Every finding on record at Waters of Sullivan Nursing Facility, The

Based on observation, interview, and record review, the facility failed to ensure facial hair was covered with beard restraints in the kitchen area for 6 of 6 observations of the kitchen; the facility failed to ensure food met the minimal holding temperature for 1 of 1 test trays reviewed; and the facility failed to ensure the hall tray food delivery carts were maintained clean and free of dried debris for 2 or 2 food carts reviewed. These concerns had the potential to affect 47 of 48 residents who eat food served from the kitchen. Findings include:1. During the initial kitchen observation with the Dietary Manager, on 4/24/26 at 8:58 a.m., Dietary Aide 4 was observed with facial hair and no beard restraint in place. He was observed to enter the food preparation area on three different occasions to collect items to run through the dish machine. At the same time, the Dietary Manager indicated she understood the need to have beards and hair restraints in place when in the kitchen. During a random observation of the kitchen area, on 4/24/26 at 10:15 a.m., Dietary Aide 4 was observed standing in the food preparation area. His beard restraint was pulled down below his mouth, not completely covering his beard and with no coverage of his mustache. During a random observation, on 4/24/26 at 11:33 a.m., Dietary Aide 4 was observed in the kitchen food preparation area, prior to the lunch meal being served. His beard restraint was pulled down below his mouth, not completely covering his beard and with no coverage of his mustache. During a random observation, on 4/24/26 at 11:40 a.m., Dietary Aide 4 was observed in the kitchen food preparation area, standing directly over the steam table loading trays into the hall tray carts. His beard restraint was pulled down below his mouth, not completely covering his beard and with no coverage of his mustache. During the lunch meal observation, on 4/24/26 at 11:50 a.m., Dietary Aide 4 was observed entering the kitchen area with the hall tray cart. His beard restraint was pulled down below his mouth, not completely covering his beard and with no coverage of his mustache. During a random kitchen observation, on 4/24/26 at 12:40 p.m., Dietary Aide 9 was observed in the kitchen food preparation area serving trays. His beard restraint did not cover his entire beard. His long sideburns were exposed while standing over open plates of food. During an interview, on 4/24/26 at 2:04 p.m., Resident G indicated the facility didn't normally use the heated tray carts. Usually, just service carts with the meal trays stacked on top of each other. In the past, he had watched a male kitchen staff with a beard not wearing a beard cover. He had seen the same staff work with raw food and cooked food without changing gloves and had also watched him drop a grilled cheese on the floor, and look around to see if anyone was watching, pick it up, and put it back on the steam table. The new kitchen manager did seem to be concerned about the residents instead of focusing on corporate priorities. However, it seemed that any of the kitchen staff that cared about the residents' food, didn't end up staying very long. Resident G's record was reviewed on 4/24/26 at 2:18 p.m. A quarterly Minimum Data Set (MDS) assessment, dated 4/12/26, indicated the resident had no cognitive deficit and indicated not documented behaviors. On 4/24/26 at 9:33 a.m., the Administrator provided an undated document, titled, Food Safety and Sanitation, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure.Hair restraints will be worn at all times. Beards should be well-trimmed and covered with an appropriate hair restraint. 2. During an interview on 4/24/26 at 10:05 a.m., the Administrator indicated the dietary staff were contracted employees and were not her staff. She was aware of the kitchen having issues but since they were contracted employees she didn't have authority over them. During an interview on 4/24/26 at 10:28 a.m., Resident C indicated the food was not good at the facility. She indicated that the food was dry, had no seasoning, and often overcooked. The scrambled eggs were overcooked and had a rubber like texture to them. Resident C indicated she had given up on ordering eggs for breakfast. She ate her meals in the dining room and even in the dining room the food was often cold. A significant change in status Minimum Data Set (MDS) assessment, dated 4/7/26 indicated Resident C was cognitively intact. During an interview on 4/24/26 at 10:33 a.m., Resident D indicated the food was of poor quality at the facility and was usually only lukewarm. The resident indicated she normally ate in her room and received a hall tray. She had received a breakfast tray recently and the bacon was rare and the eggs were odd looking and were rubbery. It was often hard for her to eat meat because it was tough, the cake was dry, and waffles were hard. She no longer ordered waffles for breakfast. A quarterly MDS assessment, dated 3/2/26 indicated Resident D was cognitively intact. During an interview on 4/24/26 at 11:59 a.m., Resident E indicated that he normally ate in his room and the food was sometimes cold when his tray was served. An admission MDS assessment, dated 4/9/26 indicated Resident E was cognitively intact. During an interview on 4/24/26 at 12:25 p.m., Resident F indicated that he normally ate in his room and the food was usually cold by the time he got his tray. An admission MDS assessment, dated 4/13/26, indicated Resident F was cognitively intact. A test tray was obtained on 4/24/26 at 12:47 p.m., the food temps were as follows (per facility thermometer): a. A piece of baked chicken 112 degrees Fahrenheit (F) b. Mashed potatoes with gravy 119 degrees F c. Mixed vegetables 105 degrees F During an interview, on 4/24/26 at 12:49 p.m., the Dietary Manager indicated the food was not at the correct holding temperature. She thought the holding temperature for the chicken should have been at least 140 degrees, the mashed potatoes should have been 160 degrees, and the vegetables should have been 145 degrees. The Dietary Manager indicated she had only worked at the facility for about 3 weeks and was still working on her certification. She was aware there had been complaints about cold food from the residents and she was trying to fix the issue with plate warmers. The residents' grievances forms were reviewed and following were noted: a. On 1/22/26, Resident G indicated the food quality was poor. b. On 2/18/26, Resident H indicated the food was cold and was often late. c. On 2/20/26, Resident G indicated the food was cold and often out of items. d. On 2/24/26, Resident J indicated the food was cold. On 4/24/26 at 2:45 p.m., the Director of Nursing (DON) provided an undated document, titled, Cooking and Cooling, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy: Foods will be cooked thoroughly reaching the appropriate internal temperatures specific to each item. Cooked foods will be cooled properly to ensure food safety. On 4/24/26 at 2:45 p.m. the DON provided an undated document, titled, .Minimum Cooking Food Temperatures and Holding Times, and indicated it was the policy currently being used by the facility. The policy indicated, .Poultry 165 degrees Fahrenheit.Food Cooked.165 degrees Fahrenheit. 3. On 4/24/26 at 12:22 p.m., observed the dietary food service carts for the East and [NAME] halls during the noon lunch meal service. The carts contained individual trays with meal service, cups containing liquids and eating utensils. The carts were soiled with heavy coating of brown debris along the rails at the bottom of the carts. The wheels were observed to have a heavy coating of brown debris. On 4/24/26 at 12:25 p.m., during an interview the Dietary Manager (DM) indicated the carts were cleaned after every meal service. She indicated the outside was wiped down as needed. On 4/24/26 at 2:47 p.m., the Director of Nursing provided an undated document, titled, Storing utensils, tableware, and equipment, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure.3. Clean and sanitize trays and carts used to carry clean tableware and utensils. Do this daily or as often as necessary. This citation relates to Intake 2807671. 410 Indiana Administrative Code (IAC) 3.1-21(i)(1) 410 Indiana Administrative Code (IAC) 3.1-21(i)(3)

Based on interview and record review, the facility failed to ensure the likes and dislikes of meal choices were indicated on the resident's record for 1 of 1 residents reviewed for meal food preferences (Resident B).Findings include:On 4/24/26 at 10:25 a.m. during an interview, Resident B indicated he did not like oatmeal and he continued to receive it on his tray. He indicated he had told the staff not to send it several times. On 4/24/26 at 2:00 p.m., reviewed the medical record of Resident B. The resident was admitted to the facility on [DATE]. Diagnoses included but were not limited to diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), and hypertension (high blood pressure). A physician order, dated 2/20/26, indicated a diet order of consistent carbs diet, regular texture. Review of the resident's care plan indicated no specific food preferences were indicated by the resident. A 5 day Minimum Data Set (MDS) assessment, dated 2/26/26, indicated the resident was cognitively intact. Review of a nutrition assessment, dated 2/22/26, indicated food preferences were on the tray card (a daily menu provided to the resident to record food selections). No additional information was recorded on the assessment record. On 4/24/26 at 2:13 p.m., during an interview the Director of Nursing (DON) indicated food preferences were recorded on the resident's nutritional assessments. On 2/24/26 at 2:17 p.m., during an interview the DON and Dietary Manager (DM) both indicated the resident had not told either of them of any food preferences. The DM indicated the residents were provided a daily menu and were asked to indicate what they wanted each day. The DM indicated she was not the person assigned to complete the nutritional assessments for the residents, but she would include likes and dislikes if the resident informed her of them. On 2/24/26 at 2:30 p.m., the DM provided a copy of the daily menu for 4/24/26 that was provided to the resident. She indicated likes and dislikes would be recorded at the bottom of the menu selection. The document lacked indications of likes or dislikes. On 4/24/26 at 2:50 p.m., the DON provided a document, titled, Clinical Nutrition documentation, dated4/2017, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy.The resident has the right to make their own food choices as it relates to their individual differences, cultural and ethnic preferences. This citation relates to Intake 2807671. 410 Indiana Administrative Code (IAC) 1.3-21(a)(4)

Based on record review and interview, the facility failed to administer insulin as ordered by the physician and failed to receive physician orders to hold insulin for low blood sugars for 1 of 3 residents reviewed for quality of care (Resident B). Findings include: The clinical record for Resident B was completed on 2/13/26 at 10:09 a.m. Diagnoses included diabetes mellitus type II. A current signed physician's order for the resident included: Lispro Insulin (to treat diabetes mellitus), inject 25 units subcutaneously with meals for diabetes. The order was dated 12/4/25. The order provided by the physician lacked parameters for holding ordered doses of insulin. The electronic Medication Administration Record (eMAR) indicated the following:a. The 7:30 a.m. dose of insulin was held on 1/18/26 for a blood sugar (BS) of 46; on 1/25/26 for a BS of 90; and on 1/28/26 for a BS of 116. b. The 11:30 a.m. dose of insulin was held on 12/8/25 for a (BS) of 76; on 12/9/25 for a BS of 80; on 12/21/25 for a BS of 77; on 12/22/25 for a BS of 69; on 12/31/25 for a BS of 78; on 1/2/26 for a BS of 59; on 1/16/26 for a BS of 72; on 1/17/26 for a BS of 54; 1/20/26 for a BS of 60; on 1/23/26 for a BS of 72; c. The 5:30 p.m. dose of insulin was held on 1/25/26 for a BS of 105. d. The clinical record lacked documentation of a blood sugar value, progress note, indication of resident being absent from the facility or indication of administration of insulin on the following dates and times: on 1/12/26 at 5:30 p.m.; on 1/19/26 at 11:30 a.m.; The clinical record lacked documentation of notification to the physician regarding the held insulin doses. During an interview on 1/13/26 at 3:02 p.m., QMA 4 indicated she obtained blood sugars for the nurses prior to insulin administration. Resident B's value was 77 on 1/21/26 at 11:30 a.m. The nurse indicated to put a note in the eMAR that the insulin was held due to the BS value of 77. During an interview on 1/13/26 at 3:05 p.m., the Director of Nursing (DON) indicated the physician had not provided parameters on when to hold an insulin injection based on the blood sugar value. The hospital discharge records had not included parameters to hold mealtime insulin and the facility's physician had not added any. The nursing staff should contact the physician regarding holding medications. Review of the current facility policy, undated, titled, Administering Medications, provided by the Director of Nursing on 2/13/26 at 2:58 p.m., included the following: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation .8. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for a resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's Attending Physician or the facility's Medical Director to discuss the concerns. This citation relates to Intake 2742096. 3.1-37(a)

Based on interview and record review, the facility had failed to ensure enough nursing staff to provide resident care while covering laundry services since the end of October. This deficient practice had the potential to affect 48 of 48 residents who resided in the facility. Findings include:During an interview on 12/4/25 at 2:30 p.m., CNA 4 indicated she sometimes worked in laundry during her shift on the floor. She tried her best to not let it affect resident care and felt the nursing staff had stepped up to answer call lights when able. During an interview on 12/4/25 at 10:35 p.m., CNA 6 indicated she did laundry during her shift and had had to work much harder. The nursing staff had had to answer more call lights which was probably affecting charting and medication administration. She felt call light response times were being affected on the rehab/west hall. During an interview on 12/4/25 at 10:42 p.m., CNA 7 indicated she had done laundry during her shift. She had to leave the floor from time to time to complete loads of laundry. It had been a definite strain on the nursing staff. The residents seemed to understand the situation and were hoping it was resolved soon. The residents had to wait longer than normal at times for call lights to be answered. She felt it was unsetting that the Administrator showed no appreciation or acknowledgement at how hard everyone had worked without laundry staff to keep residents cared for. They had not scheduled additional staff to help that she had seen. Two to three times a week there were only two aides, a nurse, and a QMA on night shift to care for residents in addition to doing laundry. During an interview on 12/4/25 at 10:51 p.m., LPN 8 indicated she had done laundry during her shift to help out. She felt call light response times had definitely been longer and meal tray delivery and pick-up had been affected. They had since come up with a way to get the trays delivered timely and assured the residents received a warm meal. During an interview on 12/5/25 at 10:00 a.m., the DON indicated the staff had been stepping up to cover laundry services. Some of the CNAs were scheduled specifically to work in laundry occasionally, but she realized that had not covered the needs. The staff had been stepping in when able. During an interview on 12/5/25 at 11:09 a.m., Resident H indicated she had not noticed an increase in call light response times, but felt the staff were a lot more stressed lately. During an interview on 12/4/25 at 12:05 p.m., the Administrator indicated the CNAs had picked up additional hours to work in laundry. The facility only had one housekeeper and she had not worked weekends, so there was no housekeeping staff on the weekends. During an interview on 12/5/25 at 12:03 p.m., the Administrator indicated she had fired the Housekeeping Supervisor around 10/13/25. They currently had one fulltime housekeeper/laundry person. She tried to jump in and help with laundry, but would get pulled away being an Administrator. She had not reached out to her Regional Director of Operations to see what options might be for laundry coverage. She had not considered an outside source to cover the vacancy. She had not spoken to residents or staff about possible effects the laundry staff shortage and the CNA's covering that position, had caused. She received feedback regarding effect on staff, as in has anybody been hired? but not specifics of the effect on resident care. She was aware of their challenges but had not known the staff had run out of linens on night shift causing them to have to do loads of laundry on evenings and nights. A Facility Assessment Tool, updated 9/17/25, provided by the Administrator on 12/4/25 at 12:30 p.m., included the following: .Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies Example 2. Describe your general staffing plan to ensure that you have sufficient staff to meet the needs of the residents at any given time .Other (e.g., department heads, nurse educator, quality assurance, ancillary staff in maintenance, housekeeping, dietary, laundry) .1 FTE [Full Time Equivalent] Housekeeping Supervisor; 3 FTE Housekeepers/Laundry. This citation relates to Intakes 2648148 and 2665791. 3.1-17(a)

Based on record review and interview, the Administrator failed to manage the facility in a manner that provided quality of life related to bug infestation, lack of available direct care staff, and a safe living condition of the facility environment. This deficient practice had the potential to affect 48 of 48 residents who resided in the facility. Findings include:Confidential interviews were conducted during the course of the survey, and indicated the Administrator never came on the floor to speak with staff or the residents. They felt she did not know the residents or staff at all and had shown a total lack of caring for the challenges being faced in the facility. The moral in the facility had suffered under the current Administrator. The added pressures placed on staff due to vacancies and the gnat infestation had been basically ignored. She had turned a blind eye to the issues facing the facility with the pests and lack of laundry staffing. During an interview on 12/4/25 at 11:16 a.m., Resident E indicated he had recently cut his arm on the door frame leading to his bathroom. During an observation at the time of the interview, the door frame to the bathroom was observed to have a trim piece that had been cut about 1/2 way up the frame, and a plastic sheeting had been placed at the bottom where the wood was missing. There was visible blood on the door frame where the resident had brushed up against it and cut his left upper arm. The resident indicated the Director of Nursing (DON), the Administrator and an outside audit group had come into his room and observed the door jam. The facility had been without a Maintenance Director for about a month and a half at that time, and the Administrator indicated they had hired a new Maintenance Director. She indicated to him not to overwhelm him and that he would fix the door frame when he was able. He indicated the Administrator had also fired housekeeping about a month ago and the CNAs had been doing the facilities laundry. They only had one girl who did the cleaning. He understood that the facility would run out of incontinent bed pads frequently causing the night nursing staff to have to do laundry. Resident E indicated his room had been full of gnats in September and October. They had since disappeared. They were so bad in the dining room, you had to cover your beverage or there would be gnats floating in it. One day, he counted 10 in his coffee that he had forgotten to cover. During the interview, Resident E pointed to a bug trap tube hanging from his fire alarm that had a sticky surface. The trap was covered in dead gnats. He indicated he knew he was not supposed to have it in his room as staff had told him the Administrator said he could not have one, but he was so tired of dealing with the infestation in his room. On 12/4/25 at 2:08 p.m., CNA 2 indicated the facility was full of gnats starting in September through mid-October. The dining room was particularly bad. This issue with the gnats had been reported many times to administration. On 12/4/25 at 2:35 p.m., CNA 4 indicated the gnats would fly straight into the residents' food and beverages. The staff had offered to get hanging traps but were told the Administrator had said they could not do that. She did not feel like the issue was addressed timely or appropriately. On 12/5/25 at 10:15 a.m., Resident J indicated she had a lot of gnats in her room. She indicated they would fly out from under a cloth she used to cover her frequently used items on her overbed table. It was annoying. She developed maggots between her toes, and she believes it was from the insects in her room. During an interview on 12/5/25 at 12:03 p.m., the Administrator indicated she had fired the former Maintenance Director, the Assistant Maintenance Director for refusing to go into a crawl space with the Regional Maintenance Consultant. This occurred around 10/13/25. The Regional Maintenance Consultant oversaw the maintenance needs of the facility after they had been let go. The Administrator indicated she had fired the Housekeeping manager in late October. They currently had one fulltime housekeeper/laundry staff person. She had tried to jump in and help with laundry, but would get pulled away being an Administrator. She had not reached out to her Regional Director of Operations as to what her options might be for laundry coverage. She had not considered an outside source to cover the vacancy. She had not spoken to residents or staff about possible effects the laundry staff vacancy and the nursing staff covering that position. She got feedback regarding the effects on staff as in has anybody been hired? but not specifics of the effect on resident care. She was aware of their challenges but had not known the staff had run out of linens in the evenings and at night, causing them to have to do laundry on those shifts. She had been aware of the gnat issue. She does not recall telling anyone that they could not have pest control devices in their rooms. During the infestation of gnats, she had not spoken to any of the residents regarding the gnats and what effect it was having on their day-to-day. She had not talked to staff regarding the gnat issue but had received information from the department heads. She had called the pest company to complete two additional visits to address the gnats, outside of their regular monthly service. They had told her they would put foam in the drains, but other than that, there was not much else they could do. She had not considered reaching out to another provider for a second opinion and did not recall reporting the gnat infestation to the Director of Operations of the company. She had seen a few gnats in her office but was not aware they had gotten so bad in the facility. During an interview on 12/4/25 at 12:05 p.m., the Administrator indicated the CNAs had picked up additional hours to work in laundry. The facility only had one housekeeper and she had not worked weekends, so there was no housekeeping staff on the weekends. The facility also was without maintenance, but a new director had started about 10 days ago. The Regional Maintenance Director had trained him for about three days. The molding in Resident E room had not been fixed since he cut his arm. She was not sure when the new Maintenance Director would be able to fix the molding. Cross reference citations F0584 and F0725. This citation relates to Intakes 2648148 and 2665791. 3.1-13(a)(1)

Based on observation, record review, and interview, the facility failed to control a gnat infestation of multiple areas throughout the facility for 4 of 4 residents reviewed for environment (Residents E, G, H, and J). This deficient practice had the potential to affect 48 of 48 residents who resided in the facility. Findings include:During resident interviews, the following was indicated:On 12/4/25 at 11:16 a.m., Resident E indicated his room was full of gnats in September and October. They had since disappeared. They were so bad in the dining room, you had to cover your beverage or there would be gnats floating in it. One day, he counted 10 in his coffee that he had forgotten to cover. During the interview, Resident E pointed to a bug trap tube hanging from his fire alarm that had a sticky surface. The trap was covered in dead gnats. He indicated he knew he was not supposed to have it in his room as staff had told him the Administrator said he could not have one, but he was so tired of dealing with the infestation in his room. On 12/5/25 at 10:56 a.m., Resident G indicated the gnats were so horrible and would crawl down his straw into his beverage. During one meal, he thought he had put pepper on his food only to realize it was gnats on his food. This went on for weeks and weeks. On 12/5/25 at 11:09 a.m., Resident H indicated the gnats were terrible in her room. She would cover her face at night with a tissue. She felt like it went on for about three months. On 12/5/25 at 10:15 a.m., Resident J indicated she had a lot of gnats in her room. She indicated they would fly out from under a cloth she used to cover her frequently used items on her overbed table. It was annoying. She developed maggots between her toes, and she believes it was from the insects in her room. A Skin Integrity Issue report, dated 10/31/25 at 8:00 a.m., provided by the Director of Nursing (DON) on 12/4/25 at 2:28 p.m., indicated Resident J was observed to have larvae in between her toes. The resident's feet were cleansed, and the resident bathed. No injuries had been observed at the time of incident. Predisposing Physiological Factors were indicated as prefers to be independent and declines assistance, incontinent, and fragile/sensitive skin. Predisposing Situation Factors were indicated as improper footwear, resistive to care, and non-compliant with safety instructions.During staff interviews, the following was indicated:On 12/4/25 at 2:08 p.m., CNA 2 indicated the facility was full of gnats starting in September through mid-October. The dining room was particularly bad. This issue with the gnats had been reported many times to administration.On 12/4/25 at 2:11 p.m., CNA 3 indicated there had been gnats everywhere and she would find them in her beverages. She felt the facility was not treating them aggressively enough and that was why they got so bad.On 12/4/25 at 2:35 p.m., CNA 4 indicated the gnats would fly straight into the residents' food and beverages. The staff had offered to get hanging traps and such, but were told the Administrator had said they could not do that. She did not feel like the issue was addressed timely or appropriately.On 12/4/25 at 10:35 p.m., CNA 6 indicated the gnats were a bad issue. She realized the facility did have a pest company spray for the gnats, but by that time they were very bad already. It would be better temporarily but quickly return to an infestation. She felt the facility failed to treat for them until they got really bad.On 12/4/25 at 10:42 p.m., CNA 7 indicated the gnats were an infestation. The pest control company that came in to treat for them had not seemed to help the situation at all. She felt the facility should have done something more to control them. On 12/4/25 at 10:51 p.m., LPN 8 indicated the gnats were horrible for a while and would get into residents' food when the covers were removed. They were everywhere.resident rooms, the nurses' stations, and the dining room. She felt the facility just ignored them for about a month until they got so bad. During an interview on 12/5/25 at 12:03 p.m. the Administrator indicated she had fired the Maintenance Director and the Assistant Maintenance Director, around 10/13/25, due to refusing to go into the crawl space with the Regional Consultant. The Regional Consultant had come into the facility to oversee the needs of the facility. She did not recall telling anyone that they could not have pest control devices in their rooms. During the infestation of gnats, she had not spoken to any of the residents regarding the gnats and what effect they were having on their day-to-day. She had not talked to staff regarding the gnat issue, but had received information from the department heads. She had called the pest company to complete two additional visits to address the gnats, outside of their regular monthly service. They had told her they would put foam in the drains, but other than that, there was not much else they could do. She had not considered reaching out to another provider for a second opinion and did not recall reporting the gnat infestation to the Director of Operations of the company. She had seen a few gnats in her office, but was not aware they had gotten so bad in the facility.A current facility policy, dated 2024, titled, Pest Control Policy, provided by the Administrator on 12/4/25 at 1:00 p.m., included the following: Purpose The purpose of this policy is to ensure a pest-free environment within out facilities by outlining procedures for the prevention, monitoring, and control of pest infestations. Responsibilities.Pest Control Provider: Conduct regular inspections, apply pest control measures, and provide detailed reports on pest activity and treatments.Monitoring: 1. Regular Inspections .Use pest monitoring devices, such as traps, to detect early signs of infestation .This citation relates to Intakes 2648148 and 2665791.3.1-19(f)(4)

A. Based on observation, interview, and record review, the facility failed to ensure a male cook with a full beard was wearing a beard restraint during food preparation and that the high temperature dish machine reached the proper temperature for the rinse cycle for 1 of 2 kitchen observations. This deficient practice had the potential to affect 52 of 52 residents receiving food served from the kitchen. B. Based on observation, interview, and record review, the facility failed to ensure proper handling of food during 1 of 1 lunchtime hall tray observations. Findings include: A. During the initial tour of the kitchen with the Dietary Manager, on 7/28/25 at 7:36 a.m., the following was observed: 1. On 7/28/25 at 7:40 a.m., [NAME] 6 was observed with a full beard. He was not wearing any beard restraint cover while preparing food for the breakfast meal. The visitor provided a beard restraint for the cook. At the same time, the Dietary Manager indicated the facility was aware that there were no beard restraints and they had placed an order for the restraints. During an interview, on 7/29/25 at 9:48 a.m., the Administrator (ADM) indicated she was not aware that the cook had been working without a beard restraint. During an interview, on 7/31/25 at 11:48 a.m., the Regional Director of Operations (RDO) indicated she was aware that there were no beard restraints available. The cook was the first male staff that had worked in the kitchen with a beard. They had beard restraints on order. On 7/28/25 at 1:51 p.m., the ADM provided a document, dated 4/2017, titled, Food Safety and Sanitation Employee Health and Personal Hygiene, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure.Hair restraints will be worn at all times. Beards should be well-trimmed and covered with an appropriate hair restraint. 2. On 7/28/25 at 7:49 a.m., observation of the high temperature dish machine indicated the rinse cycle temperature only reached a temperature of 174 degrees Fahrenheit (F). At the same time, the Dietary Manager indicated the temperature should reach at least 180 degrees F for the rinse cycle to sanitize the dishes. There had been a problem with the dish machine's booster (a device that boosts the temperature of the water during the rinse cycle) and she had reported this to the Maintenance Director. During an interview, on 7/28/25 at 8:49 a.m., the Administrator (ADM) indicated she had not been made aware of the dish machine not getting up to the proper rinse temperature. She would make sure the Maintenance Director was aware and that the kitchen staff would use paper and plastic items until the machine was functioning properly again. During an interview, on 7/29/25 at 9:48 a.m., the ADM indicated there had been some concerns with the Dietary Manager's job performance. She had been a no-call/no-show for her shift on this date. She would no longer hold that position and they would be looking for a new manager in the kitchen. On 7/28/25 at 1:51 p.m., the ADM provided a document, dated 4/2017, titled, Food Safety and Sanitation Machine Dishwashing and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure.High temperature dish machine has a final sanitizing rinse of at least 180 degrees F. B. On 7/28/25 at 12:45 p.m., A drink cart was noted on the East wing hallway, the cart contained a metal bucket of ice and the bucket did not contain a lid, the ice was open to air and there was a metal scoop in the ice bucket. The drink cart was moved down the hallway by room [ROOM NUMBER] and was pushed by Licensed Practical Nurse (LPN) 16. A drink was prepared by the LPN and the ice scoop was placed in the opened metal ice bucket. The drink cart was left by room [ROOM NUMBER] until 12:48 p.m. The Director of Nursing (DON) pushed the cart up to the nurses' station and left the cart at the nurses' station. The cart contained an ice bucket that was left open to air and contained an ice scoop still in the bucket. On 7/28/15 at 1:10 p.m., the drink cart continued to be sitting at the nurses' station. The metal scoop was noted to still be in the ice bucket with the ice melting. There was no staff currently by the nurse's station. On 7/28/25 at 12:53 p.m., A drink cart was noted be at the nurses' station on the [NAME] wing, the cart contained a metal bucket that did not contain a lid, and the ice was open to air. There was no scoop in the ice bucket. There were 3 plastic drinking cups of ice on the second shelf of the cart and they were left open to air with no lids on them. On 7/28/25 at 1:13 p.m. Activity Aide 15 pushed the cart down the hallway and took a plastic drinking cup and scooped ice out of the ice bucket into the cup. The activity aide poured lemonade into the cup that contained the ice, she served it to the resident with their lunch tray. On 7/28/25 at 1:13 p.m., a housekeeper was observed to be pushing her cart down the hallway as staff were serving lunch hall trays. During an interview, on 7/28/25 at 1:20 p.m., the DON indicated the lid was removed from the ice bucket when the drink cart left the kitchen. She was not aware it should be covered while out in the hallway. During an interview, on 7/28/25 at 1:35 p.m., the Regional Nurse Consultant (RNC) indicated ice should be covered when the leaving the kitchen and staff should not leave the scoop in the ice bucket or use drinking glasses to scoop ice into and then use. During an interview, on 7/28/25 at 1:38 p.m., the DON indicated the facility had decided to no longer use the ice buckets during meal service and use the ice coolers on the hallways instead. She indicated the coolers had lids and ice scoops with a designated container for them to remain in while not in use. She had provided education to staff as well. On 7/28/25 at 1:40 p.m., the Administrator provided an undated document, titled, Serving Food and Beverages, and indicated it was the policy currently being used by the facility. The policy indicated, .6. Foods will be covered when not being served . 10. All food/beverages will be covered if transported to residents that are eating in their room, or to a dining room that is not adjacent to kitchen 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to provide meals that were palatable during 2 of 2 mealtime observations. This deficient practice had the potential to affect 52 of 52 residents receiving food served from the kitchen. Findings include:During breakfast meal service in the main dining room on 7/28/25 at 8:03 a.m., a breakfast menu was noted to be dated 7/11/25 and indicated breakfast trays were served at 7:45 a.m. The first breakfast tray was served at 8:23 a.m. On 7/28/25 at 8:23 a.m., Certified Nurse's Aide (CNA) 11 served a male resident his breakfast tray and indicated she was unable to cut the waffle very easily because it was hard and crunchy. The waffle was noted to be dark brown and hard on half of it. During an interview, on 7/28/25 at 8:35 a.m., Resident 61 indicated he was unable to eat his waffle because it was overcooked and too hard to cut with a butter knife. During an interview, on 7/28/25 at 8:40 a.m., Resident 40 indicated he didn't have waffles or biscuits on his plate this morning, but they appeared to be overcooked and too hard to cut because his table mate was unable to eat hers. During an interview, on 7/28/25 at 1:45 p.m., Resident 60 indicated she was unable to eat most of her lunch meal because the French fries were overcooked and too crunchy to eat, she didn't like the pizza crust because there was too much of it and it was hard to chew. There was no protein on the pizza, just cheese. Resident 60 was not sure why the facility would pair pizza and French fries together in the first place. During an interview, on 7/29/25 at 8:56 a.m., Resident 36 indicated the food at the facility was not good. She indicated the waffles and biscuits were hard if they served them and her eggs were never cooked right. The yellow yolk of the eggs appeared to be gel like on her breakfast tray. Review of May, June, and July resident council meeting minutes indicated residents had concerns with food palatability each month. During an interview, on 7/31/25 at 1:15 p.m., the Regional Director of Operations (RDO) indicated the facility was aware of the ongoing kitchen concerns and how the food was being prepared. She indicated the food was not being prepared properly and they now have all new staff in the kitchen. She thought the food was being cooked all together and was being left out for too long and that was why the food was hard and crunchy. The day the kitchen served pizza it should have contained a protein and should not have been served with French fries, there should have been a salad or [NAME] slaw served with it not another starch. She was aware that the food being prepared by the kitchen was unacceptable. During an interview, on 7/31/23 at 2:45 p.m., the Administrator indicated the facility was aware of the kitchen concerns and they were working on getting new cooks and a Dietary Manager for the kitchen. On 7/31/25 at 3:00 p.m., the Administrator provided an undated document, titled, The Dining Service, and indicated it was the policy currently being used by the facility. The policy indicated, .6. Meals will be nourishing, attractive, palatable, .On 7/31/25 at 3:00 p.m., the Administrator provided a document with a revised date of 1/2025, titled, Menu & Nutritional Adequacy, and indicated it was the policy currently being used by the facility. The policy indicated, .Meals will be prepared and served in an attractive manner that enhances palatability.3.1-21(a)(1)3.1-21(a)(2)

Based on record review and interview, the facility failed to ensure a resident's dialysis (medical treatment that helps remove waste products and excess fluid from the blood when a person's kidneys are not functioning properly) access site was accurately assessed for 1 of 1 residents reviewed for dialysis (Resident 42). Findings include:Resident 42's record was reviewed on 7/31/25 at 11:39 a.m. Census information indicated the resident was admitted to the facility on [DATE]. Diagnoses on the resident's profile included, but were not limited to, stage four chronic kidney disease (severe kidney disease with significantly reduced kidney function) and dependence on renal dialysis. An admission Minimum Data Set (MDS) assessment, dated 7/10/25, indicated the resident was cognitively intact. A medication administration record (MAR), dated July 2025, included a physician's order, dated 7/7/35, to maintain the resident's dialysis access site. The order indicated check for blood flow by feeling for a pulse or rushing sensation (thrill) on the access site (an assessment technique to ensure blood is flowing to a fistula [surgically created connection between a vein and artery used for dialysis]). The MAR indicated the assessment was completed twice daily from 7/7/25 to 7/31/25. The MAR, dated July 2025, included a physician's order, dated 7/4/25, to monitor the resident's Permacath (tunneled dialysis catheter) site to the right upper chest every shift for complications. The Permacath was only to be accessed by dialysis, and the dressing was changed by dialysis. The MAR indicated the assessment was completed twice daily from 7/4/25 to 7/31/25. Current care plans indicated the resident had a Permacath to the right upper chest and received dialysis three times weekly. During an interview, on 7/31/25 at 12:37 p.m., Resident 42 indicated she had a Permacath in her chest/neck area as an access for her dialysis. The dialysis staff provided the care for the access site, and the facility staff did not normally do anything with it or look at it. The resident indicated she would notify the facility staff if there was an issue with the access site. The resident did not have a fistula for dialysis. During an interview, on 7/31/25 at 12:39 p.m., Licensed Practical Nurse (LPN) 17 indicated the resident had a Permacath for the dialysis access site. The order to assess the fistula should not have been in place because the resident did not have a fistula. During an interview, on 7/31/25 at 1:05 p.m., the Director of Nursing (DON) indicated the resident had Permacath for the dialysis access site. The order to assess the fistula was put in by mistake. The nurses should not have documented they assessed a fistula because the resident did not have one. On 7/31/25 at 1:16 p.m., the DON provided an undated document titled, Community Hemodialysis, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: To ensure coordination of care for residents requiring hemodialysis in the community. Policy: 1. All residents that are admitted to the facility with needs for hemodialysis will have coordination of services between the facility and the hemodialysis unit prior to admission. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure medication was labeled properly for 1 of 2 medication storage rooms reviewed for medication storage. Findings include:On 7/30/25 at 1:45 p.m., the East wing medication storage room contained an undated and opened multi use vial of Tubersol (a clear, colorless solution for injection as an aid in the diagnosis of tuberculosis) solution.During an interview, on 7/30/25 at 1:44 p.m., Licensed Practical Nurse (LPN) 14 indicated Tubersol solution was good for 30 days once it had been opened. She would dispose of the vial since it was not labeled with an open date, and she wasn't sure how long it had been in the refrigerator.During an interview, on 7/30/25 at 1:54 p.m., LPN 7 indicated Tubersol solution was good for 30 days once it had been opened and should be dated when opened.On 7/30/25 at 2:17 p.m., the Director of Nursing (DON) provided a document, dated July 2024, titled, Medication Storage in the Facility, and indicated it was the current policy used by the facility. The policy indicated, .Medications and biologicals are stored safely, securely, and properly following the manufacture or supplier recommendations On 7/30/25 at 2:34 p.m., the DON provided an undated document, titled, Tuberculin Purified Protein Derivative, and indicated it was the current policy used by the facility. The policy indicated, .A vial of Tubersol which has been entered and in use for 30 days should be discarded. Do not use after expiration date.3.1-25(j)

Based on record review and interview, the facility failed to ensure an Advance Beneficiary Notice (ABN) (written notice to inform a Medicare beneficiary when they can expect Medicare to deny payment for services) form as required for 2 of 3 residents reviewed for beneficiary notices (Residents 62 and 19). Findings include:Findings include: 1. Resident 62's record was reviewed on 8/1/25 at 10:55 a.m. A Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review, completed by the Business Office Manager (BOM), indicated the resident's Medicare Part A stay started on 3/1/25, and the last Medicare Part A stay covered day was 4/30/25. The facility initiated the discharge from Medicare Part A Services when benefit days were not yet exhausted. A Notice of Medicare Non-Coverage (NOMNC) (a document that Medicare providers must give to beneficiaries when their Medicare-covered services are ending), was signed by the resident on 4/28/25.The record lacked documentation an ABN was provided with the NOMNC. 2. Resident 19's record was reviewed on 8/1/25 at 10:48 a.m. A Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review, completed by the Business Office Manager (BOM), indicated the resident's Medicare Part A stay started on 1/27/25, and the last Medicare Part A stay covered day was 3/24/25. The facility initiated the discharge from Medicare Part A Services when benefit days were not yet exhausted. A Notice of Medicare Non-Coverage (NOMNC) (a document that Medicare providers must give to beneficiaries when their Medicare-covered services are ending), was signed by the resident's representative on 3/18/25. The record lacked documentation an ABN was provided with the NOMNC. During an interview, on 8/1/25 at 10:57 a.m., the BOM indicated ABNs were not provided to Residents 62 and 19 because they were provided a detailed NOMNC. She was not aware she still needed to issue them an ABN. On 8/1/25 at 11:11 a.m., the Administrator provided an undated document titled, Form Instructions Advance Beneficiary Notice of Noncoverage (ABN), and indicated it was the policy currently being used by the facility. The policy indicated, .Overview: The ABN is a notice given to beneficiaries in Original Medicare to convey that Medicare is not likely to provide coverage in a specific case.All of the aforementioned.providers must complete the ABN as described below, and deliver the notice to the affected beneficiaries or their representative before providing the items or services that are the subject of the notice. 3.1-4(f)(2)

Based on observation, interview and record review, the facility failed to ensure prompt response regarding resident council grievances for 3 of 3 resident council meetings reviewed. Findings include:On 7/28/25 during initial observation, the daily menu posted was dated 7/11/25. Subsequent daily survey observations noted the daily menu had not been posted.On 7/31/25 at 1:00 p.m., during resident council meeting, the Resident Council President presented several concerns the residents had presented to him during the council meetings. He asked for the daily meal menu to be posted and indicated it had not been done. The residents were to choose a meal of their choice once a month; they chose a meal, but it was not served to them.He indicated if the facility had snacks available, they would pass them out. He was told the budget did not allow the facility to purchase snacks. The resident indicated he was a diabetic and he purchased snacks to keep in his room. He had snacks if needed but other diabetic residents had reported to him they had not received snacks.He indicated grievances were not responded to him or other residents.On 7/31/25 at 1:45 p.m., during interview the Administrator indicated the resident's grievances were addressed in daily stand up and stand down meetings, and the response to the grievance should be written on the grievance form. She indicated the kitchen should provide snacks daily for the residents and if they did not have food supplies, she would ensure they were available.Review of the resident council minutes from 5/27/25 to 7/29/25 indicated grievances were presented. The documentation lacked evidence of follow-up responses to complaints.On 8/1/2025 at 9:43 p.m., the Administrator provided a document titled, Resident council Policy, dated 3/1/16, and indicated it was the policy currently being used by the facility. The policy indicated, .Group Concerns and Follow-Up.The council group members who voice a concern usually expect a timely response about the resolution to their concern. This must happen. The Administrator monitors this process. Concerns-When concerns are voiced show serious interest and approach follow-up on all concerns and GET BACK WITH RESOLUTION/Document demonstrate that all concerns/requests brought up by the council either individually or by the group are very important.3.1-3(l)

Based on observation, record review, and interview, the facility failed to ensure a resident's call light was kept within reach for 1 of 24 residents reviewed for call lights (Resident 7). Findings include:On 7/28/25 at 9:35 a.m., Resident 7 was observed lying in bed. The resident's call light was lying on the recliner next to her bed and was out of the resident's reach. At the same time, the resident indicated the call light was not within her reach. On 8/1/25 at 9:03 a.m., Resident 7 was observed lying in bed with the call light under the pillow and out of her reach. At the same time, the resident indicated she did not know where her call light was and was unable to find it. The resident indicated she would yell for help if she needed something but would have used the call light if she had it. Resident 7's record was reviewed on 7/31/25 at 9:14 a.m. Diagnoses on the resident's profile included, but were not limited to, moderate vascular dementia (a disruption in blood flow to the brain leading to damage in brain tissue) with anxiety and history of falling. A quarterly Minimum Data Set (MDS) assessment, dated 7/6/25, indicated the resident had severe cognitive impairment and required moderate staff assistance with transfers. Current care plans indicated the resident required staff assistance with activities of daily living (ADLs) and was at risk of falls. During an interview, on 8/2/25 at 9:17 a.m., Licensed Practical Nurse (LPN) 16 indicated Resident 7 was capable of using her call light, and it should have been within her reach. During an interview, on 8/1/25 at 9:19 a.m., the Director of Nursing (DON) indicated the resident was able to use her call light, and it should have been kept within her reach. On 8/1/25 at 9:36 a.m., the DON provided a document titled, Call Light, Use of, dated 2006, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure Details.8. When providing care to residents be sure to position the call light conveniently for the resident to use. Tell the resident where the call light is and show him/her how to use the call light.11. Be sure all call lights are placed on the bed at all times, never on the floor or bedside stand. 3.1-3(v)(1)

Based on observation, interview, and record review, the facility failed to ensure a resident's representative was notified of a new order for 1 of 4 resident representative interviews (Resident 7). Findings include:On 7/28/25 at 9:35 a.m., Resident 7's room was observed with a contact precautions (a set of infection control practices used in healthcare settings to prevent the spread of germs that can be transmitted by direct or indirect contact with a patient or their environment) isolation sign on the wall next to the door. During an interview, on 7/28/25 at 1:12 p.m., Resident 7's representative indicated they were not aware the resident was on isolation precautions or why they were in place. They were not notified the resident was placed on isolation precautions. Resident 7's record was reviewed on 7/31/25 at 9:14 a.m. Diagnoses on the resident's profile included, but were not limited to, moderate vascular dementia (a disruption in blood flow to the brain leading to damage in brain tissue) with anxiety and urinary tract infection (UTI). A quarterly Minimum Data Set (MDS) assessment, dated 7/6/25, indicated the resident had severe cognitive impairment. A nursing progress note, dated 7/21/25, at 12:36 p.m., indicated the physician ordered Macrobid (antibiotic) for seven days for a UTI. A nursing progress note, dated 7/21/25 at 12:49 p.m., indicated the resident's representative was notified of the antibiotic order but lacked documentation the resident's representative was notified of isolation precautions. A physician's order, dated 7/23/25, indicated contact isolation precautions for Escherichia coli (E. coli) (bacteria) in the urine until 7/29/25. The order lacked documentation the resident's representative was notified of the new order. A current care plan indicated the resident was on isolation precautions related to E. coli in the urine. On 7/31/25 at 11:49 a.m., the Director of Nursing (DON) provided a Nurse Practitioner (NP) progress note and indicated it was documentation the NP notified the resident's representative of the contact isolation precautions order. The NP progress note, dated 7/23/25, indicated, .This pt [patient]/family was made aware that this visit is being performed using remote telephonic technology. The note lacked documentation the resident's representative was notified of the contact isolation precautions order. The DON indicated she was not able to provide any additional documentation to support the resident's representative was notified of the order. On 7/31/25 at 11:57 a.m., the DON provided a document titled, Change in a Resident's Condition or Status, last revised in 2021, and indicated it was the policy currently being used by the facility. The policy indicated, .Our facility promptly notifies.the resident representative of changes in the resident's medical.condition and/or status.Policy Interpretation and Implementation.4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when.b. there is a significant change in the resident's physical.status.5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical.condition or status. 3.1-5(a)(3)

Based on record review and interview, the facility failed to ensure behavior monitoring was completed for 1 of 5 residents reviewed for unnecessary medications (Resident 22).Findings include:Resident 22's record was reviewed on 7/29/25 at 11:31 a.m. The profile indicated the resident's diagnoses included, but were not limited to, metabolic encephalopathy (a condition where the brain's function is impaired due to a metabolic or chemical imbalance in the body), Parkinson's disease (a progressive neurological disorder that affects movement), and hallucinations unspecified (when someone experiences something with their senses [see, hear, smell, taste, or feel] that isn't actually there). A quarterly Minimum Data Set (MDS) assessment, dated 4/19/25, indicated the resident had severe cognitive deficit, had no documented behaviors, and received hospice services. A care plan was observed that indicated the resident was at risk for hallucinations and delusions (a fixed, false belief that is not based on reality and is held with strong conviction, despite evidence to the contrary). Interventions included, but were not limited to, monitor for effectiveness of medications and interventions. A physician's order, dated 11/15/23, indicated to monitor for the behaviors of hallucinations and delusions every shift. Hospice nurse progress notes, dated 3/3/25 and 3/19/25, indicated the resident continued to have frequent hallucinations daily. The March 2025 Treatment Administration Record (TAR) lacked documentation of the resident having any behaviors for the entire month. Hospice nurse progress notes, dated 4/9/25 and 4/30/25, indicated the resident continued to have frequent hallucinations daily. The April 2025 TAR lacked documentation of the resident having any behaviors for the entire month. Hospice nurse progress notes, dated 5/2/25, 5/5/25, 5/7/25, and 5/14/25, indicated the resident continued to have frequent hallucinations daily. The May 2025 TAR lacked documentation of the resident having any behaviors for the entire month. Hospice nurse progress notes, dated, 6/4/25, 6/11/25, and 6/27.25, indicated the resident continued to have frequent hallucinations daily.The June 2025 TAR lacked documentation of the resident having behaviors on the dates documented by the hospice nurse. The TAR documented behaviors on day shifts of 6/17/25, 6/18/25, 6/23/25, and 6/24/25, and on the night shifts of 6/17/25, 6/22/25, 6/23/25, and 6/24/25. The dates lacked documentation of what interventions had been attempted for the behaviors. Hospice nurse progress notes, dated, 7/16/25, 7/18/25, 7/23/25, and 7/25/25, indicated the resident continued to have frequent hallucinations daily. The July 2025 TAR lacked documentation of the resident having any behaviors for the entire month. Review of the resident progress notes, dated March 2025 through July 2025, lacked documentation of any hallucinations by the facility nursing staff. Review of the facility's interdisciplinary team (a group of professionals from different fields who work together to achieve a common goal, typically by sharing their expertise and collaborating on a solution) progress notes, from July 2024 through July 2025, lacked documentation of any hallucination or delusions by the resident. During an interview, on 7/30/25 at 8:55 a.m., Licensed Practical Nurse (LPN 7) indicated all nurses were responsible to complete the behavior tracking on the TAR each shift. During an interview, on 7/30/25 at 9:46 a.m., Hospice Registered Nurse (RN) 8 indicated she had witnessed the resident having visual hallucinations on a few of her visits. She had reported the incidents to the nursing staff of the facility. She was not sure if the facility nurses documented the reported behaviors in the resident's medical record or not. During an interview, on 7/30/25 at 9:52 a.m., Hospice Aide 9 indicated she worked with the resident two days a week. She had observed the resident hallucinating at times. She would report the incidents to both her Hospice nurse and to the facility nurse. She was unsure what the facility did to follow up on the report. During an interview, on 7/30/25 at 9:55 a.m., Hospice Aide 10 indicated she also came to the facility two days a week to assist the resident with her bathing and other needs. She had observed the resident hallucinating and had reported to both her Hospice nurse and to the facility nurse. She was unsure what the facility did to follow up on the report. During an interview, on 7/30/25 at 10:10 a.m., Certified Nurse Aides (CNAs) 11 and 12 indicated the resident still hallucinated frequently. CNA 11 indicated she was not sure where she was to document behaviors in the medical record. CNA 12 indicated the nurses were responsible for documenting behaviors. Both CNAs indicated they would report any behaviors that were observed to the nurse. During an interview, on 7/30/25 at 10:50 a.m., the Director of Nursing (DON) indicated the CNAs were not responsible to document the behaviors they witness. They were to report the behaviors to the nurse who was responsible for documenting the behavior. On 7/30/25 at 10:37 a.m., the DON provided a document, dated 8/18/23, titled, Guidelines for Behavior Management Meetings Psychotropic Medication, and indicated it was the policy currently being used by the facility. The policy indicated, .Roles-Responsibilities.Nursing.2. Monitors for presence of target behaviors on daily basis and documenting same. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure staff immediately reported an abuse allegation to the Administrator for 1 of 1 reportable incidents reviewed (Resident 23). Findings include:On 7/29/25 at 11:30 a.m., a police officer answered a knock at the Administrator's office door and indicated the Administrator was not available because she went to find a resident. At the same time, the Director of Nursing (DON) indicated the police officer was at the facility because a reportable incident had occurred. During an interview, on 7/29/25 at 2:01 p.m., the Administrator indicated Resident 23 reported another resident touched her shoulder inappropriately while making a sexual advance towards her. The Administrator indicated the staff had not reported the incident to her immediately and instead left a note under the Social Services Director's (SSD) door. The resident reported the incident to the evening/night shift Qualified Medication Aide (QMA) who reported it to the evening/night shift nurse. The nurse left a note for the SSD but did not call the Administrator. Resident 23's record was reviewed on 7/30/25 at 11:30 a.m. An admission Minimum Data Set (MDS) assessment, dated 7/9/25, indicated the resident was cognitively intact and did not have behaviors during the assessment look-back period. A current care plan indicated the resident had experienced significant trauma throughout her life and was a trauma survivor. An incident investigation file included the following documents: An undated handwritten note indicated, I wasn't sure what to do about this. I'm working nights and wasn't sure if you would be here before I left. [Resident 23] told [QMA 13] about it. I guess [Resident 23] was very upset about it everything [male resident's name] is saying and him touching her. She is afraid to say anything to him to stop because she isn't sure how he will react. A behavior tracking tool, dated 7/28/25, indicated Resident 23 reported to a QMA that an identified male resident has been saying, she is the perfect height for her to do what he needs. The male resident has been massaging Resident 23's back. Resident 23 did not want him to do that, and she was scared to tell him to stop. A statement from Resident 23, taken by the Administrator, dated 7/29/25, indicated the resident stated the male resident was touching her and sometimes massaged her shoulder or between her shoulder blades. The resident indicated it started about two weeks ago, made her uncomfortable, but she was not scared of the male resident. She stated the resident had not said anything sexual to her. A statement from the male resident, dated 7/29/25, indicated he stated he did not mean anything by touching or rubbing Resident 23's shoulders. The resident stated some people liked that, but he would need to ask before doing that. A statement from Resident 23, taken by the SSD, dated 7/29/25, indicated the resident was asked if she felt like the male resident rubbing her shoulders felt like sexual abuse or if she felt like the resident was making a sexual advance towards her. Resident 23 indicated, Yes, because in the past others would do that and one thing would lead to another. During an interview, on 7/30/25 at 1:56 p.m., the Administrator indicated any abuse allegation should have been reported to her immediately. If she was not in the facility then the staff should have called her. The QMA should have called the Administrator and notified her of the allegation, instead of only reporting it to the nurse. On 7/28/25 at 2:00 p.m., the Administrator provided a document titled, Abuse Prevention Program, dated 10/22/22, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy.The following procedures shall be implemented when an employee or agent becomes aware of abuse.or of an allegation of suspected abuse.of a resident.Procedure.III. Reporting.Employees are required to report any incident, allegation, or suspicion of potential abuse, neglect or mistreatment they observe, hear about or suspect to the Administrator or an immediate supervisor who will immediately report the allegation to the Administrator. The Administrator is the Abuse Coordinator. 3.1-28(c)

Based on record review and interview, the facility failed to ensure a Minimum Data Set (MDS) assessment had been coded correctly for 1 of 19 resident MDS assessments reviewed (Resident 46). Findings include:Resident 46's record was reviewed on 7/31/25 at 2:23 p.m. The profile indicated the resident's diagnoses included, but were not limited to, hypertensive heart disease (a condition where high blood pressure over a long period damages the heart, leading to various heart problems) and congestive heart failure (when the heart does not pump blood efficiently as it should). The census indicated the resident began hospice services on 3/13/25. A care plan indicated the resident wished for hospice services. Interventions included, but were not limited to, hospice services as ordered. A quarterly MDS assessment, dated 6/17/25, indicated the resident received hospice services. The assessment lacked documentation of a terminal prognosis. During an interview, on 7/31/25 at 2:47 p.m., the MDS Coordinator indicated the resident's prognosis had been coded incorrectly. The standard was that the rules from the RAI (Resident Assessment Instrument) would be followed when documenting information about the resident on the MDS assessment. On 8/1/25 at 9:47 a.m., the Director of Nursing (DON) provided a copy of Section J of the Centers for Medicare and Medicaid Services (CMS) RAI Version 3.0 Manual, dated October 2024, and indicated it was the policy currently being used by the facility. The policy indicated, .J1400 Prognosis.Coding Instructions.Code 1, yes: if the medical record includes physician documentation: .2) the resident is receiving hospice services. 3.1-36(a)(6)

Based on interview and record review the facility failed to ensure residents were invited to attend quarterly care plan meetings for 2 of 3 residents reviewed for care plan meetings (Residents 19 and 8), and failed to ensure code status care plans were consistent with the resident's advanced directive for 1 of 19 residents' care plans reviewed (Resident 7). Findings include: 1. On [DATE] at 1:33 p.m., during an interview, Resident 19 indicated she had not attended a care plan meeting and had not been asked to attend one. On [DATE] at 11:35 a.m., during interview the Social Service Director (SSD) indicated she invited residents to attend care plan meetings and documented the meeting and if the resident attended the meeting. Attendance was included in the meeting documentation. On [DATE] at 10:35 a.m., the medical record of Resident 19 was reviewed. The resident was admitted to the facility on [DATE]. Admitting diagnosis included but not limited to, hypertension (high blood pressure) and dementia (the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities). A Minimum Data Set (MDS) assessment, dated [DATE], indicated that the resident had limited cognition. The record lacked documentation of quarterly care plan meeting or of the resident attending a quarterly care plan meeting on the following months, 3/2024, 9/2024, 12/2024 and 6/2025. A care plan note, dated [DATE], indicated that the resident attended a care plan meeting. 2. On [DATE] at 9:59 a.m., during an interview, Resident 8 indicated she did not remember attending a care plan meeting to discuss care needs and concerns. On [DATE] at 10:45 a.m., the medical record of Resident 8 was reviewed. The resident was admitted to the facility on [DATE]. Admitting diagnosis included, but was not limited to, diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high) and hypertension (high blood pressure). A Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident was cognitively intact. Review of the medical record indicated the record lacked documentation of a quarterly care plan meeting or of resident attending a quarterly care plan meeting on the following months: 7/2024, 10/2024, 1/2025, and 7/2025. Care plan meeting notes, dated [DATE] and [DATE], indicated the resident attended a care plan meeting. On [DATE] at 9:00 a.m., the Administrator provided a document titled, Baseline Care Plan Assessment/Comprehensive Care Plans, dated [DATE], and indicated it was the policy currently being used by the facility. The policy indicated, .6. The facility Social Services Director or designee will notify the resident of their scheduled Care Plan Conference and will invite and encourage the resident to attend. This notification will continue for any subsequent Care Plan Conferences. These notifications will be documented for reference.9. The Comprehensive Care Plans will be reviewed and updated every quarter at a minimum. 3. Resident 7's record was reviewed on [DATE] at 9:14 a.m. A quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident had severe cognitive impairment. A Physician's Orders for Scope of Treatment (POST) (a document that outlines a patient's preferences for treatment particularly at the end of life) form, dated [DATE], indicated the resident wanted cardiopulmonary resuscitation (CPR) to be performed if she was found in cardiac arrest. A care plan, initiated on [DATE], indicated POST form-full intervention including life support measures. A care plan, initiated on [DATE], indicated POST form-comfort measures, allow natural death. During an interview, on [DATE] at 10:26 a.m., the Director of Nursing (DON) indicated she was not sure why there were two conflicting care plans for the resident's POST form. The care plan should have been consistent with what the resident indicated in the POST form. On [DATE] at 10:39 a.m., the DON provided a document titled, Baseline Care Plan Assessment/Comprehensive Care Plans, last revised on [DATE], and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure.9. The Comprehensive Care Plans will be reviewed and updated every quarter at a minimum. The facility may need to review the care plans more often based on changes in the resident's condition and/or newly developed health/psycho-social issues. 3.1-35(a) 3.1-35(c)(2)

Based on record review and interview, the facility failed to ensure urinary tract infections (UTIs) were treated in a timely manner after receiving urinary culture results for 2 of 2 residents reviewed for UTI (Residents 3 and 7). Findings include: 1. Resident 3's record was reviewed on 7/29/25 at 11:27 a.m. An admission Minimum Data Set (MDS) assessment, dated 6/30/25, indicated the resident was cognitively intact. A nursing progress note, dated 7/3/25, indicated the resident's daughter was concerned about how much the resident was sleeping and noted increased confusion. A new physician's order for a urinalysis (UA) culture and sensitivity (C&S) was received. A nursing progress note, dated 7/6/25, indicated a urine sample was obtained from the resident and sent to the hospital for a UA C&S. A UA C&S indicated the report was finalized on 7/8/25. The report indicated a colony count greater than 100,000 proteus mirabilis (bacteria) The C&S did not include ciprofloxacin (antibiotic) as an antibiotic that was tested for efficacy against the bacteria. The C&S indicated the bacteria was susceptible to Bactrim double strength (DS) (antibiotic). A nursing progress note, dated 7/9/25, indicated the UA C&S results were received from the lab. The results were faxed to the physician. The note lacked documentation an antibiotic order was obtained at that time. A nurse practitioner (NP) progress note, dated 7/11/25, indicated the NP was at the facility and reviewed the UA C&S results. The NP gave an order for ciprofloxacin for five days for UTI. The note lacked documentation of why ciprofloxacin was ordered despite it not being included on the C&S. An NP order, dated 7/11/25, indicated ciprofloxacin 250 milligrams (mg), 1 tablet by mouth every 12 hours for 5 days, for UTI. A nursing progress note, dated 7/15/25, indicated the physician's office called and ordered Bactrim DS twice daily for five days for UTI and discontinued the ciprofloxacin after the dose that evening. A physician's order, dated 7/16/25, indicated Bactrim double strength (DS) (antibiotic) 800-160 mg, 1 tablet by mouth, twice daily for 5 days, for UTI. During an interview, on 7/30/25 at 1:24 p.m., the Director of Nursing (DON) indicated the UA C&S was faxed to the physician's office on 7/9/25, but the physician was on vacation. The NP came into the facility on 7/11/25 and ordered ciprofloxacin. The DON indicated she was not sure why the NP ordered an antibiotic that was not included on the C&S. The physician reviewed the UA C&S on 7/15/25, when he returned from vacation. The physician changed the antibiotic upon his review. It should have been followed up on before 7/15/25. 2. Resident 7's record was reviewed on 7/31/25 at 9:14 a.m. A quarterly Minimum Data Set (MDS) assessment, dated 7/6/25, indicated the resident had a severe cognitive impairment. A urinalysis (UA) culture and sensitivity (C&S) report indicated it was finalized on 7/16/25. The report indicated a colony count greater than 100,000 Escherichia coli (E. coli) (bacteria) in the urine. The C&S did not include Macrobid (antibiotic) as an antibiotic that was tested for efficacy against the bacteria. A nursing progress note, dated 7/18/25, indicated the C&S report was received and faxed to the physician. The note lacked documentation physician's orders were obtained related to the UA C&S at that time. A Medication Administration Record (MAR), dated July 2025, included the following physician's orders. A physician's order, dated 7/21/25 and discontinued on 7/22/25, indicated Macrobid 100 milligrams (mg) by mouth, twice daily for UTI, for 7 days. The MAR indicated the medication was administered on evening shift of 7/21/25. A physician's order, dated 7/22/25 and discontinued on 7/22/25, indicated Macrobid 100 mg by mouth, twice daily for UTI, for 7 days. The MAR indicated an administration was scheduled for day shift, on 7/22/25, but lacked documentation the medication was administered or refused. A physician's order, dated 7/22/25 and discontinued on 7/24/25, indicated Macrobid 100 milligrams (mg) by mouth, twice daily for UTI, for 7 days. The MAR indicated the medication was administered once on 7/22/25 and twice on 7/23/25. A physician's order, dated 7/23/25, indicated contact isolation precautions for E. coli in the urine, until 7/29/25. A physician's order, dated 7/24/25, indicated Macrobid 100 milligrams (mg) by mouth, twice daily for UTI, for 7 days. The MAR indicated the medication was administered once on 7/24/25, twice on 7/25/25, 7/26/25, 7/27/25, 7/28/25, 7/29/25, 7/30/35, and once on 7/31/25. The record lacked documentation the resident's UTI was treated prior to 7/21/25. Current care plans indicated the resident was on isolation precautions due to E.coli in the urine and received an antibiotic for a UTI. During an interview, on 7/31/25 at 10:26 a.m., the Director of Nursing (DON) indicated she was not able to find any additional information regarding the resident's antibiotic and why it was not ordered until 7/21/25. The physician should have been notified immediately of UA C&S results that required an antibiotic. If the physician ordered something that was not included on the C&S then the nurse should have told the physician the antibiotic was not included on the C&S to ensure it was the correct order. Although the physician may have wanted to continue the Macrobid as he ordered, the conversations should have been documented. On 7/30/25 at 1:48 p.m., the DON provided a document titled, Guidelines for Lab Scheduling/Tracking, dated 9/1/23, and indicated it was the policy currently being used by the facility. The policy indicated, .Intent: it is the policy of the facility to ensure that laboratory tests ordered by the physician are systematically scheduled and tracked so that ordered lab work is obtained and results are received and reported timely.Procedure.6. The Charge Nurse will monitor the scheduled labs daily to check to ensure that any collected lab results are received timely as well as to confirm that received results are reported to the physician.and that any orders received related to the lab results are carried out. Critical lab results will be reported to the physician upon receipt. On 7/30/25 at 2:16 p.m., the DON provided a document titled, Guidelines For Addressing/Managing Urinary Tract Infections-UTIs, last revised on 9/26/24, and indicated it was the policy currently being used by the facility. The policy indicated, .What are some complications that can present related to UTIs? When treated promptly and appropriately, lower urinary tract infections rarely lead to complications. However, left untreated, UTIs can cause multiple serious health problems.Additional Information: It is imperative that staff be made aware of signs/symptoms of UTIs so that UTIs can be identified and addressed and treatment for resolution be implemented immediately. 3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to ensure proper storage of respiratory equipment for 2 of 3 reviewed for respiratory care (Residents 51 & 46). Findings include:1. On 7/28/25 at 11:28 a.m., Resident 51's unbagged nebulizer mask was observed on top of a blanket and other linens on the resident's chair next to her bed. The nebulizer machine was sitting on the chair cushion. On 7/28/25 at 1:15 p.m., Resident 51's unbagged nebulizer mask was observed on top of a blanket and other linens on the resident's chair next to her bed. There was also a metal lid next to the nebulizer mask from the resident's lunch tray. On 7/29/25 at 9:30 a.m., Resident 51's unbagged nebulizer mask was observed on top of a blanket and other linens on the resident's chair next to her bed. On 7/30/25 at 10:10 a.m., Resident 51's unbagged nebulizer mask was observed sitting on top of the chair cushion next to her bed. The medication chamber was detached from the mask and was in contact with the floor. During an interview, on 7/30/25 at 10:16 a.m., Resident 51 indicated she received breathing treatment several times a day. She indicated that staff would prepare the breathing treatment for her and would turn off the machine when it was completed; she had noticed that staff don't always place the nebulizer mask in a bag after the treatment was completed. Resident 51's record was reviewed on 7/30/25 at 11:42 a.m. The profile indicated the resident diagnoses, included, but were not limited to, chronic obstructive pulmonary disease (COPD- a group of disease that cause airflow blockage and breathing-related problems), and chronic respiratory failure with hypoxia (chronic impairment of gas exchange between the lungs and the blood causing hypoxia [inadequate supply of oxygen]). A quarterly Minimum Data Set (MDS) assessment, dated 6/30/25, indicated the resident was cognitively intact and received oxygen therapy. A care plan, dated 4/8/25, indicated the resident displayed complications with gas exchange due to chronic respiratory failure and received oxygen. Interventions included but were not limited to, monitor that nasal cannula and or mask is properly positioned, elevate head of bed to facilitate breathing, and notify MD (medical doctor) of any changes. A physician order, dated 4/24/25, indicated albuterol sulfate nebulization solution (a medication that can help people with lung problems, like asthma or obstructive pulmonary disease, breathe easier); 1.25mg (milligrams)/3ml (milliliters). One vial orally via nebulizer 4 times a day. During an interview, on 7/31/25 at 1:37 p.m., Licensed Practical Nurse (LPN) 17 indicated after the resident had completed their nebulizer treatment, the nurse was to rinse out the nebulizer equipment and then place it in a plastic bag for storage while not in use. 2. During the initial pool observation, on 7/28/25 at 10:52 a.m., Resident 46's nebulizer (a device that converts liquid medicine into a fine mist, allowing it to be inhaled directly into the lungs) mask was observed unbagged and sitting on her bedside table. At the same time, the resident indicated she had not had a nebulizer treatment on this date. Her last treatment was the day prior. During a random observation, on 7/30/25 at 10:35 a.m., the resident's nebulizer mask was observed unbagged and sitting on her bedside table. During a random observation, on 7/30/25 at 2:41 p.m., the resident's nebulizer mask was observed unbagged and sitting on her bedside table. During a random observation, on 7/31/25 at 09:04 a.m., the resident's nebulizer mask was observed unbagged and sitting on her bedside table. Resident 46's record was reviewed on 7/31/25 at 2:23 p.m. The profile indicated the resident's diagnoses included, but were not limited to, congestive heart failure (when the heart isn't pumping blood as efficiently as it should). A quarterly Minimum Data Set (MDS) assessment, dated 6/17/25, indicated the resident had no cognitive deficit and received respiratory therapy treatments. A care plan indicated the resident was at risk of experiencing wheezing. The care plan lacked documentation of any medication orders or procedure for treatment. A physician's order, dated 5/6/25, indicated to administer one vial of albuterol sulfate nebulization solution (used to relax the muscles around the airways in the lungs, making it easier to breathe) 2.5 milligrams (mg) per 3 milliliters (ml) every 24 hours as needed for shortness of breath. The July 2025 Medication Administration Record (MAR) indicated the resident had received nebulizer treatments on 7/5/25, 7/7/25, and 7/31/25. During an interview, on 7/31/25 at 11:17 a.m., Licensed Practical Nurse (LPN) 7 indicated nebulizer equipment should be cleaned and then placed into a dated bag when not in use. During an interview, on 7/31/25 at 11:20 a.m., the Director of Nursing (DON) indicated the nebulizer masks should be placed in a bag when not in use. On 7/31/25 at 12:11 p.m., the DON provided an undated document, titled, Aerosolized Medication Therapy, and indicated it was the policy currently used by the facility. The policy indicated, .Procedure.16. When finished, place the nebulizer in a labeled bag with patient name and date. 3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure safety procedures were followed during a bed bath resulting in actual harm when a resident rolled out of bed and sustained a fracture to the shoulder (Resident B) and to ensure a resident was transferred safely resulting in actual harm when a resident sustained a laceration which required staples to repair (Resident C) for 2 of 3 residents reviewed for accidents. Findings include: 1. Resident B's record was reviewed on 6/29/22 at 10:15 a.m. A quarterly Minimum Data Set (MDS) assessment, dated 4/27/22, indicated the resident had a severe cognitive impairment and required extensive assistance of two staff members for bed mobility. Diagnoses on the resident's profile included but were not limited to morbid (severe) obesity due to excess calories and displaced (a gap where a bone has broken) fracture of greater tuberosity (bump at the top of the bone) of left humerus (the bone in the arm between the shoulder and elbow) initial encounter for closed (not broken through the skin) fracture. A physician's order, dated 10/19/21, indicated hospice (care for the terminally ill) services. A physician's order, dated 12/1/21, indicated low air loss mattress, set at 3 to 6 per resident comfort, do not leave on static mode (constant pressure redistribution and support used when care is performed). A training record, dated 12/14/21, indicated facility staff received training regarding low air loss mattresses. Training included, but was not limited to, may use static mode for changing a bed or incontinence care but never leave the mattress in static mode. A care plan, initiated 12/31/21, indicated it was normal for the resident to roll out of bed and onto the mat on the floor. The resident was in a high/low bed for safety. Interventions included, but were not limited to, complete an occurrence report if any injury was noted and document on the treatment record the date and time of any roll out. A physician's order, dated 1/30/22, indicated it was normal for the resident to roll out of the low bed onto the mat on the floor, document date and time of any roll out, perform head to toe assessment, and complete initial occurrence report on the computer and on paper if any injuries. An initial occurrence assessment, dated 5/14/22 at 10:30 a.m., indicated the resident had a fall with injury. The resident was in bed receiving a bed bath, being assisted by one Certified Nursing Assistant (CNA) with the bed in the high position. The resident was turned onto her right side, facing the window, and the CNA washed her back. Resident indicated there was a penny on the floor, and the CNA instructed the resident not to reach for it. The resident reached over the side of the bed, attempted to pick up the penny, and rolled out onto the floor mats next to the bed. CNA attempted to stop her, but her hand slid down the resident's back as she rolled. The resident complained of left arm and shoulder pain and there was soft tissue swelling. The physician was notified and ordered an x-ray of the left shoulder. The intervention was to ensure resident was assisted by two staff members when the bed was in the high position during bathing, peri care, turning and repositioning, or any care involving bed mobility. An x-ray report, dated 5/14/22, indicated the resident had a fracture at the anatomical neck of the left humerus with involvement of the greater tuberosity and soft tissue swelling. A nursing note, dated 5/14/22, indicated the resident received a bed bath from the CNA as per the assignment. The nurse was notified assistance was needed. Upon entrance, the resident was receiving a bed bath and was supine (laying on back) in bed. The resident complained of pain at a 10 on the numeric pain scale. The resident was assessed, pain medication was administered, the physician was notified, and an x-ray was ordered. A care plan, initiated 5/14/22, indicated the resident was at risk for complications related healing from my left humerus fracture. Interventions included but were not limited to administer sling to left arm as ordered. A follow up occurrence, dated 5/15/22, indicated there was a new order for sling to be placed when available. A physician's order, dated 5/15/22, and discontinued the same date, indicated sling to left arm when available, every shift, for fractured left humerus. A follow up occurrence report, dated 5/17/22, indicated the fractured left shoulder was in a sling and elevated on one pillow. A treatment administration record (TAR), dated May and June 2022, lacked documentation the sling to the left arm was applied, or the resident had any occurrences of rolling out of bed. During an interview, on 6/29/22 at 1:22 p.m., Licensed Practical Nurse (LPN) 8 indicated the resident was dependent on staff for care. The bed was raised up at the time of the incident because staff was providing care. She was not sure if two staff members were required to provide care when the fall occurred, but when she was working, she wanted there to be two staff members during care because of the low air loss mattress. During an interview on 6/29/22 at 1:26 p.m., CNA 4 indicated the resident was dependent on staff for care and bed mobility. When care was provided in bed it took two staff members. She thought that was always the requirement, not just after the fall. She worked the day the fall occurred but was not the CNA in the room at the time. CNA 7 came into another resident's room and notified CNA 4 that Resident B had fallen on 5/14/22. CNA 4 was providing care to the other resident. CNA 4 indicated she wondered why CNA 7 had not gotten her to help with the bed bath because they normally used two people to assist Resident B. At the same time, CNA 4 provided her assignment sheet, which indicated use two people with turning. CNA 4 indicated the assignment sheet included that information at the time of the fall. The resident had a history of rolling out of bed, but it had not happened when staff was in the room before. During an interview, on 6/29/22 at 1:50 p.m., CNA 4 indicated the settings on the low air loss mattress could be adjusted if the resident was having a hard time rolling over, but they did not have to adjust the settings or set it to static mode. Resident B had not normally needed the settings adjusted when care was provided. During an interview on 6/29/22 at 1:56 p.m., CNA 7 indicated she was the CNA providing care when the incident occurred on 5/14/22. The resident was on a low air loss mattress, dependent for care, and could sometimes roll over. Care was normally provided in bed with the resident rolling over. The resident rolled over and saw a penny on the floor. CNA 7 told the resident not to reach for it, but she reached for it anyway, and rolled out of bed. CNA 7 grabbed for the resident's hip, but her hand slipped. The bed was raised up to CNA 7's waist. She had provided care to Resident B by herself a lot of times and did not think two staff members were required. She was unable to remember what the assignment sheet said at that time. They were not required to adjust the low air loss mattress during care unless they needed to. They could put it on static mode for increased firmness if needed, but Resident B had not normally required adjustments, and the mattress was not on static mode at the time of the incident. She had not been told static mode was a requirement, just it could be used if needed. The resident complained of pain when she rolled out of bed. The unit manager was notified, assessed the resident, and they used the Hoyer (mechanical) lift to get her back into bed. During an interview, on 6/30/22 at 9:40 a.m., the Director of Nursing (DON) indicated the resident had not required two staff members for turning and repositioning for bed baths prior to the incident on 5/14/22. She had a history of rolling out of bed, but not when staff were present. The resident did not require a bariatric (wide) bed. They put an intervention in place for there to be two staff members to provide care after the incident. They instructed employees at the in-service, on 12/14/21, that static mode could be used if residents using a low air loss mattress had trouble turning or moving, but it was not required. During an interview, on 6/30/22 at 10:28 a.m., the DON indicated the resident received the sling, but she was not sure when. The resident removed the sling frequently. Normally, there would have been an order to check placement of the sling every shift. During an interview, on 6/28/22 at 11:03 a.m., the DON indicated the sling was ordered and discontinued the same day, 5/15/22, because the resident would not leave it on. She was unable to find any documentation of this. On 6/29/22 at 2:42 p.m., the Administrator provided a document titled, .Specialty Mattress Use, and indicated it was the policy currently being used by the facility. The policy indicated, .1. Protocol for using Low Air Loss/Therapeutic Support Mattress: A. If indicated by clinical team to utilize specialty mattress, the facility will complete the following process prior to implementation of the mattress: .VIII. Follow manufacturer's recommendations for settings; static mode, comfort settings On 6/30/22 at 9:50 a.m., the DON provided a document titled, Ultra-Care Series User Manual, and indicated it was the manufacturer's guidance for the low air loss mattress currently being used by the facility. The guidance indicated, .OPERATION .For patients: .A firm surface will make it easier for the patient to transfer or reposition. Make use of the static mode function .Step 4: The static or low air loss mode provides a stable surface that makes it easier for the patient to transfer or reposition 2. Resident C's record was reviewed on 6/29/22 at 10:24 a.m. The profile indicated the resident's diagnoses included, but were not limited to, [CONDITION(S)] ([CONDITION(S)]) (a condition involving [MEDICATION(S)] of the airways and difficulty or discomfort in breathing), muscle weakness, and unsteadiness on her feet. A quarterly Minimum Data Set (MDS) assessment, dated 3/11/22, indicated the resident had moderate cognitive deficit and required extensive assist of 2 with transfers. An annual MDS assessment, dated 6/11/22, indicated the resident had severe cognitive deficit and required extensive assist of 2 with transfers. A care plan, dated 9/18/21, indicated the resident had a loss in her activities of daily living (ADLs) (a person's ability to perform daily self-care activities) and required extensive assist with transfers. An Indiana Department of Health (IDOH) reportable incident document, dated 6/7/22, indicated the resident had been transferring from her wheelchair to her bed and hit her right lower leg on the bed which resulted in a 6 centimeter (cm) laceration (a deep cut or tear in skin or flesh) to right lower leg. The wound was cleaned, and a dressing was applied. In the morning, the resident had been transferred to the emergency room (ER) and received 10 staples to close the wound area. The document indicated the physician, Administrator, and the resident's family had been notified. A Nursing-Occurrence Initial Assessment, dated 6/7/22 at 7:30 p.m., indicated the incident occurred in the resident's room as she was transferring from her wheelchair to her bed. A head-to-toe assessment was completed, and the resident was sent to the ER. The initial intervention put into place was to remove the siderails on the resident's bed. A physician's order, dated 6/8/22, indicated to monitor the staples to the right lower leg that surrounding skin was intact with no signs or symptoms infection and/or pain/discomfort until healed. Every day and night shift for 10 days. Staples can be removed on 6/18/22. A physician's order, dated 6/10/22 with a start date of 6/11/22, indicated keep site to outer right lower leg clean. Use soap and water daily to clean site and apply a thin layer of [MEDICATION(S)] ointment (topical antibiotic ointment) daily. Cover with [MEDICATION(S)] One (one-sided, soft silicone wound contact layer) and wrap with Kerlix (white gauze dressing) until healed, one time daily for 10 days. A progress note, dated 6/7/22 at 7:30 p.m., indicated a Certified Nursing Assistant (CNA) was transferring the resident to bed. The resident's right lower leg hit the side rail and the resident received an approximate 6 cm laceration to right lateral (of at or toward the right side) compartment (a grouping of muscles, nerves, and blood vessels in your arms and legs). [MEDICATION(S)] One and Kerlix applied to laceration due to bleeding. Family and physician notified. An undated CNA assignment sheet indicated the resident was a skin risk and a fall risk. The document indicated 1 assist up to extensive assist of 2 but lacked clarification documentation for the activities where the additional assist was needed. During an interview, on 6/29/22 at 1:19 p.m., CNA 4 indicated she was aware of the incident, but was not working at the time of the incident. The CNA assignment sheet indicated the resident was 1 extensive assist to extensive of 2. A gait belt (a device put on a resident who has mobility issues, by a caregiver prior to that caregiver moving the resident) was supposed to be used when transferring the resident. She was able to transfer the resident by herself, when using the gait belt. During an interview, on 6/29/22 at 1:32 p.m., CNA 5 indicated she transferred the resident by herself using a pivot disc (a device used to assist transfers of an individual with limited or no ability to pivot). She felt the resident was strong enough to be transferred this way. She was aware of the incident but was not working when the incident happened. During a telephone interview, on 6/29/22 at 2:32 p.m., CNA 6 indicated she was the staff who transferred the resident at the time of the incident. She transferred the resident by herself. She did not use a gait belt, rather just used a bear hug, to lift, support, and transfer the resident. The resident hit her shin on the portion of the side rail of the bed that protruded down from the bed frame, as the rails were down during the transfer. She had been trained to transfer the resident with just one person. During an interview, on 6/30/22 at 9:42 a.m., the Director of Nursing (DON) indicated the area of the bed that the resident had hit her leg on was a portion of the bedrail that had an area where a call-light could be placed. After the incident, the interdisciplinary team (IDT) elected to just replace her entire bed. On 6/30/22 at 10:02 a.m., the Administrator (ADM) provided physical therapy (PT) notes. The notes indicated the resident had been seen by PT from 2/22/22 to 5/6/22. The goal of the therapy was to get the resident able to perform a sit to stand to her bed from a chair with stand by assist (assistance for residents who can physically function on their own, but may not be safe without someone around to help in case of an emergency) and using the transfer disc. The document indicated the resident did not meet this goal due to she had ceased to progress with her therapy. The discharge plan and instructions indicated to discharge back to the skilled nursing facility (SNF) with assistance from caregivers but lacked documentation of the amount of assistance required. On 6/29/22 at 1:26 p.m., the ADM provided a document, dated 3/18/22, titled, Transfer from Chair to Bed, and indicated it was the policy currently being used by the facility. The policy indicated, .B. Procedure: .3. Obtain additional assistance as necessary .8. If the resident cannot stand alone, apply the gait belt, grasp sides and assist resident to standing position, pivot turn, and sit resident on edge of bed This Federal tag relates to Complaint IN 202. 3.1-45(a)(1) 3.1-45(a)(2)