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

Based on record review, observation and interview, the facility failed to ensure a resident who required thickened liquids was not given thin liquids for 1 of 1 residents reviewed for professional standards of care. (Resident 7) Finding includes: During a random observation, on 6/26/2025 at 11:35 A.M., R.N. 2 was observed to administer a soufflé' cup of crushed medications mixed with pudding to Resident 7. After administering the medications, RN 2 asked Resident 7 if he wanted a drink of water. The resident did not respond verbally or physically to the nurses's question. Nurse 2 poured a small amount, approximately 60 ml (milliliters) of cold water into a cup and put it up to Resident 7's mouth. Resident 7 was observed drinking the water. He swished it around in his mouth for a few seconds and then swallowed it. Nurse 2 asked the resident if he wanted another drink of water. Resident 7 did not respond verbally or physically to the nurses' question. Nurse 2 again put the cup up to his mouth where he took a drink of the water and swished it around in his mouth and then swallowed it. She then took the resident down to the dining room for lunch. The record for Resident 7 was reviewed on 6/25/2025 at 1:25 P.M. Diagnoses included, but were not limited to paraplegia, dysphagia, diabetes, cerebral infarction, dysfunction of bladder and chronic kidney disease. Current Physician Orders' for Resident 7 included:- Diet: Pudding thick liquid. A Significant Change MDS (Minimum Data Set) assessment, dated 4/16/2025, indicated Resident 7 was severely cognitively impaired, and received a mechanically altered diet and was dependent on staff for all adl's (activities of daily living, including eating). During an interview, on 6/26/2025 mat 11:45 A.M., the Director of Nursing was made aware of the nurse not administering thickened liquids when she had given his medications. The Director of Nursing indicated they were going to order an x-ray of his chest to ensure he had not aspirated any of the unthickened water into his lungs. During an interview, on 6/27/2025 at 7:09 A.M., RN 2 indicated Resident 7's chest x-ray came back negative and provided a copy of the x-ray that had been obtained on 6/26/2025. Nurse 2 indicated she should have not given him the unthickened water and she did not know why she had given him unthickened water. On 6/27/2025 the Director of Nursing provided the policy titled, Thickened Liquids, dated 1/2025, and indicated the policy was the one currently used by the facility. The policy indicated . 5. d. Pudding-Thick - Not pourable; they hold their shape. Comparable to pudding and yogurt. They sit on the prong of a fork. They are consumed with a spoon. 6. The Nutrition services department will have pre thickened beverages and commercial thickeners available The Standards of Professional Nursing Practice are authoritative statements of the actions and behaviors that all registered nurses, regardless of role, population, specialty, and setting, are expected to perform competently. [4] These standards define a competent level of nursing practice based on the critical thinking model known as the nursing process. Article 2 of the Standards for the Competent Practice of Registered and Licensed Nurses indicated . Sec. 1. The registered nurse shall do the following: (1) Assess the patient/client in a systematic, organized manner. (2) Formulate a nursing diagnosis based on accessible, communicable, and recorded data which is collected in a systematic and continuous manner. (3) Plan care which includes goals and prioritized nursing approaches or measures derived from the nursing diagnosis. (4) Implement strategies to provide for patient/client participation in health promotion, maintenance, and restoration. (5) Initiate nursing actions to assist the patient/client to maximize his or her health capabilities. (6) Evaluate with the patient/client the status of goal achievement as a basis for reassessment, reordering priorities, new goal-setting, and revision of the plan of nursing care. (7) Seek educational resources and create learning experiences to enhance and maintain current knowledge and skills for his or her continuing competence in nursing practice and individual professional growth 3.-35(g)(1)

Based on observation, record review and interview, the facility failed to ensure a urinary drainage bag was positioned in a sanitary manner for 1 of 1 resident reviewed for urinary catheter. (Resident 7) Finding includes: During an observation, on 6/24/2025 at 9:50 A.M. and 1:54 P.M., the covered urinary drainage bag for Resident 7 was observed touching the floor at the bedside. During an observation, on 6/27/2025 at 9:18 A.M., the covered urinary drainage bag for Resident 7 was observed touching the floor at the bedside. A record review for Resident 7 was completed on 6/25/2025 at 2:10 P.M. Diagnoses included, but were not limited to: paraplegia, pressure ulcer of sacral stage 3, retention of urine, neuromuscular dysfunction of bladder and chronic kidney disease. A Significant Change Minimum Data Set (MDS) assessment, dated 4/16/2025, indicated Resident 7 had severe cognitive impairment and had an indwelling urinary catheter. A Physician's Order, dated 1/15/2025 indicated a Suprapubic 20 French 10 milliliter balloon catheter for a neurogenic bladder. A Care Plan, initiated on 10/14/2021 and revised on 2/11/2025, indicated Resident 7 required the use of a suprapubic catheter for neurogenic bladder with urinary retention. The goal was for the catheter to be maintained per the care plan. Interventions included, but were not limited to: catheter care every shift and to maintain the urinary drainage bag below the bladder level to facilitate the flow of urine. During an interview, on 6/27/2025 at 9:50 A.M., CNA 3 indicated the covered catheter drainage bag should not have been touching the floor. A policy was provided by the Director of Nursing (DON), on 6/27/2025 at 11:42 A.M. The current policy titled, Catheters, indicated, .Further, that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections 3.1-41(a)(2)

Based on observation and interview, the facility failed to properly label over the counter medications for 1 of 2 medication carts observed for medication storage. (Memory Care unit) Finding includes: The medication cart for the Memory Care unit was observed on 6/27/2025 at 1:09 P.M. with QMA 4. The following was observed. 1. Resident 31 had 2 boxes of Chlorasepic lozenges, one opened and one sealed. There was no labeling for Resident 31's medication observed on the boxes. 2. Resident 2 had the following over the counter medications without the proper labeling for identification: -One bottle of supplement of Lutein only had Resident 2's initials. -One bottle of B6 vitamins only had Resident 2's initials and an open date on the bottle. -One bottle of Stool Softner, 100 milligram capsules, only had Resident 2's initials on the bottle. -One bottle of Centrum vitamins only had Resident 2's first name on the bottle. -One bottle of Magnesium, 250 milligrams, only had Resident 2's initials on the bottle. -One bottle labeled Allergy Releif, 10 milligrams, only had Resident 2's initials on an open bottle and no identifying information on an unopened bottle. During an interview, on 6/27/2025 at 1:22 P.M., QMA 4 indicated over the counter medication should have had the following identifying information on the bottles: the resident's first and last name, the pharmacy provider, the open date, the name of the drug, the strength of the drug and the directions for use. A policy was provided by the Executive Director, on 6/27/2025 at 1:36 P.M. The policy titled, Prescription Labels, indicated, .Medications are labeled in accordance with State and Federal law as well as facility requirements .5. a. Indiana law for nonprescription labeling requires the following: Resident name, Physician name, Expiration date, Name of drug and Strength 3.1-25(j)

Based on observation, interview and record review the facility failed to ensure physician ordered snacks were provided for 1 of 1 pantry areas observed and failed to ensure staff did not thumb the eating surface of dinner plates when serving in 1 of 2 dining rooms observed. This had the potential to affect all 34 residents who reside in the facility and who receive food from the kitchen. Findings include: 1. A food storage area on the south hall was observed, on 7/23/2024 at 1:08 P.M. In the refrigerator was a tray with snacks for 6 residents that were dated 7/22/2024, and a hard boiled egg in the side door. During an interview, on 7/23/2024 at 1:14 P.M., the Social Service Director indicated the snacks should have been passed out last night and the hard boiled egg should have been in a container. On 7/23/2024 at 2:12 P.M., the Administrator provided the policy titled,Clinical Nutrition Documentation, dated 4/2017, and indicated the policy was the one currently used by the facility. The policy indicated .The Food & Nutrition department will send snacks to the nursing stations between meals and at HS. The Food & Nutrition department will maintain a system of snack list for labeling and delivering snacks to those residents that receive scheduled snacks as part of their plan of care/preference 45120 2. During a dining observation on 7/21/2024 at 11:49 A.M. through 12:10 P.M., staff was observed removing bread from a sandwich bag with their bare hands for a resident, thumbing dinnerware for 3 residents, and cupping the top of the glassware for 2 residents. On 7/22/2024 at 11:40 A.M. through 11:58 A.M., staff was observed thumbing dinnerware for 6 residents, and cupping the top of glassware for 2 residents. During an interview on 7/24/2024 at 10:58 A.M., the Director of Nursing indicated that the thumb should not be over the edge of the dinnerware, and the glassware should not be cupped. A policy was provided, on 7/24/2024 at 2:08 P.M., by the Director of Nursing. The policy titled, Handling Tableware, indicated, .7. All tableware will be handled appropriately so that the eating surface of the utensil/tableware is not contaminated 3.1-21(2)

Based on record review and interview, the facility failed to provide written bed hold information to the resident and/or patient representative upon transfer to a hospital for 1 of 3 residents reviewed for hospitalization (Resident 5). Findings include: The record for Resident 5 was reviewed on 7/21/24 at 2:12 PM. Diagnoses included but were not limited to: disorder of central nervous system, diabetes mellitus, violent behavior, insomnia, psychotic disorder with delusions, anxiety disorder, and major depressive disorder. A Quarterly MDS (Minimum Data Set) Assessment, dated 4/17/2024, indicated a BIMS (Brief Interview for Mental Status) score of 6, severe cognitive impairment. A Progress Note, dated 7/15/2024 at 9:55 P.M., indicated the resident was sent to the emergency room for evaluation for abdominal distention and hyperactive bowel sounds. Nursing staff documented the bed hold policy was sent with the emergency medicine technician (EMT) staff. A Progress Note indicated the resident returned to facility on 7/20/2024. The clinical record did not contain documentation of written notification to the patient representative of the facility bed hold policy. During an interview, on 7/24/2024 at 10:47 A.M., the DON (Director of Nursing) indicated the facility had never mailed the bed hold policy to the family and have just notified family or patient representative by phone when the patient is cognitively impaired. She indicated all residents and families are given a copy of the bed hold policy at time of admission. During an interview, on 7/24/2024, at 2:14 P.M., the DON indicated that nurses should send the bed hold notice to the family by mail or email the policy. On 7/24/2024 at 2:12 P.M., the DON provided a document titled The Waters Bed Hold Policy, and indicated it was the policy currently being used by the facility. The policy indicated .facility to provide Resident, Resident's family member, and/or the Resident's legal representative .in written form and/or by a telephone conversation prior to transfer . 3.1-12(a)(25) 3.1-12(a)(26)

Based on record review and interview, the facility failed to complete the resident Care Area Assessment in a timely manner for 1 of 13 residents reviewed for comprehensive assessments. (Resident 30) Finding includes: A record review of Resident 30 was conducted on 7/22/2024 at 11:09 A.M. Diagnoses included, but were not limited to: dementia, history of malignant neoplasm of the bladder, and chronic kidney disease. An Admission Minimum Data Set (MDS) assessment, dated 7/2/2024, indicated Resident 30 was cognitively intact, was frequently incontinent of bladder and bowel, required substantial/maximal assistance for transfer and toileting hygiene, had minimal difficulty with hearing, and had broken or loose-fitting denture/partial and obvious or likely cavity or broken natural teeth. The MDS assessment triggered Care Area Assessments (CAA) (identification of problems, strengths and preferences) to be further evaluated and potentially care planned for urinary incontinence, dental care, activities of daily living (ADL) abilities, and communication. The CAA area for ADL's indicated this area was an actual problem/need. Resident 30 had triggered related to ADL's and transfers. Resident 30 was able to participate in ADL's requiring staff assistance up to partial/substantial assist to complete his ADL's. Resident 30 was receiving therapy to help with his strengthening and endurance. The facility will continue to assist residents with ADL's, monitor for changes, and notify the physician as necessary. The facility will proceed to care planning. ADL abilities will be addressed in the care plan to slow or minimize decline, avoid complications, and minimize risks. The CAA area for urinary incontinence indicated and actual problem/need. Resident 30 had triggered for urinary incontinence related to Resident 30 required substantial/max assistance with toileting. Resident 30 was unable to resist voiding at times, requiring staff assistance with cleansing, and changing if incontinent episodes occurred. The facility will continue to assist Resident 30 with ADL's, monitor for changes, and notify the physician as necessary. The facility will proceed to care planning. ADL abilities will be addressed in the care plan to slow or minimize decline, avoid complications, and minimize risks. The CAA area for dental care indicated a potential problem/need. Resident 30 triggered due to having a partial plate, and noted broken natural teeth. The facility will monitor Resident 30 for any further issues and complaints. The facility will continue to monitor Resident 30 for any problems and notify the physician as needed. Dental care will be addressed in the care plan to slow or minimize decline, avoid complications, and maintain current level of functioning. The CAA area for communication indicated an actual problem/need. Resident 30 triggered due to being hard of hearing with minimal difficulty, he wears hearing aids, and had demonstrated no issue with the use of his hearing aids. The facility will continue to address any problems, notify the physician as needed, and proceed to care plan. Communication will be addressed in the care plan to slow or minimize decline, avoid complications, and maintain current level of functioning. During an interview on 7/23/2024 at 3:14 P.M., the MDS Coordinator indicated the comprehensive care plan should be completed within 14 days of the assessment reference date, and Resident 30's comprehensive care plan was not completed. On 7/24/2024 at 8:44 A.M., the MDS Coordinator indicated that Resident 30 was admitted to the facility on [DATE]. The completion of the MDS assessment was on 7/2/2024, and the CAA has 7 days from that date to be completed, and the comprehensive care plan had 14 days from that date to be completed. She indicated all comprehensive care plans should be completed by the 21st day of admission. A policy was provided, on 7/24/2024 at 1:25 P.M., by the Director of Nursing. The policy was from the Resident Assessment Instrument Manual, dated October 2023. The manual indicated, .The CAA[s] completion date must be no later than 14 days [of the admitted ]. The care plan completion date must be not later than the 7 days after the CAA[s] completion date 3.1-31(e)

Based on record review and interview, the facility failed to ensure a comprehensive person centered plan of care was created for a resident with behaviors (Resident 5) and for a resident receiving hospice care (Resident 24) for 2 of 17 residents reviewed for comprehensive care plans. Findings include: 1. The record for Resident 5 was reviewed on 7/22/2024 at 8:46 A.M. Diagnoses included but were not limited to disorder of central nervous system, diabetes mellitus, violent behavior, insomnia, psychotic disorder with delusions, anxiety disorder, and major depressive disorder. Resident 5's current medications included Risperidone (anti-psychotic) 0.25 mg (milligram) 1 tablet by mouth at bedtime every Sunday for psychotic disorder and Risperidone 0.25 mg give 1 tablet by mouth two times a day six days a week for psychotic disorder. A current Care Plan, dated 5/7/2024, indicated the resident had agitation and physical behaviors demonstrated as throwing legs over the bed, posturing in the wheelchair/bed, cursing, hitting, pinching, and grabbing staff. Interventions included but were not limited to: administer psych medication as ordered, monitor medication side effects at least daily on psychoactive administration record, notify physician as needed, monitor quarterly for medication GDR (Gradual Dose Reduction) for psychoactive medication through pharmacy consultant and psychiatric services, and social services (SS) to visit as needed. Resident 5's clinical record lacked a person-centered Care Plan for behaviors. During an interview, on 7/24/2024 at 10:33 A.M., the Social Service Director indicated the interventions should have been individualized around the preferences of each resident. She indicated Resident 5 enjoys watching baseball, old movies, and IU, and indicated the Care Plans for Resident 5 were not person-centered. 45120 2. A record review of Resident 24 was completed on 7/22/2024 at 8:33 A.M. Diagnoses included, but were not limited to: fracture of the humerus, wedge compression fracture of thoracic vertebra, and anxiety disorder. A Significant Change Minimum Data Set (MDS) assessment, dated 6/1/2024, indicated Resident 24 was receiving hospice services. A Nurse's Note, dated 5/31/2024 at 10:33 A.M., indicated that the hospice company was at the facility to conduct a face-to-face evaluation, and that Resident 24 met the criteria for hospice services. A Physician's Order, dated 6/3/2024, indicated Resident 24 was admitted to hospice service on 6/1/2024 due to heart failure, COPD (chronic obstructive pulmonary disease), and acute respiratory failure related to terminal prognosis. A Care Plan could not be located in the medical record for hospice care. During an interview, on 7/24/2024 at 8:36 A.M., the MDS Coordinator indicated that Resident 24 should have a care plan for hospice care. During an interview with the MDS coordinator she indicated that the resident should have a hospice care plan that included contact information and coordination of care with the hospice company. A policy was provided on, 7/24/2024 at 1:25 P.M., by the Director of Nursing. The policy titled, Baseline Care Plan Assessment/Comprehensive Care Plans, indicated, .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 3.1-35(b)(1)

Based on record review an interview, the facility failed to revise and updat care plans for activities, residing on the memory care unit, an eye infection, a pressure ulcer, for 1 of 17 residents whose care plans were reviewed (Resident 18) Finding include: The record for Resident 18 was reviewed on 7/22/2024 at 3:07 P.M. Diagnoses included but were not limited to dementia, intellectual disabilities, Down syndrome, depression and congestive heart failure. An Annual MDS (Minimum Data Set) Assessment, dated 5/7/2024, indicated the resident activity preferences were books, magazines, newspapers, listen to music, being around animals. A current Care Plan, dated 1/18/2024 indicated, ACTIVITIES: Although the resident was considered cognitively impaired, is still capable of making decisions about activity involvement and prefer to not attend some group activities. She stays busy watching TV, relaxing, coloring & communicating with staff & occasionally looking at magazines. Know Resident has times where she prefers to stay in her room or stay in the common area of the memory care unit ,color and watch what is going on around her. Interventions included, but were not limited to. She occasionally enjoys listening to music in the common area of the Boulevard (locked unit). A Care Plan, dated 10/21/2021, indicated: MEMORY CARE: The resident resides on the Memory Care unit. I benefit from the programming on this unit. Although it is a locked unit, she is able to come off the unit for special activities I enjoy with staff/family as desired. Secured Unit. Physician has certified resident is appropriate for this unit and programming. Specialized programming provided. The resident does not reside on the locked unit and does not receive specialized programming. A current Care Plan, dated 5/27/2024, indicated the resident had an eye infection and was non compliant with isolation and does not understand the rationale for it. The resident gets agitated and refuses to stay in her room even after multiple attempts from staff to try to make me understand why she needed to be in isolation. The record lacked any documentation of an eye infection at this time. A Care Plan, dated 5/8/2024, indicated the resident had developed an actual pressure injury. The record lacked any documentation of Resident 18 having a pressure injury at this time. During an observation, on 7/23/2024 at 2:18 P.M., of Resident 18's buttocks and thighs were free from pressure injuries. During an interview, on 7/23/2024 at 9:10 A.M., the Director of Nursing indicated the care plans were not updated and should have been revised. During an interview, on 7/23/2024 at 11:44 A.M., the Activity Director indicated the resident care plans were not updated and should have been. On 7/23/2024 at 1:27 P.M., the Social Service Director provided the policy titled,Baseline Care Plan Assessment/Comprehensive Care Plans, undated, and indicated the policy was the one currently used by the facility. The policy indicated.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(d)(2)(B)

Based on observation, interview and record review the facility failed to implement an activities program that incorporated the resident's interest and hobbies for 1 of 3 resident reviewed for activities. (Resident 18) Finding includes: During an interview, on 7/21/2024 at 10:51 A.M., Resident 18's family indicated the resident used to like music and TV. During an observation, on 7/21/2024 at 1:44 P.M., Resident 18 was lying in bed with the television on, but unable to see it. The television was positioned above and at the back of her head. During an interview, on 7/22/2024 at 10:47 A.M.,CNA 3 indicated it depended on the resident if she wanted to or not to get out of bed. She indicated we try to encourage her. During an observation, on 7/22/2024 at 3:03 P.M., Resident 18 remained in bed with the bed sheet covering her face. The record for Resident 18 was reviewed on 7/22/2024 at 3:07 P.M. Diagnoses included but were not limited to dementia, intellectual disabilities, Down syndrome, depression, and congestive heart failure. An Annual MDS (Minimum Data Set) Assessment, dated 5/7/2024, indicated the resident had adequate hearing. The activity preferences were documented as books, magazines, newspapers, listen to music, and being around animals. During an observation, on 7/23/2024 at 8:37 A.M., Resident 18 was in bed with a sheet over her face. A current Care Plan, dated 1/18/2024 indicated: ACTIVITIES: The resident is considered cognitively impaired, and still capable of making decisions about activity involvement and prefer to not attend some group activities. She would like her preferences not to attend activities be honored by staff. She stays busy watching TV, relaxing, coloring & communicating with staff & occasionally looking at magazines. Interventions included, but were not limited to: Through past history & staff interview it has been determined that religion is somewhat important to resident. Religious programs are on her TV program list. Staff offer to turn on for her. She occasionally enjoys listening to music in the common area of the Boulevard. Through past history and staff interview it has been determined that resident's favorite activities are: coloring, counting crayons, watching some TV and watching what is going on around her when she is in the common area. A pink care has been placed in the resident's room to assist staff in resident preferences for (TV shows, music, of other activities) resident might enjoy while in room. During an observation, on 7/23/2024 at 8:54 A.M., the residents room lacked a pink card for television preferences and the television was positioned where the resident could not see it. During an observation, on 7/23/2024 at 11:23 A.M., Resident 18 was in bed with coloring book and crayons in her hands. The television was on, but was placed above her bed to the back of her head where she could not see it. During an interview, on 7/23/2024 at 11:44 A.M., the Activity Director indicated the resident should be able to watch TV, but her bed was is in the wrong position and she should have had the pink list in her room. She indicated the resident did not attend the religious service on Sunday. On 7/23/2024 at 1:27 P.M., the Social Service Director provided the policy titled,Activities Program, undated, and indicated the policy was the one currently used by the facility. The policy indicated .It is the policy of this facility to provide an ongoing program of Activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental and psychosocial well-being of the residents. 6. Facility will provide activities that are appropriate for residents related to their interests, culture and background 3.1-33(a)

Based on record review and interview, the facility failed to properly use a mechanical lift for 1 of 1 resident reviewed for a facility reported incident, which resulted in a laceration to the scalp. (Resident 9) Finding includes: A record review of Resident 9 was completed on 7/23/2024 at 2:03 P.M. Diagnoses included, but were not limited to: paraplegia, obesity, and muscle weakness. A Quarterly MDS assessment, dated 6/11/2024, indicated Resident 9 was cognitively intact, and was dependent for transfers. A Nurse's Note, dated 6/22/2024 at 5:48 P.M., indicated that while transferring Resident 9 to his wheelchair with the Hoyer lift, the Hoyer lift tipped over onto the top of his head causing a 3-centimeter laceration. There was a moderate amount of blood initially, but stopped bleeding when pressure was applied. Neurological checks were within normal limits, but Resident 9 indicated after 10 minutes of the incident he was not feeling right, and complained of neck and head pain. Resident 9 was sent to the emergency room for further evaluation. On 6/22/2024 at 7:10 P.M., Resident 9 arrived back from the emergency room with steri-strips covering the sutures to the frontal skull. He complained of a minor to moderate headache. A Care Plan, dated 1/31/2021, and revised on 4/20/2023, indicated Resident 9 was a total assist for transfers with a mechanical lift. A facility reported incident was sent to the Indiana Department of Health, on 6/23/2024. The report indicated that CNA 12 and CNA 10 were transferring resident 9 with a Hoyer lift (mechanical lift) from his bed to the wheelchair. The Hoyer lift fell over as Resident 9 was being placed in the wheelchair making contact to his head. Resident 9 was immediately disconnected from the Hoyer lift, and an assessment was completed. Resident 9 sustained a 3-centimeter laceration to the top of his head. Resident 9 was transported to the local hospital. During an interview, on 7/23/2024 at 1:24 P.M., CNA 10 indicated that she and CNA 13 were getting Resident 9 up for supper. She indicated CNA 12 was using the Hoyer lift, and she was assisting. She indicated CNA 12 put the Hoyer lift legs in between the front wheels and back wheels of the wheelchair, and that the legs were not extended or locked. She indicated the Hoyer lift tipped over and hit Resident 9's head. She indicated she assisted in pulling the Hoyer lift off Resident 9's head. A review of CNA 12 and CNA 10 employee files indicated CNA 12 had completed the competency checklist for the use of the Hoyer lift on 10/1/2019, and CNA 10 had completed the competency on 4/19/2024. An Annual Skills Checklist was provided by the Executive Director that was completed on 3/20/2024-3/21/2024. CNA 12 completed the annual training which included use of the Hoyer lift. A policy was provided, on 7/24/2024 at 1:25 P.M., by the Director of Nursing. The policy titled, Guidelines for Mechanical Lift Transfer/Usage, indicated, .About the Mechanical Lift .16. Position the lift around the resident's bed/chair/surface. Base legs are usually more stable in the fully open position .Using the Mechanical Lift .32. The mechanical lift should be moved so that the extended legs slide under the bed [for bed transfers]. As stated prior, the mechanical lift legs are able to open and close to accommodate wheelchair transfers. 33. Slide the legs under the bed until the swivel bar hook of the lift is directly over the resident's abdomen. The legs are widened using the shift handle located on the back. Widening the legs is essential in order to get a stable base under the mechanical lift. 34. Apply the wheel lock so it does not move once the mechanical lift is in position 3.1-45(a)(1)

Based on observation, record review, and interview, the facility failed to provide interventions to prevent significant weight loss for 1 of 3 residents reviewed for nutrition, and failed to provide adequate fluids for 1 of 2 residents reviewed for hydration. (Residents 24 & 18) Findings include: 1. During an observation on 7/21/2024 at 1:42 P.M., Resident 24 was observed to appear thin and frail. A record review was completed on 7/22/2024 at 8:33 A.M. Diagnoses included, but were not limited to: fracture of the humerus, wedge compression fracture of thoracic vertebra, and anxiety disorder. A Significant Change Minimum Data Set (MDS) assessment, dated 6/1/2024, indicated Resident 24's nutrition was not assessed. A review of resident 24's weights indicated: - 3/18/24 86.0 (admission weight) - 3/30/24 76.8 - 3/31/24 75.5 - 4/8/2024 76.1 - 5/6/2024 79.6 - 6/4/2024 78.1 Physicians' Orders indicated the following orders: - Ensure Clear two times a day for Supplement 3/21/2024-3/26/2024. - Regular diet 3/30/2024 - admitted to hospice 3/30/2024-4/12/2024. - Ensure Clear two times a day for Supplement 4/3/2024-5/28/2024. - Admit to hospice on 6/1/2024. A Nurse's Note, dated 3/19/2024 at 2:11 P.M., indicated Resident 24's daughter informed the staff that Resident 24 had vomited after she had eaten. The daughter indicated that Resident 24 only had 1/3 of her stomach with multiple surgeries completed, vomiting happened at times after meals, and had a history of weight loss due to not being able to keep down. A Mini Nutritional Assessment, dated 3/20/2024 at 8:16 A.M., indicated Resident 24 was malnourished. A Nutritional Assessment, dated 3/20/2024 at 8:27 A.M., indicated Resident 24 was lactose intolerant, drank one vanilla Ensure a week, and inadequate oral intake even though she reported her appetite as good. Resident 24 indicated her physician wanted her to gain weight to a minimum of 100 pounds. Her body weight index indicated she was underweight. Interventions recommended included Ensure Clear three times a day, and providing lactose-free alternatives. A Nurse's Note, dated 3/22/2024 at 12:07 P.M., indicated to hold the Ensure Clear for 3 days due to awaiting delivery. A Nutritional Assessment, dated 4/3/2024 at 7:15 A.M., indicated 12.2 percent weight loss in approximately 2 weeks. She had been readmitted to the facility from her hospitalization related to a fall and newly found tracheal mass. Her body mass index was 15.8, indicating she was underweight. An Interdisciplinary Note, dated 4/17/2024 at 12:53 P.M., indicated Resident 24 was receiving Ensure Clear 237 milliliters twice daily, and consumed 51-75 percent of her meals and approximately 50 percent of her supplements for 7 days. Continues to receive hospice services with weight loss anticipated and unavoidable as disease processes progress. No new nutritional recommendations were placed. An Interdisciplinary Note, dated 4/17/2024 at 12:53 P.M., indicated Resident 24 was receiving Ensure Clear 237 milliliters twice daily, and consumed 51-75 percent of her meals and approximately 51-75 percent of her supplements for 7 days. Continues to receive hospice services with weight loss anticipated and unavoidable as disease processes progress. No new nutritional recommendations were placed. Resident 24 was discontinued from nutritional monitoring. A Nutritional Assessment, dated 4/24/2024 at 8:21 A.M., indicated a 11.6 percent weight loss in approximately 2 weeks. Resident 24 had good supplement intake on most days, and does not accept snacks. Her body mass index was 15.8, indicating underweight, but closer to her self-reported usual body weight of 78 pounds. Resident 24 to continue with Ensure Clear. A Nurse's Note, dated 5/28/2024 at 3:03 P.M., indicated Ensure Clear was discontinued due to resident refusals and stating the drink makes her sick to her stomach. A Care Plan, dated 3/19/2024, and revised on 7/14/2024, indicated Resident 24 was at nutritional risk. During an interview on 7/24/2024 at 9:03 A.M., the Dietary Manager indicated that interventions should have been put in place when Resident 24 was not on hospice services from 4/13/2024-5/31/2024, and more options to further increase weight should have been put in place. A policy was provided on 7/24/2024 at 1:25 P.M., by the Director of Nursing. The policy titled, Weights, indicated, .Nursing will notify the dietician or designee of any significant weight changes. Significant weight changes is defined as 5% change x [times] 1 month, 7.5% change x 3 months, 10% changes x six months 38845 2. During an observation, on 7/21/2024 at 1:43 P.M., Resident 18 was observed with dry/cracked lips and her tongue had a coating. The residents water pitcher was not in reach of the resident. During an observation, on 7/21/2024 at 2:21 P.M., the resident tried to move the bed side table with the water pitcher on it but was unable to move it. The record for Resident 18 was reviewed on 7/22/2024 at 3:07 P.M. Diagnoses included but were not limited to: dementia, intellectual disabilities, Down syndrome, chronic kidney disease stage 3, dysphagia and congestive heart failure. An Annual MDS (Minimum Data Set) Assessment, dated 5/7/2024, indicated the resident required supervision/touching assistance during for eating. A current care plan, dated 8/26/2022, indicated Late loss ADL (activities of daily living): the resident needs limited assist with eating/drinking, supervision up to extensive assistance with bed mobility due to diagnosis of dementia and Down Syndrome. Interventions included, but were not limited to: assist at meals with tray set-up and meals/eating as needed. During an observation, on 7/23/2024 at 8:36 A.M., the water pitcher was on the over the bed side table not within reach of the resident. During an observation, on 7/23/2024 at 9:38 A.M., Resident 18's water pitcher was on the over the bed side table not within reach of the resident. During an observation, on 7/23/2024 at 11:58 A.M., Resident 18 was observed in bed, leaning to the left with her lunch tray on the over the bedside table. The resident was trying to hold onto a glass of chocolate liquid. Resident 18 drank 1/2 of the chocolate liquid and placed it back on the tray. Resident 18 was observed with dry/cracked lips and a coating on her tongue. There were no staff around the residents room to assist with her meal. On 7/23/2024 at 12:05 P.M., the Social Service Director entered the residents room and started to assist with her lunch meal. The Social Service Director observed the chocolate liquid was spilled on the blanket and indicated she would change the linens and would try to feed the resident. During an interview, on 7/23/2024, at 12:06 P.M., the Social Service Director indicated the residents' lips were dry and cracked and her tongue had a coating on it and she should have more liquids. On 7/23/2024 at 3:40 P.M., the Director of Nursing provided the policy titled,Clinical Nutrition Documentation, dated 4/2017, and indicated the policy was the one currently used by the facility. The policy indicated . Residents will be provided with a sufficient fluid amount and consistency to maintain proper hydration status 3.1-46(a)(1) 3.1-46(b)

Based on observation, record review, and interview, the facility failed to follow physician's orders for oxygen use, and store oxygen tubing appropriately for 1 of 2 residents reviewed for oxygen therapy. (Resident 24) Finding includes: During an observation on 7/21/2024 at 9:43 A.M. and 10:32 A.M., Resident 24 was observed sleeping in bed, and her wheelchair was outside the room with the nasal cannula draped over the wheelchair seat. On 7/21/2024 at 2:40 P.M., Resident 24 was observed to be connected to the oxygen concentrator via nasal cannula. The oxygen concentrator was not on, and Resident 24 was sleeping, and was pale. On 7/21/2024 at 2:44 P.M., LPN 13 was requested to check Resident 24's oxygen saturations. Resident 24's oxygen saturation was 84 percent. LPN 13 requested Resident 24 to take several deep breaths, and then noted the oxygen concentrator was not on. The oxygen concentrator was placed on, and within several minutes Resident 24's oxygen saturations were 93 percent. LPN 13 stated, There you go. You are pinking up. During an interview on 7/21/2024 at 2:55 P.M., CNA 3 indicated Resident 24 was in bed upon her arrival to the shift at 1:00 P.M. During an interview on 7/21/2024 at 3:01 P.M., LPN 13 indicated she was responsible for the transition of oxygen. She indicated she was not aware resident 24 was in bed, but thought she was in an activity due to asking the CNA's to keep her upright due to previous vomiting. LPN 13 indicated she was not aware of how resident 24 transitioned from the portable oxygen tank to the oxygen concentrator. A record review was completed on 7/22/2024 at 8:33 A.M. Diagnoses included, but were not limited to: chronic respiratory failure, COPD (chronic obstructive pulmonary disease), and anxiety disorder. A Significant Change Minimum Data Set (MDS) assessment, dated 6/1/2024, indicated Resident 24 was cognitively intact, on hospice therapy. The assessment indicated oxygen was not in use. A Physician's Order, dated 3/30/2024, indicated oxygen at 3 liter per minute per nasal cannula continuously. A Nurse's Note, dated 7/21/2024 at 2:50 P.M., indicated a nurse from the State Department of Health asked for an oxygen saturation of Resident 24. LPN 13 was unaware that Resident 24 had been placed in bed related to verbalizing to staff that Resident 24 needed to remain upright until further notice due to vomiting. LPN 13 thought Resident 24 was in an activity, and had not observed Resident 24 return to the unit. The oxygen saturation was obtained and noted to be 84 percent with the nasal cannula in her nares. LPN 13 noted the oxygen concentrator to be off. LPN 13 turned on the oxygen concentrator, and instructed Resident 24 in breathing exercises to increase her oxygen saturation. Resident 24's oxygen saturations recovered to 93 percent on 3 liters of oxygen via nasal cannula, her cheeks pinked up, and was smiling. Resident 24 indicated, I feel better than I did earlier. A Care Plan, dated 3/19/2024, and revised on 3/25/2024, indicated Resident 24 had chronic respiratory disease with the potential for exacerbation related to COPD and chronic respiratory failure. An intervention, dated 3/19/2024, indicated to administer oxygen as ordered. During an observation on 7/23/2024 at 8:34 P.M., the nasal cannula was draped over the back of the wheelchair. During an interview, on 7/24/2024 at 8:38 A.M., CNA 8 indicated that nasal cannulas should be stored in a respiratory bag when not in use. A policy was provided, on 7/24/2024 at 1:25 P.M., by the Director of Nursing. The policy titled, Guidelines for Transporting and Storage of Oxygen, indicated, .Note: Only staff who have been educated on Oxygen storage and Oxygen administration will manage and administer oxygen 3.1-47(a)(6)

Based on observation, interview and record review, the facility failed to ensure staff changes gloves and completed hand hygiene when providing peri care for 1 of 1 resident reviewed for peri care. (Resident 14) Finding includes: On 7/22/2024 at 1:25 P.M., CNA 3 and CNA 7 was observed providing peri care to Resident 14. CNA 3 washed her hands and applied gloves. CNA 7 rolled the resident to the right side and pushed the brief under the resident. CNA 3 removed the brief from under the resident. CNA 3 used a soapy washcloth and wiped the residents left groin area, then with the same area of the washcloth,wiped the right groin area. CNA 3 moved the residents penis and wiped underneath it with the same area of the washcloth and then wiped towards the groin area. CNA 3 then dried the areas with a towel. CNA 7 turned the resident to his left side and CNA 3,with her dirty gloves applied a clean brief to the resident. CNA 3 removed the bed sheet and covers due to wetness. CNA 3 & CNA 7 applied clean linens to the bed. CNA 3 was observed to move the residents pillow, adjust his clothes and move his hands with the dirty gloves still on. During an interview, on 7/22/2024 at 1:57 P.M., CNA 3 indicated she did not remove her gloves and wash her hands and should have when she completes peri care for any resident. On 7/24/2024 at 1:30 P.M. the Social Service Director provided the policy titled, Guidelines For Incontinence Care, undated and indicated the policy was the one currently used by the facility. The policy indicated .5. Apply latex free non-sterile gloves .12.Use separate area of cloth for each stroke . 16. Remove and discard gloves. 17. Perform hand hygiene. 18. Apply clean linen or underpad, brief or other incontinent product(s) as needed 3.1-18(a)

Based on observation, record review and interview, the facility failed to follow Physician orders for administration of a pain medication and the use of palm protectors and offloading boots for 2 of 19 residents whose physician orders were reviewed. (Resident 5 & 11) Findings include: 1. During a medication observation on 8/23/2023 at 4:07 A.M., RN 4 was observed to administer a Percocet (narcotic pain medication) to Resident 5. A record review was completed on 8/23/2023 at 4:25 A.M. Resident 5's diagnoses included, but were not limited to: anxiety, depression, hypertension, pain and insomnia. Resident 5's physician orders included: Oxycodone- Acetaminophen 5/325 mg (milligram). Give 1 tablet by mouth every 4 hours as needed for severe pain (pain related 4-7 on the scale) maximum of 6 doses daily. The Medication Administration Record (MAR), dated August 2023, indicated Resident 5 had received the narcotic pain medication for a pain level of 3 on 8/23/2023 and had received it 14 other times for pain levels of 0 to 3. During an interview, on 8/23/2023 at 4:48 A.M., RN 4 indicated he should not have given the medication to her and he did not follow the physician orders. 48145 2. During an observation, on 8/21/2023 at 10:35 A.M., Resident 11 was observed without a palm shield on either hand or a heel lift device on right foot. During an observation, on 8/22/2023 at 1:43 P.M., Resident 11 was observed not wearing a palm shield on either hand or a heel lift device on right foot. During an observation, on 8/23/2023 at 1:45 P.M., Resident 11 was observed not wearing a palm shield on either hand or a heel lift device on right foot. A record review was completed on 8/24/2023 at 8:55 A.M. Resident 11's diagnoses included, but were not limited to: traumatic brain dysfunction, non-Alzheimer's dementia, diabetes mellites, anxiety disorder, depression, and psychotic disorder. A Physician's order, dated 7/12/2022, indicated palm shield should be worn on both hands while in bed. A Physician's order, dated 3/28/2023, indicated a heel lift device for lower right extremity should be worn at all times. An August 2023 Treatment Administration Record (TAR) indicated Resident 11 was wearing a palm shield on both hands and wearing a heel lift device on lower right extremity on 8/21/2023, 8/22/2023, and 8/23/2023. During an interview, on 8/25/2023 at 9:02 A.M., LPN 10 indicated the TAR is used to document the use of Resident 11's palm shields and heel lift device, and if the resident refused to wear the palm shields or heel lift device, the treatment should be documented as refused on the TAR. During an interview, on 8/25/2023 at 9:14 A.M., the Director of Nursing indicated Resident 11 should have been wearing the heel lift device and a palm shield on both hands while in bed on 8/21/2023, 8/22/2023, and 8/23/2023. The DON indicated the TAR has an option for staff to code refused when a resident refuses a treatment, and that the heel lift device and palm shield entries on Resident 11's TAR for 8/21/2023, 8/22/2023, and 8/23/2023 were charted incorrectly and should have been charted correctly. An undated policy titled Physician Orders (Following physician orders) was provided by the Administrator on 8/23/2023 at 11:03 A.M. and identified as current. The policy indicated, It is the policy of the facility to follow the orders of the physician . 3.1-37(a)

Based on observation, record review and interview, the facility failed to ensure oxygen concentrators were clean and free from dust for 2 of 2 residents who were reviewed for oxygen use. (Resident 11 & 13) Findings include: 1. During an observation, on 8/21/2023 at 10:24 A.M., Resident 11's oxygen concentrator's vent was covered with dust. During an observation, on 8/23/2023 at 8:57 A.M., Resident 11's oxygen concentrator's vent was covered with dust. During an observation, on 8/24/2023 at 10:30 A.M., Resident 11's oxygen concentrator's vent was covered with dust. During an observation, on 8/25/2023 at 9:39 A.M., Resident 11's concentrator vent covered with a large amount of dust. A record review was completed on 8/25/2023 at 10:01 A.M. Resident 11's diagnoses included, but were not limited to: dementia, diabetes, dysphagia, gastroenteritis, depression, and acute and chronic respiratory failure. Resident 11's current physician orders included: O2: Change oxygen tubing and humidifier and clean concentrator filter weekly every night shift every Sunday. The Treatment Administration Record (TAR), dated August 2023, indicated the concentrator filter had been cleaned on 8/20/2023. During an interview, on 8/25/2023 at 9:40 A.M., the Director of Nursing (DON) indicated the filter was not cleaned and should have been. She indicated that companies will come in and clean their own machines. 2. During an observation, on 8/25/2023 at 9:39 A.M., Resident 13's oxygen concentrator vent was covered with a large amount of dust. A record review was completed on 8/25/2023 at 10:01 A.M. Resident 13's diagnoses included, but were not limited to: dementia, diabetes, delusional disorder, hallucinations, and hypertension. Resident 13's current physician orders included; O2: Change oxygen tubing and humidifier. (concentrator filter cleaned yearly by [name of company] every night shift every Sunday. During an interview, on 8/25/2023 at the 9:40 A.M., the DON indicated the filter was not cleaned and should have been. She indicated the last time the filter was cleaned was sometime in 2022. On 8/25/2023 the DON provided the policy titled, Oxygen Administration Protocol, dated 10/25/2022, and indicated the policy was the one currently used by the facility. The policy indicated .B. Concentrators wipe clean with mild soap and sterile or distilled water as needed. If the concentrator has a visible filter on the back of machine, it must be removed weekly and rinsed with sterile or distilled water until clean, pat dried and replaced. Document filter cleaning on treatment sheet. [Name of Company] will clean all internal filters on concentrators with no visible filter 3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 5 of 18 rooms toured and 1 of 2 lounge areas reviewed for environment, related to wainscoting falling off the wall, peeling paint, unpainted spackle in resident's rooms, and an unattached electrical outlet in lounge area. (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], Boulevard Unit) Findings include: During a tour with the Director of Maintenance, (DM) on 8/25/2023 at 10:22 A.M., the following was observed: room [ROOM NUMBER]-2 had wainscoting falling off the wall behind bed. room [ROOM NUMBER]-2 had bubbling and peeling paint above the air conditioner unit. room [ROOM NUMBER], 34, and 59 had unpainted spackle areas on the walls. The Boulevard Unit had an outlet not attached to the wall in a lounge room. During an interview, on 8/25/2023 at 10:35 A.M., the Director of Maintenance indicated he was not aware of the wainscoting falling off the wall in room [ROOM NUMBER]-2, bubbling and peeling paint above the air conditioner unit, or an outlet not attached to the wall in a lounge area on the Boulevard Unit. For the unpainted spackle in rooms [ROOM NUMBER], DM indicated that spackle needs to dry for 24 hours before it can be sanded down and determined if it can be painted or if more spackle is needed. Painting spackle generally gets done within a week, but it depends on the urgency of other work orders. When asked how work is prioritized, DM indicated work is prioritize by importance. For example, resident safety comes first, then broken AC/heater, pipes, etc. DM indicated he is the only employee in the maintenance department. DM indicated he tours the facility daily, inspects lights, exit doors, and spot checks resident rooms. Each resident room is toured by maintenance monthly. On 8/25/2023 at 10:37 A.M., a policy was requested for preventative maintenance, but one was not provided. On 8/25/2023 at 10:42 A.M., The DM provided a document titled Monthly Preventative Maintenance Report and indicated that it is currently being used by the facility. HVAC Compressor Operational and Wallpaper/Paint not marked, are listed as monthly checks on the Monthly Preventative Maintenance Report. 3.1-19(f)

Based on observation, record review and interview, the facility failed to ensure care plans were initiated for 1 of 17 Care plans reviewed. (Resident 10, 17, 36 and 14) Findings include: 1. During an interview with alert and oriented Resident 10, he indicated he had not seen an eye doctor recently but did wear glasses. He indicated his glasses were okay. Resident 10 was observed on 5/17/2022 - 5/20/2022 to wear his glasses everyday. The clinical record for Resident 10 was reviewed on 5/18/2022 at 2:30 P.M. The most recent MDS (Minimum Data Set) assessment for Resident 10, completed as an annual review on 1/21/2022, indicated the resident's vision was adequate and that he wore corrective lenses (glasses). The current care plans for Resident 10 did not address the resident's vision issues and need for eye glasses. During an interview with the Social Service Director, on 5/20/2022 at 1:30 PM., she confirmed the resident was seen by the facility eye doctor. She provided documentation which indicated Resident 10 had been seen by the eye doctor on 1/10/2022 and no changes to his current use of bifocal glasses were recommended. 2. Resident 17 was observed on 5/18/2022 at 11:18 A.M ., seated in her reclining wheelchair. She was noted to have bilateral contractures of her hands and there was no orthosis splint noted in either hand. On 5/19/2022 at 9:25 A.M., Resident 17 was observed in her room, in her bed, asleep. Her left hand was noted to be contracted in a fist fashion. There was no orthosis splint noted in her left hand. Her right hand was not visbile at the time of the observation. On 5/20/2022 at 9:44 A.M., Resident 17 was observed lying in her bed, asleep. Resident 17 was in bed asleep - tubi grips on forearms, hands contracted in fists and no orthosis noted. On 5/19/2022 at 11:33 A.M., in MDR in broda type chair leg with padded bootie on it, bilateral hands contracted, resident attempting to pick up napkin -using her limited thumb movement, fingers fisted in contracture no orthosis. On 5/19/2022 at 1:39 P.M., in bed in room, mat on floor, uncovered observed left AKA, right foot in padded bootie, hands contracted no orthosis, awake. Review of therapy notes, dated 07/26/2021 and 04/18/2022 indicated the resident was evaluated mainly for w/c positioning. [NAME] co lead PTA - 5/23/2022 at 9:42 A.M., indicated the last therapy treatment had only focused on w/c positioning. Therapist went to try to find contracture evaluation and treatment notes 5/23/2022 at 10:08 A.M., an interview with [NAME] (9) indicated therapy had never evaluated the resident for her contractures as she could still feed herself but they definitely should be evaluating her contractures. 3. A clinical record review was completed, on 5/19/2022 at 8:05 A.M Resident 14's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/19/2022 at 8:43 A.M., the MDS Nurse indicated he did not have a care plan for oxygen and he should have had. 4. A clinical record review was completed for Resident 36 on 5/20/2022 at 10:12 A.M. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Significant Change MDS Assessment on 4/28/2022, indicated Resident 36 had moderate cognitive impairment. Resident 36 displayed physical and verbal behavioral symptoms directed towards others for 4-6 days of the 14-day look back period. He was wandering and significantly intruded on the privacy or activities of others. Resident 36 received an antipsychotic medication. A review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nurse's Note on 5/21/2022 at 6:01 P.M., indicated Resident has been going in and out of other resident's rooms today, the woman's rooms. Was able to redirect but would turn around and do it again. On 5/22/2022 at 5:57 P.M., a Nurse's Note indicated, Resident was in the dining room for lunch and was asking kitchen staff to come closer to him and then made sexual advances toward her. She explained to him that that was inappropriate. Resident then came back to his room. A review of Resident 36's Care Plans, indicated Resident 36 displays inappropriate physical behavioral issues as exhibited by physical aggressiveness related to impulse disorder. Resident 36's interventions for this behavior included: accept gentle reminders without incident, my verbal aggression and anger toward others will not result in injury, listen to concerns and follow-up on these promptly as needed, provide support and encouragement as needed, and social service to visit as needed. A Care Plan indicated Resident 36 displays inappropriate physical behavioral issues as exhibited by verbal and profanity related to impulse disorder. Resident 36's interventions included: my inappropriate physical behavior will not cause injury, will have a neat, clean, odor free appearance, notify physician as needed, provide education and support to family as needed and social services to visit as needed. Documentation of the May 2022 Gradual Dose Reduction Meeting (a monthly meeting for reducing resident [CONDITION(S)] medications) indicated Resident 36 was still exhibiting sexually inappropriate behavior and the facility was still looking for alternative placement. During an interview on 5/24/2022 at 9:57 A.M., the Social Service Director (SSD) indicated that the CNAs and nurses chart on resident's behaviors. The CNAs document every shift the behaviors exhibited and the interventions that were attempted. The SSD indicated that a care plan was not available for Resident 36's sexual preservation and the behavioral care plans are not person centered. On 5/24/2022 at 1:28 P.M., the Administrator provided a policy entitled, Care Plan Development & Review. The policy indicated, 1. Purpose-To assure that a comprehensive care plan for each resident includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment process. To assure that the care is communicated effectively to the staff and responsible party. 3. The comprehensive care plan is designed to: 1. Address needs, strengths and preferences that are identified in the comprehensive assessments. 2. Identify and incorporate risk factors associated with identified focuses. 4. Reflect treatment goals and objectives in measurable outcomes. 9. Show evidence that treatment or services provided are to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. 6. Overall review of the care plan is completed in conjunction with the MDS quarterly, annual and significant change assessments 3.1-35(a)

Based on record review and interview, the facility failed to follow antibiotic stewardship principles in regard to antibiotic use for 5 of 5 residents reviewed for medication use and urinary tract infections. (Resident 10, 5, 248, 27 and 34) Findings include: 1. Resident 10 was observed on 5/17/2022 at 10:45 A.M. seated in his room in a wheelchair. An indwelling urinary catheter bag was noted attached to the resident's wheelchair. During an interview with Resident 17 on 5/17/2022 at 10:46 A.M., he indicated he had the indwelling catheter due to multiple urinary tract infections. The clinical record for Resident 10 was reviewed on 5/18/2022 at 1:45 P.M., with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's urinalysis results for 12/15/2021 indicated the resident's urine had been collected on 12/13/2021. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The antibiotic was discontinued and a new antibiotic, [MEDICATION(S)] was ordered on 12/15/2021, after the culture and sensitivity results were received by the facility and reported to the physician. Review of the resident's urinalysis results for 11/11/2021 indicated the resident's urine had been collected on 11/08/2021. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was discontinued on 11/11/2021 and a new antibiotic order received on 11/11/2021 for the antibiotic, [MEDICATION(S)]. 2. Resident 5 was admitted to the facility with diagnoses, including but not limited to: Disorder of the central nervous system, [CONDITION(S)] stage 4, neuromuscular dysfunction of the bladder, [CONDITION(S)] and urine retention. Resident 5 was observed seated in an adaptive wheelchair in his room on 5/17/2022 at 10:25 A.M. He was noted to have an indwelling urinary catheter bag and tubing attached to his wheelchair. Review of the nursing progress notes, dated 4/ - 04/3/2022 indicated the resident was having aggressive behaviors. A note, dated 4/3/2022 indicated an order was received for the antibiotic, [MEDICATION(S)] to be given for 7 days due to an [CONDITION(S)] (urinary tract infection). A note, dated 4/4/2022 at 3:25 A.M., indicated Resident 5's urine was sent laboratory. The antibiotic order was received prior to the resident's urine being collected and/or sent to the laboratory. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a nursing progress note for Resident 5, dated 1/28/2022 at 2:40 A.M., indicated the laboratory had received urine for an ordered urinalysis with culture and sensitivity test. On 1/28/2022 at 1:40 P.M., an order was received via fax from the physician for the antibiotic [MEDICATION(S)] 500 mg three times a day for seven days, due to the urine dip results. Review of laboratory results for Resident 5 indicated urine was collected on 1/28/2022 and results were reported on 2/01/2022. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. During an initial interview on 5/18/2022 at 10:19 A.M., Resident 248 indicated she had a recent urinary tract infection. On 5/19/2022 at 11:10 A.M., Resident 248 indicated during an interview she feels like she has a urinary tract infection. She complained of worsening burning with urination that brings tears to her eyes. A Nursing Assessment on 5/5/2022 at 12:03 A.M., indicated a straight catheterization for a urinalysis was completed with 60 ml of urine return. A Nurse's Note on 5/5/2022 2:40 A.M., indicated [laboratory name] received urine for urinalysis with culture and sensitivity. On 5/5/2022 at 6:06 A.M., a Nurse's Note indicated a new order of [MEDICATION(S)] capsule 500 MG and to give one capsule by mouth three times a day for urine tract infection for seven days On 5/9/2022 at 1:03 P.M., a Nurse's Note indicated results of urine culture and sensitivity received and reported to [physician's name]. On 5/12/2022 at 5::30 P.M., a Nurse's Note indicated no new orders related to culture and sensitivity per [physician's name]. The physician indicated to continue [MEDICATION(S)] ([MEDICATION(S)] capsule) as ordered. On 5/17/2022 10:31 A.M., a Nurse's Note indicated, .Resident is also confused at this time, daughter states when her mother acts like this she usually has a [CONDITION(S)] (urinary tract infection). Notified [physician's name] at this time. New order to obtained urine for a U/A C&S (urinalysis with culture and sensitivity) On 5/18/2022 at 2:24 A.M., a Nurse's Note indicated [laboratory name] received urine for urinalysis with culture and sensitivity. On 5/18/2022 at 2:25 P.M., a Nurse's Note indicated the nurse received a fax back from [laboratory name] regarding the urinalysis results and notified [physician name] at this time. On 5/19/2022 at 1:19P.M., A Nurse's Note indicated the nurse received a fax back from [physician's name] regarding the urinalysis results. A new order was received to start resident on [MEDICATION(S)] 100 mg twice daily for seven and fax the physician with the culture and sensitivity results as soon as received. On 5/20/2022 at 6:05 P.M., a Nurse's Note indicated no new orders related to culture and sensitivity per [physician's name] and to continue [MEDICATION(S)] as ordered. A laboratory result for the urinalysis with culture and sensitivity for 5/9/2022 was reviewed. The report indicated a bacteria of Escherichia coli greater than 100,000 CFU/ml (colony-forming unit per milliliters). The laboratory culture and sensitivity result did not have [MEDICATION(S)] listed as a susceptible antibiotic to treat Escherichia coli. On the laboratory sheet it indicated the following hand-written note: 5/9/2022 Attn: [physician's name] Resident currently on [MEDICATION(S)] 500 mg TID (three times a day) Any N.O. (new order)? The physician signed the laboratory result on 5/11/2022 and wrote, continue same. 4. A record review of the infection surveillance tracking binder on 5/24/22 at 10:55 A.M., indicated Resident 27 had a urinalysis obtained on 4/21/2022. A Nurse's Note on 4/20/2022 at 3:13 P.M., indicated a new order was obtained for a urinalysis with culture and sensitivity. On 4/22/2022 at 9:32 A.M., indicated the nurse received the urinalysis results at this time. [Physician's name] notified awaiting response at this time. On 4/22/2022 12:45 P.M., a Nurse's Note indicated [Physician's name] gave a new order for [MEDICATION(S)] 100 mg twice daily for seven days. On 4/25/2022 at 3:04 P.M., a Nurse's Note indicated the nurse received a fax back from [laboratory name] regarding the urinalysis with culture and sensitivity. The nurse notified [physician's name] at this time. On 4/26/2022 at 3:15 P.M., a Nurse's Note indicated no new physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 5. A record review of the infection surveillance tracking binder on 5/24/22 at 10:55 A.M., indicated Resident 34 had a urinalysis obtained on 4/21/2022. A Nurse's Note on 4/21/2022 at 10:49 P.M., indicated a new order for a urinalysis with culture and sensitivity. On 4/22/2022 at 3:26 A.M., a Nurse's Note indicated [laboratory name] received urine for urinalysis with culture and sensitivity. On 4/22/2022 at 12:43 P.M., a Nurse's Note indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] On 4/27/2022 at 4:46 P.M., a Nurse's Note indicated the nurse received a fax back from [physician's name] regarding culture and sensitivity from urine. The nurse received orders to place a PICC (Peripherally Inserted Central Catheter) line and to start [MEDICATION(S)] every 6 hours for 5 days. The nurse notified [physician's name] at this time that the [CONDITION(S)] center will not let the facility place a PICC line due to a [CONDITION(S)] catheter in place. The [CONDITION(S)] center informed the physician during the last urinary tract infection, Resident 34 was started on [MEDICATION(S)] IM (intramuscular) and asked if the physician would like the facility to do this again. The facility received a new order to start [MEDICATION(S)] 1 gm IM for 5 days for [CONDITION(S)]. During an interview on 5/24/22 at 10:30 A.M., the Infection Preventionist indicated an alert on the electronic medical record will identify if a new antibiotic has been prescribed. She indicated she reviews the 24-hour and 72-hour communication reports generated from the electronic medical record. She indicated [physician's name] will frequently start an antibiotic prior to the culture and sensitivity is received. She indicated the attending physician is aware of the antibiotic stewardship regulations. She indicated she believed the physician is trying to [NAME] it in the bud before the sensitivity comes back from the laboratory. On 5/24/2022 at 1:28 P.M., the Administrator provided a policy entitled, Antibiotic Stewardship. The policy indicated, .It is the policy of Miller's Health Systems, Inc. to utilize an Antimicrobial and Antibiotic Stewardship Program based upon the guidance and recommendations of the CDC (Centers for Disease Control & Prevention) and within CMS (Center for Medicare & Medicaid Services) guidelines .Collaboratively, with the Medical Director, Resident's Attending Physician, the Consultant Pharmacist and the Administration of each facility every effort will be made to prevent the misuse or overuse of antimicrobials

Based on interview and record review the facility failed to ensure the appropriate Medicare financial liability notification forms were provided to 1 of 3 Residents who were reviewed for SNF (Skilled Nursing Facility) Beneficiary Protection Notification. (Resident 52) Findings include: On 05/18/2022 at 11:51 A.M., the Administrator provided the Medicare SNF Beneficiary Protection Notification Review, which was completed by the facility and the Notice of Medicare Non-Coverage documents for Resident 52. Resident 52's Medicare Beneficiary Notification documents were reviewed on 5/23/2022 at 1:23 P.M. Resident 52 was identified by the facility to have remained in the facility after being discharged from Medicare Skilled Services. The SNF Beneficiary Protection Notification Review document indicated Resident 52's Medicare Part A Skilled Services Episode Start Date was 11/13/2021 and the Last Covered Day of Part A Services was on 12/23/2021. The document also indicated the facility initiated the discharge from Medicare Part A Services when the benefit days were not exhausted. The document did not indicate a SNF ABN (Skilled Nurse Facility Advance Beneficiary Notice of Non-Coverage) form had been provided to Resident 52's Representative. The document indicated the facility provided a NOMNC (Notice of Medicare Non-Coverage) form to Resident 52's Representative. The NOMNC form had been signed by Resident 52's Representative on 12/20/2021. The form indicated the current Skilled Nursing Services would end on 12/23/2021. During an interview on 5/23/2022 at 1:39 P.M., the Business Office Manager (BOM) indicated the SNF ABN form was not provided for Resident 52 when she discharged from Skilled Nursing Services. The BOM indicated a SNF ABN form should have been provided to the resident or the resident's representative. On 5/24/2022 at 1:28 P.M., the Administrator provided a policy entitled, Noncovered Letters with a policy start date of 5/25/2006. The policy indicated, .1. Noncovered letters are to be issued to a resident when: e. Medicare services are going to be noncovered. 2. These letters are important because they determine when the beneficiary becomes liable .b. Letter II SNF Determination on Continued Stay-Medicare covered services are going to be noncovered. This letter mist always be dated and mailed, or signed by the responsible party, no sooner and no later than the day before (24 hours) the noncovered days 3.1-12 (f)(1)(2)

Based on interview and record review, the facility failed to ensure that care conference was conducted for 1 out of 1 resident reviewed for care conferences. (Resident 43) Finding includes: A clinical record review was completed on 5/19/2022 at 12:40 P.M., and indicated Resident 43's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview, on 5/19/2022 at 11:23 A.M., the Social Worker Director indicated that she had a care conference on 7/15/2021 and did not have one every quarter and should have had. During an interview, on 5/19/2021 at 11:39 A.M., the MDS Nurse indicated she provides a schedule with the MDS's (Minimum Data Set) due, and the Social Worker sends postcards to families to set up the care conferences. A care conference is set up with the quarterly and annual assessments which is 4 times a year. The Social Worker fills out the LTC (long term care) plan meeting template and she only had one filled out for 7/15/2021 and should have had with each conference. On 5/19/2022 at 11:45 A.M., the MDS Nurse provided a policy titled, Care Plan Development and Review, dated 1/24/2020, and indicated the policy was the one currently used by the facility. The policy indicated .4. A. Care plan conferences with all disciplines will be held with resident and representative, at their convenience within seven days of admission, 21 days of admission, quarterly, and as needed 3.1-35(2)(B)

Based on observation, interview and record review, the facility failed to appropriately assess a pressure ulcer for 1 of 5 residents, resulting in the development of a stage 3 pressure ulcer. (Resident 63) Finding includes: A clinical record review was completed on 4/2/2018 at 2:15 P.M., and indicated Resident 63's [DIAGNOSES REDACTED]. A care plan, dated 7/3/2017, indicated Resident 63 was at a risk for skin breakdown due to being unaware when she was incontinent. A form titled, Nursing-Occurrence Initial Assessment, dated 1/21/2018, indicated Resident 63 had an abrasion to her right trochanter(hip). Resident 63's medical record showed no treatment had been obtained for this area. A form titled, Wound: Pressure Injury Assess w/Braden, dated 2/25/2018, indicated Resident 63 had a stage 3 pressure ulcer to her right buttock, measuring 1cm(centimeters) x 0.6cm x 0.3cm. On 4/3/2018 at 1:37 P.M., Resident 63's stage 3 pressure ulcer was observed. Nurse 80 indicated the area to Resident 63s upper right buttocks was a stage 3 pressure ulcer, 80% covered with yellow slough, with no redness noted surrounding the area. Nurse 80 indicated the dressing was missing and must have come off in the shower that morning. She indicated this stage 3 pressure ulcer was the same area as the documented abrasion. During an interview, on 4/3/2018 at 3:28 P.M., the ADON (assistant director of nursing) indicated the area of the stage 3 pressure ulcer was the same area as the documented abrasion. She indicated there had not been a treatment obtained until 2/25/2018. A policy was provided by the ADON, on 4/4/2018 at 11:42 A.M., titled Skin Management Program, dated 8/14/2014, and indicated this was the policy currently used by the facility. The policy indicated .A. It is our policy to assess for and reduce risk factors that may contribute to the development of pressure ulcers and other skin alterations unless the individual's condition demonstrates that the development is clinically unavoidable 3.1-40(a)(2)

Based on observation, record review, and interview, the facility failed to ensure the care plan to prevent falls was followed for 1 of 7 residents reviewed for falls in a sample of 15 resulting in a fall with facial fracture. (Resident #71). The facility further failed to follow physician's orders [REDACTED]. (Resident #30) Findings includes: 1. During the initial tour of the facility, conducted on 01/30/12 between 10:45 A.M. - 11:15 A.M., LPN #7 indicated Resident #71 had fallen and had facial fractures, was confused, and had a shuffling gait when he ambulated. The clinical record for Resident #71 was reviewed on 01/31/12 at 1:15 P.M. Resident #71 was admitted to the facility with diagnosis, including but not limited to, dementia with behavior disturbances, [MEDICAL CONDITIONS], dysarthria, and anxiety state. Review of the initial care plan for falls, initiated on 11/18/11, indicated Resident #71 was at risk for falls due to a history of falls, confusion with dementia, unsteady gait, poor trunk control, use of narcotics, shuffled gait related to [MEDICAL CONDITION], and knees bent when ambulating. A plan included the following interventions: "call light in reach. Explain use of it upon admission and reinforce as needed, encourage and assist with wearing non-skid footwear, ensure environment is free of clutter, assist with ambulation." Nursing progress notes, dated 01/16/12 at 9:50 P.M., indicated the resident had fallen in the hallway. Review of the POS [REDACTED].M., indicated a certified nursing assistance had given Resident #71 a shower and the resident had exited the shower room and walked into the hallway. The nursing assistant had gathered up the personal care items and was walking a few steps behind the resident with her arms full. The resident turned to look at the nursing assistant, lost his balance and fell hitting his face. Another staff member was entering the unit, but was unable to get to the resident in time to prevent the fall. The resident was sent to an acute care facility and was diagnosed with [REDACTED]. Resident #71 was observed on 01/30/12 at 12:37 P.M., ambulating with assistance from his room to the dining room. The resident was wearing slippers and was noted to shuffle his feet and keep his head pointed towards the floor. In addition, the resident was noted to have visible bruising along the left side of his face, nose, and under his chin. There were also sutures noted on the left side of his face. Interview with the Director of Nursing, on 02/02/12 at 10:15 A.M. indicated the resident did not require actual supervision for ambulation just supervision while he ambulated. She indicated the care plan intervention to provide assistance with ambulation is not what the resident needed at the time. 2. Resident #30's record was reviewed on 2-1-2012 at 11:00 a.m. Resident #30's [DIAGNOSES REDACTED]. A current physician's orders [REDACTED]. The original date of the order was 5-28-2010. A review of the laboratory results available on the chart did not indicate a Complete blood Count had been drawn within the last year. In an interview on 2-2-2012 at 9:27 a.m., the Director of Nursing indicated the lab test should have been drawn. She further indicated although there was no policy addressing following physician's orders [REDACTED]. 3.1-35(g)(2)

Based on observation, record review, and interview, the facility failed to provide adequate supervision to prevent multiple falls for Resident #11. The last fall resulted in a fractured hip for Resident #11. The facility further failed to provide supervision to prevent fall that resulted in a facial fracture for Resident #71. In addition, the facility failed to provide adequate supervision for 13 of 13 residents on the Alzheimer's dementia unit. (Resident #62, Resident #63, Resident #64, Resident #65, Resident #66, Resident #67, Resident #68, Resident #69, and Resident #70, Resident #71, Resident #72, Resident #73, and Resident #74). Finding includes: 1. During the initial tour of the facility, conducted on 01/30/12 between 10:30 A.M. - 10:50 A.M., RN #8 indicated Resident #11 had fallen on the dementia unit and had fractured his hip. She indicated the resident had been transferred to the skilled unit after his hospitalization to care for his fractured hip. The clinical record for Resident #11 was reviewed on 01/31/12 at 2:00 P.M. Resident #11 was admitted to the facility on [DATE] with diagnosis, including but not limited to, Alzheimer's dementia, osteoarthritis, and retinopathy. Review of an admission Fall Risk Assessment, completed for Resident #11 on 12/08/11, indicated the resident had a history of [REDACTED]. A care plan addressing falls was initiated on 12/08/11 with interventions to "keep the call light in reach and explain the use of it upon admission and reinforce as needed, encourage and assist with wearing non-skid foot-wear, and ensure the environment is free of clutter." Nursing progress notes, dated 12/09/11 at 2:47 A.M., indicated on 12/08/11 at 10:00 P.M., the resident had rearranged all of the furniture in his room and was found lying on the floor halfway underneath a bed. Review of a fall investigation for the incident indicated the facility was going to put rubber coasters under the wheels of the beds to prevent the resident from moving the beds, keep clutter out of the room, and monitor the resident's behaviors. Nursing progress notes, dated 12/09/11 at 11:28 A.M., indicated the resident was found underneath his bed on 12/08/11 and on the floor in front of his recliner on 12/09/11 in the A.M. Review of a fall investigation, dated 12/09/11 at 11:00 A.M., indicated the resident was found on the floor in front of his recliner after having attempted to ambulate unassisted. A physical and occupational therapy evaluation was ordered. A physical therapy evaluation , completed on 12/09/11, indicated the resident was assessed to have impaired balance and lower extremity weakness that influenced his ability to walk safely. The assessment indicated the resident required at the time of the evaluation, stand by assist to safely move backwards, turn corners, and change directions using a rolling walker, and required stand by assistance to ambulate with the rolling walker, and contact guard assist to transfer from a seated position to a standing position. There were no interventions added to the fall care plan except to identify on 12/09/11 the PT and OT evaluations had been ordered. The resident was transferred to an acute care psychiatric hospital on [DATE] and remained there until 12/30/11. Nursing notes, dated 01/01/12 at 7:19 P.M., indicated the resident was unsteady on his feet. Nursing note, dated 01/03/12 at 1:56 A.M., indicated the resident had an unwitnessed fall. Review of the post fall investigation, dated 01/03/12, indicated the resident had gotten up and fell trying to go to the bathroom. The interventions documented as having been in place were a low bed and mat of the floor, but the adjustments needing to be made were a low bed and mat on the floor. Interview with the Director of Nursing, on 02/02/12 at 3:45 P.M., indicated any resident who is a fall risk would have already been placed in a low bed with a mat on the floor. She indicated after the fall on 01/03/12, the intervention put in place was "every 2 hour monitoring." However, after review of the initial care plans, the resident was already being monitored, since 12/08/11, every two hours to address his incontinence issues. She indicated she had made a mistake and probably should have placed Resident #11 on every 1 hour monitoring. Nursing notes, dated 01/08/12 at 11:30 P.M., indicated "writer sitting at computer when hearing a 'crash' writer and aide went into res room and res was laying l side by other bed. When helping res to turn over onto back, res was saying how his leg hurt. res was able to stretch out leg but was wincing an d saying that it did hurt. writer asked res what he was doing when he fell but res could not remember...." The resident was transferred to an acute care facility and diagnosed with [REDACTED]. There were no additional interventions implemented to prevent reoccurring falls and prevent injury for Resident #11. 2. During the initial tour of the dementia unit, conducted on 01/30/12 between 10:45 A.M. - 11:15 A.M., LPN #7 indicated Resident #71 had fallen and had facial fractures, was confused, and had a shuffling gait when he ambulated. The clinical record for Resident #71 was reviewed on 01/31/12 at 1:15 P.M. Resident #71 was admitted to the facility on [DATE] with diagnosis, including but not limited to, dementia with behavior disturbances, Parkinson's disease, osteoporosis, dysarthria, and anxiety state. Review of the initial care plan for falls, initiated on 11/18/11 indicated the following interventions were included: "call light in reach. Explain use of it upon admission and reinforce as needed, encourage and assist with wearing non-skid footwear, ensure environment is free of clutter, assist with ambulation." Nursing progress notes, dated 01/16/12 at 9:50 P.M., indicated the resident had fallen in the hallway. Review of the post fall investigation, and interview with the Director of Nursing on 02/02/12 at 10:00 A.M., indicated a certified nursing assistance had given Resident #71 a shower and the resident had exited the shower room and walked into the hallway. The nursing assistant had gathered up the personal care items and was walking a few steps behind the resident with her arms full. The resident turned to look at the nursing assistant, lost his balance and fell hitting his face. Another staff member was entering the unit, but was unable to get to the resident in time to prevent the fall. The resident was sent to an acute care facility and was diagnosed with [REDACTED]. Resident #71 was observed on 01/30/12 at 12:37 P.M. ambulating with assistance from his room to the dining room. The resident was wearing slippers and was noted to shuffle his feet and keep his head pointed towards the floor. In addition, the resident was noted to have visible bruising along the left side of his face, nose, and under his chin. There were also sutures noted on the left side of his face. Resident #71 was observed on 01/31/12 at 11:40 A.M., lying on his bed in his room. The resident's feet were noted to be hanging over the side of his bed with one foot touching the ground. The resident was not in a low bed, nor was there a mat on the floor. In addition, the privacy curtain was pulled along the bottom of the bed and the resident's body and bed was not visible from the hallway, even though the door to his room was partially opened. 3. During the initial tour of the secured dementia unit, conducted on 01/30/12 between 10:45 A.M. - 11:15 A.M., there were no structured activities observed. There were 4 residents ( Resident #71, Resident # 72, Resident #66, Resident #67) observed seated in the dining room/lounge and one resident noted walking in the hallway. There were also residents noted to be lying in their beds in their rooms. Nursing staff were working on paperwork or attending to other residents during this time. On 01/31/12 from 11:35 A.M. - 12:00 P.M., there were no structured activities noted to occur on the secured dementia unit. There were 3 residents in the dining room/lounge, (Resident #63, Resident #65 and Resident #69). A nurse was in the dining room talking on the telephone and working with a clinical chart, a nursing assistant was in a resident room with the door closed, and a housekeeper was cleaning resident rooms. The nursing assistant was noted to bring residents into the dining room and seat them at the table. At 11:50 A.M., a social service staff member entered the dining room/lounge, chatted for 3 minutes with a female resident about coffee and family visit the resident had recently experienced, and then the social service staff member left the unit. At 12:00 noon, the nursing assistant turned on soft background music and then proceeded to assist residents to the dining room chairs. At 1:10 P.M., there were 14 residents in the dining room/lounge eating lunch. At 1:20 P.M., an activity staff member entered the dining room/lounge and asked the residents if any of them desired to go help "fold towels." Only 1 resident expressed a desire to go help "fold towels." However, at 1:27 P.M., 3 female residents (Resident #66, Resident #72 and Resident #68) exited the unit with the activity staff member to go to a "linen" activity. The activity staff member indicated they would just stay out of the unit to play Bingo after the linen folding activity. There were no structured activities for the residents that did not leave the unit. There was no nursing staff available to supervise the residents in the dining room/ lounge. At 1:33 P.M., there were 7 residents (Resident #62, Resident #63, Resident #65, Resident #67, Resident #68, Resident #70 and Resident #72) left in the dining room/lounge and one visitor. There were no structured activities or any staff in the room. At 1:36 P.M., the nurse came back into the dining room/lounge, but no activity was provided for the 7 residents left in the room. At 2:00 P.M., Resident #66 came into the dining room/lounge and indicated she desired to go to Bingo and no one had came back (to the unit) to get her. She indicated if the Bingo had already started when she got there she did not want to play. Resident #66 was then escorted off of the unit to the Bingo activity. From 2:00 P.M. - 2:45 P.M., there were no structured activities provided for 9 residents (Resident #62, Resident #63, Resident #65, Resident #67, Resident #68, Resident #69, Resident #70, Resident #71, and Resident #72) who did not go off the unit for activities. There was soft music playing in the dining room/lounge, and the nurse was seated at a dining room table working on paperwork. On 02/01/12 at 8:47 A.M., there were 6 residents (Resident #62, Resident #64, Resident #68, Resident #71, Resident #72, and Resident #73) noted in the dining room/lounge. There were no activities and there were no staff in the room. The activity director was noted to be in the hallway taping new activity calendars onto individual resident room walls. A nursing assistant was noted to be ambulating a resident into their room, and the nurse was noted to have been in a resident room. At 8:50 A.M., the nurse entered the dining room/lounge and proceeded to clean up dirty breakfast dishes and then at 9:06 A.M., both the nurse and the nursing assistant had left the dining room/lounge. The nurse, employee #7, exited the dementia unit. There were 4 residents still in the dining room/lounge (Resident #62, Resident #68, Resident #71, and Resident #72). Nursing staff left the residents in the lounge without supervision for 23 minutes. At 9:10 A.M., the Certified Nursing Assistant, CNA, employee #5, came back to the dining room/lounge and put soft background music on for the residents. From 9:10 A.M. - 9:35 A.M., CNA #5 was noted to answer a resident's request for help to the bathroom, and help another resident ambulate out of the dining room/lounge. At 9:36 A.M., Resident #66 ambulated into the dining room/lounge and asked a visitor if they could help her put on a "Bluegrass" DVD. There was no video player noted and at 9:38 A.M., CNA #5 reentered the dining room lounge and informed Resident #66 she would put on a "Bluegrass" music CD as the DVD player was "put up." From 9:42 A.M. - 9:48 A.M., there were 3 residents (unsupervised) with no structured activities in the dining room/lounge. At 9:48 A.M., a therapist, Employee #6 entered the dining room/lounge and spoke with one of the 3 residents (Resident #64, Resident #70, and Resident #72) in the room. Employee #6 exited the room and unit at 9:52 A.M. From 9:52 A.M., there were no staff supervising the residents. At 9:54 A.M., LPN #7, entered the dining room/lounge and Resident #66 questioned her about the "Fancy Nails" activity. LPN #7 informed the resident the activity was scheduled for 10:00 A.M. At 9:57 A.M., LPN #7 started to read the newspaper to the 3 residents (Resident #64, Resident #70, and Resident #72) who were still sitting in the dining room/lounge. At 10:01 A.M., Resident # 72 was taken off the unit to smoke. At 10:11 A.M., Resident #66 questioned LPN #7 about the fingernail polishing activity and pointed out it was past 10:00 A.M. CNA #5, who had entered the room was instructed to call activity staff to come to the unit and escort the residents to the "Fancy Nails" activity off of the unit. The CNA attempted to call but got no answer and in the meantime, the Food Service Supervisor, who had entered the unit to drop off menus, volunteered to escort residents off of the unit to the activity. Resident #66 was then escorted off of the unit to the "Fancy Nails" activity. LPN #7 continued to read the newspaper until 10:15. From 10:15 A.M. - 10:42 A.M., there was music again playing for the residents, but no structured activities. At 10:42 A.M., Resident #66 returned from the off unit "Fancy Nails" activity and Resident #72 exclaimed, "Hey, they are getting their nails done down there and I want my nails done." Resident #66 informed Resident # 72 that the nails activity had ended. LPN #7 informed Resident # 72 that she would paint her nails later for her and also informed Resident #66 that she would hook up the video player so she could watch the "Bluegrass" DVD she had requested earlier. At 11:05 A.M., LPN #7 got out fingernail polish and sat at a dining room table with Resident #72 and started to file and paint her fingernails. At 11:20 A.M., CNA #5 got out a wooden corn hole bean bag toss game and started playing with the 6 residents (Resident #62, Resident #64, Resident #68, Resident #71, Resident #70, and Resident #72) who where seated in the lounge part of the dining room/lounge room. At 11:24 A.M., CNA #5 left to go answer a call light. No staff were available to assist the resident's in continuing their game. Resident #68 was heard stating, "I'm not sure I could bend over enough to get them (bean bags)." LPN #7, turned around and instructed Resident #68 to wait for (CNA's name) to return. At 11:35 A.M., CNA #5 returned to the dining room/lounge and continued to play bean bag toss with the residents. At 11:40, LPN #7, who had finished painting Resident #72 's fingernails, left the unit for her lunch break. At 11:41 A.M., CNA #5 left the bean bag toss game to assist another resident who had ambulated to the doorway of the dining room/lounge and requested assistance. CNA #5 did not return to the dining room lounge until 11:49 A.M. The 6 residents who were playing the bean bag toss game, just sat in chairs or on the sofa while no staff were there to facilitate the game. At 1:50 P.M., LPN #7 indicated there were 4 residents out with activities' staff and they were staying off of the unit for the "Movie." LPN #7 also indicated she was going to escort, Resident #72 off the unit to the activity. There were 3 residents in the dining room/lounge (Resident #67, Resident #65, Resident #73) and 1 male resident ( Resident #71) ambulating in the hallway. CNA #5 had to leave the dining room lounge, to redirect Resident #69 out of another resident's room. Resident #67's visitors also entered the dining room/lounge. There were no nursing staff supervising residents from 1:50 P.M. to 2:15 P.M. Interview with the Director of Nursing, on 02/02/12 at 10:15 A.M., indicated the facility had opened the dementia unit within the past year and LPN #7 was the Program Director of the dementia unit. She indicated when she had gone back to the unit she had observed lots of activities. She was unsure of the schedule of activities for the Dementia unit. She indicated the nursing staff were responsible for providing supervision for the unit. 3.1-45(a)(2)