Every finding on record at Waters of Hobart Skilled Nursing Facility, The

Based on observation, record review, and interview, the facility failed to ensure antihypertensive medications and insulin were held per parameters for 1 of 2 residents reviewed for blood pressure parameters and 1 of 2 residents reviewed for insulin. The facility also failed to ensure follow-up documentation was completed after a fall for 1 of 3 residents reviewed for a change in condition and dry scaly feet were assessed and treated for 1 of 2 residents reviewed for non-pressure related skin conditions. (Residents M, L, E, and N) Findings include: 1. The record for Resident M was reviewed on 7/21/26 at 10:11 a.m. Diagnoses included, but were not limited to, dementia without behavior disturbance and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS) assessment, dated 6/10/26, indicated the resident was cognitively impaired for daily decision making. A Care Plan, reviewed on 6/23/26, indicated the resident had a diagnosis of hypertension and was receiving antihypertensive medications. Interventions included, but were not limited to, administer prescribed medications as ordered. A Physician's Order, dated 7/10/25 and listed as current on the July 2026 Physician's Order Summary (POS), indicated the resident was to receive Carvedilol (a medication used to treat high blood pressure) 6.25 milligrams (mg) twice a day for hypertension. Hold the medication for a systolic (top number) blood pressure of less than 110 and pulse less than 60. The May 2026 Medication Administration Record (MAR) indicated the resident's AM (morning) pulse on 5/27/26 was 58 and the medication was given. The June 2026 MAR indicated the resident's AM and HS (evening) pulse was below 60 on the following dates and the medication was given: - 6/8/26 AM pulse 58 - 6/25/26 AM pulse 58 - 6/16/26 HS pulse 58 - 6/18/26 HS pulse 58 On 6/9/26 the resident's AM blood pressure was 99/55 and the medication was given. On 6/26/26, the resident's AM blood pressure was 107/66 and the medication was given. The July 2026 MAR indicated on 7/4/26 and 7/7/26 the resident's pulse was 58. The resident received the medication when it should have been held. During an interview on 7/22/26 at 3:45 p.m., the Nurse Consultant indicated the resident's medication should have been held per the parameters. 2. The record for Resident E was reviewed on 7/21/26 at 2:22 p.m. Diagnoses included, but were not limited to, hip surgery, adult failure to thrive, abnormalities of gait, unsteadiness on feet, weakness, anxiety disorder, and Alzheimer's dementia late onset. The 6/18/26 Modification of the Quarterly Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for decision making and had no range of motion physical impairments. The resident needed partial to moderate assistance with transfers and supervision or touch assistance with ambulating. The resident had one fall with no injury since the last assessment. A Care Plan, revised 7/16/26, indicated the resident was at risk for falls. An e-Interact Change in Condition Evaluation, dated 7/15/26, indicated the resident had a fall in the afternoon on 7/15/26 with no injury. The 72 hour follow up incident charting occurred on 7/15/26 at 6:48 p.m., 7/16/26 at 3:45 a.m., 7/16/26 at 10:40 a.m., 7/16/26 at 10:58 p.m., 7/17/26 at 11:39 a.m., and 7/17/26 at 7:31 p.m. There was no follow up after the fall after 7/17/24 at 7:31 p.m. A Nurse's Note, dated 7/17/26 at 10:13 a.m., indicated the IDT (interdisciplinary team) met to discuss the resident's recent fall which occurred by the vending machines she was using by herself per her norm. The IDT decided to provide oversight and assistance as needed when she was at the vending machines especially when she was retrieving items after purchase. During an interview on 7/22/26 at 2:00 p.m., the Assistant Director of Nursing (ADON) indicated follow up after a fall was supposed to be documented for 72 hours. During an interview on 7/22/26 at 3:10 p.m., the Regional Nurse Consultant indicated documentation after a fall should be for 72 hours. The 6/20/23 and identified as current Guidelines for Incidents/Accidents/Falls policy, provided by the Administrator on 7/23/26 at 12:16 p.m., indicated documentation after an incident/accident of the physical and mental status of the resident(s) involved will be completed each shift (every eight hours minimally) over at least the next 72 hours or until the resident(s)'s condition improved. 3. The record for Resident L was reviewed on 7/20/26 at 2:16 p.m. Diagnoses included, but were not limited to, type 2 diabetes. The 6/30/26 Quarterly Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making and received insulin injections. A Care Plan, revised 7/2026, indicated the resident was at risk for unstable blood glucose related to the diagnosis of diabetes. The approaches were to administer insulin as ordered. A Physician's Order, dated 8/5/25, indicated Insulin Aspart (a rapid-acting insulin) 100 units per milliliter, inject 20 units subcutaneously with meals, hold if glucose was less than 110. The 4/2026 Medication Administration Record (MAR) indicated the Insulin Aspart was administered on the following days when the resident's blood sugar was less than 110: 8:00 a.m. on 4/25/26, the blood sugar was 101. 5:00 p.m. on 4/3/26, the blood sugar was 94. The 5/2026 Medication Administration Record (MAR) indicated the Insulin Aspart was administered on the following days when the resident's blood sugar was less than 110: 8:00 a.m. on 5/21/26, the blood sugar was 94. 5:00 p.m. on 5/8/26 the blood sugar was 109, on 5/20/26 the blood sugar was 95, and on 5/27 and 5/28/26 the blood sugars were 80. The 6/2026 Medication Administration Record (MAR) indicated the Insulin Aspart was administered on the following days when the resident's blood sugar was less than 110: 8:00 a.m. on 6/26/26 the blood sugar was 102, on 6/27/26 the blood sugar was 92, and on 6/28/26 the blood sugar was 109. 5:00 p.m. on 6/1/26 the blood sugar was 103, on 6/24/26 the blood sugar was 67, on 6/27/26 the blood sugar was 83, and on 6/28/26 the blood sugar was 87. The 7/2026 Medication Administration Record (MAR) indicated the Insulin Aspart was administered on the following days when the resident's blood sugar was less than 110: 8:00 a.m. on 7/4/26 the blood sugar was 109, on 7/5/26 the blood sugar was 100. 5:00 p.m. on 7/6/26 the blood sugar was 62, on 7/8/26 the blood sugar was 78, and on 7/11/26 the blood sugar was 100. During an interview on 7/22/26 at 3:10 p.m., the Regional Nurse Consultant had no additional information to provide. 4. On 7/19/26 at 2:16 p.m., Resident N was resting in bed. The skin on his lower legs was dry and scaly with small scabs. A stain of dried blood was on the cuff of his left sock. The resident indicated his legs were itchy and dry. He tried to put lotion on, but he could not reach. On 7/22/26 at 11:00 a.m., LPN 4 removed the resident's socks. Large amounts white skin flakes on came off when the socks were removed. There was a row of small scabs on the resident's left shin and a dime-sized scab on his right shin. At that time, LPN 4 indicated the resident needed lotion on his legs. There was no lotion in his room. The resident indicated he would like to have lotion put on his legs. The record for Resident 3 was reviewed on 7/22/26 at 10:55 a.m. Diagnoses included, but were not limited to, heart disease, diabetes, and morbid obesity. The Quarterly Minimum Data Set (MDS) assessment, dated 6/1/26, indicated the resident had moderate cognitive impairment, and required moderate assistance with activities of daily living (ADLs). The last Weekly Skin Check was documented on 7/4/26. The record lacked documentation of the dry, scaly, scabbed skin as well as treatment or refusal of treatment . A Care Plan, reviewed on 7/22/26, indicated the resident was at increased risk for impaired skin integrity, and had a history of venous ulcers (wounds caused by poor circulation) to his lower leg. Interventions included checking skin during routine care on a daily basis. During an interview on 7/22/26 at 3:30 p.m., the Nurse Consultant was informed of findings and provided no additional information. A policy titled, Guidelines for Preventive Skin Care, received as current from the Administrator on 7/23/26 at 12:16 p.m., indicated appropriate skin care should be provided by staff each shift and / or as necessary. 410 IAC (Indiana Administrative Code) 16.2-3.1-37(a) This citation relates to Intake 2990870.

Based on observation, record review and interview, the facility failed to ensure infection control practices were in place and implemented related to the improper storage of bed pans and urinals during random room observations and staff failing to wear the correct personal protective equipment (PPE) for residents in droplet and enhanced barrier precautions for 2 of 2 units. (The East and [NAME] Units, Residents O and K) Findings include: 1. During a random observation on 7/19/26 at 8:50 a.m., a half full urinal was observed on the over bed table in room [ROOM NUMBER] on the East Unit. 2. During a random observation on 7/19/26 at 9:09 a.m., a half full urinal was observed hanging from the side rail of the bed in room [ROOM NUMBER] on the East Unit. 3. On 7/19/26 at 11:03 a.m., LPN 2 was observed to donn an isolation gown, gloves, and a mask and enter Resident O's room. There was a sign on the resident's door indicating he was in droplet precautions. The verbiage on the sign indicated a gown, gloves, mask, and eye protection was to be worn while in the room. On 7/20/26 at 9:28 a.m., CNA 3 was observed to enter Resident O's room. She took an isolation gown into the resident's room and did not donn it in the hallway prior to entering. At 9:36 a.m., the CNA opened the door to the resident's room and she was wearing an isolation gown and gloves. She was not wearing a mask or a face shield. She used her gloved hand to retrieve something off of the linen cart. At 9:49 a.m., the CNA again entered the resident's room. She donned a gown in the hallway and carried gloves and a garbage bag into the room. She was not wearing a mask or eye protection when she went back into the resident's room. At 9:50 a.m., she opened the door and reached out with her gloved hand and retrieved a draw sheet from the top of the linen cart. She was not wearing a mask or eye protection when she opened the door. At 10:11 a.m., Activity Aide 1 was observed entering the resident's room. She did not donn any personal protective equipment (PPE) prior to entering the room. At 10:40 a.m., LPN 2 donned a gown, mask, and gloves prior to entering the resident's room, however, she was not wearing any face protection. During an interview on 7/20/26 at 1:15 p.m., LPN 2 indicated the resident was in isolation due to rhinovirus (a highly contagious RNA virus that spreads via airborne droplets or contaminated surfaces). During an interview on 7/22/26 at 3:30 p.m., the Nurse Consultant indicated PPE including a face shield should have been donned by staff prior to entering the resident's room. The Acute Respiratory Illness policy provided by the Nurse Consultant and identified as current indicated HCP (Health Care Professionals) who enter the room of a resident with signs or symptoms of an unknown respiratory viral infection that is consistent with SARS-CoV2 infection should adhere to Standard Precautions and use a NIOSH approved N95 facemask, gown, gloves, and eye protection. The Center for Disease Control (CDC) recommended the four following essential items of PPE for droplet precautions: - Surgical Mask: Worn to prevent the inhalation of large-particle droplets from coughing, sneezing, or talking.- Eye Protection: Includes goggles or a face shield to protect the eyes from splashes or spray.- Gown: Worn to protect clothing and skin from contamination during close patient contact.- Gloves: Worn to prevent hand contamination 4. During a random observation on 7/20/26 at 10:19 a.m., Resident K was observed in bed with an indwelling Foley (urinary) catheter and a peg tube (a tube inserted directly into the stomach for nutrition). At that time, CNA 2 was standing at the resident's bedside wearing gloves to both hands and no isolation gown. The CNA was providing incontinence care for the resident. At 10:28 a.m., the CNA removed her gloves, performed hand hygiene and donned a clean pair of gloves to both hands. She then assisted the resident to a sitting position to the side of the bed, placed the gait belt around the resident's waist, and lifted her into the wheelchair. She did not wear an isolation gown prior to the transfer. The record for Resident K was reviewed on 7/21/20 at 3:58 p.m. Diagnoses included, but were not limited to, dementia, adult failure to thrive, and obstructive and reflux uropathy (trapped urine backup and abnormal backward flow in the urinary system). The 6/30/26 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and had an indwelling catheter. A Care Plan, revised on 6/25/26, indicated the resident was in Enhanced Barrier Precautions (EBP) for a feeding tube and a catheter. The approaches were to follow EBP guidelines when providing care and coming in direct contact with the resident, for example changing briefs, incontinence care and transfers. A Physician's Order, dated 7/20/26, indicated enhanced barrier precautions for catheter and peg tube. During an interview on 7/23/26 at 11:00 a.m., the Infection Prevention Nurse and the Assistant Director of Nursing (ADON) indicated they were both aware of CNA 2's actions and not wearing an isolation gown while providing care for the resident. The ADON indicated she should have worn an isolation gown when coming in contact with the resident. The current and revised 2/2023 Guidelines for Infection Control policy provided by the Administrator on 7/22/26 at 4:15 p.m., indicated EBP required use of gloves and a gown if coming in contact with the resident. This citation relates to Intake 2990870. 410 IAC (Indiana Administrative Code) 16.2-3.1-18(b)

Based on observation, record review, and interview, the facility failed to ensure food was stored and prepared under safe conditions related to storage of housekeeping chemical test kits in the walk-in cooler near food items, unlabeled and undated opened stored food, and lack of accurate temperature and sanitation logs for 1 of 1 kitchen. This had the potential to affect 57 of 59 residents who resided in the facility and received food from the kitchen. (The Main Kitchen) Findings include: During the Initial Kitchen Sanitation Tour on 6/9/25 at 8:49 a.m. with the Kitchen Supervisor, the following was observed: a. In the walk-in cooler, three large boxes of UltraSnap Surface ATP tests (a chemical swab kit for testing the cleanliness of a surface) were observed on the top shelves, above food items. The Safety Data Sheet for UltraSnap, revised 12/4/24, indicated for safe handling, the product should be kept away from food and drink. b. In the walk-in cooler, the following items were open and undated: a bottle of tea, a bottle of ranch dressing, and a package of sliced cheese. The following items were unlabeled and undated: a container of jelly, individual cups of mustard, a bag of sliced tomatoes, a plastic bin of onions, and a clear plastic bag of cheese. c. In the walk-in freezer, there were open, unlabeled bags of brussel sprouts and hamburger buns. d. In the reach-in cooler, there was an unlabeled and undated clear plastic bag of cheese. e. In the food prep area, there was a large unlabeled, undated bin filled with oats. f. In the dry storage room, there was an open can of shortening, dated 8/14/23. g. The temperature and sanitation logs were reviewed on 6/9/25 at 9:00 a.m. At that time, the refrigerator temperature, freezer temperature, and sanitizer solution logs were already filled out for 6/9/25 at 3:30 p.m. The dishwasher temperature log was filled out through 6/10/25. During an interview on 6/9/25 at 9:05 a.m., the Kitchen Supervisor indicated the boxes of UltraSnap tests were being kept in the walk-in cooler for Housekeeping, but she did not know what they were or why they were there. All food items should have been labeled and dated when opened. The shortening should have been disposed one year after opening. The temperature and sanitation checks should be recorded in the log when the task was completed, after each meal service. During an interview on 6/11/25 at 3:50 p.m., the Regional Dietary Director indicated the UltraSnap should be removed from the walk-in cooler and the staff needed to be re-educated on performing and documenting temperature and sanitation checks. A policy titled Date Marking, received as current from the Corporate Dietary Manager on 6/12/25 at 3:00 p.m., indicated, Any ready-to-eat, potentially hazardous food prepared and held in refrigeration shall be date marked utilizing an established procedure to ensure food safety. 3.1-21(i)(3)

3. During random observations on 6/9/25 at 9:10 a.m., 6/10/25 at 10:10 a.m., and 6/11/25 at 9:10 a.m., tubes of clotrimazole and betamethasone diphenhydramine (a topical antifungal) and hydrogel (an advanced topical wound treatment) were observed on Resident 32's nightstand. At that time, the resident indicated staff left the topical medications in the room for when they provided wound care to her and Resident 36, who shared the room. The record for Resident 32 was reviewed on 6/17/25 at 10:30 a.m. Diagnoses included, but were not limited to, morbid obesity, chronic kidney disease, and difficulty walking. The 5/28/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident had moderate cognitive impairment and required maximal assistance with activities of daily living (ADLs) and transfers. A Physician's Order, dated 4/15/25, indicated to cleanse the left plantar foot with wound cleanser, mix collagen particles and hyrogel to form a paste, fill wound bed with paste, cover with an ABD dressing, and wrap with rolled gauze every evening shift and PRN (as needed). During an interview on 6/11/25 at 4:21 p.m., the Director of Nursing was informed of the treatment medications left at the bedside and offered no further information. Based on observation and interview, the facility failed to ensure medications were properly labeled and stored for 2 of 3 medication carts observed and random room observations. (East medication cart and Northwest medication cart, Residents 48, 10, 21 & 32) Findings include: 1. On 6/9/25 at 9:39 a.m., the East Medication Cart was observed with LPN 1. The following medications were not labeled or stored appropriately: a. There were 2 loose pills inside a medication cup in the top drawer. b. There was 1 loose pill inside a medication cup in the sixth drawer. During an interview at the time, LPN 1 indicated the resident had refused the pills in the top drawer and she needed a second nurse to waste the medication. She denied either pill was a narcotic. The single loose pill in a medication cup found in drawer six was not given by the night nurse. LPN 1 and RN 1 indicated they were told in shift report the medication, which was an antibiotic, needed to be wasted. 2. On 6/9/25 at 11:22 a.m., the Northwest Medication Cart was observed with QMA 1. The following medications were not labeled or stored appropriately: a. There was an insulin pen in the top drawer that was labeled with Resident 48's first name only. There were no administration instructions. b. There was a second insulin pen labeled with Resident 10's first name and last initial. There were no administration instructions. During an interview at the time, QMA 1 indicated she would have new labels put on the insulin pens. c. There was a probiotic bottle in the third drawer that was labeled with Resident 21's first and last initial. There were no administration instructions. During an interview at the time, QMA 1 indicated the medication was brought in by Resident 21, and she thought it was okay because the bottle had administration instructions. During an interview on 6/10/25 at 4:10 p.m., the Director of Nursing indicated the medication had already been corrected with new labels. There was no additional information provided. 3.1-25(j)

Based on observation and interview, the facility failed to ensure the residents' environment was clean and in good repair related to marred walls, floors, and doors, missing toilet paper holders, dirty base boards, dirty over bed table, and uncontained personal care items in a shared environment in 2 of 2 units. (The East and [NAME] Units) Findings include: During the Environmental Tour on 6/16/25 at 1:40 p.m., with the Maintenance Director, the following was observed: 1. East Unit a. The chair rail in room [ROOM NUMBER] was scratched. There was one resident residing in the room. 2. [NAME] Unit a. In room [ROOM NUMBER], the floor was marred in front of the television. There were two residents residing in the room. b. In room [ROOM NUMBER], the toilet paper holder was taped up and there were 2 uncontained toothbrushes laying on the vanity. There was one person who used the bathroom. c. In room [ROOM NUMBER], the bathroom door was marred and there was dirt along the base board in the room. There was no toilet paper holder in the bathroom. There was one resident residing in the room and used the bathroom. d. In room [ROOM NUMBER], the walls were marred in the room and there was dirt along the base board. There was one resident residing in the room. e. In room [ROOM NUMBER], there was no toilet paper holder in the room and the seat of the resident's wheelchair was peeling and cracked. There were two residents residing in the room. f. In room [ROOM NUMBER], the bottom of the over table was stained and dirty. There were two residents residing in the room. During an interview on 6/16/25 at 1:50 p.m., the Maintenance Director indicated all of the above was in need of cleaning and/or repair. 3.1-19(f)

Based on observation, record review, and interview, the facility failed to ensure residents had physician's orders for medications and an assessment to self-administer their own medications for 2 of 3 residents reviewed for self-administration of medication. (Residents 18 and 52) Findings include: 1. During a random observation on 6/10/25 at 1:55 p.m., two Preparation H suppositories were observed on Resident 18's bed side table. There was also a bottle of lubricating eye drops on the resident's over bed table. The record for Resident 18 was reviewed on 6/11/25 at 11:54 a.m. Diagnoses included, but were not limited to, constipation and chronic pain. The Quarterly Minimum Data Set (MDS) assessment, dated 5/20/25, indicated the resident had moderate cognitive impairment. The June 2025 Physician's Order Summary (POS) indicated the resident had orders for Artificial Tears Solution 1.4%, instill 1 drop in both eyes every 8 hours as needed (PRN) for dryness and redness. The resident also had an order for Anusol-HC External Cream 2.5% (a hemorrhoid cream) apply to rectum topically every 8 hours PRN for pain or irritation. There was no physician's order for the Preparation H suppositories and there was no order for the medications to be left at the bedside. A Self-Administration of Medication Assessment, dated 7/12/24, indicated the resident did not want to self-administer his medications. During an interview on 6/11/25 at 3:30 p.m., the Director of Nursing indicated the medications should not have been left at the resident's bed side. 2. On 6/10/25 at 9:47 a.m., a cup with a separated yellow liquid with sediment was observed on Resident 52's bedside table. The resident indicated it was medicine QMA 2 had left for her to take later. On 6/10/25 at 9:50 a.m., the QMA came into the resident's room. The QMA indicated the cup contained Cholestyramine (a cholesterol lowering medication) and that she did not have to stay with the resident until she took the medication, and left the room. The record for Resident 52 was reviewed on 6/12/25 at 1:53 p.m. Diagnoses included, but were not limited to, Parkinson's Disease, peripheral vascular disease, and anxiety. The 3/31/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident had moderate cognitive impairment, and was dependent in activities of daily living (ADLs) and transfers. There were no assessments or orders for the resident to self-administer medications. During an interview on 6/11/25 at 3:38 p.m., when informed of the findings, the Corporate Nurse indicated they would have to do staff education on medication administration. The current facility policy titled, Self-Administration of Medications by Residents was provided by the Director of Nursing on 6/17/25 at 3:35 p.m. The policy indicated if the resident desired to self-administer medications, an assessment was conducted by the interdisciplinary team. The assessment included the resident's cognitive, physical, and visual ability to carry out the responsibility. The policy also indicated a physician order was to be obtained to self-administer medications if the above storage and skill assessment had been approved for the resident by the interdisciplinary team. 3.1-11(a)

Based on record review and interview, the facility failed to ensure the resident's physician was notified of medication refusals for 1 of 6 residents reviewed for unnecessary medications. (Resident 47) Finding includes: During an interview on 6/10/25 at 2:15 p.m., Resident 47 indicated he did not like taking his Eliquis (a blood thinner). The record for Resident 47 was reviewed on 6/17/25 at 9:00 a.m. Diagnoses included, but were not limited to, hypertension, orthopedic aftercare, and peripheral vascular disease. The Quarterly Minimum Data Set (MDS) assessment, dated 5/2/25, indicated the resident was cognitively intact and received an anticoagulant (blood thinner). A Physician's Order, dated 2/25/25, indicated the resident was to receive Eliquis 2.5 milligrams (mg) twice a day. The June 2025 Medication Administration Record (MAR) indicated the resident refused his Eliquis on the following dates and times: - AM dose: 6/3/25, 6/8/25, 6/10/25, 6/11/25, and 6/17/25 - PM dose: 6/1/25 and 6/2/25 - AM and PM dose: 6/7/25, 6/9/25, 6/14/25, 6/15/25, and 6/16/25 There was no documentation indicating the physician was made aware of the resident's refusals of the Eliquis. During an interview on 6/17/25 at 12:10 p.m., the Director of Nursing (DON) indicated the physician should have been notified of the medication refusals. The current facility policy titled Drug Administration-General Guidelines was provided by the DON on 6/17/25 at 3:35 p.m. The policy indicated if a dose of regularly scheduled medication was withheld, refused, or given at another time than the scheduled time (e.g. resident not in facility at scheduled dose time, initial dose of antibiotic), the MAR should reflect documentation as to the reason the medication could not be administered. If two consecutive doses of a medication were withheld or refused, the physician was to be notified. 3.1-5(a)(3)

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) comprehensive assessment was accurately completed related to mobility, hearing, and insulin use for 2 of 19 MDS assessments reviewed. (Residents 3 and 38) Findings include: 1. On 6/10/25 at 10:47 a.m., Resident 3 was observed resting in his bed. He could not move his left arm, and his left hand was contracted (a structural change in the body's soft tissues that cause them to stiffen and shorten). He indicated he could not hear. On 6/12/25 at 9:35 a.m., the resident was observed propelling himself in his wheelchair using his right leg. His left leg remained on the footrest. He put in his hearing aid with his right hand. At that time, he indicated his left arm was dead and he could not move it, and he had minimal movement of his left leg. With the hearing aid on, the resident could only hear when spoken to loudly and in close proximity. The record for the resident was reviewed on 6/11/25 at 1:29 p.m. Diagnoses included, but were not limited to, stroke, hemiplegia (paralysis of one side of the body), and hearing loss. The 4/21/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident had severe cognitive impairment, used a hearing aid, was able to hear with minimal difficulty, and was dependent in activities of daily living (ADLs). The assessment indicated the resident had no impairment in range of motion or functional limitation to his upper and lower extremities. During an interview on 6/11/25 at 9:02 a.m., LPN 3 indicated the resident couldn't hear much, they had been working on his hearing aides, but they weren't working anymore. During an interview on 6/16/25 at 1:22 p.m., the MDS coordinator indicated the MDS assessment should have indicated the resident had a mobility impairment and probably should not have indicated the resident could hear with minimal difficulty, but she did not assess the resident. 2. The record for Resident 38 was reviewed on 6/16/25 at 10:50 a.m. Diagnoses included, but were not limited to, metabolic encephalopathy, dementia, and bipolar disorder. The 3/17/25 Quarterly MDS assessment indicated the resident had moderate cognitive impairment, required partial assistance with ADLs and supervision or touching assistance with transfers. It indicated the resident received insulin injections. The record lacked physician's orders or any documentation that the resident received any insulin in March 2025. During an interview on 6/16/25 at 1:22 p.m., the MDS Coordinator indicated the assessment had been coded in error and the resident had not received insulin. 3.1-31(i)

Based on observation, record review, and interview, the facility failed to ensure activities of daily living (ADLs) were completed for dependent residents related to skin and nail care for 1 of 3 residents reviewed for ADLs. (Resident 166) Finding includes: During random observations on 6/9/25 at 10:31 a.m., 6/10/25 at 9:24 a.m., 6/11/25 at 8:35 a.m., and 6/12/25 at 9:41 a.m., Resident 166's fingernails were dirty and long. Her feet were dry and scaly with flakes of skin accumulating on the bed sheet. During an interview at the time, the resident indicated she did not want her fingernails to be that long, and she would like it if someone put lotion on her feet. The record for the resident was reviewed on 6/11/25 at 9:45 a.m. Diagnoses included, but were not limited to, diabetes and heart failure. The 5/2/25 Medicare-5 Day Minimum Data Set (MDS) assessment indicated the resident had severe cognitive impairment, and was dependent in Activities of Daily Living (ADLs) and transfers. A 3/14/25 Podiatry Note indicated the resident had extremely dry, scaly skin on greater than 60% of her feet, and she required at-risk foot care. The shower sheets from the prior 30 days lacked documentation of skin and nail care completed or refused. During an interview on 6/16/25 at 2:18 p.m., the Director of Nursing (DON) was informed of the findings and offered nothing further. 3.1-38(a)(3)(A) 3.1-38(a)(3)(E)

Based on observation, record review, and interview, the facility failed to ensure residents received the necessary treatment and services related to a delay in scheduling a post-operative doctor's appointment for 1 of 2 residents reviewed for skin conditions non-pressure related, assessment and treatment of edema for 1 of 2 residents reviewed for edema, and holding an insulin dose without an order for 1 of 6 residents reviewed for unnecessary medications. (Residents 166, 52, and 36) Findings include: 1. During random observations on 6/9/25 at 10:31 a.m., 6/10/25 at 9:24 a.m., 6/11/25 at 8:35 a.m., and 6/12/25 at 9:41 a.m., Resident 166 had a dressing to her left upper chest. The dressing was no longer fully adhering to the skin, and at times, an incision underneath was visible. The resident indicated she had pacemaker surgery and had to keep the dressing on until she saw the doctor, but it was taking too long to get an appointment. The record for the resident was reviewed on 6/11/25 at 9:45 a.m. Diagnoses included, but were not limited to, diabetes and heart failure. The 5/2/25 Medicare-5 Day Minimum Data Set (MDS) assessment indicated the resident had severe cognitive impairment, and was dependent in Activities of Daily Living (ADLs) and transfers. The physician's post-operative instructions from the 5/28/25 pacemaker surgery indicated to schedule an appointment with the doctor as soon as possible for an appointment in one week for wound re-check. During an interview on 6/12/25 at 2:45 p.m., the Medical Records Coordinator indicated she had been calling the doctor's office for two weeks, but had not been able to speak to someone there to make the follow-up appointment. She indicated she informed the resident she had not been able to contact the office, but no one else. During an interview on 6/16/25 at 2:18 p.m., the Director of Nursing (DON) indicated she was not aware that the follow up had not been scheduled, and the Medical Records Coordinator should have informed her or someone else who could follow up on the problem. 2. During random observations on 6/10/25 at 9:51 a.m., 6/11/25 at 9:18 a.m., 6/12/25 at 10:08 a.m., and 6/16/25 at 9:05 a.m., Resident 52's legs and feet were visibly swollen and she was not wearing compression socks or Tubigrips (compression sleeves) to her legs. The record for the resident was reviewed on 6/12/25 at 1:53 p.m. Diagnoses included, but were not limited to, Parkinson's Disease, peripheral vascular disease, and weakness. The 3/31/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident had moderate cognitive impairment, and was dependent in activities of daily living (ADLs) and transfers. A Care Plan, last reviewed 4/23/25, indicated the resident had potential for cardiac distress. Interventions included to observe and report any increased edema (swelling) to the physician. A 4/30/25 Physician's Order indicated Tubigrips to both legs, on during the day, off in evening for bed. A 5/16/25 Nurse Practitioner Progress Note indicated the resident reported swelling to both legs, and that her legs felt heavy like a ton of bricks. A 5/22/25 Physician's Progress Note indicated the resident had 1+ pitting edema (swelling where a slight indentation appears on the skin after pressure is applied) to both legs. The record lacked regular assessment of the resident's edema. During an interview on 6/17/25 at 12:14 p.m., the Director of Nursing was informed of the findings and offered no further information. 3. The record for Resident 36 was reviewed on 6/16/25 at 2:28 p.m. Diagnoses included, but were not limited to, diabetes and acquired absence of left foot. The 3/14/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident had moderate cognitive impairment, and required substantial assistance with ADLs and transfers. The June 2025 Medication Administration Record (MAR) indicated Insulin Glargine Solution (a long-acting insulin), 22 units at bedtime. The 6/13/25 dose was held with the reason of No Sliding Scale Insulin Required Per Order. The June 2025 MAR indicated Humalog (a fast-acting insulin) 8 units, three times a day. The 6/1/25 and 6/6/25 4:30 p.m. doses were held with the reason of No Sliding Scale Insulin Required Per Order. There were no blood sugar parameters, sliding scale, or physician's orders to hold the insulin. A Care Plan, last reviewed 6/11/25, indicated the resident had the potential for having high or low blood sugars due to diabetes. Interventions included giving medications as ordered. During an interview on 6/17/25 at 12:14 p.m., the Director of Nursing was informed of the findings and offered no further information. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure timely podiatry visits were provided related to painful ingrown toenails for 1 of 1 resident reviewed for foot care. (Resident 55) Finding includes: During a random observation on 6/9/25 at 10:30 a.m., Resident 55 was in his room in bed. A band aid was observed on his left great toe. During an interview at that time, the resident indicated he wanted to see the podiatrist for his painful toenails. He indicated he had told staff several times and no one ever followed up with him. The record for Resident 55 was reviewed on 6/11/25 at 9:41 a.m. Diagnoses included, but were not limited to, type 2 diabetes and acute infarction of the spinal cord. The Quarterly Minimum Data Set (MDS) assessment, dated 5/27/25, indicated the resident was cognitively intact. A Physician's Order, dated 3/19/25, indicated the resident may receive services of eye care, audiologist, podiatrist, dental, psychiatrist, cardiologist, physiatrist, Nurse Practitioner, Wound Physician and any other specialist as deemed necessary An SBAR (Situation, Background, Assessment, and Recommendation) Summary, dated 3/27/25 at 3:29 p.m., indicated the resident had complaints of ingrown toenails with slight drainage. Recommendations were received to refer to the in-house podiatrist. A Nurse Practitioner (NP) note, dated 4/1/25, indicated the resident's great toes were described as infected and painful. The resident reported that both of his thumb toes were ingrown. Will monitor the resident's toes for signs of worsening. If necessary, a referral to podiatry would be made for further evaluation and treatment. An NP note, dated 4/22/25 at 12:04 p.m., indicated the resident was being seen for his bilateral ingrown toenails. He had ingrown toenails on the bilateral hallux (big toes) and the left second toe. The left second toe recently expressed purulent (a thick pus-like fluid) and sanguineous (a type of fluid that is composed primarily of blood) drainage. He had redness to his bilateral big toes and left middle toe. A topical steriod cream was ordered along with warm soapy water soaks. The resident was also to be seen by in-house podiatry. A Care Plan, dated 4/24/25, indicated the resident was at risk for complications related to acute skin impairment (ingrown toenails). Interventions included, but were not limited to, refer to podiatrist as needed (PRN). An NP note, dated 4/28/25 at 10:02 a.m., indicated the resident had persistent swelling in his toes and toe pain. He was to see the in-house podiatrist when available. There was no documentation the resident had been seen by the in-house podiatrist. During an interview on 6/12/25 at 9:55 a.m., the Social Service Designee (SSD) indicated the last time the podiatrist was at the facility was on 5/16/25. She also indicated the resident was not on the list to be seen. The SSD indicated she would put the resident on the list to be seen by the podiatrist the next time he visited. 3.1-47(a)(7)

Based on observation, record review, and interview, the facility failed to ensure oxygen was set at the correct flow rate for 2 of 3 residents reviewed for respiratory care. (Residents 5 and 13) Findings include: 1. During a random observation on 6/9/25 at 10:50 a.m., Resident 5 was in her room in bed. The resident had oxygen in use by the way of a nasal cannula. The oxygen concentrator was set at 1 1/2 liters. On 6/10/25 at 10:25 a.m., the resident was again observed in her room in bed. The resident had oxygen in use via a nasal cannula and her oxygen concentrator was set at 1 1/2 liters. On 6/12/25 at 9:30 a.m. and 2:05 p.m., the resident was in her room in bed. The resident had oxygen in use via a nasal cannula and her oxygen concentrator was set at 1 1/2 liters. The record for Resident 5 was reviewed on 6/11/25 at 2:52 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF). The Quarterly Minimum Data Set (MDS) assessment, dated 5/23/25, indicated the resident had moderate cognitive impairment and was using oxygen while a resident of the facility. A Physician's Order, dated 5/7/25, indicated the resident was to have oxygen at 2 liters per nasal cannula as needed (PRN) for shortness of breath. Maintain oxygen saturations greater than 90 percent. During an interview on 6/17/25 at 12:10 p.m., the Director of Nursing indicated the flow rate on the resident's oxygen concentrator should have been set at 2 liters. 2. During a random observation on 6/9/25 at 2:53 p.m., Resident 13 was in her room in bed. The resident had oxygen in use by the way of a nasal cannula. The resident's oxygen concentrator was set at 4 liters. On 6/11/25 at 9:01 a.m. and 2:25 p.m., the resident was observed in her room in bed. She had oxygen in use via a nasal cannula and the oxygen concentrator was set at 4 liters. On 6/12/25 at 9:30 a.m. and 2:15 p.m., the resident was observed in her room in bed. She had oxygen in use via a nasal cannula and the oxygen concentrator was set at 4 liters. The record for Resident 13 was reviewed on 6/17/25 at 9:23 a.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD) and chest pain. The Quarterly Minimum Data Set (MDS) assessment, dated 3/17/25, indicated the resident had moderate cognitive impairment and received oxygen therapy. A Care Plan, dated 12/13/24 and reviewed 3/2025, indicated the resident was at respiratory risk related to COPD. Interventions included, but were not limited to, administer oxygen per physician's order. A Physician's Order, dated 1/2/25 and listed as current on the June 2025 Physician's Order Summary (POS), indicated the resident was to receive 3 liters of oxygen continuously per a nasal cannula. During an interview on 6/17/25 at 12:10 p.m., the Director of Nursing indicated the flow rate on the resident's oxygen concentrator should have been set at 3 liters. 3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure blood pressure and heart rate parameters were monitored for 1 of 6 residents reviewed for unnecessary medications. (Resident 5) Finding includes: The record for Resident 5 was reviewed on 6/11/25 at 2:52 p.m. Diagnoses included, but were not limited to, ischemic heart disease, hypertensive heart disease with heart failure, and congestive heart failure (CHF). The Quarterly Minimum Data Set (MDS) assessment, dated 5/23/25, indicated the resident had moderate cognitive impairment. A Physician's Order, dated 3/25/25 and listed as current on the June 2025 Physician's Order Summary (POS), indicated the resident was to receive Metoprolol Tartrate (a medication used to treat high blood pressure and chest pain) 25 milligrams (mg), give 0.5 tablet twice a day. Hold for a heart rate less than 60 and systolic blood pressure (top number) greater than 110. The May and June 2025 Medication Administration Records (MARs), indicated the medication had been signed out as being given twice a day as ordered, however, there was no documentation of the resident's heart rate or blood pressure. During an interview on 6/17/25 at 12:15 p.m., the Director of Nursing indicated the resident's heart rate and blood pressure should have been documented. The Assistant Director of Nursing indicated a clarification order needed to be obtained regarding the resident's blood pressure parameter. 3.1-48(a)(3)

Based on record review and interview, the facility failed to ensure the medical record was complete and accurately documented related to infection monitoring for 2 of 3 records reviewed for infections. (Residents 3 and 36) Findings include: 1. The record for Resident 3 was reviewed on 6/11/25 at 1:29 p.m. Diagnoses included, but were not limited to, stroke, hemiplegia (paralysis of one side of the body), and hearing loss. The 4/21/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident had severe cognitive impairment and was dependent in activities of daily living (ADLs). The June 2025 Medication Administration Record (MAR) indicated, Monitor for s/s [signs/symptoms] of infection to include: fever, new/worsening skin impairments, sore throat, nausea/vomiting/diarrhea every day shift for change in condition screening-Start Date 05/17/2025. The documentation for 6/7/25 and 6/8/25 was y. The record lacked any other documentation of the resident having signs or symptoms of an infection on 6/7/25 and 6/8/25. During an interview on 6/17/25 at 12:14 p.m., the Director of Nursing indicated that was a documentation error and the nurse probably did not understand how to document correctly for that task. 2. The record for Resident 36 was reviewed on 6/16/25 at 2:28 p.m. Diagnoses included, but were not limited to, diabetes and acquired absence of left foot. The 3/14/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident had moderate cognitive impairment and required substantial assistance with ADLs and transfers. The June 2025 Medication Administration Record (MAR) indicated, Monitor for s/s [signs/symptoms] of infection to include: fever, new/worsening skin impairments, sore throat, nausea/vomiting/diarrhea every day shift for change in condition screening-Start Date 05/17/2025. The documentation for 6/7/25 and 6/8/25 was y. The record lacked any other documentation of the resident having signs or symptoms of an infection on 6/7/25 and 6/8/25. During an interview on 6/17/25 at 12:14 p.m., the Director of Nursing indicated that was a documentation error and the nurse probably did not understand how to document correctly for that task. 3.1-50(a)(2)

Based on observation, record review, and interview, the facility failed to ensure infection control practices were in place and implemented related to the cleaning of a shared glucometer before and after use for 1 of 1 glucometer (machine used to test blood sugar levels) test observed. (Resident 34) Finding includes: On 6/9/25 at 11:43 p.m., LPN 2 indicated she was going to check Resident 34's blood sugar level. The LPN walked in with the glucometer and indicated she had already cleaned the monitor, but she would clean it again. She grabbed a bottle of germicidal wipes and donned a new pair of gloves, she grabbed a couple of pieces of dry tissue and placed it on the bedside table. She then used the germicidal wipe to clean the glucometer. After cleaning the monitor she immediately wiped it dry with the dry tissue. Once the glucometer was dry, LPN 2 proceeded to obtain the resident's blood sugar. When the blood sugar test was completed, she walked the glucometer back to the medication cart and proceeded to clean the glucometer with a germicidal wipe. She again, immediately dried off the glucometer with a dry tissue. The glucometer was then placed back in the medication cart. During an interview on 6/9/25 at 12:01 p.m., LPN 2 indicated she cleaned the glucometer with the purple wipes (germicidal wipes) and then dried it off and wrapped it in a tissue. She indicated she did not know of any other way to clean the glucometer. During an interview on 6/10/25 at 11:46 a.m. with the Infection Preventionist (IP) and the Director of Nursing, the IP indicated she would expect staff to wipe down a glucometer with an appropriate germicidal wipe and wrap the germicidal wipe around the glucometer for 2-3 minutes. That was how she had educated the staff to clean the glucometer. The Director of Nursing (DON) indicated she would expect staff to follow manufacturer guidelines. A facility policy titled, Disinfecting Glucose Meters and received as current from the facility, indicated, .Contact time, also known as dwell/contact time is the amount of time an EPA registered disinfecting product needs to be present on a surface to be effective against microorganisms listed on it's label. Contact times usually fall between 30 seconds and 10 minutes . .5. Use disinfected wipe per manufactures guidelines. Ensure all surfaces are wet and contact/dwell time is followed . The manufacturer guidelines for Sani Wipes indicated to disinfect and deodorize nonporous surfaces, .Unfold a clean wipe and thoroughly wet surface. Allow surface to remain wet for 2 minutes. Let air dry . 3.1-18(b)

Based on observation, record review, and interview, the facility failed to ensure a resident with a pressure ulcer received the necessary treatment and services to promote healing, related to treatments not completed as ordered for 1 of 3 residents reviewed for pressure ulcers. (Resident F) Finding includes: During an observation on 10/28/24 at 9:34 a.m., CNA 1 and QMA 2 were providing morning care to Resident F. The resident was turned to the right side and an uncovered pressure area was observed to the right side of the sacral area. The area had depth and was approximately 3 centimeters (cm) by 2 cm in size. There was no observed drainage. CNA 1 indicated she had not received the information in morning report at 6:30 a.m. that the dressing was off. She indicated the night staff had reported they last completed rounds around 5 a.m. CNA 1 left the room to report the dressing was not in place to the nurse. During an observation on 10/28/24 at 10 a.m., LPN 1 entered the room. He indicated he had not been informed by the night nurse during the shift report that the dressing was off the pressure area. The wound was then washed with wound wash and patted dried. The gloves were changed and then collagen was placed inside the wound wound and it was covered with calcium alginate and a border gauze. LPN 1 then dated the dressing. Zinc oxide was not applied during the treatment. Resident F's record was reviewed on 10/29/24 at 1:14 p.m. The diagnoses included, but were not limited to, stroke and diabetes mellitus. A Quarterly Minimum Data Set assessment, dated 9/5/24, indicated the cognition status was not completed due to the resident unable to answer, there were no behaviors, dependent for all activities of daily living, always incontinent of bowel and bladder, and had one stage three (full thickness skin loss) pressure area. A Care Plan, dated 10/20/24, indicated a pressure wound to the right buttocks. The interventions included, the treatment would be completed as ordered. A Skin/Wound Progress Note, dated 9/8/24 at 8:32 p.m., indicated a stage three pressure area had been found on the right buttock. The measurement was 2.5 cm by 1.1 cm with a depth of 0.1 cm. A Physician's Order, dated 9/9/24, indicated the wound was to be cleansed, collagen was to be applied and the area was to be covered, daily on evening shift and as needed. A Physician's Order, dated 10/3/24, indicated a new treatment for the right buttock wound. The area was to be cleansed, patted dry, and medical grade honey was to be placed into the wound. Calcium alginate was to be applied and the area covered with a foam dressing every evening and as needed. The order was discontinued on 10/20/24. A Wound Nurse Practitioner Progress Note, indicated on 10/4/24, the wound was improving without complications. There was 30% of slough covering the wound. The peri-wound was intact, fragile, and macerated. A treatment of collagen in the wound, covered by calcium alginate and then border foam was to be completed daily. The Wound Nurse Practitioner's treatment order had not been transcribed on 10/4/24 and the treatment of the medical grade honey to the wound continued. A Physician's Order, dated 10/12/24, indicated zinc oxide paste was to be applied to the peri-wound daily with the pressure wound treatment. A Physician's Order, dated 10/20/24, indicated the right buttock pressure area was to be cleansed, patted dry, collagen was to be applied in the wound then covered with calcium alginate and a border gauze daily on evening shift and as needed. A Wound Nurse Practitioner Progress Note, dated 10/24/24, indicated the wound was stable with 10% slough. The peri-wound remained fragile, macerated, and now excoriated. There was a moderate amount of serosanguinal drainage. The daily treatment orders were changed to cleanse the wound, apply collagen in the wound, cover with calcium alginate and a border gauze. Zinc oxide was to be used on the peri-wound daily. During an interview on 10/29/24 at 2:27 p.m., the Corporate Regional RN indicated the Wound Nurse at the facility documented the information from the Wound Nurse Practitioner. She acknowledged the treatment orders were different than the Nurse Practitioner's orders. During an interview on 10/29/24 at 2:51 p.m., the Corporate Regional RN indicated there was no documentation that indicated why the medical grade honey had been ordered for the right buttock wound and acknowledged the treatment had not been changed when ordered by the Wound Nurse Practitioner on 10/4/24. The treatment order had not been changed until 10/20/24. The facility's skin/wound policy, dated 10/9/23, and received from the Minimum Data Nurse as current, indicated, the Physician/Nurse Practitioner was to be notified for orders for treatment for the wound and the orders were to be entered into the medical record and treatment and medication record as they are received. The orders were to be documented in the progress notes. Upon receipt of the order, immediate transcription of the order onto the Medication/Treatment Administration Record was to be completed and the treatment was to be initiated. This citation relates to Complaints IN00440342 and IN00443034. 3.1-40(a)

Based on record review and interview, the facility failed to ensure appropriate treatment and services were provided to residents with feeding tubes, related to physician's orders not followed when checking for proper placement of the feeding tubes, for 2 of 3 residents reviewed for feeding tube care. (Residents B and E) Findings include: 1) Resident B's closed record was reviewed on 10/28/24 at 1:06 p.m. The diagnoses included, but were not limited to, stroke. A Quarterly Minimum Data Set (MDS) assessment, dated 9/14/24, indicated a severely impaired cognitive status, a feeding tube was present and supplied 51% or more of nutrition and 501 cubic centimeters (cc) or more of fluids daily. A Physician's Order, dated 6/7/24, indicated the feeding tube placement was to be checked for placement and the residual was to be documented prior to the administration of medications, formula, and flushing. A Care Plan, dated 6/13/24, indicated a feeding tube was required. The interventions included, the tube would be checked for placement and gastric contents/residual volume would be recorded. The Medication Administration Records (MARs), dated 8/2024 and 9/2024, indicated the placement of the feeding tube was to be checked prior to the administration of medications, formula, and flushing, and the residual was to be documented. The placement check was scheduled for days, evening, and nights. The amount of residual after each check had not been documented. 2) Resident E's record was reviewed on 10/29/24 at 10:58 a.m. The diagnoses included, but were not limited to, severe protein deficiency. An Admission MDS assessment, dated 9/15/24, indicated a moderately impaired cognitive status, a feeding tube was present and supplied 51% or more of nutrition and 501 cubic centimeters (cc) or more of fluids daily. A Physician's Order, dated 9/17/24, indicated the feeding tube was to be checked for placement prior to the administration of medications, formula and flushing. The amount of residual was to be documented. A Care Plan, dated 10/9/24, indicated a feeding tube was present. The interventions indicated the feeding tube was to be monitored for proper placement/gastric residual. The Medication Administration Records (MARs), dated 9/2024 and 10/2024, indicated the placement of the feeding tube was to be checked prior to the administration of medications, formula, and flushing and the residual was to be documented. The placement check was scheduled for days, evening, and nights. The amount of residual after each check had not been documented. During an interview on 10/29/24 at 1:46 p.m., The Corporate Regional RN, indicated the amount of residual had not been documented on the MARs. A facility policy for enteral feedings, dated 7/3/2023 and received from the Minimum Data Set (MDS) Nurse as current, indicated the feeding tube would be assessed every eight hours and as needed. Placement of the tube in the stomach would be completed by observing for a change in the enteral tube length during feedings. If there is a change in length, aspiration of gastric contents may be used for placement evaluation. This citation relates to Complaint IN00443034. 3.1-44(a)(2)

Based on record review and interview, the facility failed to have ongoing communication with a resident's dialysis center, related to the facility not checking on a resident's location when they did not return from a dialysis appointment, for 1 of 2 residents reviewed for dialysis. (Resident C) Finding includes: Resident C's closed record was reviewed on 10/29/24 at 8:06 a.m. The diagnoses included, but were not limited to, end stage renal disease with dialysis, stroke, and dementia. An Modification of the Admission Minimum Data Set assessment, dated 6/17/24, indicated a severely impaired cognitive status, dependent on staff for all activities of daily living, and received dialysis. A Care Plan, dated 6/11/24, indicated dialysis was required. The interventions included, dialysis would be provided as scheduled. A Physician's Order, indicated dialysis was to be completed at a dialysis center on Monday, Wednesday, and Friday. A Nurse's Progress Note, dated 8/5/24 (Monday) at 4:39 p.m. and signed by LPN 3, indicated the medications were not administered due to the resident was discharged against medical advice. The next Nurse's Progress Note written, which was the last Nurse's Progress Note in the record, dated 8/6/24 at 7:29 a.m., indicated the medications were not administered due to the resident was discharged against medical advice. During an interview on 10/29/24 at 11:06 a.m., the Assistant Director of Nursing (ADON) indicated the resident had gone to the dialysis Facility on 8/5/24 and they must have sent her to the emergency room (ER). She had just reviewed the resident's hospital information and saw she was admitted into the hospital on 8/5/24. The information should have been documented in the record. During an interview on 10/29/24 at 11:11 a.m., LPN 4 indicated the resident had gone to dialysis. She was informed the resident's Power of Attorney transferred her to the hospital from the dialysis center, though was unsure who informed her of this and when she was informed. LPN 4 indicated the resident had not been discharged against medical advice and she did not know why she charted that. LPN 4 indicated the dialysis center did not always contact the facility when they sent residents to the hospital. The facility staff had not contacted the dialysis center for information when the resident had not returned to the facility on [DATE]. During an interview on 10/29/24 at 11:21 a.m., Dialysis Staff 1 indicated the resident's family entered the dialysis center on 8/5/24 and informed them he was taking the resident home after the treatment. The dialysis center had not transferred the resident to the ER, they had discharged her to the family. They had not notified the facility, as they presumed the family member would have informed them. During an interview on 10/29/24 at 11:30 a.m., the Corporate Regional RN indicated improvement was needed with documentation and she was looking for more information. No further information had been received upon exit of the facility on 10/29/24 at 4:00 p.m. An undated hemodialysis policy and procedure, received from the Minimum Data Set (MDS) Nurse on 10/29/24 at 8:42 a.m., indicated the dialysis center and the facility will communicate information regarding the dialysis session. This citation relates to Complaint IN00440342. 3.1-37(a)

Based on record review and interview, the facility failed to ensure a resident's record had thorough and accurate documentation related to a Physician consult appointment, admission cardiac assessment, pressure ulcer assessment, and documentation of pressure ulcers, for 1 of 5 residents reviewed for medical record documentation. (Resident B) Finding includes: Resident B's closed record was reviewed on 10/28/24 at 1:06 p.m. The diagnoses included, but were not limited to stroke. a) A Nurse's Admission Assessment, dated 6/7/24, indicated a pacemaker and defibrillator was present. There were no physician's orders for routine pacemaker monitoring. The Chest Physician Consult from the hospital, dated 6/4/24, lacked documentation of a pacemaker and/or defibrillator. The Nurse Practitioner's Admission Progress Note, dated 6/18/24 at 1:38 p.m., indicated the cardiovascular status was normal cardiac rhythm and no murmurs. There was no documentation that indicated a pacemaker and defibrillator was present. A Nurse's Progress Note, dated 6/21/24 at 10:27 a.m., indicated an open area in the skin had been found on the resident's left lower back. There was an abdominal binder on that protected a heart monitoring devise, placed on the upper left side of his chest. There was no further documentation in the record that indicated the resident had a pacemaker, defibrillator, or heart monitor. During an interview on 10/29/24 at 9:28 a.m., the Corporate Regional RN indicated all the hospital paperwork had been read and there was no heart monitor, pacemaker, or defibrillator documented in the records. The nurses who had documented the information were no longer employed by the facility. The Nurse Practitioner completed an assessment after admission and there was no pacemaker, defibrillator, or heart monitor. The nurses may have charted on the wrong record. b) A Nurse's Progress Note, dated 8/20/24 at 3:11 p.m., indicated an appointment with the Neurosurgery and Spine institute on 8/21/24 had been canceled due to being unable to find transportation to the appointment. A new appointment would be rescheduled and gurney transportation could be found. There was no further documentation the appointment had been rescheduled and transportation had been found. During an interview on 10/29/24 at 9:29 a.m., the Corporate Regional RN indicated she notified the Neurosurgery and Spine Institute and was informed the appointment was for 8/1/24 and the Physician's Office canceled the appointment after the CT of the head results on 7/12/24 showed the hematoma had resolved. There had been no appointment scheduled on 8/21/24. She indicated it may have been another resident who was scheduled to go to an appointment and there were documentation problems. c) A Weekly Skin Assessment, dated 8/20/24, indicated there were no pressure areas. The Daily Skilled Notes, dated 8/22/24, indicated there were no pressure ulcers. The Skin-Weight-Assessment-Team (SWAT) Progress Notes, dated 8/22/24, indicated there were no pressure ulcers. A Nutrition at Risk Note, dated 8/23/24 at 1:08 p.m. and written by Registered Dietitian (RD) 6, indicated nursing had informed her there were two open areas on the skin, on the sacrum and the back and the Wound Nurse was to evaluate. There was no documentation of the two open areas on the sacrum and back in the Nurses' Progress Notes. During an interview on 10/29/24 at 10:52 a.m., the Corporate Regional RN indicated the meeting on 8/23/24 at been completed per the phone with the RD. She had notified RD 6 and she was unable to recall who informed her about the open areas, only that she was told. This citation relates to Complaints IN00440342 and IN00443034. 3.1-50(a)(1) 3.1-50(a)(2)

Based on observation, interview, and record review, the facility failed to ensure correct Personal Protective Equipment (PPE) was used by staff members (CNA 5, CNA 1, and QMA 2) when providing care to residents (Residents E and F) who were in Enhanced Barrier Precautions (EBP) for two random observations for infection control. Findings include: 1) During an observation on 10/28/24 at 8:51 a.m., Resident E had a sign on the room door that indicated the resident was in EBP. There was PPE located at the doorway to the room. Upon entering the room, CNA 5 was completing morning care on the resident. Gloves were worn. She indicated she had just finished washing him and provided incontinent care. The feeding tube insertion site was clean. CNA 5 was applying lotion to the resident's legs. She indicated the resident was no longer in EBP and stated, he doesn't have anything, they just forgot to take the signs down. She then completed the resident's oral care. Resident E's record was reviewed on 10/29/24 at 10:58 a.m. The diagnoses included, but were not limited to, severe protein deficiency. An Admission MDS assessment, dated 9/15/24, indicated a moderately impaired cognitive status, a feeding tube was present and supplied 51% or more of nutrition and 501 cubic centimeters (cc) or more of fluids daily. He was dependent for bathing and required maximum assistance for hygiene. A Care Plan, dated 10/28/24, indicated EBP was required related to the feeding tube. The interventions included EBP guidelines would be followed with direct care activities, which included, bathing, hygiene, incontinent care. A Physician's Order, dated 10/28/24, indicated EBP was to be used every shift due to the feeding tube and nebulizer treatments. 2. During an observation on 10/28/24 at 9:34 a.m., Resident F's door to the room indicated EBP was required. CNA 1 and QMA 2 were prepared to begin Resident F's morning care. They had donned gloves. Prior to the start of the care, they were interviewed about EBP. QMA 2 indicated the resident was on EBP. CNA 1 and QMA 2 then applied gowns and changed gloves. Morning care was completed, which included incontinent care. The insertion site of the feeding tube was clean and had a clean dressing marked with the date 10/28/24. Resident F's record was reviewed on 10/29/24 at 1:14 p.m. The diagnoses included, but were not limited to, stroke and diabetes mellitus. A Quarterly Minimum Data Set assessment, dated 9/5/24, indicated the cognition status was not completed due to the resident was unable to answer, there were no behaviors, dependent for all activities of daily living, always incontinent of bowel and bladder, and had a feeding tube present. A Care Plan, dated 10/28/24, indicated EBP was required related to the feeding tube. The interventions included EBP guidelines would be followed with direct care activities, which included, bathing, hygiene, incontinent care. A Physician's Order, dated 2/7/24, indicated EBP was to be used every shift due to the feeding tube. During an interview on 10/28/24 at 10:30 a.m., the Assistant Director of Nursing was informed of EBP not being followed. No further information was received at this time. A facility EBP policy, dated 12/2022 and received from the Minimum Data Set (MDS) Nurse as current, indicated EBP would be used for residents during high-contact resident care activities for residents who were at risk. The residents at risk included residents with feeding tubes. The high-contact examples included bathing/showering, hygiene, and changing briefs/incontinent care. Gowns and gloves would be utilized. This citation relates to Complaint IN00443034. 3.1-18(b)

Based on observation, record review and interview, the facility failed to assess a resident and promptly notify the Physician in a timely manner after a fall resulting in a three day delay in treatment and hospitalization for a fracture (Resident N) and also failed to complete an assessment of a resident including vital signs after a fall (Resident E) for 2 of 4 residents reviewed for falls. Findings include: 1. 8/30/23 at 9:15 a.m. Resident N was observed in bed with her eyes closed. The bed was low and there was a floor mat on the left side, the right side of the bed was against the wall. At that time, the Nurse Practitioner (NP) was seated on a chair by the bed. Interview with the NP at that time, indicated she was waiting for the resident's daughter to call because they were placing the resident on hospice care today. When asked about the fall with resulting in the fracture, she indicated she really did not know how she fell out of bed, but ever since the fall and fracture, the resident's condition had gone downhill. Her daughter wanted an orthopedic consult, and one was ordered, however, surgery was not an option because the resident was very high risk. On 8/30/23 at 11:00 a.m., 2 LPNs were asked to remove the bandage from the resident's pressure ulcer on the sacrum. The resident's right leg had a large yellow and faded blue bruise and was wrapped with an ace bandage with a soft splint support on the backside. The record for Resident N was reviewed on 8/30/23 at 9:30 a.m. Diagnoses included, but were not limited to, dementia, osteoarthritis, high blood pressure, heart disease, depressive disorders, anxiety, osteoporosis, fracture of shaft of right tibia and of right fibula. The 5/30/23 Quarterly Minimum Data Set (MDS) assessment, indicated the resident was cognitively impaired and had no falls since the last assessment. The resident was totally dependent on staff with a 2 person physical assist for bed mobility and transfers. The 8/2/23 Significant Change MDS assessment, indicated the resident was cognitively impaired and had 1 fall with a major injury since the last assessment. The resident was an extensive assist with a 2 plus person physical assist with bed mobility and totally dependent on staff with a 2 person assist for transfers. The 7/24/23 Quarterly Fall Risk Review Assessment indicated the resident was a high risk for falls The Care Plan, dated 7/25/23, indicated the resident had a fractured right tibia and fibula. The Care Plan, dated 7/25/23, indicated the resident had an actual fall with injury and a fracture. The approaches to make sure the bed was in the lowest position and a floor mat next to the bed. A Nurses' Note, dated 7/25/23 at 9:45 p.m., indicated the resident was observed with a large bruise on the right leg and it was in an anatomically odd position. A full head to toe assessment was completed and there was dark purple bruising noted with a green and yellow border to the right lower leg. The Physician was notified and a new order was obtained to send the resident to the hospital. 911 was called and arrived 20 minutes later and the resident was transported to the emergency room . The emergency room Notes, dated 7/25/23, indicated the resident arrived at 11:44 p.m. An assessment of the right lower leg indicated the extremity compartments are soft, mild tenderness to palpation and not out of proportion to injury, no paralysis, non-circumferential swelling, normal sensation, no pallor, strong pulses, no paresthesias [sic], not cool to the touch. The right knee has swelling, effusion and ecchymosis present. Decreased range of motion and tenderness present. An X-ray of the right knee indicated there was a long blade plate and screws in place indicating an old distal femoral shaft fracture. The impression was there was an acute comminuted slightly displaced impacted fracture in the proximal right tibia shaft distal to the tibia plateaus and an associated fracture with angulation in the neck of the fibula. An X-ray of the right tibia and fibula indicated acute proximal tibia and fibular fractures, however, better seen on the knee X-ray. The bones were osteoporotic (a bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of the bone changes. This can lead to a decrease in bone strength that can increase the risk of fractures.) A long leg post mold splint was applied to the right leg. There was no clear indication for surgery given the patient's condition and the POA's desire. A Nurses' Note, dated 7/26/23 at 4:10 a.m., indicated the resident returned from the hospital. The resident was noted with a long leg splint to the right leg. A IDT (Interdisciplinary Team) Progress Note, dated 7/26/23 at 2:55 p.m., indicated the resident had a recent unwitnessed fall from bed and was sent out for abnormal posture of leg. The resident returned with a fracture to tibia/fibula with a splint in place. The facility protocol was initiated and the IDT team met to discuss the incident and prevent future falls. The Care Plan was reviewed and updated, and staff were inserviced on fall protocol and reporting. New interventions were to have the bed in lowest position and a floor mat on open side of bed. A Fall Investigation initiated by the Director of Nursing, dated 7/25/23, indicated staff were asked to answer these questions: - Any incidents that occurred over the weekend? - Did you report any incident to the nurse at any time during your shift? - Did You hear from another staff member about any incident? A CNA indicated she was told by another CNA that Resident N was on the floor. The CNA gave the name of the staff member who told her that information. The CNA did not report the incident as she thought the other staff member had already told the nurse. The Follow Up to the Investigation indicated the resident had an unwitnessed fall on 7/22/23 from bed. The staff had noted on 7/25/2023 the resident had an obvious deformity to her right leg and the resident was sent to the emergency room for X-rays and an evaluation. The resident had a right tibia/fibula fracture and returned to the facility with a follow up appointment with a referral to an orthopedic specialist, scheduled for 8/3/23. The staff were educated. Interview with the Director of Nursing (DON) on 8/30/23 at 3:00 p.m., indicated when the bruising and deformity was discovered on 7/25/23 and the resident was sent out to the hospital, a CNA came up to her and indicated the resident had fallen out of bed over the weekend. The DON started an investigation and reviewed the security cameras. The resident's room was near the nurses' station and the resident's bed could be seen by the camera. On 7/22/23, she saw movement on the floor under the bed and at that moment 2 CNAs entered the room and closed the door. After they left the room, there was no more movement on the floor. She asked every staff member over the weekend to answer questions regarding any unusual events or if any resident had a fall. Only 1 CNA indicated she was told by another CNA, Resident N was on the floor. The 2 CNAs who picked the resident up and put her back to bed, denied any resident fell and they were terminated. The DON indicated a full set of vital signs were checked on 7/22/23, however, there was no physical assessment of the resident for 3 days after the fall on 7/22/23. An undated, but identified as current Incident/Accident/Falls policy provided by the Interim Administrator on 8/30/23 at 4:38 p.m., indicated It was the policy of the facility to ensure that any incident/accident to include fall is reported immediately to the nurse or appropriate person designated to be in charge. 2. The closed record for Resident E was reviewed on 8/30/23 at 2:55 p.m. The resident was admitted to the facility on [DATE] and discharged against medical advice on 8/5/23. Diagnoses included, but were not limited to, osteomyelitis of the left foot and ankle, MRSA infection in the left foot, anxiety, arthritis, major depressive disorder, schizoaffective disorder, and high blood pressure. A Nursing Admission Assessment, dated 8/4/23, indicated the resident had a left foot wound and was admitted for Intravenous (IV) antibiotics. The resident was cognitively intact. A Fall Risk Assessment, dated 8/4/23, indicated the resident was a low risk for falls. An e-Interact Change in Condition Evaluation, dated 8/5/23 at 10:15 a.m., indicated the resident had an unwitnessed fall and no injuries were noted. There were no current vital signs checked after the fall or neurological checks initiated. Interview with the Director of Nursing on 8/30/23 at 4:00 p.m., indicated there were no neuro checks initiated or current vital signs checked after the fall. An undated, but identified as current Incident/Accident/Falls policy provided by the Interim Administrator on 8/30/23 at 4:38 p.m., indicated in case of a fall, the resident will have a head to toe assessment completed. Any resident who had an unwitnessed fall must have neuro checks started and continued per policy. Neuro checks will be initiated even if the resident states they did not hit their head in an unwitnessed fall. This Federal tag relates to Complaints IN00411506, IN00415513, and IN00416438. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to provide treatment and services related to the development of a pressure ulcer to the right heel with no assessment or treatment orders in place, resulting in an unstageable wound for 1 of 3 residents reviewed for pressure ulcers. (Resident F) Finding includes: Observation on 7/14/20 at 1:15 p.m., Resident F was observed in bed lying on her back. At that time, QMA 1 was asked to turn the resident over onto to her side to observe the pressure ulcer on the coccyx. When the QMA rolled the resident onto her left side, an area to the right heel was observed. The area was black, scabbed, and with bloody drainage. At that time, there was no bandage covering the right heel and there was also dried blood on the bed sheet from the sore. The resident had a bandage in between the crack of her buttocks, however, it was not covering the pressure sore over the coccyx. The bandage was bloody and soiled. At that time, heel boots were observed on the floor by the night stand and not on her feet. Interview with CNA 1 at that time indicated she and another CNA had just repositioned the resident and the bandage on the coccyx could have moved. Interview with LPN 1 on 7/14/20 at 1:30 p.m., indicated she was the nurse on duty taking care of Resident F. No staff had told her the resident had a new open area on the right heel. Interview with the Wound Nurse on 7/14/20 at 1:35 p.m., indicated she had completed a skin assessment on the resident last week on 7/8/20. She had changed the treatment for [REDACTED]. At that time, the Wound Nurse was made aware of the new area on the resident's right heel. She indicated it was not there last week on 7/8/20 when she had changed the treatment for [REDACTED]. Interview with CNA 1 on 7/14/20 at 1:40 p.m., indicated she had worked 7/10-7/12/20 during the day shift last week. She indicated on Saturday, 7/11/20, there was a tiny square bandage noted on the right heel. The resident did not get out of bed for showers, therefore she preferred full bed baths on her shower days. She indicated there was no information on her CNA assignment sheet regarding heel boots for the resident. Observation on 7/14/20 at 1:45 p.m., the Wound Nurse preformed a skin assessment of the resident's right heel and was going to change the bandage on the coccyx. CNA 1 turned the resident onto her left side and the wound to the right heel was observed. The Wound Nurse indicated it was an unstageable (Full thickness tissue loss in which actual depth of the ulcer was completely obscured by slough and/or eschar (necrotic) tissue) pressure ulcer. The ulcer measured 2.5 centimeters (cm) by 5.5 cm. with a moderate amount of bloody drainage noted. The Wound Nurse indicated the right heel had a large amount of black necrotic tissue covering it. She cleansed the ulcer with normal saline and placed a calcium alginate bandage on top of the wound and covered it with a foam dressing. The bandage on the coccyx was not fully covering the pressure ulcer, had no date on it to indicate when it was last changed and was removed by the Wound Nurse. The pressure ulcer was clean and had some bloody drainage noted. The record for Resident F was reviewed on 7/14/20 at 12:32 p.m. [DIAGNOSES REDACTED]. The resident was admitted to the hospital on [DATE] and did not return to the facility until 5/13/20. An Admission Minimum Data Set (MDS) assessment, dated 5/20/20, indicated the resident was alert and oriented with mild cognition deficits. She needed extensive assist with 2 person physical assist with bed mobility and was totally dependent with 2 person physical assist for transfers. She was readmitted with a Stage 2 and a Deep Tissue Injury (DTI) pressure ulcer. The Care Plan, dated 5/13/20, indicated the resident had developed a pressure injury to the coccyx and left buttock. The approaches were to float or bridge heels when in bed and the nurse was to measure/assess weekly and notify family and Physician as needed. There was no Care Plan for the right heel pressure ulcer. The last weekly skin assessment, dated 7/7/20, indicated there was no documentation regarding a pressure ulcer to the right heel. The last documented Nurses' Note, dated 7/10/20 at 4:54 p.m., indicated no documentation regarding the pressure ulcer to the right heel. There was no documentation indicating the Physician was notified of the new pressure ulcer to the right heel. physician's orders [REDACTED]. Change 3 times a week and as needed. physician's orders [REDACTED]. The Treatment Administration Record (TAR) for July 2020, indicated the treatment for [REDACTED]. The as needed treatment was not signed out at all during that time frame. Interview with the Wound Nurse on 7/14/20 at 2:30 p.m., indicated the wound to the right heel was not there last week when she last assessed it on 7/8/20. She indicated there was a wound protocol for the nurses to follow when a new wound was found. A new skin authorization form was to be completed and that information goes to the dashboard. When she comes to work the next day, depending on how many days she had been off, she would look back that far on the dashboard to see if there was anything new she needed to observe and assess. There was no documentation or information on the dashboard regarding the pressure ulcer to the right heel. She indicated she was the only person allowed to Stage pressure ulcers, however, she had made a template for the nurses to follow to obtain a treatment, depending on where and what the wound looked like. She had been off and out of the facility 7/10-7/13/20. The current 8/14/2014 Skin Management Program policy, provided by the Wound Nurse on 7/14/20 at 3:10 p.m., indicated Communication will occur with the resident and Physician when there is a change in condition and or a change in treatment plan. Nursing staff will communicate changes via 24 hour condition report and written or electronic nurse aide assignments. This Federal tag relates to Complaints IN 335 and IN 758. 3.1-40(a)(1) 3.1-40(a)(3)

Based on record review and interview, the facility failed to ensure proper supervision and assistance was provided while transferring a resident with a mechanical lift , resulting in a resident falling and obtaining a hip fracture for 1 of 3 residents reviewed for falls. (Resident B) Finding includes: The record for Resident B was reviewed on 1/12/17 at 8:30 a.m. [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated the resident had a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident was unable to finish the evaluation. The resident was an extensive assist with a 2 person physical assist for transfers. A Fall Investigation dated 12/29/16 at 4:00 p.m., indicated previously planned interventions were not in place, and effective at the time of the occurrence. There was a problem with the hoyer lift pad which caused the pad to slip from under the resident while being lifted from the chair to the bed with the assist of 1 staff member. Interventions on the manager review were for a 2 staff assist with transfers, assistive device (amputee pad?), and staff inservice with the mechanical lift representative. The witness statement from CNA #1 on 12/30/16, indicated the resident fell out of the sling and hit her head on the floor. A Fall Risk assessment post occurrence progress note dated 12/30/16, indicated on 12/29/16 at 1600 (4:00 p.m.) the resident slipped from the lift pad. CNA #1 was present and witnessed the resident fall and hit her head and there was a small laceration to her head. A staff correction Teachable Moment form included in the fall follow-up dated 1/5/17, indicated CNA #1 performed a returned demonstration with the hoyer lift. The staff member was informed of an amputee sling. There were no issues noted. A physician's orders [REDACTED]. The Radiology reports dated 1/4/17 concluded early healing of the right intertrochanteric fracture, and a distal femur fracture with early healing and persistent displacement. A physician's orders [REDACTED]. An Education In-Service dated 1/10/17 was given by an Arjo (brand of mechanical lift) Sales Representative. The topic was Arjo lifts, safety, and amputee slings. A Fall Risk assessment dated [DATE], indicated the resident was at risk for falls due to the left AKA and [DIAGNOSES REDACTED]. A skilled assessment dated [DATE], indicated the resident required a maximum assist by staff for transfers. Device of mechanical lift (hoyer). A Physical Therapy note from admitted d 2/11/10, indicated the resident required a hoyer lift for transfers. The Plan of Care dated 10/18/16, indicated the resident required extensive to total assist with ADL's (activities of daily living) and transfers. The interventions included, but were not limited to, use 2 person for all hoyer lifts. Interview with CNA #1 on 1/11/17 at 2:55 p.m., indicated prior to the fall on 12/29/19, the resident was sitting in her wheelchair with her mechanical lift pad underneath her when he entered the room. He brought the mechanical lift in the room and attached the clips from the sling to the mechanical lift. During the transfer the resident fell out of the sling about 3 foot from the bed, and landed on the floor. At that time of the interview he indicated that the front left leg clip was not attached to the mechanical lift hook. He denied ever seeing or using an amputee sling at the facility. Interview with Director of Nursing (DON) on 1/12/17 at 2:30 p.m., indicated the resident should have had a 2 person physical assist during the transfer. The In-Service Director had just held a staff education in-service on the facilities Arjo lift. Interview with the In-Service Director on 1/12/17 at 2:50 p.m., indicated that on 1/10/17 the Arjo lift sales representative came to the facility and educated the staff on safety and the amputee slings. The recommendation of the company was to use the amputee sling on the residents with an amputation, and not the standard slings. The amputee sling was designed to hold the resident securely because it has a shorter piece of fabric which would hold in the amputated leg. The facility Arjo Maxi Move Lift policy was provided on 1/12/17 at 8:45 a.m. The policy read to select the appropriate type and size of sling and to double check all sling attachment clips to ensure they are fully in position before and during the lifting cycle. This Federal Tag relates to Complaint IN 542. 3.1-45(a)(2)