranoia or infidelity). The census indicated the resident had been admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) assessment, dated 10/22/25, indicated the resident had moderate cognitive deficit and had no documented behaviors. A physician's order, dated 7/13/25, indicated to initiate the administration of 50 milligrams (mg) of quetiapine fumarate (a medication used to treat symptoms such as seeing or hearing things that are not real and false beliefs that are not based in reality), at bedtime. A physician's order, dated 7/13/25, indicated to initiate the administration of 100 mg of trazodone (a medication used to treat symptoms of major depressive disorder) one time daily. A physician's order, dated 7/14/25, indicated to initiate the administration of 100 mg of sertraline hydrochloride (HCl) (a medication used to treat symptoms of major depressive disorder) one time daily. The record lacked documentation that a psychotropic medication (any psychoactive drug that affects the brain's chemical makeup to treat mental and emotional disorders) consent to administer the quetiapine, sertraline, and trazodone had been obtained prior to the initiation of the medications. 4. Resident 22's record was reviewed on 12/3/25 at 1:36 p.m. The profile indicated the resident's diagnoses included, but were not limited to, active primary progressive multiple sclerosis (where disability worsens steadily over time, unlike the relapsing-remitting form, with symptoms like walking difficulty, fatigue, and cognitive issues), chronic obstructive pulmonary disease (COPD- a progressive lung disease, including emphysema and chronic bronchitis, that blocks airways, making breathing difficult due to inflammation, mucus, and damaged air sacs), and bipolar disorder (a lifelong mental health condition causing extreme mood swings, from manic highs to depressive lows). A quarterly Minimum Data Set (MDS) assessment, dated 9/23/25, indicated the resident was cognitively intact and received anti-psychotic (used primarily for psychosis) and anti-depressant medications. A care plan, dated 7/3/18, indicated the resident had a diagnosis of bipolar disorder. Interventions included, but were not limited to, medication administration and continue current mental health services. A care plan, dated 3/12/19, indicated the resident was at risk for behavioral disturbances related to diagnosis of bipolar, including racing thoughts and mood swings. Interventions included, but were not limited to, monitor for effectiveness of meds and interventions, gradual dose reduction per guidelines, and antipsychotic meds per order. A physician order, dated 5/29/25, indicated to administer Zoloft (anti-depressant) 50 mg, one tablet by mouth one time a day for depression. A progress note, dated 5/29/25 at 1:55 p.m., new orders received to start Zoloft and increase dose over the next few months. The record lacked documentation of a psychotropic medication consent being obtained with the initiation of a new psychotropic medication (Zoloft). During an interview on 12/3/25 at 2:42 p.m., Director of Nursing (DON) indicated she was not aware if a psychotropic medication consent had been obtained prior to when Resident 22 started the new medication. During an interview on 12/4/25 at 10:49 a.m., the DON indicated she could not find a psychotropic consent for when the Zoloft medication was initiated. She was aware that psychotropic medication consents should be completed with the initiation of a new psychotropic medication and/or when there was an increase in the dosage. During an interview, on 12/3/25 at 11:15 a.m., the Director of Nursing (DON) indicated the nurse who was responsible to obtain the consent for the psychotropic medications was to sign and have the MDS nurse verify education, and consent had been obtained. On 12/4/25 at 11:40 a.m., the DON provided an undated document, titled, Guidelines for Psychotropic Medication, and indicated it was the policy currently being used by the facility. The policy indicated, .Obtain informed consent.from the resident and/or representative.and document education.for any change in dose, one form per medication. 3.1-3(n)(2)

Based on interview and record review, the facility failed to ensure the grievances expressed by the residents were addressed and resolutions were explained to the residents for 6 of 24 residents reviewed for food concerns (Residents 6, 71, 38, 24, 68, and 65). Findings include:During an interview, on 12/01/25 at 11:19 a.m., Resident 6 indicated she ate in her room. The food was often cold when she got it. The residents were not getting the food that was posted on the menus. The menu had not been right for a while. She was not sure who was ordering the food, but they frequently ran out of items. They recently had run out of coffee. During an interview, on 12/02/25 at 10:52 a.m., Resident 71 indicated he did not like the food and when he asked for an alternative, he was told they did not have any. There were times when all he wanted was peanut butter and jelly and the kitchen staff told him they did not have any peanut butter. During an interview, on 12/02/25 at 11:20 a.m., Resident 38 indicated he had to buy himself his own peanut butter, jelly, and bread so that he would have something to eat. He had eaten both in the dining room and in his room. The food was sometimes cold when it was delivered to his room. During an interview, on 12/02/25 at 1:48 p.m., Resident 24 indicated the food was never what was posted on the menu. They recently had no coffee for two days. They had not had many vegetables for quite some time and serve mac and cheese all the time. The food was often cold. He would have his family bring him salads to eat because the kitchen didn't have much. One time they only gave him five tater tots and two slices of bread with lettuce on it for a meal. There was not any meat on the sandwich at all. During an interview, on 12/3/25 at 10:43 a.m. [NAME] 7 indicated there have been issues with the kitchen running out of things at times. They had run out of coffee before. He didn't believe they were able to get ice cream anymore. He thought it had been because they had been in between Dietary Managers, and that position oversaw ordering the food. The corporate support had been trying to help right now while they didn't have a manager. During an interview, on 12/3/25 at 1:13 p.m. the Regional Director of Dietary acknowledged they had run out of coffee and pink sweetener because one of their trucks didn't come in. She denied running out of other things. On 12/04/25 at 10:09 a.m., the Resident Council interview was conducted. The primary concerns voiced by the members of the Council were related to the kitchen and the food. During the Resident Council interview, on 12/04/25 at 10:22 a.m., Resident 68 indicated there had been concerns with the kitchen running out of items like coffee, creamer, and orange juice. The residents had brought this up multiple times in the Resident Council meetings but were still having issues. During the Resident Council interview, on 12/04/25 at 10:26 a.m., Resident 65 indicated the Council had brought several concerns to the facility, but the food issues had been ongoing. She did not wish to cause anyone any trouble or make anyone unhappy. They used to meet with the kitchen staff to discuss the issues, but that stopped when the manager of the kitchen stopped attending. She no longer worked at the facility, and she was unsure if they even had anyone in charge in the kitchen anymore. During an interview, on 12/04/25 at 10:35 a.m., the Activity Director indicated she was always invited by the Resident Council to attend their meetings to take the minutes. They used to have a food council and would get together with the Dietary Manager to air their concerns. That was about two Dietary Managers ago. The Dietary Manager eventually stopped coming to the meetings and the council just stopped meeting. Now there was a new contracted group who oversaw the kitchen. They have had a hard time keeping a manager in the kitchen. She did remember when the kitchen ran out of coffee. It was on a weekend. One of the staff had suggested going out and buying some coffee, but was told that, because the kitchen was run by a contracted company, they may not get reimbursed for it and it would be considered a donation. During an interview, on 12/4/25 at 3:00 p.m., the Administrator (ADM) indicated she had been given the food concerns by the Resident Council. She had interviewed the Resident Council President who had told her there were no longer concerns and she felt like that the members of the Council were content with the situation. When the next meeting brought forth more concerns, she made sure that the sub-contracted company was made aware and had addressed the concerns. They had indicated the items had been ordered but were out of stock. She had not attended any of the Resident Council meetings to address the concerns directly. On 12/4/25 at 3:00 p.m., the ADM provided a document, with a revision date of 2/9/16, titled, Resident Council Policy, and indicated it was the policy currently used by the facility. The policy indicated, .The Resident Council offers an avenue by which resident can have an active role in influencing decisions which affect them.Some objectives of the council are as follows: .C. Helps to identify quality of life issues.Regulations.6. When a resident.group exists, the facility must listen to the views and act upon the grievances and recommendations of residents.concerning proposed policy and operational decisions affecting resident care and life in the facility. On 12/4/25 at 3:00 p.m., the ADM provided an undated document, titled, I Would Like To Know., and indicated it was the policy currently in use by the facility. The policy indicated, .1. When a resident.presents a question/concern, a staff member will obtain the I Would Like To Know. form.3. During the following morning meeting, the Administrator or designee reads the.form to the CQI committee and logs the questions/concern on the tracking form.6.the Administrator or designee will review the log and the status of the unanswered questions/concerns will be discussed. The objective being to answer all logged questions/concerns as soon as possible.10. When the question/concern has been resolved or has been resolved to the greatest possible extent, the assigned Department Head will contact the appropriate party to discuss what has been done. 3.1-3(a)3.1-3(g)3.1-3(k)3.1-3(l)

Based on record review and interview, the facility failed to ensure Abnormal Involuntary Movement Scale (AIMS) (a clinical tool to detect and monitor tardive dyskinesia (TD) in patients taking (antipsychotic) medications, rating involuntary facial, limb, and trunk movements) assessments were completed timely for 2 of 5 residents reviewed for unnecessary medications (Residents 7 and 22).Findings include:1. On 12/3/25 at 10:25 a.m., the medical record of Resident 7 was reviewed. The resident was admitted to the facility on [DATE]. admission diagnoses included, but were not limited to, dementia (the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), hypertension (high blood pressure), and depression (an illness characterized by persistent sadness and a loss of interest in activities that you normally enjoy, accompanied by an inability to carry out daily activities, for at least two weeks). The record did not indicate the resident had any related heart conditions. An admission Minimum Data (MDS) assessment, dated 4/2/25, indicated the resident was cognitively impaired and required extensive assistance with activities of daily care needs. The medical record indicated an AIMS assessment was completed on 4/2/25. Documentation lacked evidence of an assessment completion every 6 months. On 12/3/25 at 11:30 a.m., medical record of Resident 8 was reviewed. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, dementia (the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), hypertension (high blood pressure), anxiety (a feeling of fear, dread, and uneasiness. It might cause you to sweat, feel restless and tense, and have a rapid heartbeat. It can be a normal reaction to stress), and depression (an illness characterized by persistent sadness and a loss of interest in activities that you normally enjoy, accompanied by an inability to carry out daily activities, for at least two weeks). A quarterly MDS assessment, dated 9/8/25, indicated the resident was cognitively impaired and required extensive assistance with activities of daily living. The medical record indicated an AIMS assessment was completed on 2/18/25 and 11/20/25. The record lacked evidence of the assessments being completed timely. On 12/3/25 at 11:15 a.m., during an interview the Director of Nursing (DON) indicated she would have to check the policy for AIMS assessments. 2. Resident 22's record was reviewed on 12/3/25 at 1:36 p.m. The profile indicated the resident's diagnoses included, but were not limited to, active primary progressive multiple sclerosis (where disability worsens steadily over time, unlike the relapsing-remitting form, with symptoms like walking difficulty, fatigue, and cognitive issues), chronic obstructive pulmonary disease (a progressive lung disease, including emphysema and chronic bronchitis, that blocks airways, making breathing difficult due to inflammation, mucus, and damaged air sacs), and bipolar disorder (a lifelong mental health condition causing extreme mood swings, from manic highs to depressive lows). Facility census information indicated Resident 22 admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) assessment, dated 9/23/25, indicated the resident was cognitively intact and received anti-psychotic (used primarily for psychosis) and anti-depressant medications. A care plan, dated 7/3/18, indicated the resident had a diagnosis of bipolar disorder. Interventions included, but were not limited to, medication administration and continue current mental health services. A care plan, dated 3/12/19, indicated the resident was at risk for behavioral disturbances related to diagnosis of bipolar, including racing thoughts and mood swings. Interventions included, but were not limited to, monitor for effectiveness of meds and interventions, gradual dose reduction per guidelines, and antipsychotic meds per order. A physician order, dated 11/21/24 with a stop date of 3/31/25, indicated to administer Zyprexa (anti-psychotic medication) 12.5 milligram (mg), by mouth at bedtime. A physician order, dated 4/1/25, indicated to administer Zyprexa10 mg, one tablet by mouth once a day for bipolar disorder. Review of Resident 22's record indicated an AIMS (Abnormal Involuntary Movement Scale) assessment had been completed on 3/25/25 but the record lacked documentation of an AIMS assessment being completed since 3/25/25. During an interview on 12/4/25 at 2:53 p.m., Registered Nurse (RN) 12 indicated the nurses working the floor were responsible for completing the AIMS assessments on the residents who were on anti-psychotic medications. The AIMS assessments were documented in the resident's electronic health record under the assessments tab. During an interview on 12/4/25 at 2:54 p.m., Licensed Practical Nurse (LPN) 16 indicated the AIMS assessments were to be completed every 6 months on the residents who were on anti-psychotic medications. On 12/4/25 at 9:22 a.m., the Administrator provided an undated document, titled, Guidelines for Abnormal Involuntary Movement Scare (AIMS), and indicated it was the policy currently being used by the facility. The policy indicated, .residents receiving psychotropic medication will have an AIMS assessment performed at intervals no less than every 6 months.2. The AIMS will be completed no less than every 6 months; however it should be completed every time the resident appears to be displaying increased symptoms of Tardive Dyskinesia (a neurological disorder causing involuntary, repetitive movements). 31-48(b)

Based on record review and interview, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessment for 2 of 17 reviewed (Residents 22 and 65).Findings include: 1. Resident 22's record was reviewed on 12/3/25 at 1:36 p.m. The profile indicated the resident's diagnoses included, but were not limited to, active primary progressive multiple sclerosis (MS - where disability worsens steadily over time, unlike the relapsing-remitting form, with symptoms like walking difficulty, fatigue, and cognitive issues), chronic obstructive pulmonary disease (COPD - a progressive lung disease, including emphysema and chronic bronchitis, that blocks airways, making breathing difficult due to inflammation, mucus, and damaged air sacs), and bipolar disorder (a lifelong mental health condition causing extreme mood swings, from manic highs to depressive lows). Facility census information indicated Resident 22 admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) assessment, dated 9/23/25, indicated the resident was cognitively intact and was marked No the resident did not have a condition or chronic disease that may result in a life expectancy of less than 6 months. A physician order, dated 6/12/24 at 10:25 a.m., indicated the physician gave verbal certification that Resident 22 had a prognosis of less than 6 months if the disease runs its normal course. A physician order, dated 6/13/24, indicated to admit the resident to hospice services for a diagnosis of MS. A care plan, dated 6/15/24, indicated the resident received hospice services. The interventions included, but were not limited to, hospice services as ordered and notify hospice nurse of any new orders or changes in condition. During an interview on 12/2/25 at 9:44 a.m., the MDS Coordinator indicated she could not remember when Resident 22 went on hospice services and she would have to look back at her medical record to see. She indicated a modification would have to be completed on the resident's most recent quarterly MDS assessment since it was not coded correctly. The MDS Coordinator indicated she was new at her position and would have to seek guidance from her corporate advisor since she had never had to complete a modification yet. When a resident was on hospice the MDS assessment should have been marked as Yes. Section J1400 of the CMS (Centers for Medicaid and Medicare Services) RAI (Resident Assessment Instrument) Version 3.0 Manual, dated October 2024, indicated .Prognosis: Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? . Code 1, yes: if the medical records include physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services. 2. Resident 65's record was reviewed on 12/4/25 at 10:58 a.m. The profile indicated the resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD- a progressive lung disease, including emphysema and chronic bronchitis, that blocks airways, making breathing difficult due to inflammation, mucus, and damaged air sacs) and heart failure (occurs when the heart can't pump enough blood to meet the body's needs, leading to symptoms like shortness of breath, fatigue, and swelling in legs/ankles, often caused by damage from heart attacks, coronary artery disease, or high blood pressure). Facility census information indicated Resident 65 admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) assessment, dated 9/27/25, indicated the resident had moderate cognitive impairment and did not use a non-invasive mechanical ventilator. A physician order, dated 3/19/24, indicated to place CPAP (continuous positive airway pressure, a common medical treatment especially for obstructive sleep apnea) at bedtime for sleep apnea and help resident place CPAP on every bedtime. Review of September MAR (medication administration record) indicated Resident 65 had used the CPAP every night. The MAR lacked documentation of the resident's refusal to wear the CPAP at night. A care plan, dated 2/9/24, indicated the resident was at risk for shortness of breath due to diagnosis of COPD. Interventions included, but were not limited to, elevate head of bed for comfort and meds per order. A care plan, dated 2/9/24, indicated the resident had obstructive sleep apnea related to diagnosis of COPD. Interventions included, but were not limited to, CPAP at night per order and observe for signs and symptoms of low Oxygen. During an interview on 12/5/25 at 9:50 a.m., the Director of Nursing (DON) was not aware of how the MDS should be coded for a resident who used a CPAP machine, she would have to speak with the corporate MDS Coordinator. During an interview, on 12/5/25 at 9:57 a.m., the MDS Coordinator indicated Resident 65's most recent quarterly assessment was not coded currently and should have been marked yes the resident used a non-invasive mechanical ventilation device. The MDS assessment would have to be modified. Section O0110 of the CMS (Centers for Medicaid and Medicare Services) RAI (Resident Assessment Instrument) Version 3.0 Manual, dated October 2024, indicated, .Special Treatments, Procedures, and Programs:.O0110G1: Non-invasive Mechanical Ventilator: Code any type of CPAP or BiPAP respiratory support devices that prevent airways from closing. O0110G3, CPAP: Check is the non-invasive mechanical ventilator support was CPAP.

Based on record review and interview, the facility failed to ensure a care plan was developed related to weight loss (Resident 7), failed to ensure a care plan was developed related skin concerns (Resident 71), and failed to ensure documentation of care plan meeting being held (Resident 19) for 3 of 24 residents reviewed for care plans. Findings include: 1. On 12/1/25 at 11:58 a.m., during initial observation observed Resident 7 in the main dining room being assisted with meal. The Certified Nurse Aide (CNA) started to assist the resident with the meal. CNA left to assist other residents. Resident continued to pick at food. Did not seem to know what to do with utensils. At 12:08 p.m., the CNA returned and assisted the resident again. The CNA began to feed the resident at that time. On 12/3/25 at 10:25 a.m., the medical record of Resident 7 was reviewed. The resident was admitted to the facility on [DATE]. admission diagnoses included but were not limited to dementia (the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), hypertension (high blood pressure) and depression (an illness characterized by persistent sadness and a loss of interest in activities that you normally enjoy, accompanied by an inability to carry out daily activities, for at least two weeks). The record did not indicate the resident had any related heart conditions. An admission Minimum Data Assessment (MDS), dated [DATE], indicated the resident was cognitively impaired and required extensive assistance with activities of daily care needs including eating. A care plan, dated 4/4/25 with a revision date of 10/26/25, indicated the resident was above ideal body weight. Included medical problems which may predispose him/her to weight gain. The care plan goal indicated the resident will experience no further weight gain by the next review date. Interventions included, but were not limited to, prepare and serve the resident's nutritional diet as ordered, determine food preferences through resident and family interview, weigh resident monthly, and notify physician of weight changes greater than 5% in one month. Review of the weight record from 4/2/25 to 12/2/25 indicated 10.66 % weight loss since admission. The record indicated a physician order, dated 10/28/25, to administer health shakes two times a day. A care plan with a revision, date 10/26/25, indicated the resident was above ideal body weight (IBW) range and confounding factors include medical problems which may predispose him/her to weight gain, and was on a therapeutic diet. The care plan lacked documentation of a care plan addressing weight loss. On 12/3/25 at 11:15 a.m., during an interview the Director of Nursing (DON) indicated the MDS nurse typically wrote and revised care plans. She was not sure why the care plan had not been updated to reflect the 10.66% weight loss in 6 months. On 12/3/25 at 1:50 p.m., during an interview the DON indicated the dietitian had indicated the resident's weight gain was related to fluid. She did not know why the care plan had not been revised to include weight loss and did not include updated interventions. 2. On 12/2/25 at 10:52 a.m., during initial observation and interview, Resident 71 was observed to have an open and scabbed area on the top of his nose. The resident indicated it was cancer. On 12/3/25 at 1:00 p.m., the medical record of Resident 71 was reviewed. The resident was admitted to the facility on [DATE]. Diagnoses included ,but were not limited to, type 2 diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), bipolar disorder (formerly called manic-depressive illness or manic depression a mental illness that causes unusual shifts in a person's mood), and dementia (the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities) A quarterly MDS, dated [DATE], indicated the resident had limited cognition and no skin related condition other than cancer. A physician order, dated 7/30/25, indicated to apply Mupirocin External Ointment 2 % (Mupirocin) to the nose topically one time a day for open area on nose, after applying mupirocin leave open to air until healed. The order indicated to also apply to nose topically at bedtime for open area on nose at hour of sleep after applying mupirocin, cover with band-aid, until healed. A care plan dated 7/7/25 indicated the resident was at risk for skin breakdown due to weakness, incontinence. Interventions included braden scale quarterly and as needed, keep clean and dry, pressure relieving mattress per facility policy, preventative treatment as ordered and skin assessment per facility policy. The care plan lacked documentation of a care plan addressing the skin lesion on the resident's nose. On 12/3/25 at 2:00 p.m., during an interview the DON indicated Resident 71 had a cancerous lesion on his nose and was being treated by a dermatologist. On 12/4/25 at 1:00 p.m., during an interview the DON indicated she did not know if the lesion on the resident's nose was cancerous and did not know if a care plan was in place. 3. During the initial interview, on 12/01/25 at 2:15 p.m., Resident 19 indicated he did not remember having a care plan meeting. Resident 19's record was reviewed on 12/3/25 at 10:02 a.m. The profile indicated the resident's diagnoses included, but were not limited to, completed traumatic amputation at level between the knee and ankle or right lower leg (the right lower leg was completely severed by an injury or trauma) and diabetes mellitus (a chronic disease where the body has high blood sugar levels). An admission Minimum Data Set (MDS) assessment, dated 10/22/25, indicated the resident had no cognitive deficit. The resident's record lacked documentation of any care plan meeting being held. During an interview, on 12/04/25 at 10:43 a.m., the Social Services Director (SSD) indicated she had documentation of the resident's scheduled care plan meeting on her cell phone. She understood that the meeting should have been documented in the resident's medical record. She could not determine why she had not documented the meeting in the record. On 12/4/25 at 3:05 p.m., the Administrator provided an undated document, titled, Baseline Care Plan Assessment/Comprehensive Care Plan, and indicated it was the policy currently being used by the facility. The policy indicated, .6. The facility Social Services Director or designee will notify the resident of their scheduled care plan conference and will invite and encourage the resident to attend.These notifications will be document for reference.8.An IDT note will be made in reference to the meeting to include who attended, significant changes addressed and date and time of the meeting. 3.1-35(c)(1) 3.1-35(c)(2)(C) 3.1-35(e)

Based on observation, record review, and interview, the facility failed to ensure it was free of a medication error rate of greater than 5 percent for 1 of 4 residents (Resident 19) observed during the medication pass. There were 32 opportunities for error observed with 4 medication errors, resulting in a medication error rate of 12.5 percent. Findings include: On 12/3/25 at 9:31 a.m., Registered Nurse (RN) 12 administered medications to Resident 19. The medications included, but were not limited to, fluticasone-salmeterol aerosol (medication to ease breathing) inhaler 250-50 micrograms (mcg) 1 puff and tiotropium bromide inhaler (relaxes and opens air passages) aerosol 2.5 mcg 1 puff. RN 12 handed the resident the inhalers, and he took 1 puff of each. The resident did not rinse and spit after the fluticasone propionate inhaler and was not prompted by RN 12 to do so. The inhalers were administered one after the other, with no wait time between the two. Aspirin 81 milligrams (mg) and cetirizine 10 mg were not administered. At the same time, RN 12 indicated the resident was out of aspirin 81 mg and cetirizine 10 mg. RN 12 usually finished her medication pass and then pulled any other needed medications from the emergency drug kit (EDK). Resident 19's record was reviewed on 12/4/25 at 11:15 a.m. A physician's order, dated 10/16/25, indicated tiotropium bromide inhalation aerosol solution 2.5 mcg, 2 puffs inhaled orally once daily for shortness of breath. A physician's order, dated 10/16/25, indicated aspirin chewable 81 mg, give 1 tablet once daily for blood thinner. A physician's order, dated 10/16/25, indicated cetirizine 10 mg, give 1 tablet by mouth once daily for allergy symptoms. A physician's order, dated 10/20/25, indicated fluticasone-salmeterol aerosol powder breath activated 250-50 mcg/dose inhaler, 1 puff inhaled orally every 12 hours for shortness of breath. Medication administration progress notes, dated 12/3/25, indicated the aspirin 81 mg and cetirizine 10 mg were out of stock. The pharmacy was called to verify the refill status, medication would arrive later that evening, the physician was aware. The progress notes lacked documentation RN 12 attempted to pull the medications from the EDK or a physician's order was obtained to hold the medications or administer them when they arrived from pharmacy. During an interview, on 12/3/25 at 9:56 a.m., RN 12 indicated the resident did not normally swish and spit after the fluticasone-salmeterol inhaler, and she was not sure if he should have or not. The resident may have only done one puff of the tiotropium bromide inhaler, but she was not sure. The resident was supposed to inhale two puffs of the tiotropium bromide inhaler. During an interview, on 12/3/25 at 10:59 a.m., the Director of Nursing (DON) indicated she would have to check the policy on the fluticasone-salmeterol inhaler to see if the resident should have swished and spit afterwards. During an interview, on 12/4/25 at 11:10 a.m., the DON indicated medications should have been pulled from the EDK and administered as ordered, if they were available. On 12/3/25 at 11:57 a.m., the Administrator provided the Food and Drug Administration (FDA) drug information for the fluticasone salmeterol inhaler, dated 1/7/19, and indicated it was the guidance currently being used by the facility. The guidance indicated, .Candida albicans (yeast) infection of the mouth and pharynx [throat] may occur. Monitor patients periodically. Advise the patient to rinse his/her mouth with water without swallowing after inhalation to help reduce the risk. On 12/3/25 at 1:10 p.m., the Administrator provided an untitled/undated document and indicated it was the list of medications available in the EDK. The list indicated aspirin 81 mg chewable tablets were available. On 12/3/25 at 1:10 p.m., the Administrator provided a document titled, Medication Administration, dated February 2017, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: To administer all medications safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms, and help in diagnosis.Procedure.11. Read and follow any special instructions written on labels.17. Give the resident the medication.24. If the medication is ordered but not present, call the pharmacy or supervisor to obtain the medication. On 12/3/25 at 1:10 p.m., the Administrator provided a document titled, Inhalation (Oral and Nasal) Administration, dated July 2024, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: Oral.inhalation medication will be administered according to physician's orders using safe and sanitary practices. Procedures: Oral Inhalation.2. Check the product directions, and shake inhaler well before each use of manufacture directions allow.6. Ask the resident to: a. Exhale completely b. Breathe in deeply and slowly through his/her mouth while fully depressing the top of the canister with index finger c. Hold his/her breath as long as it is comfortable before exhaling.8. If more than one inhalation is ordered, wait one minute, and then repeat steps 2 through 7 above for each inhalation ordered. 9. If specified by the manufacture, rinse patient's mouth with water after last inhalation. 3.1-48(c)(1)

Based on record review and interview, the facility failed to document resident refusal or justification for holding insulin, and failed to document notification to the physician for 1of 1 resident reviewed for unnecessary medications (Resident 8). Findings include:On 12/04/25 at 10:00 a.m., the medical record of Resident 8 was reviewed. The resident was admitted to the facility on [DATE]. Diagnosis included but was not limited to, type 2 diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high). A quarterly Minimum Data Assessment (MDS), dated [DATE], indicated the resident was cognitively impaired and received daily insulin injections. A care plan, dated 11/22/22, indicated diabetes with risk for hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar). Interventions included, but not limited to, antidiabetic medications per order, and notify physician and family as needed. A physician order, dated 7/24/25, indicated to administer Lantus SoloStar Solution Pen-injector 100 UNIT/ML (Insulin Glargine) inject 10 unit subcutaneously (under the skin) at bedtime for diabetes mellitus. The medication administration record for the months of October 2025 and November 2025 indicated Lantus insulin was not administered on 10/30/25, 11/1/25, 11/2/25, and 11/27/25. The record lacked documentation of resident refusal, justification for holding the insulin, or notification to the physician. On 12/3/25 at 1:50 p.m., during an interview the Director of Nursing (DON) indicated if a nurse would hold an insulin administration it would depend on the resident if the nurse would need to notify the physician. She indicated it would be the same for holding Lantus insulin. On 12/4/25 at 10:19 a.m., during an interview with Registered Nurse (RN) (12) the nurse indicated she would write a progress note and notify the physician of the request to hold insulin, and she would notify the physician if a resident refused insulin. On 12/4/25 at 10:22 a.m., during an interview RN (13), indicated she would notify the physician and ask for parameters to hold insulin. She indicated she would notify the physician if a resident refused to allow administration of insulin. She indicated Resident 8 did not often refuse her insulin. On12/4/25 at11:27 a.m., the provided an undated document, titled, Physician Orders - (following physician orders), and indicated it was the policy currently being used by the facility. The policy indicated, .Policy.It is the policy of the facility to follow the orders of the physician. 3.1-50(a)

Based on observation, record review, and interview, the facility failed to ensure hand hygiene was performed during the medication pass for 3 of 4 residents reviewed on the medication pass (Residents 19, 26, and 67). Findings include: During a continuous medication pass observation, on 12/3/25 from 9:31 a.m. to 9:52 a.m., the following was observed. -Registered Nurse (RN) 12 prepared and administered medication to Resident 19. The medication included a nasal spray, two inhalers, and application of lidocaine patches (topical pain reliever). RN 12 wore gloves during the medication administration but did not perform hand hygiene before, or after, the medication administration. -RN 12 then prepared and administered medication to Resident 26. No hand hygiene was performed before or after the medication administration. -RN 12 then prepared and administered medication to Resident 67. The medication included eye drops. RN 12 wore gloves while administering the eye drops but did not perform hand hygiene before, or after, the medication administration. During an interview, on 12/3/25 at 9:56 a.m., RN 12 indicated she should have used hand sanitizer between residents. During an interview, on 12/3/25 at 10:59 a.m., the Director of Nursing (DON) indicated the staff should have used hand sanitizer between residents. She was not sure when they would have to wash their hands instead of using hand sanitizer, but she would check the policy. During an interview, on 12/4/25 at 1:45 p.m., the Infection Preventionist (IP) indicated hand sanitizer should have been used between residents on the medication pass and after procedures that required gloves. On 12/3/25 at 1:10 p.m., the Administrator provided a document titled, Medication Administration, dated February 2017, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: To administer all medications safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms, and help in diagnosis.Before the Medication Pass.2. Cleanse your hands before beginning and before contact with each resident.Procedure: 1. Wash hands before beginning, whenever you contaminate your hands, and if contact is made with the medication. On 12/3/25 at 1:10 p.m., the Administrator provided a document titled, Inhalation (Oral and Nasal) Administration, dated July 2024, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: Oral and nasal inhalation will be administered according to physician's orders using safe and sanitary practices. Procedures: Oral Inhalation: 1. Cleanse hands before and after medication administration.Nasal Inhalation: 1. Cleanse hands before and after medication administration. On 12/3/25 at 1:10 p.m., the Administrator provided a document titled, Eye Drop Administration, dated July 2024, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: The appropriate and safe administration of liquid ophthalmic medication (eye drops).for therapeutic treatment, or for help in the production of tears. Procedure.2. Proper hand washing before and after administration of medication. 3.1-18(l)

Based on observation, interview, and record review, the facility failed to honor a resident's preference regarding meal service for 1 of 3 records reviewed for quality of care (Resident C). Findings include: During a wound care observation on 5/14/25 at 1:59 p.m., accompanied by LPN 5 and the Assistant Director of Nursing (ADON), the resident indicated he had lunch in the dining room, but he would rather eat in his room. The staff made him go to the dining room for all meals. The ADON indicated to the resident that he knew why they liked him to go to the dining room and smiled at him. He indicated to the ADON that he could eat on his own without problems. The clinical record for Resident C was reviewed on 5/14/25 at 9:49 a.m. Diagnoses included hypertensive heart disease without heart failure, dysphagia, anxiety disorder, major depressive disorder, diabetes mellitus type II, and obesity. A significant change Minimum Data Set (MDS) assessment, dated 4/21/25, indicated the resident had was cognitively intact, required partial moderate assistance with eating, and was receiving hospice care. He had no impairment of range of motion of his upper extremities and was dependant on staff for transfers. He felt down, depressed and hopeless daily and found little pleasure or interest in doing things. He had no delusions, hallucinations or rejection of care. A current health care plan, dated 4/4/23, indicated the resident had a diagnosis of malnutrition and muscle wasting. Interventions included to assist the resident with setting up his tray at meals as needed. A current health care plan, dated 4/22/19, indicated the resident was at risk for increased anxiousness related to his diagnoses of anxiety. Interventions included to offer him choices. A speech therapy discharge summary, dated 4/10/25, indicated to facilitate safety and efficiency, it was recommended the resident use general swallow techniques/precautions, alternation of liquid and solids, and rate modification. The resident should sit upright during meals and upright posture for greater than 30 minutes after meals. The resident should have close supervision during meals. A physician's order, dated 3/27/25, indicated the resident's diet texture as pureed and nectar thick liquids. The order was discontinued on 4/14/25. A current physician's order, dated 4/14/25, indicated the resident's diet texture as regular and thin liquids. A Client Coordination Note Report, dated 4/14/25, from the hospice provider included that the resident indicated he could feed himself, but sometimes he had a hard time getting hand to mouth during meals. The nurse educated the resident regarding the risk of aspiration (inhaling food particles and liquids into the lungs) with a regular textured diet and thin liquids. The resident verbalized his understanding and awareness, but requested a regular textured diet and thin liquids. During a telephone interview on 5/15/25 at 1:08 p.m., the hospice nurse case manager indicated she had educated the resident regarding his risk for choking and he made it clear that he wanted to eat in his room. He had indicated he had not gone to breakfast because he had not wanted to go to the dining room. She had spoken to the staff regarding his comment that he had not been eating breakfast because he does not want to go to the dining room. The staff indicated it was the policy that he would have to go to the dining room during meals due to him being a choking risk. A review of Resident C's meal intake record indicated the resident had refused breakfast 17 times, lunch 3 times, and dinner 5 times, over a 28 day period. During an interview on 5/14/25 at 3:10 p.m., the DON indicated all residents who were assisted to eat were required to eat in the dining room for meals. During an interview on 5/15/25 at 10:53 a.m., Resident C indicated it was embarrassing for him to eat in the dining room because he can be a messy eater. It was also embarrassing having staff helping him to eat his meals. His preference has always been to eat in his room. He was aware of his risk for aspiration, but would really prefer to eat in his room and it had upset him being made to go to the dining room for all his meals. During an interview on 5/15/25 at 10:59 a.m., Resident C's spouse indicated she felt her husband should be able to eat in his room despite the risk of him choking. He had always eaten in his room since he admitted to the facility and that was what he wants to do now. During an interview on 5/15/25 at 12:16 p.m., the DON indicated it was safer for Resident C to go to the dining room for meals, and he had been pushed and encouraged to go to the dining room. Behaviorally, Resident C did what he wanted or did not do what he did not want to do. He was struggling with acceptance of needing more staff help. During an interview on 5/15/25 at 12:25 p.m., the Administrator indicated the other residents who require assistance to eat want to go to the dining room. This had been a non-issue. Resident C had not wanted a pureed texture diet and as his health had declined, he had become more behavioral. He struggled to accept his need for increased staff assistance. He had been accepting of going to the dining room for meals unless his family was present, then he would put on a better show and became more argumentative. When he had an audience, he became less agreeable to going to the dining room for meals. A current facility policy, dated 7/12/13, titled, Guidelines for Observing and Implementing - Resident Rights, provided by the Administrator on 5/15/25 at 2:49 p.m., indicated the following: .Procedure: .7) It is important that staff be aware of the Resident Rights to include, but not limited to: .Self-determination - residents should control their own lives - as much as is possible with consideration of any physical, mental, emotional, social or cognitive deficits .Residents must have the ability to exercise their Resident Rights as a citizen of the United States This Federal tag relates to Complaint IN00458584. 3.1-3(a)(1)

Based on record review and interview, the facility failed to ensure a reweight was completed for a resident with a significant weight change for 1 of 3 residents reviewed for nutrition (Resident 47). Findings include: Resident 47's record was reviewed on 9/26/24 at 10:48 a.m. The profile indicated the resident's diagnoses included, but were not limited to, vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), chronic pain syndrome (symptoms beyond pain alone, like depression and anxiety, which interfere with one's daily life), and need for assistance with personal care. A physician's order, dated 1/27/22 indicated to provide the resident a general diet, regular texture, and thin liquids. A quarterly Minimum Data Set (MDS) assessment, dated 8/21/24, indicated the resident had severe cognitive deficit, was on a therapeutic diet, and had both a 5% or more in 1 month or 10% or more in 6 months weight loss and weight gain documented. A care plan, dated 7/8/22, indicated the resident was at increased nutritional risk secondary to diagnoses of dementia and mild depression. Interventions included, but were not limited to, weigh the resident monthly and as needed. Review of the resident's 6-month weight history indicated the resident weighed 122.5 pounds (lbs) on 6/2/24 and had decreased to 111.5 lbs on 7/1/24. The resident's weight loss was 11 lbs or 8.98 percent (%). The weight history lacked documentation that the resident had been reweighed after the significant decrease in her weight was noted. A nutrition at risk (NAR) progress note, dated 7/4/24, indicated the resident was being monitored due to a significant weight loss. The resident had triggered for significant weight loss of 9.00% in the past 30 days. An order to receive house shakes (drinks which were fortified with essential vitamins, minerals, protein, and fiber to help support overall health and well-being) three times daily (TID) and add weekly weights to ensure weight stabilization. The note lacked documentation of any reweight of the resident being completed. A NAR progress note, dated 7/11/24, indicated a Registered Dietician (RD) follow-up for significant weight loss of 9.4% in 30 days, 7.9% in 90 days and 12.3% in 180 days. A 0.5% weight loss was noted since last review on 7/4/24 and was considered fairly stable. Recommended to continue with house shakes and weekly weights. The note lacked documentation of any reweight of the resident being completed. A NAR progress note, dated 7/17/24, indicated an RD follow-up for significant weight loss. The resident had triggered for an 8.1 % weight gain since recent weight loss. Possible weight inaccuracy related to wheelchair weighing would be confirmed through weekly weights. Recommended to continue with house shakes and weekly weights. The note lacked documentation of any reweight of the resident being completed. During an interview, on 9/26/24 at 3:45 p.m., Registered Nurse (RN) 7 indicated it was her understanding if a resident had a significant weight discrepancy from one weigh to another, the staff would reweigh the resident as soon as the discrepancy was discovered. The nurse would also assess the resident for any edema or anything else that may have caused the weight fluctuation. During an interview, on 9/26/24 at 3:48 p.m., RN 8 indicated the staff should reweigh any resident immediately if there was a significant discrepancy in a weight from one weight to another. On 9/26/24 at 3:20 p.m., the Director of Nursing (DON) provided a document, dated 4/2017, titled, Weights, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure .Nursing will notify the dietician or designee of any significant weight changes .A reweight will be obtained and recorded for all significant weight changes 3.1-46(l)

Based on record review and interview, the facility failed to ensure a pharmacy recommendation had been addressed in a timely manner for 1 of 5 residents reviewed for unnecessary medications (Resident 35). Findings include: Resident 35's record was reviewed on 9/26/24 at 9:40 a.m. The profile indicated the resident's diagnoses included, but were not limited to, Alzheimer's disease late onset (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks that occurs after [AGE] years of age). A quarterly Minimum Data Set (MDS) assessment, dated 5/1/24, indicated the resident had severe cognitive deficit and received no scheduled or as needed (PRN) pain medication. A quarterly Minimum Data Set (MDS) assessment, dated 8/5/24, indicated the resident's cognitive status was unable to be assessed and she received no scheduled or PRN medication. A care plan, dated 12/2/23, indicated the resident had the potential for pain. Interventions included, but were not limited to medications as ordered. A pharmacy recommendation, dated 2/12/24, indicated the resident had two PRN orders for acetaminophen (medication used to relieve pain and/or fever). The orders indicated to administer two 500 milligrams (mg) tablets of acetaminophen every 6 hours PRN and a second order to administer two 325 mg tablets of acetaminophen every 4 hours PRN. The recommendation was to discontinue one of the orders to prevent possible overdose. The form lacked documentation that the physician had addressed the recommendation and lacked a signature and date of when the physician had reviewed the recommendation. A pharmacy recommendation, dated 6/9/24, indicated a second notice that the resident's two PRN for the acetaminophen were still in the resident's physician orders. The physician documented that he agreed with the recommendation and had ordered the discontinuation of the administration of the two 500 mg tablets of acetaminophen every 6 hours PRN. The physician signed and dated the form on 6/18/24. A historical review of the resident's physician's orders indicated the medication had been discontinued on 6/18/24. During an interview, on 9/26/24 at 1:17 p.m., the Administrator (ADM) indicated the pharmacy recommendation, dated 2/12/24, had not been addressed by the Director of Nursing (DON) or the physician. The Pharmacist had written the recommendation again on 6/9/24. This recommendation was addressed as required. She was not aware why the initial recommendation had not been addressed. Pharmacy recommendations were to be addressed as soon as they were received. On 9/26/24 at 2:50 p.m., the ADM provided an undated document titled, Distribution of Medication Regimen Review Report, and indicated it was the policy currently being used by the facility. The policy indicated, Policy: .Each recommendation must be acted upon. Procedure: .3. The report will be directed to the Director of Nursing. 4. The attending physician and/or Medical Director will document their review and response to the recommendation .directly on the medication regimen review form 3.1-48(a)(1)

Based on observation, interview, and record review, the facility failed to ensure adequate sanitation of drinking glasses, pitcher, and kitchen equipment for 2 of 2 kitchen observations, and failed to ensure snacks were served in a sanitary manner for 1 of 1 random snack distribution observation. Finding includes: 1a. On 9/24/24 at 9:53 a.m., during initial kitchen tour, a thick white cloudy substance was observed on the inside surface of a 2-gallon pitcher. The pitcher was used to make lemonade, juice, and or tea for the residents. A thick cloudy substance was observed on a sink in the kitchen. The white substance was noted on the faucet base and went down into the inside of the sink. During an interview, on 9/25/24 at 10:41 a.m., Resident 21 indicated the plastic glasses that come from the kitchen were filthy and he did not like to drink out of them. During an interview, on 9/26/24 at 11:54 a.m., the Dietary Manager indicated she was aware of the facility having an issue with lime deposits on the plastic glasses and the 3-compartment sink. They had checked the salt levels to make sure it was at the appropriate level. They had tried running bleach through the dishwasher and used a de-[NAME] solution which had worked. The only way she had been able to remove the lime on the drinking cups was to have staff scrub each individual cup by hand and she did not have the staff to be able to do that. During an interview, on 9/27/24 at 8:53 a.m., Registered Nurse (RN) 7 indicated they have had issues in the past with lime deposits on the drinking glasses on the closed unit, but they had purchased new ones, and she hadn't noticed an issue lately. During an interview, on 9/27/24 at 9:00 a.m., Resident 6 indicated she had noticed a white cloudy substance on the drinking glasses, and it had been an issue for a while. During an interview, on 9/27/24 at 9:01 a.m., Resident 37 indicated she had noticed a white cloudy substance on the inside of the drinking glasses ever since she had been there. She indicated she had been at the facility for a few weeks. During an interview, on 9/27/24 at 9:04 a.m., Resident 32 indicated she had noticed a white cloudy substance on the inside of the drinking glasses for as long as she could remember, and she thought it was because of the hard water. She indicated at home she would use vinegar water to treat it. 1b. On 9/27/24 at 10:50 a.m., during a second kitchen observation, a thick white cloudy substance was observed on the inside of several plastic drinking cups stored on 3 pallets full of drinking cups. The Dietary Manager held up two of the plastic drinking cups and both contained a thick white cloudy substance. During an interview, on 9/27/24 at 10:55 a.m., the Dietary Manager, indicated they tried to run a de-[NAME] solution through the dishwasher once a week. She had considered purchasing glass cups if the lime did not come off the plastic cups. During an interview, on 9/27/24 at 10:56 a.m., [NAME] 13 indicated they needed to run the de-[NAME] solution through the dishwasher again because the glasses were getting bad. He indicated the de-[NAME] was ran through about once or twice a month. During an interview, on 9/27/24 at 11:38 a.m., the Administrator indicated she had hard water at home, and she believed that was why they had issues with lime at the facility. During an interview, on 9/27/24 at 2:18 p.m., the Administrator indicated the kitchen had a schedule for the de-liming to be done twice a week. She indicated the cleaning list was check marked as if it had been completed. During an interview, on 9/30/24 at 1:30 p.m., the Administrator indicated they had a service man come to the facility over the weekend to look at the dishwasher and he did not identify a concern with the equipment, but he did take a plastic glass from the facility to run some tests on it. She indicated she had not received a lab report yet from the company. On 9/27/24 at 12:00 p.m., the Administrator provided an undated document, titled, Sanitizing Equipment and Food Contact Surfaces, and indicated it was the policy currently being used by the facility. The policy indicated, .Employees shall sanitize equipment and food contact surfaces utilizing proper sanitizing solution .3. Sanitizing solutions are changed in accordance with manufacturer instructions or when the become visibly soiled. In general, each should prepare fresh solutions 2. During a random snack distribution observation, on 9/26/24 at 9:39 a.m., Activity Aide 14 was on the closed unit and was removing an oatmeal cream pie from its plastic packaging and removing the snack with her bare hands and handed one to a female resident. Activity Aide 14 proceeded to hand two other residents an oatmeal cream pies in the same manner as the first one. The activity aide was not observed using gloves or hand sanitizer during the observation. During an interview, on 9/27/24 at 9:35 a.m., Certified Nurse's Assistant (CNA) 15 indicated she would place on a pair of gloves when serving a resident a food item or use the plastic cover to hand the resident the item. The CNA indicated staff should not touch food with their bare hands. On 9/27/24 at 11:31 a.m., the Administrator provided a documented with a date of 4/2017, titled, Food Safety and Sanitation, and indicated it was the policy currently being used by the facility. The policy indicated, .The facility will practice safe food handling and avoid cross contamination through proper use of gloves .The Food and Nutrition Department Manager or designee will ensure that employees practice proper use of gloves .Single-use gloves should be used, and bare-hand contact must be avoided when handling ready to eat food 3.1-21(i)(3)

A. Based on observation, interview, and record review, the facility failed to ensure proper handwashing in the kitchen, and sanitary practices while pureeing foods and measuring the temperature of food to be served from the kitchen, during 4 of 4 kitchen observations. This deficient practice had the potential to effect 11 of 11 residents who received pureed food, and 63 of 63 residents who received food from the kitchen. B. Based on observations, interview, and record review, the facility failed to use proper hand hygiene when 3 certified nursing aides (CNA's) were observed assisting 6 residents to eat during 1 of 2 dining room observations (Residents 34, 36, 14, 30, 9, and 37). Findings include: A1. During a random continuous observation of the kitchen, on 8/7/23 from 10:07 a.m. to 10:31 a.m., Dietary Aide 5 was observed taking a soiled drinking pitcher from the dining room window and without wearing gloves, removed the soiled straw by the mouthpiece and tossed it in an open garbage container positioned partially under a stainless steel drain board (area for scraping or rinsing food into garbage containers or disposer). Dietary Aide 5 loaded a plastic rack with soiled dishes and ran it through the dishmachine (warewashing machine). She then went to the refrigerator and removed a drink pitcher and poured an unidentified pink liquid into multiple clean plastic glasses being prepared for the next meal. Dietary Aide 5 went back to the dishwashing area and scrubbed out a soiled pan. She then set up drinks and prepared trays with cereal, napkins, and silverware on lunch meal trays. Dietary Aide 5 was not observed to be wearing gloves or to wash her hands during the observation as she moved back and forth between the dirty dishmachine area and clean food preparation areas where she assisted the day cook by touching items on the counters and in the refrigerator, clean glasses, trays, and silverware. On 8/7/23 at 10:10 a.m., Dietary Aide 5 indicated as there were just 2 staff members in the kitchen at this time, she was responsible for washing dishes and helping with whatever was needed in the kitchen. On 8/7/23 at 10:10 a.m., a garbage container in the kitchen was positioned partially under a stainless steel drain board in the dirty dishmachine area, the lid was on the ground under the drain board against the wall. Subsequent observations of the kitchen on 8/10, and 8/14 indicated the garbage container with soiled paper products and food, was never observed to be covered with a lid. On 8/10/23 at 11:01 a.m., Dietary Aide 18 was observed to be making peanut butter and grape jelly sandwiches. She then removed her gloves, threw the gloves and other items into an open garbage container, then moved the garbage container underneath the drain board with her bare hands. Dietary 18 then returned to the workstation, poured leftover jelly into a pan, covered the pan with plastic wrap, and placed the pan in the refrigerator. She was not observed to wash her hands after removing her gloves, touching the garbage container, and then pouring the jelly into a pan and placing it in the refrigerator. On 8/10/23 at 11:03 a.m., Cook 19 was observed to enter the kitchen, walk through the food preparation area, entered the dietary office, and back to the food preparation area where she obtained and donned a hair net from a cabinet containing spices. Cook 19 was observed to wash her hands, she turned the faucets on and off with her bare hands. Observation of the dietary staff washing their hands, indicated, a. On 8/10/23 at 1:47 p.m., Dietary Aide 19 was observed to wash her hands, she turned the faucets on and off with her bare hands. Subsequent observations of hand washing on this date at 1:53 p.m., 1:58 p.m., and 2:02 p.m., she was observed to turn the faucets on and off with her bare hands. b. On 8/10/23 at 2:08 p.m., Dietary Aide 5 was observed to wash her hand for less than 5 seconds, she turned the faucets on and off with her bare hands. c. On 8/10/23 at 2:08 p.m., Dietary Aide 20 was observed to wash his hands, he turned the faucets on and off with his bare hands. A second observation of the dietary staff washing their hands, indicated, a. On 8/14/23 at 10:23 a.m., Dietary Aide 5 was observed to wash her hands, she turned the faucets on and off with her bare hands. b. On 8/14/23 at 10:24 a.m., Cook 19 was observed to wash her hands, she used a towel to dry her hands, used the same wet paper towel to turn off the faucets. She was not wearing a hair net. c. On 8/14/23 at 10:32 a.m., Cook 19 was observed to wash her hands, she used a towel to dry her hands, used the same wet paper towel to turn off the faucets. She was observed to then don a hair net. d. On 8/14/23 at 10:37 a.m., Cook 19 was observed to wash her hands, she used a towel to dry her hands, used the same wet paper towel to turn off the faucets. e. On 8/14/23 at 10:40 a.m., Dietary Aide 20 was observed to wash his hands, he used a paper towel to dry his hands, used the same wet towel to turn off the faucets. A handwashing poster taped above the kitchen handwashing sink indicated, wash your hands with soap and water for at least 20 seconds, there were no further instructions. During an interview on 8/14/23 at 10:43 a.m., the Dietary Manager (DM) indicated staff were required to have hair nets on before entering the kitchen that was why hair nets were stored outside the kitchen for easy access. Proper hand washing procedure included turn on the water with a dry paper towel, let the water flow a few seconds to clear the water and bring it up to temp, wash hands for 20 - 30 seconds, leave water running while using a paper towel to dry hands, then turn off faucets with a new dry paper towel. Staff were to make sure hands were dry before donning gloves, and hands were to be washed every time gloves were changed. The dishwasher was to wash their hands between washing dishes and helping in the rest of the kitchen, as they were going from dirty to clean areas. The garbage containers were supposed to always have a lid on when not in use. A2. On 8/14/23 at 10:20 a.m., Cook 19 was observed mixing food in a large metal bowl, indicated she was making spaghetti sauce for dinner. The cook was not wearing a hair net. On 8/10/23 at 2:10 p.m., Cook 19 was observed to check the temperature of and puree beef stroganoff for dinner. She was observed to remove a food thermometer from a basket that contained items to include thermometers, pens, and scissors. Cook 19 was not observed to clean the thermometer before putting it into the beef stroganoff and temping the food at 164 degrees Fahrenheit (F), she indicated it should be 165 F. Food temperatures were not observed to be logged. On 8/14/23 at 10:30 a.m., Cook 21 was observed checking the temperature of meat in the oven. She was observed to clean a thermometer by rubbing an alcohol prep up and down the thermometer probe, then laid the thermometer on a food tray on the island among other cooking utensils without replacing the thermometer probe cover. Cook 21 demonstrated the technique for cleaning a food thermometer and checking the temperature of meat. Indicated, remove thermometer cover, and clean the probe with an alcohol prep. Place the probe into the center of product, wait until the digital numbers stop moving, then clean probe ready for next temp. Demonstrated cleaning thermometer probe by running alcohol prep up and down the probe multiple times. On 8/14/23 at 10:39 a.m., Cook 21 was observed checking the temperature of a tray of meat, she did not clean the thermometer after having been laid without the probe cover on a tray among other cooking utensils. She was observed to remove a second tray of meat from the oven, put the meat into a metal pan and placed it on the steam table, she was not observed to check the temperature of the 2nd tray of meat. The food temperatures were not observed to be logged. On 8/14/23 at 11:03 a.m., review of food temperature logs with the DM, dated 8/7/23 - 8/14/23. The food temperature logs lacked documentation of temperatures observed for lunch food on 8/14/23 that had been observed being placed on the steam table. The DM indicated, cooks were only documenting final temperatures before food was served, they did not document holding temperatures. DM indicated she had been instructed by a regional supervisor, only final temperatures needed logged, they were not required to log holding temps. Acknowledged, by using this process, cooks would have no way of knowing if food dropped below acceptable holding temperatures, or if the food would need to be re-heated or re-cooked. Food temperature logs, dated 8/7 - 8/14, indicated the column titled final internal preparation temperatures were filled out with food temperatures. The 2 columns titled meal service holding temps were blank on all forms. The forms also lacked re-temping documentation, time food temperatures were checked, or initials of person temping the food as instructed on the form. During an interview on 8/14/23 at 10:43 a.m., the DM indicated, when the cook was checking the temperatures of food, the thermometer was calibrated every day to reset by putting the thermometer into cold and hot water. The food thermometer was cleaned before and after temping food with alcohol wipes or with sanitizer. The entire thermometer was to be cleaned from the top (handheld area) to tip of the probe, then cleaned with a 2nd wipe from probe to tip. The cleaning prep was not to be rubbed up and down, potentially re-contaminating the probe. Let the thermometer dry before use. Probe was inserted into the thickest part of the food, wait for the digital temperature to stop, and record the temperature on the food log. If food was not hot enough, the food was to be reheated and re-temped before being placed on the steam table or being served. The thermometer was to be stored in the thermometer sleeve between uses, it was not appropriate to lay the thermometer down without the cover on the counters or among other kitchen items where it could get exposed to contaminants. The cook was supposed to check the temperature of food when placing it on the steam table, every 30 minutes while holding, and again before serving. Food on the steam table was not supposed to be held for more than 2 hours or if the food dropped below 135 F. Food temperatures were supposed to be logged every time taken. If food temperatures dropped below 135 F on the steam table, the food must be tossed and recooked. On 8/14/23 at 3:15 p.m., the Regional Director of Operations indicated, to his knowledge the dietary staff did not calibrate the food thermometer before using to temp food, they just turned it on and used. There was no policy, procedure, or staff training documentation on calibrating or cleaning of the food thermometers. A3. Dining room mealtimes were posted at dining room entrance, indicated breakfast at 6:45 a.m., lunch at 11:45 a.m., and dinner at 4:45 p.m. On 8/10/23 at 11:15 a.m. Cook 19 indicated she tried to have all food pureed for the evening meal by 2:00 p.m. On 8/10/23 at 2:10 p.m., Cook 19 was observed to scoop beef stroganoff into a metal container to puree and put the remaining pan of stroganoff onto the steam table. Cook 19 scooped the stroganoff into a blender using a rubber spatula, turned on the blender, checked the consistency of the stroganoff, then retrieved 2% milk from the refrigerator at the prompting of the Administrator (ADM) and added it to the puree mixture. Cook 19 then used the rubber spatula to scrape the stroganoff from the blender into a pan, used her finger to remove the stroganoff from the spatula into the pan, and removed food that was on the rim of the pan with her finger and put it into the pan. Cook 19 was observed to wear the same gloves from the time she took the stroganoff from the oven, through the pureeing process, while retrieving milk from the refrigerator, and while scooping food with her fingers into the serving pan. She was not observed to replace her gloves or wash her hands during the observation. On 8/14/23 at 1:46 p.m., ADM provided copy of pureed list of residents, indicated on this date there were 11 residents receiving pureed diets. There were no residents receiving nutrition via tube feeding, and 52 residents were receiving regular diets. During an interview on 8/14/23 at 10:43 a.m., the DM indicated when the cook pureed vegetables, she was required to first assure the internal temperature of the food. Food was then taken and put into the food processor, food was pulsed to texture, she was to follow the recipe for what was used to thin food as needed, re-temp the food after adding liquid, and if food was too thin add bread. The food was scooped out of the food processor into a metal pan and placed on the steam table. Staff were not allowed to use their hands to scoop food off the spatula or outside of pan to put excess food into the pan that was to be served to residents. On 8/11/23 at 2:30 p.m., the ADM provided a Monitoring Food Temperatures for Meal Service policy, dated 2017, and indicated the policy was the one currently being used by the facility. The policy indicated, Food temperatures will be monitored daily to prevent food borne illness and to ensure foods are served at palatable temperatures .2. The temperature for each food item shall be recorded on the Food Temperature Log. Foods that require a corrective action, like reheating; will have the new temperature recorded on the log .3. Proper procedures are used to ensure measured temperatures are accurate and contamination is avoided. a. A properly functioning, calibrated thermometer is used when taking temperatures .b. Thermometers are clean, rinsed, and sanitized before and after each meal use. An alcohol swab may be used to sanitize between uses during the same meal. c. When taking temperatures, the thermometer is inserted in the thickest part of the food .4. If hot food is not 135 F or higher when checked, they will be reheated to at least 165 F for a minimum of 15 seconds. The item may be reheated only once and must be discarded or consumed within 2 hours . Indiana State Department of Health, Food Protection Program (October 29, 2022), also retrieved 8/16/23 at United States Dietary Association (USDA.gov), indicated instructions for thermometer calibration by using the ice point method when placing thermometer into a container of ice water at 32 F, or boiling point method when putting thermometer into water that reaches a complete rolling boil at 212 F. Either method should permit calibration to within 1.0 F. Remember: sanitize thermometers before use and in between uses, and calibrate thermometers frequently. Retail Food Establishment Sanitation Requirements, effective November 13, 2004, hand cleaning and drying procedure indicated clean hand and exposed portions of arms with a cleaning compound at a handwashing sink that is equipped as specified, by vigorously rubbing together the surfaces of their lathered hands and arms for at least 20 seconds. Hands should be washed after handling soiled surfaces, equipment, and utensils. During food preparation, as often as possible to remove soil and contamination and to prevent cross-contamination when changing tasks, when touching food and food-contact surfaces, before placing gloves on hands, and after engaging in other activities that contaminate the hands. 48226 B1. On 8/7/23 at 12:00 p.m., during the noon meal service observed Certified Nurse Aide (CNA) 3 feeding Resident 34 while feeding a second resident at the same time. The CNA failed to disinfect her hands between residents. The admitted resident 34 was on 9/20/22. A quarterly Minimum Data Set (MDS) assessment (a standardized assessment tool that measures health status in nursing home residents), dated 7/3/23, indicated the resident required extensive assistance of one person to eat. On 8/7/23 at 12:00 p.m., during the noon meal service observed CNA 3 feeding Resident 36 while feeding a second resident at the same time. The CNA failed to disinfect her hands between residents. The admitted resident 36 was on 3/12/21. A quarterly MDS, dated [DATE], indicated the resident required extensive assistance of one person to eat. 34129 B2. During an observation of lunch dining service in the main dining room, on 8/7/23 at 12:06 p.m., Certified Nursing Assistant (CNA) 24, assisted Residents 14 and 30 with eating their food, without hand sanitation and after touching the residents' clothing, the residents' wheelchairs, and wiping her hands on her pants, after giving bites of food to the residents. B 3. During an observation of lunch dining service in the main dining room, on 8/7/23 at 12:09 p.m., Certified Nursing Assistant (CNA) 16, assisted Residents 9 and 37 with eating their food, without hand sanitation and after touching the residents' clothing, the residents' wheelchairs, and wiping her hands on her pants and touching her face, after giving bites of food to the residents. On 8/8/23 at 8:35 a.m., the Administrator (ADM) indicated staff should sanitize their hands with alcohol-based hand gel between assisting each resident with their meal. At that time, the ADM provided and identified an undated document as a current facility policy, titled, Dignity. The policy indicated, .As an extension of appropriate interactions between staff and residents, the following will be practices of the facility .Dining .10.) When feeding resident(s), only 2 resident can be fed at once. Hand hygiene must take place if staff touch one of these residents; prior to going back to assisting the other of the two residents 3.1-21(a)(2) 3.1-21(i)(1) 3.1-21(i)(3)

A. Based on observation, interview, and record review, the facility failed to ensure proper handling of oral and eye drop medication for 2 of 2 residents observed during the medication administration observation (Residents 63 and 42). B. Based on observation, interview, and record review, the facility failed to ensure hand sanitization was performed in between glucometer blood testing for 3 of 3 residents observed during medication administration (Residents 52, 27, and 41). Findings include: A1. During a medication administration observation, on 8/10/23 at 9:14 a.m., RN 11 was administering eye drops to Resident 63. The RN administered the eye drops to the resident with her bare hands. The resident received a drop in each eye and the nurse touched underneath each eye with her bare finger. During an interview, on 8/10/23 at 11:40 a.m., Director of Nursing (DON) indicated she would need to pull the policy on rather staff were to wear gloves during eye drop administration. Resident 63's record was reviewed on 8/10/23 at 3:30 p.m. The profile indicated the resident's diagnosis included, but were not limited to, unspecified glaucoma (a group of eye conditions that can cause blindness). A physician order, dated 6/20/23, indicated Alphagan P Ophthalmic Solution 0.1% (eye drop medication for glaucoma), instill 1 drop in both eyes two times a day. A2. During a medication administration observation, on 8/10/23 at 9:25 a.m., RN 11 was preparing oral medications for Resident 42. The RN placed a potassium pill into a cup and she touched the pill with her bare hands to break it in half. She placed water into the cup with the pill to help dissolve the pill. RN 11 indicated it helped the resident to swallow the pill if it was not whole. During an interview on 8/10/23 at 11:40 a.m., DON indicated staff was not to touch oral medication with their bare hands. Resident 42's record was reviewed on 8/10/23 at 2:57 p.m. The profile indicated the resident's diagnosis included, but were not limited to, hypokalemia (a blood level that is below normal in potassium, an important body chemical). A physician order, dated 4/12/23, indicated Potassium Chloride extended release 20 milliequivalent (meq), give 1 tablet by mouth two times a day. On 8/10/23 at 1:20 p.m., the Administrator (ADM) provided an undated document, titled, Eye Medications, Administration of, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure:1. Put on gloves On 8/10/23 at 4:15 p.m., the ADM provided a document, dated March 2023, titled, 5.1: Drug Administration General Guidelines, and indicated it was the policy currently being used by the facility. The policy indicated, .a. A tablet splitter is used to avoid contact with the tablets 48226 B1. On 8/07/23 at 11:56 a.m., observed Licensed Practical Nurse (LPN) 4, assisted Resident 52 in his wheelchair, from the main dining room, and wheeled him into the main hallway in front of the reception desk. The LPN donned (for to (put) on) gloves and cleaned a glucometer machine (an instrument for measuring the concentration of glucose in the blood) with disinfectant wipes. The nurse picked up the glucometer, a testing strip, and a lancet and stuck the resident's finger with a lancet, obtained a blood sample and completed the glucometer reading. She cleaned the finger of the resident with an alcohol prep pad (a two-layer pad which contain 70% isopropyl alcohol. Prep Pads help clean the skin and can be used on cuts, scrapes, and abrasions prior to bandaging), and assisted the resident back to the dining room. The nurse failed to remove soiled gloves, sanitize hands and donned clean gloves prior to completing the blood glucose test. On 8/14/23 at 11:43 a.m., record review resident had diagnosis's of but not limited to, type 2 diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high) with diabetic chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should) dated 4/7/2022. Type 2 diabetes mellitus with diabetic neuropathy (a type of nerve damage that can occur if you have diabetes) dated, 7/26/2023. A care plan dated 10/12/22, indicated, the resident had a diagnosis of diabetes with risk for Hypo/or Hyperglycemia. Nursing intervention dated, 10/12/22 check blood sugars per order. 34129 B2. On 8/7/23 at 11:28 a.m., Resident 27 was observed propelling herself down the main hallway, when Licensed Practical Nurse (LPN) 4 asked Resident 27 to stop at the medication cart to complete a blood glucose test (measures how much sugar was in the blood). LPN 4 donned (put on) gloves, without sanitizing her hands, retrieved a glucometer (a device for measuring the concentration of glucose (sugar) in the blood by using a small drop of blood, placed on a disposable test strip in the glucometer) from the medication cart, cleaned the glucometer machine with a disinfectant wipe, and placed the glucometer directly onto the medication cart, without a barrier. LPN 4 cleaned Resident 27's finger with an alcohol pad, pricked the resident's finger with a lancet, obtained a blood sample, completed the glucometer reading, cleaned the resident's finger with an alcohol pad, and then removed her gloves. LPN 4 with her bare hand, cleaned the glucometer with a disinfectant wipe, then placed the glucometer back into a container and then placed the container in a drawer in the medication cart. LPN 4 was not observed to sanitize her hands, during the blood glucose test. On 8/14/23 at 12:27 p.m., Resident 27's record was reviewed. Diagnosis included, but was not limited to, diabetes mellitus (DM). A quarterly Minimum Data Set (MDS) assessment, dated 7/19/23, indicated the resident was cognitively intact and required supervision-oversight, encouragement, or cueing of one person for locomotion on and off the unit. A care plan, dated 7/9/21, indicated the resident had a diagnosis of DM with risk for hypo/hyperglycemia (low/high blood sugar) with an intervention included, but not limited to, check blood sugar per physician order. A physician's order, dated initiated 7/9/21, indicated blood glucose monitoring before meals and HS (bedtime) for the diagnosis of DM. B3. On 8/7/23 at 11:32 a.m., Resident 41 was observed propelling himself down the main hallway, when Licensed Practical Nurse (LPN) 4 asked Resident 41 to stop at the medication cart to complete a blood glucose test (measures how much sugar was in the blood). LPN 4 donned (put on) gloves, without sanitizing her hands, retrieved a glucometer (a device for measuring the concentration of glucose (sugar) in the blood by using a small drop of blood, placed on a disposable test strip in the glucometer) from the medication cart, cleaned the glucometer machine with a disinfectant wipe, and placed the glucometer directly onto the medication cart, without a barrier. LPN 4 cleaned Resident 41's finger with an alcohol pad, pricked the resident's finger with a lancet, obtained a blood sample, completed the glucometer reading, cleaned the resident's finger with an alcohol pad, and then removed her gloves. LPN 4 with her bare hand, cleaned the glucometer with a disinfectant wipe, then placed the glucometer back into a container and then placed the container in a drawer in the medication cart. LPN 4 was not observed to sanitize her hands, during the blood glucose test. On 8/7/23 at 11:37 a.m., LPN 4 indicated, per the facility policy, staff were allowed to perform blood glucose testing on residents in the hallway. All residents have their own glucose meters. She had forgotten to wash her hands and should have washed or sanitize her hands between residents. Resident 41's record was reviewed, on 8/9/23 at 3:37 p.m. Diagnosis included, but was not limited to, diabetes mellitus (DM). A quarterly Minimum Data Set (MDS) assessment, dated 7/21/23, indicated the resident had a moderate cognitive impairment and required extensive assistance of one person for locomotion on the unit and limited assistance of one person for locomotion off the unit. A physician's order, dated 1/16/23, indicated blood glucose monitoring four times a day for the diagnosis of DM. A care plan, dated 1/17/23, indicated, the resident had a diagnosis of DM with risk for hypo/hyperglycemia (low/high blood sugar) with an intervention included, but not limited to, check blood sugar per physician order. On 8/7/23 at 3:29 p.m., the ADM provided and identified an undated document as a current facility policy, titled, Policy and Procedure Cleaning/Disinfecting/Maintaining Glucose Meters. The policy indicated, .The Glucose meters will be disinfected between each resident use to prevent the spread of microorganisms including blood borne pathogens .If a resident has their own meter, it still must be cleaned after each use .Two disposable wipes will be needed for each cleaning and disinfecting procedure; one wipe for cleaning and the second wipe for disinfecting .Note: Always create a dry 'barrier' between the meter and any surface on which it is placed during actual use or cleaning .Procedure: .Cleaning and Disinfecting .1. Don nonsterile gloves .2. Inspect for blood/debris/dust/lint anywhere on the meter .3. Open the towelette container or package and remove one towelette .4. Wipe the entire surface of the meter 3 times horizontally and 3 times vertically using one towelette to clean blood and other body fluids .5. Dispose of the towelette .6. Obtain a second towelette and wipe the entire surface of the meter 3 times horizontally and 3 times vertically to remove blood borne pathogens. The meter must be maintained wet for 2 minutes with the Super Sani cloth wipe .7. Once the exterior of the glucose meter has remained wet for the appropriate contact time, the meter may be wiped dry with a dry cloth .10. Dispose of the used towelette .11. Remove gloves .12. Wash hands (may use ABHR [alcohol-based hand rub] On 8/8/23 at 8:28 a.m., the Administrator (ADM) indicated, staff were to complete accuchecks/blood glucose testing on residents in a private area for dignity. Staff should wash hands, when visibly soiled and before and after direct contact with residents. The ADM, on 8/7/23 at 3:29 p.m., provided and identified a document as a current facility policy, titled, Handwashing/Hand Hygiene, dated 2001. The policy indicated, .This facility considers hand hygiene the primary means to prevent the spread of infections .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: .a. When hands are visibly soiled .c. Before and after coming on duty .7. Use an alcohol-based hand rub containing at least 62% alcohol, or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .a. Before and after direct contact with residents .b. Before preparing or handling medications .c. Before performing any non-surgical invasive procedures .e. Before donning sterile gloves .h. After contact with a resident's intact skin .i. After contact with blood or bodily fluids .k. After contact with objects (e.g., medical equipment) in the immediate vicinity .l. After removing gloves .The use of gloves does not replace handwashing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections .10. Single-use disposable gloves should be used: .When anticipating contact with blood or body fluids 3.1-18(a) 3.1-18(b) 3.1-18(b)(1)

Based on observation, interview, and record review, the facility failed to ensure residents' rights to privacy and dignity were maintained for 3 of 3 residents when completing blood glucose testing (Residents 27, 41, and 52). Findings include: 1. On 8/7/23 at 11:28 a.m., Resident 27 was observed propelling herself down the main hallway, when Licensed Practical Nurse (LPN) 4 asked Resident 27 to stop at the medication cart to complete a blood glucose test (measures how much sugar was in the blood). LPN 4 donned (put on) gloves, without sanitizing her hands, retrieved a glucometer (a device for measuring the concentration of glucose (sugar) in the blood by using a small drop of blood, placed on a disposable test strip in the glucometer) from the medication cart, cleaned the glucometer machine with a disinfectant wipe, and placed the glucometer directly onto the medication cart, without a barrier. LPN 4 cleaned Resident 27's finger with an alcohol pad, pricked the resident's finger with a lancet, obtained a blood sample, completed the glucometer reading, cleaned the resident's finger with an alcohol pad, and then removed her gloves. LPN 4 with her bare hand, cleaned the glucometer with a disinfectant wipe, then placed the glucometer back into a container and then placed the container in a drawer in the medication cart. LPN 4 was not observed to sanitize her hands, during the blood glucose test. On 8/14/23 at 12:27 p.m., Resident 27's record was reviewed. Diagnosis included, but was not limited to, diabetes mellitus (DM). A quarterly Minimum Data Set (MDS) assessment, dated 7/19/23, indicated the resident was cognitively intact and required supervision-oversight, encouragement, or cueing of one person for locomotion on and off the unit. A care plan, dated 7/9/21, indicated, the resident had a diagnosis of DM with risk for hypo/hyperglycemia (low/high blood sugar) with an intervention included, but not limited to, check blood sugar per physician order. A physician's order, dated initiated 7/9/21, indicated, blood glucose monitoring before meals and HS (bedtime) for the diagnosis of DM. 2. On 8/7/23 at 11:32 a.m., Resident 41 was observed propelling himself down the main hallway, when Licensed Practical Nurse (LPN) 4 asked Resident 41 to stop at the medication cart to complete a blood glucose test (measures how much sugar was in the blood). LPN 4 donned (put on) gloves, without sanitizing her hands, retrieved a glucometer (a device for measuring the concentration of glucose (sugar) in the blood by using a small drop of blood, placed on a disposable test strip in the glucometer) from the medication cart, cleaned the glucometer machine with a disinfectant wipe, and placed the glucometer directly onto the medication cart, without a barrier. LPN 4 cleaned Resident 41's finger with an alcohol pad, pricked the resident's finger with a lancet, obtained a blood sample, completed the glucometer reading, cleaned the resident's finger with an alcohol pad, and then removed her gloves. LPN 4 with her bare hand, cleaned the glucometer with a disinfectant wipe, then placed the glucometer back into a container and then placed the container in a drawer in the medication cart. LPN 4 was not observed to sanitize her hands, during the blood glucose test. On 8/7/23 at 11:37 a.m., LPN 4 indicated, per the facility policy, staff were allowed to perform blood glucose testing on residents in the hallway. All residents have their own glucose meters. She had forgotten to wash her hands and should have washed or sanitize her hands between residents. Resident 41's record was reviewed, on 8/9/23 at 3:37 p.m. Diagnosis included, but was not limited to, diabetes mellitus (DM). A quarterly Minimum Data Set (MDS) assessment, dated 7/21/23, indicated the resident had a moderate cognitive impairment and required extensive assistance of one person for locomotion on the unit and limited assistance of one person for locomotion off the unit. A physician's order, dated 1/16/23, indicated blood glucose monitoring four times a day for the diagnosis of DM. A care plan, dated 1/17/23, indicated, the resident had a diagnosis of DM with risk for hypo/hyperglycemia (low/high blood sugar) with an intervention included, but not limited to, check blood sugar per physician order. On 8/8/23 at 8:28 a.m., the Administrator (ADM) indicated, staff were to complete accuchecks/blood glucose testing on residents in a private area for dignity. Staff should wash hands, when visibly soiled and before and after direct contact with residents. 48226 3. On 8/07/23 at 11:56 a.m., observed Licensed Practical Nurse (LPN) 4, assisted Resident 52 in his wheelchair, from the main dining room, and wheeled him into the main hallway in front of the reception desk. LPN 4 donned gloves and cleaned a glucometer machine (an instrument for measuring the concentration of glucose in the blood) with disinfectant wipes. The nurse picked up the glucometer, a testing strip, and stuck the resident's finger with a lancet, obtained a blood sample and completed the glucometer reading. She cleansed the finger of the resident with an alcohol prep pad (a two-layer pad which contain 70% isopropyl alcohol. Prep Pads help clean the skin and can be used on cuts, scrapes, and abrasions prior to bandaging), and assisted the resident back to the dining room. On 8/14/23 at 11:43 a.m., record review resident had diagnoses of but not limited to, type 2 diabetes mellitus (DM), (a disease that occurs when your blood glucose, also called blood sugar, is too high) with diabetic chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should) dated 4/7/2022. Type 2 diabetes mellitus with diabetic neuropathy (a type of nerve damage that can occur if you have diabetes) dated 7/26/2023. Physician orders, dated 8/1/23, NovoLOG FlexPen, (insulin medication) Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 100 - 120 = 0; 121 - 160 = 2; 161 - 200 = 4; 201 - 240 = 6; 241 - 280 = 8; 281 - 320 = 10; 321 - 360 = 12; 361 - 400 = 15 contact MD (medical doctor), subcutaneously before meals for DM subcutaneously At breakfast and Lunch for DM breakfast and lunch only. Do not give at qhs (at bedtime). A care plan, dated 10/12/22, indicated, the resident had a diagnosis of diabetes with risk for Hypo/or Hyperglycemia. Nursing intervention, dated 10/12/22, check blood sugars per order. A Medicare 5-day Minimum Data Set Assessment (MDS), a standardized assessment tool that measures health status in nursing home residents, dated 7/28/23, indicated the resident was on insulin and had a diagnosis of type 2 diabetes mellitus. On 8/7/23 at 3:29 p.m., the Administrator provided an undated document titled, Policy and Procedure Cleaning/Disinfecting/Maintaining Glucose Meters and indicated this was the current policy of the facility. The policy indicated .Procedure cleaning and disinfecting .4. Wipe the entire surface of the meter 3 times horizontally and 3 times vertically using one towelette to clean blood and other body fluids. 5. Dispose of the towelette. 6. Obtain a second towelette and wipe the entire surface of the meter 3 times horizontally and 3 times vertically to remove blood borne pathogens. The meter must be maintained wet for 2 minutes with the Super Sani cloth wipe. When utilizing any other type of sanitizing (bleach) wipe, the meter must be maintained wet paper towelette manufacturer's recommendation. A 1/10 bleach solution requires a 10-minute contact time .When glucometers are being discontinued from isolation, the glucometer is to be discarded in biohazard .10. Dispose of the used towelette. 11. Remove gloves. 12. Wash hands (may use ABHR [alcohol based hand rub]) 3.1-3(a) 3.1-3(b)(1) 3.1-3(b)(1)(2)

Based on observation, interview, and record review, the facility failed to provide comfortable water temperatures of more than 105 degrees Fahrenheit (F) and less than 115 degrees F in 8 of the 9 shared resident bathrooms on the secured memory care area observed for unsafe water temperatures. Findings include, During the initial tour, on 8/7/23 at 11:15 a.m., Resident 40 was observed standing at the sink in his shared bathroom. Steam was observed rising from the water, the resident indicated the water was too hot to touch. Water temperature was 129.6 Fahrenheit (F). Temperature with the Maintenance Director on 8/7/23 at 12:25 p.m. was 122.9 F. On 8/07/23 11:19 a.m., water temperature in the bathroom sink on the 100 hall was 129.0 F. A visitor observed steam rising from the water and the thermometer temperature and indicated it was too hot for Resident 63. On 8/07/23 at 11:36 a.m., water temperature in the bathroom sink shared between rooms [ROOM NUMBERS] was 130.6 F. Temperature with the Maintenance Director on 8/8/23 at 9:48 a.m. was 100.3 F. On 8/07/23 at 11:53 a.m., water temperature in the bathroom sink shared between rooms [ROOM NUMBERS] was 129.0 F. Temperature with the Maintenance Director on 8/08/23 at 9:49 a.m. was 103.4 F. On 8/07/23 at 11:57 a.m., water temperature in the bathroom sink shared between rooms [ROOM NUMBERS] was 118.2 F. Temperature with the Maintenance Director on 8/08/23 at 9:54 a.m. was 101.2 F. On 8/07/23 at 12:06 p.m., water temperature in the bathroom sink shared between rooms 108 and the dining room was 124.5 F. Temperature with the Maintenance Director on 8/08/23 at 9:51 a.m. was 103.4 F. On 8/09/23 at 9:33 a.m., water temperature in the bathroom sink shared between rooms [ROOM NUMBERS] was 104.4 F. On 8/09/23 at 9:31 a.m., Housekeeper 27 was observed cleaning a shared bathroom between rooms [ROOM NUMBERS]. She had not noticed the water temperature in the resident's bathrooms either being too hot or too cold, she used a special cleaner and did not usually turn on resident water in the sinks. During an interview on 8/08/23 at 9:57 a.m., the Maintenance Director indicated, he thought resident bathroom sink water temperatures were supposed to be between 110-120 F. He was not sure but would ask. He indicated he thought the fluctuations were due to residents getting showers and the holding tank. He had adjusted the water value the day before, but the difference in temperatures from hot to cooler could also have been from routine water use on the unit once residents got up in the morning and water being used during showers. During an interview on 8/08/23 at 10:24 a.m., Registered Nurse (RN) 11 indicated, she had never noticed the resident's bathroom water being too hot or tepid, she did not wash her hands in their bathrooms or assist them to wash their hands in their bathrooms. A Domestic Hot Water Temperature Log, Daily Check, dated July 2023, indicated 18 of 44 temperatures documented as being in resident rooms were between 115.1 - 127.1. There were no documented temperatures for weekend dates, or in the afternoon hours on Monday 7/17/23 and Tuesday 7/18/23. Form instructions indicated initial to right of row. There were no initials documented. During an interview with the Maintenance Director and Administrator (ADM) on 8/9/23 at 10:15 a.m., the Maintenance Director indicated he did not check water temperatures and record with a visitor on 8/7/23, then restated he had checked temperatures and observed some resident bathroom temperatures out of range but had not recorded them as he had already recorded temperatures in the morning on his log. The ADM indicated the water temperatures were supposed to run between 100 F - 120 F. On 8/9/23 at 11:57 a.m., the ADM provided Physical Plants--Daily Inspections instructions, undated, and indicated the instructions for Domestic Water Temperatures were currently to be followed by the Maintenance Director. The instructions indicated, Take water temperature readings daily [once during morning rounds and once in the afternoon during the high usage times] from 1 area of each hot water system and document in the Domestic Water Temperature log to be kept on file. On 8/9/23 at 11:57 a.m., the ADM provided a blank Maintenance Supervisor Orientation Checklist, updated 3/26/21, and indicated the water temperatures section was the one currently to be followed by the Maintenance Director. The Specific Responsibilities and Duties indicated, Water Temperatures 1. Check daily to maintain between 105 - 115 degrees. 2. Anything above 115 must be reported to Administrator and [NAME] President of Property Management immediately On 8/9/23 at 11:57 a.m., the ADM provided a copied paper, undated, and indicated it was a copy of the current state regulation regarding water temperatures. The regulation indicated, Hot water temperatures for all bathing and hand washing facilities shall be controlled by an automatic control valve. Water temperature at point of use must be maintained between one hundred [100] degrees Fahrenheit and one hundred twenty [120] degrees Fahrenheit. 3.1-19(r)(1) 3.1-19(r)(2)

Based on observation, interview, and record review, the facility failed to ensure the care plans were revised for concerns and interventions for 3 of 19 residents' care plans reviewed (Residents 14, 41 and 32). Findings include: 1. On 8/08/23 at 10:15 a.m., during initial observation Resident 14, did not have a palm pillow (layers of MicroSpring Textile rolled to 1 1/2 think pillow prevents digging fingernails into palms. Adjustable soft band with Velcro) applied to the contracted (a permanent shortening (as of muscle, tendon, or scar tissue) producing deformity or distortion) left hand. The fingernails on the left hand were long and jagged and were pressing into the palm of the hand. On 8/09/23 at 11:30 a.m., observed the resident sitting in a wheelchair in the main dining room. Palm pillow was not applied to the left hand. Fingernails on both hands were long and jagged. On 8/10/23 at 10:00 a.m., observed the resident sitting in a wheelchair. The call light was placed on the left side of her upper left arm. The resident's left hand was contracted, palm pillow was not applied to the left hand. Fingernails of both hands were long and jagged. On 8/11/23 at 11:00 a.m., observed the resident sitting in a wheelchair. Palm pillow soft hand pillow device was applied to the contracted left hand. Fingernails on the right and left hands were cut to a level which prevented them from pushing into the palm of the hands. On 8/10/23 at 11:40 a.m., medical record review. Diagnoses included but were not limited to vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), anxiety (a feeling of fear, dread, and uneasiness. It might cause you to sweat, feel restless and tense, and have a rapid heartbeat. It can be a normal reaction to stress), hemiplegia (a loss of strength in the arm, leg, and sometimes face on one side of the body) left side, contracture of the left wrist, and contracture of the left hand. A Physician's order, dated 6/29/22, indicated an order for, patient to wear Palm Pillow hand splint on the left hand at all times during day except for meals, hygiene care and ROM (range of motion) to prevent skin integrity issues and to help prevent further contractures. Instructions indicated to dry the resident's hand before applying splint each time and to monitor for any signs and symptoms of redness or swelling. On 8/10/23 at 10:04 a.m., Certified Nurse Aide (CNA) 10 indicated she had not seen a brace or splint on the residents left hand and it was not indicated on her assignment record. On 8/10/23 at 10:06 a.m., Registered Nurse (RN) 9 indicated she was a PRN (as needed) staff member, and she did not know if the resident was to have a palm pillow applied to her contracted left hand. On 8/10/23 at 10:09 a.m., the Director of Nursing (DON) indicated she did not know if the resident had an order for a palm pillow to be applied in her contracted left hand. A care plan, dated 6/9/2016, titled contracted left hand indicated the resident had a contracture of the left hand and arm, secondary to decrease mobility and history of CVA (cerebral vascular accident, stroke). Goal was for the resident to have no further contractures and the contracture to not worsen. Interventions included inform MD (medical doctor) of any changes to contracture, restorative care as needed, and therapy as needed. The care plan lacked documentation indicating an intervention of palm pillow or splint to the left hand. A quarterly Minimum Data Set (MDS) assessment a standardized assessment tool that measures health status in nursing home residents, dated 5/29/23, lacked documentation of palm pillow or anticontracture splint to contracted left hand. An annual MDS, dated [DATE], lacked documentation of palm pillow to contracted left hand. On 8/10/23 at 3:08 p.m., the MDS nurse indicated section O of the MDS, restorative services would identify a brace or splint that were being used for the resident. She indicated she was not aware the resident had an order for a palm pillow and had not identified it on the MDS. 34129 2. On 8/8/23 at 11:44 a.m., Resident 41's CPAP mask was observed unbagged on the resident's bed. Resident 41 indicated, he used the CPAP machine with the mask every night to help him breath while sleeping. On 8/11/23 at 10:59 a.m., Resident 41's CPAP mask was observed unbagged on the nightstand. On 8/11/23 at 11:28 a.m., the Director of Nursing (DON) indicated, Resident 41 wore the CPAP throughout the day, when he was napping and took it off and put it on by himself. The facility needed to educate staff and the resident to bag the CPAP mask when not in use. Resident 41's record was reviewed, on 8/9/23 at 3:37 p.m. The profile indicated the resident had been admitted to the facility, on 1/16/23, for diagnoses included, but were not limited to, dementia (condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), sleep apnea (sleep disorder in which breathing repeatedly stops and starts) and chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe). A quarterly Minimum Data Set (MDS) assessment, dated 7/21/23, indicated the resident had a moderate cognitive impairment, was an extensive assistance of one person for bed mobility, limited assistance of one person for transfers, and an extensive assistance of one person for personal hygiene. A physician's order, dated 1/16/23, indicated CPAP at bedtime for the diagnosis of sleep apnea. A sleep apnea care plan, initiated on 1/27/23 and revised on 3/30/23, with interventions included, but not limited to, keep head of bed raised as tolerated and oxygen per physician's order and a goal of the resident would be free of respiratory distress, lacked documentation or interventions for the CPAP usage. On 8/14/23 at 11:10 a.m., the DON indicated, the resident should have CPAP interventions for the sleep apnea care plan. The CPAP should be bagged and stored per the facility policy. On 8/14/23 at 11:53 a.m., the DON provided and identified an undated document as a current facility policy, titled, Continuous Positive Airway Pressure (CPAP). The policy indicated, .Purpose: To improve ventilation on patients with obstructive sleep apnea (OSA), airway obstruction and upper airway resistance .15. When the CPAP machine is not in use the face mask is stored in a plastic bag at the bedside 3. Resident 32's record was reviewed, on 8/10/23 at 2:25 p.m. The profile indicated the resident had been admitted to the facility, on 9/26/22, with diagnoses included, but not limited to, quadriplegia (paralysis that affects all a person's limbs and body from the neck down), multiple sclerosis (progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, whose symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue) and had an unstageable pressure ulcer (an ulcer that has full thickness tissue loss but is either covered by extensive necrotic tissue or by an eschar [dead tissue that has fallen off (sheds) from healthy skin]) to the right gluteal fold/perineum (the horizontal skin crease that forms below the buttocks, separating the upper thigh from the buttocks and the tiny patch of sensitive skin between the genitals and anus) and was on hospice (end of life) services. A quarterly Minimum Data Set (MDS) assessment, dated 6/16/23, indicated the resident had a moderate cognitive impairment, was an extensive assistance of two persons for bed mobility, toilet use, dressing, and personal hygiene, was total dependence of two persons for transfers and bathing, was on hospice services, and had a pressure ulcer. A physician's order, dated 8/2/23, indicated to apply Triad Hydrophilic wound paste topically to the pressure ulcer and cover with a bandage in the evening for wound care. A skin and wound progress note, by the wound nurse practitioner, dated 7/11/23 at 9:47 a.m., indicated the resident had a pressure ulcer to the perineal/buttocks that had separated into 2 areas as the wound was healing with epithelial tissue (new skin tissue) separating the wound beds and was classified as a stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle). A pressure ulcer to the perineum care plan, initiated on 9/28/22 and revised on 11/28//22, with a goal of wound will not show signs/symptoms of infection and will improve with next review had interventions included, but not limited to, complete wound treatment per physician's order and resident to be followed by the wound nurse practitioner. The care plan lacked documentation of interventions for the wound separation into 2 areas of the wound. On 8/14/23 at 10:53 a.m., the MDS Corporate Consultant indicated, since Resident 32 was admitted with the stage 4 pressure ulcer, even though it split it would still be listed as 1 pressure ulcer. There should be a more specific care plan for the pressure ulcers. The Director of Nursing (DON), on 8/14/23 at 12:20 p.m., provided and identified a document as a current facility policy, titled, Baseline Care Plan Assessment/Comprehensive Care Plans, dated 11/25/17. The policy indicated, .Policy .The Comprehensive Care Plan will further expand on the resident's risks, goals, and interventions using the 'Person-Centered' Plan of Care approach for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, physical functioning, mental and psychosocial needs .The facility Interdisciplinary team in conjunction with the resident, resident's family, surrogate or representative as appropriate along with a 'hands on' caregiver, such as a Certified Nursing Assistant will discuss and develop quantifiable objectives along with appropriate interventions in an effort to achieve the highest level of functioning and the greatest degree of comfort/safety and overall well-being attainable for the resident .9. The Comprehensive Care plans will be reviewed and updated every quarter at a minimum. The facility may need to review the care plans more often based on changes in the resident's condition and/or newly developed health/psycho-social issues 3.1-35(a) 3.1-35(c)(1)

Based on observation, interview, and record review the facility failed to ensure proper sanitation procedures for cleaning 14 of 14 contaminated, reusable blood glucose meters resulting in potential, serious harm from exposure to a communicable disease for 21 of 21 residents reviewed for blood glucose monitoring (Residents #1, #7, #14, #16, #18, #19, #26, #27, #30, #32, #38, #51, #61, #62, #65, #73, #74, #90, #91, #121, and #122). The immediate jeopardy began on 9/22/14 and was identified on 9/22/14 at 3:00 p.m. The Administrator and Director of Nursing were notified of the immediate jeopardy at 12:15 p.m. on 9/23/14. The immediate jeopardy was removed on 9/25/14, but noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: On 9/22/14 at 11:40 a.m. Resident #19's blood sugar was tested . LPN #1 cleaned the blood glucose monitor with a sterile alcohol prep pad, waved the monitor in the air to dry, then proceeded to perform the blood glucose test on Resident #19. The LPN indicated she was drying the monitor. LPN #1 indicated there were two glucose monitors in use on the medication cart. She indicated she used alcohol swabs to cleanse the blood glucose monitors. On 9/22/14 at 2:20 p.m., LPN #2 was interviewed regarding sanitization of glucometers. LPN #2 took a canister of sanitizing wipes from the medication cart drawer and indicated she would clean the meter with a sanitizing wipe, keeping the surface wet for one minute, then let it air dry. The LPN indicated she worked on all facility units. On 9/22/14 at 2:30 p.m., RN #3 indicated she would sanitize glucometers with an alcohol prep wipe. The nurse indicated there were no residents currently on the Moonlight Bay Unit that required blood glucose monitoring. Four blood glucose monitors were observed in a drawer in the medication cart. On 9/22/14 at 3:00 p.m., the product Sani-Wipe label was read. The canister labeled, PROFESSIONAL SANI-WIPE NO RINSE HARD SURFACE, NON-POROUS SURFACE SANITIZING WIPE, indicated, .Designed for sanitizing cleaned hard, non-porous food contact surfaces. The product label indicated the sanitizer was 99.999% effective in 60 seconds against Staphylococcus aureus, Escheria coli, and Shigella boydii on hard, non-porous food contact surfaces. The label indicated, .For use in retail and institutional food establishments, food processing plants and other health department regulated food facilities . The information on the canister did not indicate the product was an effective disinfectant for blood borne pathogens and did not indicate it contained bleach. On 9/22/14 at 3:00 p.m., an owner's booklet for the blood glucose monitoring system used in the facility was provided by the DON. The booklet indicated the meter should be cleaned between use with soap and water. The booklet indicated the meter was intended for use by health care professionals in a clinical setting, but did not indicate how the meter should have been cleaned between uses when used for multiple residents. On 9/22/14 at 4:00 p.m., the Director of Nursing (DON) was interviewed. The DON indicated the Corporate Quality Assurance Nurse indicated in a phone conversation the white canister with the red top (Sani-Wipe) that was used to clean the blood glucometers was not the correct product for glucometer sanitation. She indicated the correct product came in a white canister with a purple lid or was bleach wipes. The DON indicated LPN #1, who was observed using the incorrect sanitation procedure, worked on all units in the facility. On 9/23/14 at 11:00 a.m., the Administrator indicated the wrong Sani-Wipe product was ordered. She indicated the item number for the incorrect wipe was item # and the product was ordered on [DATE]. The administrator provided the product order documentation, dated 7/15/14 and indicated item # was the product approved for blood glucose monitor sanitation that should have been ordered. On 9/23/14 at 11:06 a.m., the DON indicated extra supplies were kept in boxes on the floor of the supply room until the product was needed to restock the shelves. She indicated the shelf used to store the sanitizing wipes was bare last week and indicated the Sani-Wipes were placed on the shelf for use last week. The DON indicated the product was not used prior to stocking the shelf last week and she was not able to determine when the product was used prior to the observation of use on 9/22/14. Resident #91's record was reviewed on 9/22/14 at 4:30 p.m. [DIAGNOSES REDACTED]. A physician's recapitulation order, dated 9/1/14-9/30/14, indicated Resident #91 had blood glucose monitoring 3 times a day. Resident #1's record was reviewed on 9/22/14 at 4:35 p.m. [DIAGNOSES REDACTED]. A physician's recapitulation order, dated 9/1/14-9/30/14, indicated Resident #1 had blood glucose monitoring 4 times a day. Resident #7's record was reviewed on 9/22/14 at 4:35 p.m. [DIAGNOSES REDACTED]. A physician's recapitulation order, dated 9/1/14-9/30/14, indicated Resident #7 had blood glucose monitoring 2 times a day. Resident #14's record was reviewed on 9/22/14 at 4:40 p.m. [DIAGNOSES REDACTED]. A physician's recapitulation order, dated 9/1/14-9/30/14, indicated Resident #14 had blood glucose monitoring 3 times a day. Resident #16's record was reviewed on 9/22/14 at 4:40 p.m. [DIAGNOSES REDACTED]. A physician's recapitulation order, dated 9/1/14-9/30/14, indicated Resident #16 had blood glucose monitoring 4 times a day. Resident #18's record was reviewed on 9/22/14 at 4:45 p.m. [DIAGNOSES REDACTED]. A physician's recapitulation order, dated 9/1/14-9/30/14, indicated Resident #18 had blood glucose monitoring 1 time a week. Resident #19's record was reviewed on 9/22/14 at 4:45 p.m. [DIAGNOSES REDACTED]. A physician's recapitulation order, dated 9/1/14-9/30/14, indicated Resident #19 had blood glucose monitoring 4 times a day. Resident #26's record was reviewed on 9/22/14 at 4:50 p.m. [DIAGNOSES REDACTED]. A physician's recapitulation order, dated 9/1/14-9/30/14, indicated Resident #26 had blood glucose monitoring 4 times a day. Resident #27's record was reviewed on 9/22/14 at 4:50 p.m. [DIAGNOSES REDACTED]. A physician's recapitulation order, dated 9/1/14-9/30/14, indicated Resident #27 had blood glucose monitoring 4 times a day. Resident #30's record was reviewed on 9/22/14 at 4:55 p.m. [DIAGNOSES REDACTED]. A physician's recapitulation order, dated 9/1/14-9/30/14, indicated Resident #30 had blood glucose monitoring 4 times a day. Resident #32's record was reviewed on 9/22/14 at 4:55 p.m. [DIAGNOSES REDACTED]. A physician's recapitulation order, dated 9/1/14-9/30/14, indicated Resident #32 had blood glucose monitoring 1 time a day. Resident #38's record was reviewed on 9/22/14 at 5:00 p.m. [DIAGNOSES REDACTED]. A physician's recapitulation order, dated 9/1/14-9/30/14, indicated Resident #38 had blood glucose monitoring 2 times a week. Resident #51's record was reviewed on 9/22/14 at 5:00 p.m. [DIAGNOSES REDACTED]. A physician's recapitulation order, dated 9/1/14-9/30/14, indicated Resident #51 had blood glucose monitoring 1 time a day. Resident #61's record was reviewed on 9/22/14 at 5:05 p.m. [DIAGNOSES REDACTED]. A physician's recapitulation order, dated 9/1/14-9/30/14, indicated Resident #61 had blood glucose monitoring 1 time a week. Resident #62's record was reviewed on 9/22/14 at 5:05 p.m. [DIAGNOSES REDACTED]. A physician's recapitulation order, dated 9/1/14-9/30/14, indicated Resident #62 had blood glucose monitoring 1 time a day. Resident #65's record was reviewed on 9/22/14 at 5:10 p.m. [DIAGNOSES REDACTED]. A physician's recapitulation order, dated 9/1/14-9/30/14, indicated Resident #65 had blood glucose monitoring 4 times a day. Resident #73's record was reviewed on 9/22/14 at 5:10 p.m. [DIAGNOSES REDACTED]. A physician's recapitulation order, dated 9/1/14-9/30/14, indicated Resident #73 had blood glucose monitoring 4 times a day. Resident #74's record was reviewed on 9/22/14 at 5:15 p.m. [DIAGNOSES REDACTED]. A physician's recapitulation order, dated 9/1/14-9/30/14, indicated Resident #74 had blood glucose monitoring 1 time a day. Resident #90's record was reviewed on 9/22/14 at 5:15 p.m. [DIAGNOSES REDACTED]. A physician's recapitulation order, dated 9/1/14-9/30/14, indicated Resident #90 had blood glucose monitoring 1 time a day. Resident #121's record was reviewed on 9/22/14 at 5:20 p.m. [DIAGNOSES REDACTED]. A physician's recapitulation order, dated 9/1/14-9/30/14, indicated Resident #121 had blood glucose monitoring 1 time a day. Resident #122's record was reviewed on 9/22/14 at 5:20 p.m. [DIAGNOSES REDACTED]. A physician's recapitulation order, dated 9/1/14-9/30/14, indicated Resident #122 had blood glucose monitoring 2 times a day. On 9/24/14 at 4:00 p.m., the Administrator provided a document, titled, Ultra Trak Pro Sample Policy Procedures, dated March 2012. The policy indicated the blood glucose monitor should have been cleaned and disinfected between each test with EPA (Environmental Protection Agency) registered germicidal or bleach wipe. A policy titled, Glucometer cleaning, dated 7/1/11, and identified as current was provided by the DON on 9/22/14 at 3:20 p.m. The policy indicated, .Complete sanitization of glucometers by wiping with approved disposable wipes between resident use. Discard wipes in appropriate receptacle. There should be 2 glucometers per medication cart-one in use and one cleaned and drying . The DON indicated the glucometer should remain wet with sanitizing wipe for 2 minutes and then air dry. The immediate jeopardy that began on 9/22/14 was removed on 9/25/14 when the facility removed the improper sanitizer wipes from the facility, and acquired EPA (Environmental Protection Agency) registered disinfectant wipes for glucometer cleaning. The facility implemented a new policy and procedure for cleaning/disinfecting/maintaining glucose meters, that specified the approved sanitation wipes, included directions for use and indicated any resident with a known communicable disease would have a glucometer designated for their use only, and in-serviced RN's (Registered Nurses), LPN's (Licensed Practical Nurses) and QMA's (Qualified Medication Aides) to the policy and procedure. The facility implemented a system for monitoring/auditing to ensure proper cleaning/disinfection of the blood glucose meter. The noncompliance remained at a lower scope and severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy because of the ongoing monitoring to ensure compliance with the new policy/procedure. 3.1-18(a)

Based on observation, interview, and record review, the facility failed to ensure implementation of assistive devices/interventions to prevent a fall resulting in large contusions to the abdomen/hip area and forehead and cheekbone requiring two hospitalization s for 1 of 3 residents reviewed for falls (Resident B). Findings include: Resident B's record was reviewed on 10/1/2013 at 1:30 P.M. Resident B had [DIAGNOSES REDACTED]. A re-admission Minimum Data Set Assessment Tool ((MDS) dated [DATE], indicated the following: 1) Resident B had been readmitted to the facility from an acute hospital 2) She had unclear speech,was rarely/never understood, sometimes understood others, and responded adequately to simple, direct communication only 3) She was unable to complete the Brief Interview for Mental Status (BIMS). 4) She had modified independence with cognitive skills for daily decision making. 5) She did not exhibit behaviors that were necessary to achieve her goals for health and well-being. 6) She required limited physical assistance of one person for bed mobility, transfers, ambulation to walk in her room, with dressing, toilet use, and with personal hygiene. 7) Her balance was not steady but she was able to stabilize without staff assistance. 8) She was occasionally incontinent of urine. 9) She had two or more falls with injury since her last assessment. 9) She was on anticoagulant therapy (blood thinner). On 10/1/2013 at 1:05 P.M., Resident B was observed sitting on the side of her bed. A large bruised raised area was observed on the left side of her forehead. She had no socks on her feet. A bed alarm was attached to her bed and to her recliner. When resident B was queried regarding what happened to her head she mumbled several words that could not be understood. She pointed to the bathroom and stated, "fall." During an interview on 10/1/2013 at 1:08 P.M., Qualified Nursing Aide (QMA) #1 was queried regarding the injury to Resident B's head. QMA #1 indicated Resident B fell . QMA #1 indicated alarms were used on the bed and her chair. QMA #1 checked the bed alarm and indicated it worked but it was not turned on. QMA #1 indicated she was not aware of Resident B having a history of turning off the alarms. During an interview on 10/2/2013 at 10:40 A.M., the DON (Director of Nursing) indicated she was aware Resident B turned off her personal alarms. The DON indicated the alarms did not prevent falls but when the alarms went off it warned the staff Resident B had attempted to get up without assistance and gave them time to get to her before she fell . The DON indicated staff were to check to see if the alarms were functioning during care however, they did not document the alarms were checked. The DON indicated her staff were aware Resident B turned the alarms off and knew to check to make sure they were turned on during care. The DON indicated they were informed of this via verbal communication but they did not have a system in place to document the alarms had been checked. The DON stated, "The alarm has never been a good intervention for her because she can remove it or shut it off." During an interview on 10/2/2013 at 11:25 A.M., the DON indicated since Resident B had returned to the facility in February 2013, she had fallen ten times. The DON indicated she had fallen three times in September and two of the falls occurred on September 15, 2013. The DON indicated Resident B fell in the evening on September 15, 2013 and was sent to the hospital to be evaluated due to her anticoagulant therapy which increased her risk for bleeding. The DON indicated Resident B fell again the same evening and was sent back to the hospital, at which time, she was admitted and given a blood transfusion due to a low hemoglobin level. The DON was queried regarding the circumstances which surrounded the falls on September 15, 2013, and if she had documentation the alarms were in place and functioning. The DON indicated she did not have documentation which indicated the alarms were on and functioning. The DON indicated a fall risk assessment was completed on 9/19/2013, as a result of Resident B's fall with injury. The DON indicated Resident B was a high risk for falls however, Resident B's previous fall prevention interventions were not reviewed for effectiveness and/or new interventions were not implemented after her falls on 9/15/2013. Nurse's notes were reviewed from 8/1/2013 through 9/27/2013. A nurse's note dated 8/7/2013 at 3:36 A.M., indicated, "Nurse heard crash and went to room. Resident sitting on buttocks in floor next to recliner with 02 (oxygen) off.... Assessment completed and no injury. Assist of two out of floor and into chair." The record lacked documentation which indicated fall prevention measures were in place. A nurse's note dated 8/8/2013 at 9:49 P.M., indicated, "Noted at this time a small, palm-sized black bruise on right side of resident from fall. Resident indicated that that area is sore. No other injuries noted from fall...." A nurse's note dated 8/13/2013 at 8:40 P.M., indicated, "Called to residents room, resident was in left lateral sims position on the floor beside her bed with face into lowered bed rail. She had tried to hang up her telephone and rolled out of bed. A bruise is noted to her left eye where 02 tubing rests. Skin is scraped but not quite broken. Resident is on Coumadin therapy...." This note indicated Resident B was sent to the hospital for an evaluation. The record lacked documentation which indicated fall prevention measures were in place. A nurse's note dated 8/14/2013 at 7:32 A.M., indicated Resident B had returned to the facility with new orders for an antibiotic to treat a urinary tract infection. Labs were drawn due to an elevated blood clotting test result. This noted indicated, "...noted 2 large bruised areas to R (right) side of abd (abdomen) and R outer hip area. Measurements for R abd are 21 cm (centimeters) x 8 cm. R outer hip area measures 15 cm x 15 cm..." A nurse's note dated 9/8/2013 at 10:31 A.M., indicated, "Nurse heard yell and resident sitting between toilet and bathtub in (sic) floor...." The record lacked documentation which indicated fall prevention measures were in place. A nurse's note dated 9/8/2013 at 7:52 P.M., and 9/9/2013 at 6:19 P.M., Resident B's pressure alarms were functioning and Resident B continued to get up unassisted causing pressure alarms to sound. A nurse's note dated 9/12/2013 at 5:39 A.M., indicated, "resident alert and responsive. nurse observed resident turning personal alarm off. nurse educated resident on importance of alarms and her safety. Slept most of night...." The nurse's notes lacked documentation from 9/12/2013 through 9/16/2013. A fall incident report dated 9/15/2013 at 10:00 P.M., indicated, "...resident found on the floor by the bedside face down @1605 (4:05 P.M.). When asked, she stated "was trying to fix my hair." has contusion on forehead 15 mm (millimeters) x 30 mm and bruise on left knee about 8 cm diameter, applied ice pack on affected areas.... EMT (Emergency Medical Technicians) arrived and picked resident up at 1715 (5:45 P.M.)..." The record lacked documentation which indicated fall prevention measures were in place. A fall incident report dated 9/15/2013 at 10:50 P.M., indicated, "CNA found resident on bathroom floor face down. she has a contusion on left side of forehead and left cheekbone approx (approximate) size 150 mm x 60 mm x 30 mm thick, irregular-shaped.... EMT came and picker (sic) resident up by 2325 (11:25 P.M.)...." The record lacked documentation which indicated fall prevention measures were in place. A nurse's note dated 9/16/2013 at 11:36 A.M., indicated a facility nurse had contacted the hospital staff. The hospital staff informed the facility nurse they would keep Resident B in observation over night. A nurse's note dated 9/20/13 at 5:16 A.M., indicated, "Alert and responsive. Bruising areas continue to face, arms, left knee. Resident indicates by gestures and garbled speech that her head hurts...." A nurse's note dated 9/28/2013 at 9:50 A.M., indicated, "...area remains discolored d/t (due to) previous fall.... Res (resident) c/o (complains) tenderness with palpitation.... Res has been more compliant with asking for help with toileting. PA (personal alarm) in place et (and) functional to recliner chair/wc(wheelchair)/bed. Will c/t (continue) to monitor. Nurse's notes from 8/1/2013 through 9/27/13, with the exception of nurse's notes dated 9/8/2013 at 7:52 P.M., 9/9/2013 at 6:19 P.M., and 9/28/2013 at 9:50 P.M., lacked documentation which indicated staff had monitored Resident B's personal alarms to ensure they had been functioning. The record lacked documentation which indicated Resident B's pressure alarms had been monitored to ensure proper functioning prior to her falls on 8/7/2013, 8/13/2013, 9/8/2013, or both falls on 9/15/2013. A care plan, identified as current by the DON, indicated on 5/23/2013, Resident B was identified as a fall risk. A goal listed for Resident B indicated she would have no injuries due to falls. Interventions to meet this goal included pressure alarms to her bed and chair and staff were to check alarms while they provided care due to Resident B, "Sometimes turn alarms off or take alarms off." A policy titled "Fall Risk Assessment" and identified as current by the DON on 10/1/2013 at 1:19 P.M., indicated, "...It is the intent of the facility that all resident will have a Risk Assessment for Falls performed on admission/readmission, with a significant change in condition, quarterly and annually. Responsible Party Licensed Nurses.... PROCEDURE: ... For residents who score 10 or above, develop a preventative care plan for falls.... Risk Assessments are reviewed on admission, quarterly, and as needed. A policy titled "Safety Alarm Devices" and identified as current by the MDS coordinator on 10/2/2013 at 10:54 A.M., indicated, "...It is the intent of the facility that the safety alarm devices are utilized when deemed appropriate by the care plan team, as an intervention to alert staff of an unassisted transfer to intervene for fall prevention. RESPONSIBILITY: Nursing staff, all facility staff under the direction of the Charge Nurse/Interdisciplinary Team.... 1. Residents at risk for falls will be discussed for appropriate fall prevention and safety alarm devices. 2. When a safety alarm device has been determined as an appropriate intervention, a physician's orders [REDACTED]. a. The alarm is to be placed on bed or chair as appropriate. b. If the resident is able to remove the alarm and if determined appropriate, relocate the alarm to another area. c. The safety device will be checked for proper functioning during care.... 3. The interdisciplinary team will review use of alarms for fall prevention at least quarterly or as needed." This Federal tag relates to Complaint IN 878 & Complaint IN 880. 3.1-45(a)(2)

a. Based on observation, interview, and record review, the facility failed to maintain a safe environment for 1 of 5 random residents reviewed utilizing mechanical air flow beds, in that the facility failed to ensure proper use of the bed according to the manufacturer's directions and ensure recommended servicing was provided. This resulted in Resident E receiving a thermal injury. b. Based on observations, interview, and record review, the facility failed to ensure toilet risers were securely attached to toilets to prevent tipping for random observations of 4 of 12 resident bathrooms (Rooms 207, 218, 220/222 (shared bathroom) and Rooms 224/226 (shared) utilizing risers. Three residents, Residents C, B, and D, were identified as able to independently utilize the toilets. This deficient practice resulted in Resident C sustaining a fall. c. Based on observations and record review, the facility failed to follow manufacturer's directions for 1 of 2 random observations of a resident transferred with mechanical lift. (Resident A) Findings include: a. Facility reported incidents were reviewed on 5/4/12 at 11:00 a.m. A report was noted of Resident E was on a low air loss mattress that was too warm for the resident's comfort and the resident received pink skin and a small blister. The immediate action taken was to change the mattress and check all other speciality mattresses. Resident E's clinical record was reviewed on 5/4/12 at 2:00 p.m. [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE], coded the resident with severe cognitive impairment, rarely understood, required total assistance of two for bed mobility and transfers, and non ambulatory. A nursing note dated 12/26/11 at 2:20 a.m., was noted of "wife phoned facility couldn't sleep had some concerns about Res. (resident) from when she was in on 12/25/11 at 6:00 p.m. This nurse listened to wife's concerns et (and) wife asked this nurse to check on Res. this nurse went to res. room obtained temp at 98.0 (degrees Fahrenheit) informed wife of temp et condition of Res. @ (at) this time." A nursing note dated 12/26/11 at 3:00 a.m. was noted of "Res. mattress was changed et wife was phoned et made aware of." A note at 3:30 a.m. was noted of "DON was notified of need to change mattress, see skin sheet." . Documentation on a form titled "Skin Assessment" dated 12/26/11, completed at 2:30 a.m., was noted of left and right ears-red; Left elbow-1.2 cm (centimeter) diameter excoriation with clear drainage; 4. Right elbow-1 cm diameter blister; 5. Left buttock 4 cm long by 1 cm wide triangle shaped area; 6. Left hip "see below." The additional information was a diagram of an irregular shaped area 10 cm long and 6 cm width on one end and 8 cm on the other end blistered area. 7. Right buttock 4 cm long by 2 cm wide; #8. Left upper thigh 4 cm long by 1 cm wide. On 5/4/12 at 2:00 p.m. the DON was interviewed. The DON indicated the measurements were completed by a facility nurse on 12/26/11 at 2:30 a.m. On 5/4/12 at 2:00 p.m. the DON provided a skin assessment completed by the Hospice nurse on 12/27/11 at 7:00 a.m. Documentation on the diagram of a body was noted of a 7.4 cm by 7 cm blister on the right upper outer thigh and a 4.3 by .3 line of purple discoloration above the blistered area. A telephone order from Hospice nurse was noted dated 12/26/11 at 6:10 a.m., for Silvadene, apply to burned areas then apply dry dressing over two times a day until healed. A physician's telephone order dated 12/26/11 at 11:00 a.m., was noted for, "Apply bacitracin to area on R (right) outer thigh then cover with foam et (and) coverall bid (two times daily)." A progress note documented by the Hospice Medical Director dated 12/29/11 included, but was not limited to: "I was asked to see pt (patient) in followup. Family called ECF (extended care facility) following concern of a warm bed and he was later noted to have a wound of the r (right) leg and buttock suspicious for a thermal injury. ...pt does have an injury noted (see below). ...pt with apparent thermal injury appropriately identified and bandaged...." On 5/4/12 at 11:00 a.m. Resident E's family member was interviewed. The family member indicated multiple family members had visited the resident on the evening of 12/25/11. The family indicated at that time warm air was felt coming from underneath the resident's bed. The family indicated this was reported to a nurse. The nurse went to check with another nurse and the visitors left the facility before receiving a response. The family member indicated she called the facility at 1:30 a.m. to inquire about the resident and asked the nurse to check on the resident. The DON provided documentation of an investigation into the incident on 5/7/12 at 11:15 a.m. The documentation included, but was not limited to, "..(nurse's name) was phoned by (resident's family member) at 2:20 p.m. she stated she couldn't sleep she was worried about her husband and wanted this nurse to check his bed it was warm she stated when she was at facility on 12/25/11 @ (at) 7 p.m. This nurse checked bed and it was very warm and this nurse informed wife that the mattress was warm et (and) would be changed to another mattress. while changing the mattress this nurse found burn marks et blisters on resident's buttocks et r (right) thigh. (Name) Hospice et DON notified at this time." Additional investigation documentation completed by another nurse, dated 12/25/11 was noted of: "On December 25th, 2011 @ (at) 7:00 p.m. (name) resident's family member, told me that his bed 'felt hot.' (Resident's name). I felt the bed at that time the bed did feel warm to the touch but not hot, the mattress did not, at that time when I felt it, feel uncomfortable or hot, it just felt warm to the touch at 7:00 p.m. I did not feel the resident was being compromised in any way." On 5/4/12 at 1:05 p.m. the DON was interviewed. The DON indicated she was present when a company representative providing the bed through Hospice came in to pick up the mattress. The DON indicated the company representative indicated the mattress had a motor in it and the filter must have clogged. The DON indicated they (the facility) was not aware there was a motor inside the mattress and told the representative they could not have that kind of equipment in the facility. The DON indicated the facility did not have any manufacturer's information/guidelines for the speciality mattress until after the incident. The DON indicated the resident had been placed on the mattress October 4, 2011. Documentation included in the manufacturer's "Rem-Air Operator's Handbook" provided by the DON on 5/4/12 at 1:50 p.m. included, but was not limited to, "General Information ...5. One thin cotton sheet may be used on top of the Rem-Air mattress cover. BE SURE NOT TO COVER THE AIR INTAKE FILTER AT THE FOOT OF THE MATTRESS. ..." Under the section titled "Introduction" information included, but was not limited to, "LIMITATION AND EXCLUSIONS: THE FOREGOING WARRANTY SHALL BE IN EFFECT IF THE FILTER HAS BEEN CHANGED EVERY 30-DAYS (NOT WASHED AND REUSED)...." On 5/7/12 at 10:10 a.m. the Administrator obtained a form titled "Tracking History At Home Health Equipment" documenting servicing of the mattress. The documentation was noted of Resident E receiving the mattress on 10/5/11. The next documentation of the mattress was noted dated 12/26/11 of replacing the mattress followed by documentation of inspection of the equipment resulting from a claim from the facility of the mattress causing a third degree burn to a patient. Documentation followed of the equipment being tested and no evidence of overheating found. b 1. On 5/1/12 at 11:05 a.m. with the Maintenance person, 4 of 12 toilet risers were observed loose. The loose toilet risers were observed in bathrooms used for rooms 207, 218, 220, 222, 224 and 226. During Interview of the Maintenance person on 5/1/12 at 11:05 a.m., the Maintenance person indicated he did not have a check system for toilet risers. The Maintenance person indicated If staff have a problem, "they let me know." He indicated he didn't remember any issues with the risers. On 5/1/12 at 11:15 a.m. during interview of LPN #17, the LPN indicated the aides are supposed to check risers, but was unsure when. During interview on 5/1/12 at 11:15 a.m., of CNAs (certified nursing assistance) #9 and 20, the CNAs indicated if a resident requires assistance to the toilet, they check the risers and tighten them if necessary. During interview on 5/1/12 at 11:30 a.m., of the DON (Director of Nursing), the DON indicated Residents B, C, and D, resided in the rooms with loose toilet risers and were independent with toileting. b. 2. Resident B's clinical record was reviewed on 5/9/12 at 11:18 a.m. A nurse's note, dated 4/26/12 at 6 a.m., indicated the resident was alert and oriented, continent of bowel and bladder and independent with toileting. b 3. Resident C's clinical record was reviewed on 5/8/12 at 11:53 a.m. [DIAGNOSES REDACTED]. A plan of care was noted, dated 3/21/12, indicating the resident had multiple risks for falls related to IDDM (insulin dependant diabetes mellitus) HTN (hypertension) diastolic heart failure and CHF(congestive heart failure). Review of a nurse's note, dated 3/23/12 at 3 a.m., indicated "Resident turned emergency BR (bathroom) light on- upon entering room found res (resident) sitting on floor (with) legs folded to side on L (left) upper leg/thigh on floor in front of toilet. When questioned about what happened he stated that 'the riser was loose when I grabbed it et (and) I knew I was going to fall'...." A "Monthly Summary" on 3/23/12 at 7 a.m. indicated "...does use toilet I'ly (independently) @ (at) times." (sic) A "Maintenance Work Order" dated 3/24/12 received from the DON on 5/9/12 at 3 p.m. indicated Misty Lane bathroom 224 & 226 -riser is not effective (needs either replaced or fixed). The bottom of the form under the title "work done" indicated "Checked Riser to see if was tight. Tightened front clamp. Done 3/29/12." During interview of the DON on 5/9/12 at 3 p.m., the DON indicated the work order was concerning the riser that was loose during Resident C's incident. b 4. Resident D's clinical record was reviewed on 5/9/12 at 12 noon. A nurse's note dated 1/15/12 at 4:15 p.m., indicated the resident is alert and oriented. c. On 5/3/12 at 12:23 p.m., Resident A was observed to be transferred from the wheelchair to the bed utilizing the Invacare stand up mechanical lift by CNAs # 9 and #7. The resident was lifted with sling in place around the resident's upper body and around the resident's upper thighs. The resident's knees were against the knee pads when lifted. As the resident was lifted, the resident held onto the handles of the lift. CNA #9 utilized the remote to activate the lift. The resident was lifted and the resident's feet were in the air beyond the point of weight bearing. The resident moaned. CNA #9 immediately lowered the resident to weight bearing with both feet. The resident was then placed in bed. Review of the resident's clinical record on 5/7/12 at 10:20 a.m. indicated the most recent Minimum Data Set (MDS) assessment was completed 4/9/12. The assessment identified the resident with long/short term memory problems, moderately impaired in cognitive decision making skills, required extensive assistance with transfers, and total dependence for personal hygiene. Review of the manufacturer's guidelines for the Invacare stand up lift on 5/7/12 at 1:55 p.m. indicated :...NOTE: The stand up lift may be operated by one (1) healthcare professional for ALL lifting preparation, transferring from and transferring to procedures with a cooperative, weight-bearing individual able to support the majority of his/her own weight....1. Make sure of the following:...B. Patient's feet are positioned on the footplate as shown in STEP 2B of FIGURE 1..." This federal tag relates to Complaint IN 871. 3.1-45(a)(1) 3.1-45(a)(2)