Every finding on record at Altenheim Health & Living Community

Based on interview and record review, the facility failed to ensure a resident diagnosed with bipolar disorder received mental health services to attain the highest practicable mental and psychosocial well-being for 1 of 3 residents reviewed for behavioral health services. (Resident B) Findings include:During an interview, on [DATE] at 8:47 a.m. Resident B indicated she thought she had refused a medication for insomnia and had been sent to the hospital because she didn't care if she died.The clinical record for Resident B was reviewed, on [DATE] at 9:03 a.m. Diagnoses included, but were not limited to, bipolar disorder, morbid obesity, and diabetes.A quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident B was not cognitively impaired.The physician's orders indicated:- Started, on [DATE] and discontinued, on [DATE], indicated administer trazodone (antidepressant used to treat insomnia) 50 milligrams (mg) tablet orally once daily at bedtime for insomnia.The Medication Administration Record (MAR), dated [DATE] at 12:00 a.m., through [DATE] at 11:59 p.m., indicated Resident B had refused to take trazodone 50mg tablet, on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. A behavioral health note, dated [DATE], indicated Resident B presented to the emergency department for passive suicidal ideations. Resident B had several stressors in her life and had felt more emotional that day. Resident B reported inconsistencies with her antidepressant medication.A progress note, dated [DATE] at 2:17 p.m., indicated late entry from early February. Resident B had declined to take trazodone 50mg which had been discussed in her care plan meeting, on [DATE]. During an interview, on [DATE] at 11:20 a.m., the Social Service Director (SSD) indicated he was not aware of the details of Resident B refusing to take trazodone 50mg.During an interview, on [DATE] at 1:10 p.m., the Social Service Assistant indicated she was not aware Resident B had refused trazodone 50mg. The Social Service Assistant hadn't been made aware that Resident B had been prescribed trazodone 50mg. Normally any medication refusals are discussed in the clinical meetings, but Resident B's refusal of trazodone had not been discussed that she was aware of. The Social Service Assistant should have been made aware of the refusals. The clinical record for Resident B lacked documentation that the physician had been notified that Resident B had been refusing to take trazodone until [DATE] when trazodone was discontinued.On [DATE] at 2:17 p.m., the Director of Nursing provided a copy of a facility policy, titled Charting and Documentation, dated 4/2008, and indicated this was the current policy used by the facility. A review of the policy indicated all services performed and changes in condition must be recorded to ensure consistency between family, physicians, and social services. This Federal citation relates to Intake 2747635 410 IAC 16.2-3.1-37(a)

Based on interview and record review, the facility failed to ensure documentation on the Medication Administration Record was complete and accurate for 1 of 3 residents reviewed for documentation. (Resident B) Findings include:The clinical record for Resident B was reviewed, on 3/24/26 at 9:03 a.m. Diagnoses included, but were not limited to, bipolar disorder, morbid obesity, and diabetes.The physician's orders indicated:- Started on 9/12/25, administer amlodipine 10 milligrams (mg) tablet orally once daily for hypertension. There was no discontinue date noted.- Started, on 9/12/25, and discontinued, on 3/9/26, administer aspirin 81mg tablet orally once daily for heart failure.- Started, on 1/6/26, administer buspirone 15mg tablet orally three times daily for anxiety. There was no discontinue date noted.- Started, on 2/3/26, administer cholecalciferol 125 microgram (mcg) tablet once daily for vitamin D deficiency. There was no stop date noted.- Started, on 2/3/26, and discontinued, on 3/2/26, administer divalproex 250mg orally twice daily for bipolar disorder.- Started, on 9/12/25, administer metoprolol succinate 50mg orally once daily for hypertension. There was no stop date noted.- Started, on 9/15/25, administer polyethylene glycol 3350 powder; 17 gram with 240 milliliters (ml) of water once daily for constipation. There was no stop date noted.The MAR, dated 2/1/26 at 12:00 a.m., until 2/28/26 at 11:59 p.m., lacked documentation as follows:- amlodipine 10 milligrams (mg) tablet orally once daily for hypertension was left blank, on 2/12/26 on morning shift and 2/19/26 on morning shift.- aspirin 81mg tablet orally once daily for heart failure was left blank, on 2/12/26 on morning shift and 2/19/26 on morning shift.- buspirone 15mg tablet orally three times daily for anxiety was left blank, on 2/12/26 at 12:00 p.m.- divalproex 250mg orally twice daily for bipolar disorder was left blank, on 2/12/26 on morning shift and 2/19/26 on morning shift.- metoprolol succinate 50mg orally once daily for hypertension was left blank, on 2/12/26 on morning shift and 2/19/26 on morning shift.- polyethylene glycol 3350 powder; 17 gram with 240 milliliters (ml) of water once daily for constipation was left blank, on 2/12/26 on morning shift and 2/19/26 on morning shift.During an interview, on 3/24/26 at 2:00 p.m. Licensed Practical Nurse (LPN) 1 indicated the documentation should have been completed on the MAR.On 3/24/26 at 2:17 p.m., the Director of Nursing provided a copy of a facility policy, titled Charting and Documentation, dated 4/2008, and indicated this was the current policy used by the facility. A review of the policy indicated documentation medication administration must be documented. This Federal citation relates to complaint 2747635410 IAC 16.2-3.1-50(a)

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assured the accurate receiving and dispensing of drugs) to meet the needs of residents for 2 of 3 residents reviewed for pharmacy services (Resident B and Resident C).Findings include:During an interview on 7/29/25 at 11:45 a.m., the Director of Nursing (DON) indicated Resident B was erroneously discharged home with Resident C's Novalog (insulin) pen and the nurse should have verified the name on the medication. During an interview on 7/29/25 at 2:48 p.m., LPN 1 indicated she was the nurse who discharged the Resident B home. She removed the insulin pens which were labeled with the resident's identification sticker on the outside of the bag, and she did not check the labels on the medication itself. She indicated she should have checked inside of the bags for the labels on the actual insulin pens. On 7/29/25 at 12:13 p.m., Resident B's clinical record was reviewed. The diagnoses included, but were not limited to diabetes mellitus and dependence on renal dialysis.A 7/7/25 order indicated the resident was prescribed 5 units of Novolog via FlexPen 3 times a day, and 20 units of Lantus via insulin pen once a day.During an interview on 7/30/25 at 12:23 p.m., the DON indicated she did not know if the medication came packaged incorrectly from the pharmacy or if a staff member placed the insulin pen in the incorrect bag. On 7/30/25 at 12:45 p.m., the DON provided the facility policy, Discharge Planning, dated 6/4/19, and indicated it was the policy currently being used. A review of the policy did not indicate the need for staff to confirm medication labels when residents' received discharge medications for home. This deficient practice was corrected on 7/14/25 after the facility implemented a systemic plan of correction that included the following actions: staff was educated on ensuring residents who discharged with insulin had the correct medications, with ongoing monitoring and audits.This citation relates to Complaint 2562216.3.1-25(p)

Based on observation, interview, and record review, the facility failed ensure self-medication administration assessments were completed for 2 of 2 residents observed with medications left at the bedside. (Resident 52 and Resident 60) Findings include: 1. During an observation on 6/10/25 at 12:06 p.m., Resident 52 was observed in her room while sitting in her wheelchair next to the bedside table. On top of the bedside table was a small clear plastic medicine cup which held three large white tablets with S9 imprinted on the tablets. No staff were visible in the area at that time. During an interview at that time, Resident 52 indicated the tablets were her binder pills that she takes prior to eating her meals. Resident 52 indicated staff provided the medication to her a little while ago so she could self-administer the medication just before eating her lunch. During an observation on 6/10/25 at 12:45 p.m., Resident 52 was observed in her room while sitting in her wheelchair and visiting with her visitor. No staff were visible in the area at that time. On top of the bedside table was a small clear plastic medicine cup while held three large white tablets with S9 imprinted on the tablets. On 6/10/25 at 12:52 p.m., Resident 52's clinical record was reviewed. The diagnoses included, but were not limited to, end stage renal disease (ESRD), diabetes, and dependence on renal dialysis. The Physician Orders included, but was not limited to: - Sevelamer carbonate tablet, 800 milligrams (mg), take three tablets with meals three times per day, initiated 2/11/25. The Quarterly Minimum Data Set (MDS) assessment, dated 5/23/25, indicated Resident 52 was cognitively intact, diagnoses included end stage renal disease, diabetes, and was dependent on renal dialysis. Resident 52's clinical record lacked a self-medication administration assessment prior to permitting the resident to administer her own medications. During an observation with Licensed Practical Nurse (LPN) 3 on 6/11/25 at 2:30 p.m., the A Hall medication cart was observed. Inside the medication cart, multiple sevelamer carbonate tablets (a binder medication used to control high blood phosphate levels in patients with chronic kidney disease, especially important for those on dialysis), were observed to have S9 imprinted on the tablet. During an interview at that time, LPN 3 indicated Resident 52 was prescribed sevelamer carbonate tablets as a binder medication and she was unsure why the tablets had been left at Resident 52's bedside on 6/10/25. During an interview on 6/11/25 at 2:45 p.m., the Director of Nursing (DON) indicated staff should not have left any medication at Resident 52's bedside. Resident 52's clinical record lacked a completed self-administration medication assessment. 2. During an observation on 6/10/25 at 12:32 p.m., Resident 60 was observed resting in bed with the over-the-bed table next to her bed. On top of the over-the-bed table was a small clear plastic medicine cup which held one large white tablet with no visible identifying information on the tablet. No staff were visible in the area at that time. During an interview at that time, Resident 60 indicated the tablet was her binder pill that she takes prior to eating her meals. Resident 60 indicated staff provided the medication to her a short time ago so she could self-administer the medication just before eating her lunch. On 6/10/25 at 1:48 p.m., Resident 60's clinical record was reviewed. The diagnoses included, but were not limited to, end stage renal disease (ESRD), diabetes, and dependence on renal dialysis. The Physician Orders included, but were not limited to: - Sevelamer carbonate tablet, 800 milligrams (mg), take one tablet with meals three times per day, initiated 1/14/25. The Quarterly Minimum Data Set (MDS) assessment, dated 5/2/25, indicated Resident 60 was cognitively intact, diagnoses included, end stage renal disease, diabetes, and was dependent on renal dialysis. Resident 60's clinical record lacked a completed self-medication administration assessment prior to permitting the resident to administer her own medications. During an observation with Licensed Practical Nurse (LPN) 3 on 6/11/25 at 2:30 p.m., the A Hall medication cart was observed. Inside the medication cart, Resident 60's sevelamer carbonate tablets (a binder medication used to control high blood phosphate levels in patients with chronic kidney disease, especially important for those on dialysis), were observed. During an interview at that time, LPN 3 indicated Resident 60 was prescribed sevelamer carbonate tablets as a binder medication and she was unsure why the tablet had been left at Resident 60's bedside on 6/10/25. During an interview on 6/11/25 at 2:50 p.m., the Director of Nursing (DON) indicated staff should not have left any medication at Resident 60's bedside. Resident 60's clinical record lacked a completed self-medication administration assessment. On 6/12/25 at 8:55 a.m., the DON provided an undated copy of the Bedside medication and self-administration of medications policy and indicated it was the current policy in use by the facility. A review of the policy indicated, .each resident who desires to self-administer medication will be permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility . On 6/12/25 at 8:55 a.m., the DON provided an undated copy of the Medication Administration: General Policies & Procedures policy and indicated it was the current policy in use by the facility. A review of the document indicated, .only licensed medical and nursing personnel are allowed to prepare, administer and document medications on the medical record .Residents are not allowed to self-administer any medication unless specifically authorized to do so by the interdisciplinary team (IDT) and the attending physician . 3.1-11(a)

Based on observation, interview, and record review, the facility failed to implement infection control practices for 1 of 4 residents observed with an indwelling urinary catheter. The urinary catheter drainage bag was on the floor. (Resident 121) Finding includes: On 6/10/25 at 8:57 a.m., Resident 121 was observed to be in bed with a staff member assisting Resident with the morning meal. Resident 121's urinary catheter drainage bag was observed to be lying on the floor next to the bed. On 6/10/25 at 9:22 a.m., Resident 121's urinary catheter drainage bag was observed to be lying on the floor. On 6/10/25 at 10:30 a.m., Resident 121's urinary catheter drainage bag was observed to be lying on the floor. During an interview on 6/10/25 at 10:35 a.m., the Director of Nursing indicated that the urinary catheter drainage bag should not be lying on the floor. On 6/10/25 at 1:02 p.m., the Director of Nursing (DON) provided the facility policy, Catheter Care, Urinary, with a revision date of December 2007, and indicated it was the policy currently being used by the facility. A review of the policy indicated, General Guidelines, .10. Be sure the catheter tubing and drainage bag are kept off the floor . 3.1-18(b)(1)

Based on observation, interview, and record review, the facility failed to ensure prescription injectable medication was secured for 1 of 1 random observations. (Resident B) Findings include: On 2/24/25 at 8:16 a.m., two sealed enoxaparin sodium (prescription blood thinner injection) 30 milligrams (mg) per 0.3 milliliter (ml) injections were observed lying on a shelf in Resident B's closet. During an interview on 2/24/25 at 8:27 a.m., LPN 1 indicated the enoxaparin 30 mg/0.3 ml injections should have been locked in the medication cart and not left in Resident B's closet. On 2/24/25 at 11:48 a.m., the Director of Nursing (DON) provided a copy of an undated facility policy, titled Drug Storage, and indicated this was the current policy used by the facility. A review of the policy indicated medications are stored in a medication cart or other secured area. This citation relates to Complaint IN00453284. 3.1-25(m)

Based on interview and record review, the facility failed to provide care and services for a resident admitted with a pressure ulcer for 1 of 3 residents reviewed for pressure ulcers. Treatments were not completed as ordered and care plans were not developed. (Resident B) Findings include: During an interview on 10/10/24 at 10:14 a.m., Licensed Practical Nurse (LPN) 1 indicated she would have checked the physician's orders for treatment orders, special repositioning instructions, and medications for wound care. If a wound treatment was not signed off as completed on the electronic medical record (EMR), then the wound treatment was not completed. The clinical record for Resident B was reviewed on 10/10/24 at 1:28 p.m. The diagnoses included, but were not limited to, physical debility, diabetes, and malnutrition. An Admission Minimum Data Set (MDS) assessment, dated 8/22/24, indicated Resident B was admitted with one unhealed stage 1 pressure ulcer (a reddened area of skin that does not change color when palpated). Hospital discharge orders, dated 8/16/24, indicated apply barrier cream to the deep tissue injury (a pressure ulcer that cannot be staged because the depth and damage under the skin cannot be evaluated) along the sacral region and reposition every two hours. A Weekly Skin Assessment, dated 8/16/24, indicated Resident B had a pressure wound to the tailbone area that measured 1.3 cm (centimeters) by 2.4 cm with the letter P drawn over the tailbone area of the picture to indicate pressure as instructed on the form. A physician's order started on 8/26/24, indicated cleanse sacral wound with wound cleanser, pat dry, apply medihoney (ointment applied to wound base to improve healing), cover with foam dressing, change every day and as needed. The dressing was to be completed on day shift. The Medication Administration Record (MAR), dated 8/26/24 through 9/9/24, indicated Resident B's sacral wound treatment was not completed on 8 of 14 days as follows: - 8/26/24, not administered due to new order. - 8/27/24, not administered due to Resident B was unavailable. - 8/28/24, not administered due to Resident B was up in chair all shift. - 8/29/24, not administered due to Resident B was unavailable. - 9/2/24, blank. - 9/4/24, not administered due to previous shift. - 9/5/24, not administered due to first shift. - 9/6/24, blank. During an interview on 10/10/24 at 1:40 p.m., the Regional Nurse indicated the sacral wound should have been measured at least weekly and the sacral dressings should have been completed as ordered by the physician. The clinical record for Resident B lacked a care plan for a sacral pressure wound. The clinical record for Resident B lacked a physician's order to turn Resident B side to side starting, on 8/16/24. On 10/11/24 at 10:30 a.m., the Regional Nurse provided a copy of a facility policy, titled Wound Management Policy, dated 2/1/19, and indicated this was the current policy used by the facility. A review of the policy indicated the wound team would observe pressure areas to provide oversight of the care plan interventions and to ensure the resident's condition was accurately assessed in a timely manner. The Interdisciplinary Team would document the wound assessment weekly in the medical record. This Federal Tag relates to Complaints IN00444835 and IN00443767. 3.1-40(a)(2)

Based on interview and record review, the facility failed to ensure care and services for residents with dialysis were provided for 3 of 4 residents reviewed for dialysis services. Daily weights as ordered by the physician, related to the resident's dialysis services, were not obtained and monitored. (Resident 54, Resident 59, Resident 67) Findings include: 1. On 7/9/24 at 2:41 p.m., Resident 54's clinical record was reviewed. The diagnoses included, but were not limited to, dependence on renal dialysis (process by which dissolved substances are removed from an individual's body by diffusion from one fluid compartment to another across a semipermeable membrane) and stage 5 chronic kidney disease (also known as end-stage kidney disease where the kidneys are severely damaged and can no longer perform their functions). The Annual Minimum Data Set (MDS) assessment, dated 5/24/24, indicated Resident 54 was cognitively intact and renal failure, End Stage Renal Disease (ESRD), stage 5 chronic renal failure, and was dependent upon dialysis. Resident 54's care plan included, but were not limited to the following: - .Problem start date: 5/16/24; Resident receives Hemodialysis due to end stage renal disease and is at risk for complications. Goal target date: 9/8/24; Resident will have effective fluid management, hemodynamically stable, without complications. Approach start date: 5/16/24; Report fluid excess (weight gain .) - .Problem start date: 8/11/23; Resident is at risk for weight loss [related to] chronic kidney disease. Goal target date 9/8/24; Resident will not have significant weight changes through next review. Approach start date: 8/11/23; Monitor resident's weight, notify physician of any significant weight changes . Physician Orders included, but were not limited to: - .daily weight, notify [Physician] if weight gain greater than 3 pounds overnight or 5 pounds in one week. Start date 2/28/24 . - .Resident to receive dialysis at the [facility] on Tuesday, Thursday, and Saturday. Start date 2/28/24 and no stop date . On 7/16/24 at 11:20 a.m., the Director of Nursing Services (DNS) provided copies of the Treatment Administration Records. A review of the records indicated the physician's prescribed daily weights, as it related to the dialysis services, were documented. The following documents identified the dates and the nursing staff's reasons the weights had not been performed. - from 2/28/24 to 3/28/24, the record lacked 4 daily weights: 3/14/24 - Not administered: Resident unavailable 3/15/24 - record lacked a reason for not obtaining the weight 3/17/24 - Not administered: On hold 3/18/24 - Not administered: Unable to obtain [weight] - from 3/29/24 to 4/28/24, the record lacked 5 daily weights: 3/29/24 - Not administered: day-shift 4/7/24 - record lacked a reason for not obtaining the weight 4/17/24 - Not administered: Resident unavailable 4/21/24 - record lacked a reason for not obtaining the weight 4/26/24 - record lacked a reason for not obtaining the weight - from 4/29/24 to 5/28/25, the record lacked 4 daily weights: 5/5/24 - record lacked a reason for not obtaining the weight 5/12/24 - Not administered: Resident unavailable 5/19/24 - Not administered: On hold 5/26/24 - Not administered: Weight not obtained - from 5/29/24 to 6/28/24, the record lacked 5 daily weights: 5/30/24 - Not Administered: Resident unavailable 6/10/24 - record lacked a reason for not obtaining the weight 6/25/24 - record lacked a reason for not obtaining the weight 6/26/24 - Not administered: Resident unavailable 6/28/24 - Not administered: nurse completed - from 6/29/24 to 7/10/24, the record lacked 1 daily weight: 7/5/24 - Not administered: Other During an interview on 7/10/24 at 9:15 a.m., Licensed Practical Nurse (LPN) 3 indicated Resident 54 was dialysis dependent and staff were to monitor his weights daily. During an interview on 7/12/24 at 10:07 a.m., Resident 54 indicated the dialysis staff weighed him during his dialysis sessions. Sometimes the nursing staff had weighed him on his non-dialysis days, his weight was not taken on a daily basis. 2. On 7/9/24 at 3:04 p.m., Resident 59's clinical record was reviewed. The diagnoses included, but were not limited to, dependence on renal dialysis and ESRD. The Quarterly MDS assessment, dated 4/23/24, indicated Resident 59 was moderately cognitively intact and had ESRD, renal disease, and was dependent upon dialysis. Resident 59's care plan included, but were not limited to, the following: - .Problem start date: 5/26/24; Resident receives Hemodialysis due to end stage renal disease and is at risk for complications. Goal target date: 9/26/24; Resident will have effective fluid management, hemodynamically stable, without complications. Approach start date: 5/26/24; Report fluid excess [weight gain] . - .Problem start date: 6/19/23; Resident has experienced significant weight loss. Goals target date: 9/26/24; Resident will have no further significant weight loss through next review. Approach: Monitor/record weight routinely, notify [Physician] of any significant changes . Physician orders included, but were not limited to: - .daily weight, notify [Physician] if weight gain greater than 3 pounds overnight or 5 pounds in one week. Start date 5/15/24 with no end date noted . - .Resident to receive dialysis at [dialysis provider], on Monday, Wednesday, and Friday .start date 5/15/24 with no end date noted . On 7/16/24 at 11:20 a.m., the DNS provided copies of the Treatment Administration Records. A review of the records indicated the physician's prescribed daily weights, as it related to the dialysis services, were documented. The following documents identified the dates and the nursing staff's reasons the weights had not been performed. - from 5/15/24 to 5/31/24, the record lacked 3 daily weights: 5/18/24 - record lacked a reason for not obtaining the weight 5/19/24 - Not administered: On hold 5/26/24 - Not administered: Weight not obtained - from 6/1/24 to 6/30/24, the record lacked 1 daily weight: 6/18/24 - Not administered: Resident unavailable - from 7/1/24 to 7/10/24, the record lacked 1 daily weight: 7/2/24 - Not administered: Other During an interview on 7/10/24 at 9:20 a.m., LPN 3 indicated Resident 59 was dialysis dependent and staff were to monitor her weights daily. During an interview on 7/12/24 at 12:30 p.m., Resident 59 indicated she was weighed during her dialysis sessions. Resident 59 indicated she had not been weighed by the nursing facility staff. 3. On 7/9/24 at 2:55 p.m., Resident 67's clinical record was reviewed. The diagnoses included, but were not limited to, dependence on renal dialysis and ESRD. The Quarterly MDS assessment, dated 5/13/24, indicated Resident 67 was cognitively intact and had ESRD and was dependent upon dialysis. Resident 67's care plan included but was not limited to the following: - .Problem start date: 3/4/24; Resident receives Hemodialysis due to end stage renal disease and is at risk for complications. Goal target date: 8/15/24; Resident will have effective fluid management, hemodynamically stable, without complications. Approach start date: 3/4/24; Report fluid excess [weight gain] . Physician orders included, but were not limited to: - .daily weight, notify [Physician] if weight gain greater than 3 pounds overnight or 5 pounds in one week. Start date 3/5/24 with no end date noted . - .Resident to receive dialysis at [dialysis provider], on Monday, Wednesday, and Friday .start date 3/5/24 with no end date noted . On 7/16/24 at 11:20 a.m., the DNS provided copies of the Treatment Administration Records. A review of the records indicated the physician's prescribed daily weights, as it related to the dialysis services, were documented. The following documents identified the dates and the nursing staff's reasons the weights had not been performed. - from 3/5/24 to 3/31/24, the record lacked 8 daily weights: 3/5/24 - record lacked a reason for not obtaining the weight 3/10/24 - record lacked a reason for not obtaining the weight 3/11/24 - record lacked a reason for not obtaining the weight 3/12/24 - record lacked a reason for not obtaining the weight 3/13/24 - record lacked a reason for not obtaining the weight 3/19/24 - Not administered: did not get out of bed 3/21/24 - Not administered: Resident unavailable 3/31/24 - record lacked a reason for not obtaining the weight - from 4/1/24 to 4/30/24, the record lacked 4 daily weights: 4/7/24 - record lacked a reason for not obtaining the weight 4/18/24 - Not administered: Resident unavailable 4/21/24 - record lacked a reason for not obtaining the weight 4/30/24 - Not administered: previous shift - from 5/1/24 to 5/31/24, the record lacked 5 daily weights: 5/2/24 - Not administered: Resident unavailable 5/14/24 - record lacked a reason for not obtaining the weight 5/18/24 - record lacked a reason for not obtaining the weight 5/19/24 - Not administered: On hold 5/26/24 - Not administered: weight not obtained - from 6/1/24 to 6/30/24, the record lacked 1 daily weight: 6/13/24 - Not administered: Resident unavailable -from 7/1/24 to 7/10/24, the record lacked 2 daily weights: 7/2/24 - Not administered: Other 7/6/24 - Not administered: Resident unavailable During an interview on 7/10/24 at 9:50 a.m., LPN 3 indicated Resident 67 was dialysis dependent and staff were to monitor her weights daily. During an interview on 7/12/24 at 9:45 a.m., Resident 67 indicated the dialysis staff weighed her during the dialysis session. The nursing staff generally did not weigh her. During an interview on 7/11/24 at 1:05 p.m., the DNS indicated staff were to follow the physician's orders regarding resident's daily weights related to their dialysis services. The resident's Treatment Administration Records identified the physician prescribed daily weights that had not been obtained. During an interview on 7/16/24 at 11:00 a.m., the Corporate Clinical Support Director indicated not all of the resident's prescribed daily weights were obtained. The dialysis protocol was to monitor the resident's weights. On 7/11/24 at 2:55 p.m., the DNS provided a copy of the Hemodialysis policy, dated 6/4/19, and indicated it was the current policy in use by the facility. A review of the policy indicated, .will ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan . On 7/11/24 at 1:50 p.m., the DNS provided a copy of the Protocol for Following Physician Orders policy, dated 4/3/17, and indicated it was the current policy in use by the facility. A review of the policy indicated, .It is the goal of [NAME] to provide care to our facility residents that will promote support for the optimal quality of life for the resident .associates .will provide the appropriate physician prescribed care to residents .all licensed staff will verify and follow the physician orders as written .the resident's plan of care will reflect the physician's orders and direction for the resident's plan of care . 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure an effective pest control program was maintained and the facility was free of rodents affecting 5 of 8 residents reviewed. (Resident D, Resident E, Resident J, Resident K, Resident M) Findings include: During the initial tour, on 4/1/24 from 9:26 a.m. to 9:50 a.m., Housekeeping (HSK) 2 indicated there were issues with mice in several resident rooms. The Maintenance Department Director was notified of the mice. The following was observed during the facility tour: 1. room [ROOM NUMBER] was observed to have one resident who resided in the room. The following was observed: - Resident J had a dresser with multiple drawers near the entry door and approximately 6 feet from the resident's bed. Inside the bottom drawer were multiple folded towels and wash cloths. Visible on the towels and wash cloths were multiple small black rice-like substances. 2. room [ROOM NUMBER] was observed to have two residents who resided in the room. The following was observed: - On the floor inside Resident K's closet, located near the entry door, was a 6 inch bait trap (mouse trap) partially covered by a dark colored piece of clothing. On the dresser stand, approximately 5 feet from the resident's bed, was a mini-refrigerator unit. Near and on top of the mini-refrigerator unit were multiple small black rice-like substances. During an interview at that time, Resident K indicated about a week or so ago there was a live mouse near the refrigerator unit and walking around on the floor in his room. - Visible on the windowsill, located next to Resident M's bed were multiple small black rice-like substances. On the other side of Resident M's bed was a three-drawer bedside table. Inside the second drawer were multiple small black rice-like substances. During an interview at that time, Resident M indicated several days ago, he saw multiple mice on the windowsill and on the floor between the two resident's beds. 3. room [ROOM NUMBER] was observed to have two residents who resided in the room. The following was observed: - Resident D had an over-the bed table next to bed. On top of the over-the bed table was a medium-sized uncovered plastic tub. Inside the tub was an unopened plastic wrapped sleeve that held chocolate stuffed cookies. At the top of the sleeve of cookies was a dime-sized hole in the plastic wrap and the top part of a cookie had been chewed. At the bottom of the tub were multiple small black rice-like substances. During an interview at that time, Resident D indicated there had been mice in his room over the past several months. About 2-3 weeks ago there was a live mouse under his pillow while he was resting in bed. Resident D indicated he was unable to catch it. - Resident E's nightstand was located next to the bed. The third drawer of the nightstand had multiple small black rice-like substances. During an interview at that time, Resident E indicated there were problems with mice. During an interview on 4/1/24 at 9:55 a.m., LPN (Licensed Practice Nurse) 3 indicated in the recent past there were several resident rooms where mice droppings were observed. The Maintenance Director was notified of the mice droppings. During an interview and facility tour on 4/1/24 at 12:30 p.m., the Director of Nursing Services (DNS) indicated the rodent/pest control provider had been treating the mice infestation for several months. The provider had treated the building twice weekly from early December to mid-February. Since that time, the provider had not seen any evidence of new mice in the building and so the scheduled treatment was changed to monthly. During a facility tour at that time, the DNS indicated she was unaware of additional mice issues again. During an interview on 4/1/24 at 1:07 p.m., the Maintenance Director indicated there was a mice infestation that started several months ago. The pest/rodent provider has been conducting the mice eradication since December 2023. They were coming to the building twice weekly. Since mid-February, the infestation had decreased and so the provider conducts the inspections monthly. The Maintenance Director indicated over the past couple of months, he had caught 157 mice. The mice infestation was on the A and B halls. On 4/1/24 at 1:20 p.m., the DNS provided a copy of the [Provider] Pest Sighting/Evidence Log. A review of the log indicated the following: Date Pest/issue Exact location 12/26/23 mice Resident rooms - 1119, 1098, 1099, 1093 12/27/23 mice Resident room - 2120 12/27/23 mice Resident room - 1122 1/8/24 mice Resident room [ROOM NUMBER] 1/9/24 mice Resident rooms 1116, 1117, 1127, 1115, 1122, 1124 1/15/24 mice Resident rooms 1082, 2115 1/16/24 mice Resident room [ROOM NUMBER] 1/24/24 mice Resident room [ROOM NUMBER] 1/25/24 mice Resident room [ROOM NUMBER] 2/2/24 mice Resident rooms 1077, 1075 On 4/1/24 at 1:40 p.m., the DNS provided a copy of the Customer Service Report. A review of the report indicated the provider implemented or continued the rodent program on the following dates: 1/2/24; 1/5/24; 1/10/24; 1/16/24; and 1/30/24. The provider indicated no sightings of rodent activity were visible on the following dates: 1/12/24; 1/19/24; 1/23/24; 2/2/24; 2/6/24; 2/9/24; 2/13/24; 2/14/24; 2/23/24; 3/13/24; and 3/15/24. On 4/1/24 at 2:15 p.m., the DNS provided an undated statement, titled Mouse Identification, and indicated it was a summary of the facility's process for eradicating the mice infestation. A review of the document indicated, December 5, 2023 - [provider] commenced treatments for activity [evidence of mice in the facility] two times per week. Per verbal agreement, [provider] would continue treating two times per week unless no activity was noted for 3 weeks. On 2/13/24, there was no noted activity for 4 weeks. The treatment was changed back to the regular once per month schedule. [Provider] treated the facility on 2/14/24; 2/23/24; 3/13/24; and 3/15/24 with no findings. During an interview at that time, the DNS indicated she was unaware of additional mice issues since mid March. Staff were to report all mice issues so that it could be addressed. On 4/1/24 at 11:33 a.m., the Administrator provided an undated copy of the [Provider] Pest Elimination Scope of Service policy and indicated it was the current policy in use by the facility. A review of the policy indicated, .[Provider] will proactively eliminate the pests you are concerned about .the facility will be serviced monthly .Rodent program is an integrated system that combines patented rodent station technology with discreet devices, regular service visits and detailed inspections .conduct a thorough inspection .to identify rodent breeding areas and facility access points .inspect interior .to identify current rodent issues as well as structural and sanitation issues . This citation relates to Compliant IN00429968. 3.1-19(f)(4)

Based on record review and interview, the facility failed to inventory and document resident belongings upon admission and discharge for 4 of 4 residents reviewed. (Resident B, Resident C, Resident D, Resident E) Findings include: 1. On 5/30/23 at 12:30 p.m., Resident B's clinical record was reviewed. Resident B admitted to the facility on [DATE] and discharged on [DATE]. An inventory sheet was not completed in Resident B's clinical record. 2. On 6/2/23 at 11:30 a.m., Resident C's clinical record was reviewed. Resident C admitted to the facility on [DATE] and discharged on [DATE]. An inventory sheet was not completed in Resident C's clinical record. 3. On 6/2/23 at 11:45 a.m., Resident D's clinical record was reviewed. Resident D admitted to the facility on [DATE] and discharged on [DATE]. An inventory sheet was not completed in Resident D's clinical record. 4. On 6/2/23 at 12:00 p.m., Resident E's clinical record was reviewed. Resident E admitted to the facility on [DATE] and discharged on [DATE]. An inventory sheet was not completed in Resident E's clinical record. During an interview on 6/5/23 at 9:30 a.m., the DON indicated that she was unable to locate inventory sheets for the four residents. The DON stated that there was an observation in the electronic record to open on admission to inventory new residents' personal belongings and that a paper copy of inventoried items would also be acceptable but was unable to locate either for Resident B, Resident C, Resident D, or Resident E. On 6/5/23 at 1:30 p.m., the DON provided a copy of the facility policy titled Personal Property, dated as revised for April 2013. The policy indicated that .5. The resident's personal belongings and clothing shall be inventoried and documented upon admission and as such items are replenished. This Federal tag relates to Complaint IN00405626. 3.1-9(g)

Based on observation, interview, and record review, the facility failed to ensure physician orders for skin treatment services were accurately provided and recorded for 2 of 7 residents reviewed. (Resident 174, Resident 25) Findings include: 1. During an interview on 5/30/23 at 1:57 p.m., Resident 174 indicated he was admitted to the facility with a sore spot on his right outer ankle area and that staff treat the area every Tuesday and Thursday. On 6/2/23 at 10:00 a.m., Resident 174's clinical record was reviewed. Resident 174 was admitted to the facility on [DATE]. The diagnoses included, but were not limited to, disorder of the skin and diabetes. The Admission MDS (Minimum Data Set) assessment, dated 4/18/23, indicated Resident 174 was cognitively intact and was receiving applications of ointment/medications for skin conditions. Resident 174's care plan included, but was not limited to, Problem: Resident has skin breakdown to outer ankle; start date: 4/12/23; Goal: Area will resolve without complication; Target date: 7/30/23; Approach: pressure reducing/redistribution cushion in chair/wheelchair; pressure reducing/redistribution mattress on bed; Turn and reposition every 2 hours with avoidance of pressure to affected area; weekly skin checks by licensed nurse . Physician orders included, but were not limited to, betadine (povidone-iodine) [OTC] solution; 10%; amt [amount]: apply a small amount topically 3x/week T [Tuesday], Th [Thursday], Sat [Saturday] for preventing bacterial infection. Apply to R [right] lateral ankle wound/scab. Start date: 4/12/23 - open ended [no end date]. The April 2023 Medication Administration Record (MAR) indicated Resident 174's right ankle was treated with betadine every Tuesday and Thursday from 4/13/23 thru 4/27/23. The May 2023 MAR indicated Resident 174's right ankle was treated with betadine every Tuesday and Thursday from 5/2/23 thru 5/30/23. The June 2023 MAR indicated Resident 174's right ankle was treated with betadine on Thursday, 6/1/23. On 6/2/23 at 11:42 a.m., Resident 174's right outer ankle area was observed. During an interview at that time, the Unit Manager indicated Resident 174 had a physician's order for betadine treatments to the healing right outer ankle area. Resident 174 was admitted with a traumatic injury as a result from a fall that affected the outer ankle area. During an interview on 6/5/23 at 1:36 p.m., the DNS (Director of Nursing Services) indicated Resident 174's physician's betadine treatment order for the right outer ankle area was supposed to be two times per week. The nursing staff should have consulted with the prescribing provider to determine the frequency for which the treatment was to be provided and then update the clinical record to ensure the record was clear and accurate. 2. During an interview on 5/31/23 at 9:04 a.m., Resident 25 indicated she had a sore below her right knee and staff wrapped her lower leg every day. On 6/5/23 at 8:34 a.m., Resident 25's clinical record was reviewed. The diagnoses included, but were not limited to, unspecified open wound on the lower leg; lower extremity arterial disease; and disorders of the skin and subcutaneous tissue. The Annual MDS (Minimum Data Set) assessment, dated 4/13/23, indicated Resident 25 was cognitively intact and was receiving applications of ointment/medications for skin conditions. Resident 25's care plan included, but was not limited to, Problem: Resident has s/s [signs and symptoms] of infection to right lower leg; start date: 5/19/23; Goal: Infection will resolve without complications; Target date: 6/2/23; Approach: administer antibiotics as ordered; monitor for any adverse side effects and notify MD [Medical Doctor] if any occur .treatment as ordered . The Physician's progress note, dated 5/25/23 at 7:15 p.m., indicated .right lower leg: clean wound with wound cleaner or NS [normal saline]; apply 0.1 gentamicin cream [antibiotic used to stop the growth of certain bacterial infections]; cover with ABD [abdominal treatment pads] and secure with kerlix. Change daily and prn [as needed]. The MAR indicated Physician orders included, but were not limited to, gentamicin cream; 0.1%; amt: dime size amount to wound; topical; frequency: once - one time; special instructions: cleanse areas with wound cleaner then apply to wound beds on rt [right] lower extremity, apply ABD and kerlix daily and prn; diagnosis: unspecified skin changes; date created: 5/26/23; verified date: 5/26/23. The 5/5/23 to 6/5/23 MAR document lacked any verification that the gentamicin cream was applied to Resident 25's lower extremity. During an interview on 6/5/23 at 2:50 p.m., the DNS (Director of Nursing Services) indicated on 5/25/23 Resident 25's physician placed a new order for gentamicin cream to be applied to the resident's lower right extremity daily. The order was data entered into the electronic clinical record as a one-time application rather than daily as prescribed by the physician. The DNS indicated the medication was applied daily to Resident 25's lower extremity even though the clinical record failed to reflect the medication administration. The clinical record should have accurately reflected the physician's order. During an interview on 6/6/23 at 9:20 a.m., Qualified Medication Aide 3 indicated if a medication or treatment order discrepancy was noted, the nurse would be notified. The nurse would then seek clarification from the physician. The medication or treatment would not be administered until the discrepancy was clarified. During an interview on 6/6/23 at 9:35 a.m., Licensed Practical Nurse 2 indicated physician's orders were to be reviewed and reconciled prior to providing a treatment. If a discrepancy was noted, the physician would be contacted to clarify the order prior to providing the treatment. If the treatment was given, the MAR would be completed by the licensed staff indicating the treatment had been performed. On 6/2/23 at 2:10 p.m., the DNS provided a copy of the Protocol for Following Physician Orders policy, dated 4/3/2017, and indicated it was the current policy in use by the facility. A review of the policy indicated, Policy statement: it is the goal of [NAME] to provide care to our facility residents that will promote support for the optimal quality of life for the residents. Policy: it is the policy of [NAME] and associates that we will provide the appropriate physician prescribed care to residents in our communities. The facility patient care, therapy and pharmacy services will reflect the orders and plan of care of the prescribing physician. Procedure: all licensed staff will verify and follow physician orders as written . On 6/2/23 at 3:05 p.m., the DNS provided a copy of the Care Plans - Comprehensive policy, dated October 2009, and indicated it was the current policy in use by the facility. A review of policy indicated, .an individualized comprehensive care plan that .meets the resident's medical, nursing .is developed for each resident .care plans are revised as information about the resident and the resident's condition change . 3.1-35(g)(2)

Based on interview and record review, the facility failed to protect the residents right to be free from misappropriation of property for 1 of 3 residents reviewed for misappropriation of property. A resident's narcotic pain medication was unaccounted for. (Resident B) Finding includes: During an interview on 1/27/23 at 8:50 a.m., QMA 1 (Qualified Medication Aide) indicated Resident B's narcotic pain medication was unaccounted for a month ago. She worked that morning and as she was getting report from the nurse, the night shift QMA indicated that narcotic pain medication had been delivered for Resident B, and she was not able to locate the medication. During an interview on 1/27/23 at 10:25 a.m., the DON (Director of Nursing) indicated the narcotic pain medication for Resident B was delivered and was unaccounted for. The staff that signed for the medication was terminated because she did not follow procedure when the medication was delivered. The staff did not immediately secure the narcotics in the narcotic lock box on the medication cart. She placed the unsecured medication delivery tote outside the medication storage room. Later that morning, the medication could not be accounted for. The pharmacy verified the narcotic pain medication was delivered. The staff member should have locked the medication in the narcotic lock box on her medication cart. The clinical record for Resident B was reviewed on 1/31/23 at 9:52 a.m. The diagnoses included, but were not limited to, left below knee amputation and chronic pain syndrome. A Significant Change MDS (Minimum Data Set) assessment, dated 1/4/23, indicated Resident B was cognitively intact and had occasional, moderate, pain that did not interfere with his day-to-day activities. The Physician's orders included, but were not limited to: Oxycodone (narcotic pain medication) 10 mg (milligrams) orally every 4 hours as needed for chronic pain syndrome, initiated 12/27/22. A pharmacy packing slip, dated 12/23/22, indicated 24 tablets of oxycodone 10 mg were delivered on 12/24/22. A police incident report, dated 12/24/22, indicated incident type: theft of prescription with a case number. On 1/31/23 at 9:53 a.m., the DON provided a copy of a facility policy, titled Abuse, Neglect and Misappropriation Prohibition and Prevention Policy, dated 6/4/19, and indicated this was the current policy used by the facility. A review of the policy indicated misappropriation of resident property is defined as deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. This Federal tag relates to Complaint IN00397745 3.1-28(a)

Based on observation, interview, and record review, the facility failed to ensure the area surrounding the dumpster containers were free of rubbish and all dumpster containers were kept closed when not in use for 1 of 2 observations. Findings include: On 7/6/22 from 10:40 a.m. to 10:45 a.m., during the initial facility tour with the Dietary Manager (DM), observed the dumpster area, located adjacent to and near the kitchen's back door. The following was observed: 1. The compactor (dumpster machine) door was observed to not be closed. Inside the compactor, multiple filled trash bags were visible. No staff were visible in the area at that time. 2. The grease dumpster was located next to the compactor. The grease dumpster was approximately ¼ full of used grease and the lid was observed to not be closed. No staff were visible in the area at that time. 3. The following debris was observed surrounding the compactor and grease dumpster containers: multiple used plastic gloves; two soiled incontinent products; [NAME] scratch off lottery tickets; multiple cigarette butts; plastic bags; and partially filled plastic trash bags. No staff were visible in the area at that time. 4. The cardboard recycle dumpster unit was approximately 20 feet from the compactor and grease dumpster area. The cardboard recycle dumpster was observed to have 2 separate top loading lids. The lid on the right side of the dumpster was observed to not be closed and inside the dumpster were multiple cardboard boxes. No staff were visible in the area at that time. During an interview at that time, the DM indicated the doors and lids for each dumpster container was to be kept closed when not in use. The area surrounding the dumpster's were to be kept clean and free of debris. On 7/7/22 at 2:06 p.m., the Corporate Dietary Consultant provided a copy of the Environmental Sanitation/Infection Control policy, dated 2012, and indicated it was the current policy in use by the facility. A review of the document indicated, .trash and refuse is kept in a secure area to avoid infestation from pests and animals .all trash bags are leak-proof and are securely closed to avoid any spillage .all trash bags are placed in a dumpster or large receptacle .no trash bags are left on the ground .the dumpster lid is closed after the trash bag is deposited . On 7/8/22 at 10:00 a.m., a review of the Retail Food Establishment Sanitation Requirements - Title 410 IAC 7-24, effective November 13, 2004, indicated, .receptacles and waste handling units for refuse, recyclables and returnables shall be kept covered with tight-fitting lids or doors if kept outside .accumulation of debris .are minimized .effective cleaning is facilitated around .the unit . 3.1-21(i)(2) 3.1-21(i)(5)

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility was free of insects in 1 of 2 halls observed for pests. (Hall A) Findings include: During an interview on 7/6/22 at 10:15 a.m., Resident J indicated she had seen ants and gnats in her bathroom. On 7/11/22 at 1:25 p.m., the clinical record of Resident J was reviewed. The diagnoses included, but were not limited to, need for assistance with personal care, [CONDITION(S)], and anxiety disorder. A Quarterly Minimum Data Set (MDS) assessment, dated 6/1/22, indicated Resident J was cognitively intact. During an observation on 7/6/22 from 11:00 a.m. to 11:15 a.m., observed Hall A, a minimum of 40 flying ants at the end of Hall A on the floor near the exit door, across from Room 1085. Some of the flying ants were observed to be alive, while most were not observed to be moving. During an observation on 7/7/22 at 10:33 a.m., observed Hall A a minimum of 40 flying ants on the floor, in the hall next to the exit door in front of Room 1085, Room 1082, and Room 1080. Some of the flying ants were observed to be alive and some of them were observed to not be moving. During an observation on 7/8/22 at 9:00 a.m., observed Hall A a minimum of 20 flying ants on the floor, in the hall next to the exit door across from Room 1085. All of the flying ants were observed to not be moving. During an interview on 7/7/22 at 11:00 a.m., the facility pest control personal indicated the insects on the Hall A floor, were flying ants. During an interview on 7/8/22 at 10:22 a.m., the Director of Nursing indicated she was unaware of the flying ants in Hall A. Work orders, dated January 1, 2022 - July 10, 2022, indicated the following: Work order: # , undated, indicated ants were in Room 1098. Work order: # , undated, indicated Room 1147 needed to be sprayed for ants. Work order: # , undated, indicated Room 1134 had bugs everywhere. Work order: # , undated, indicated ants were in most rooms and hallway, A and B wing. Work order: # , undated, indicated ants were on floor and on the wall in Room 1114 Work order: # , undated, indicated ants were coming in under PTAC (heating and cooling) unit in Room 1098. Work order: # , undated, indicated ants were in Room 1222. Work order: # , undated, indicated ants were all over, Room 1079 Work order: # , undated, indicated ants were all over Room 1098 Work order: # , undated, indicated Room 1319 had ants, resident wanted traps. On 7/11/22 at 12:55 p.m., the Director of Nursing provided a policy titled: Homelike Environment, dated August 2009, and indicated it was the current policy being used by the facility. A review of the policy indicated .2. the facility staff and management shall maximize, to the extent possible the characteristics of the facility that reflect a personalized homelike setting. These characteristics include, a. cleanliness and order. This Federal tag relates to Complaints IN 966 and IN 773. 3.1-19(f)(4)

Based on observation, interview, and record review, the facility failed to implement the plan of care for 1 of 7 residents reviewed for pressure ulcers. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: On 7/8/22 at 3:05 p.m., observed Resident B's powerchair. A spectrum foam cushion was observed on the seat portion of the powerchair. No other powerchair cushion was visible. The clinical record for Resident B was reviewed on 7/8/22 at 9:51 a.m. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS (Minimum Data Set) assessment, dated 6/22/22, indicated Resident B was at risk of developing a pressure ulcer. The care plan, initially dated 3/31/21, updated on 7/6/22, and valid through 10/6/22, indicated Resident is at risk of skin breakdown R/T [related to]: pain, incontinence, DM [diabetes mellitus], debility, noncompliance with preventative interventions such as ted hose and turning/repositioning and hoyer lifts for transfers . Nursing progress notes, titled Wound Rounds, indicated: -On 6/30/22 at 9:00 a.m., .resident seen at this time .wounds evaluated .all areas epithelialized [restoration of damaged skin] and discharged from wound services. Due to high risk of recurrence r/t [related to] compliance inconsistency to recommendation of not sitting for extended periods .Gel or Roho cushion [specialized pressure redistribution cushion designed to prevent and decrease the development of pressure ulcers] to powerchair for pressure reduction . On 6/23/22 at 9:00 a.m., the Wound Physician documented the following: plan .upgrade powerchair cushion to gel or Roho .upgrade powerchair cushion for improved pressure redistribution . On 6/30/22 at 9:00 a.m., the Wound Physician documented the following: plan .upgrade powerchair cushion to gel or Roho .areas are resolved; due to inconsistency of offloading compliance, recurrence is likely . On 7/8/22 at 3:30 p.m., the DNS (Director of Nursing Services) provided a copy of the EquaGel Straight Comfort Wheelchair Equal Pressure GL -31-520 cushion purchase order. A review of the purchase order indicated the cushion was ordered on 7/7/22 at 3:17 p.m. During an interview with the DNS at that time, the spectrum foam cushion observed on Resident B's powerchair was the one that came with the chair and was not the one ordered by the Physician. The Wound physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/12/22 at 11:10 a.m., the Corporate Clinical Specialist provided a copy of the Protocol for Following Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the policy indicated, .we will provide the appropriate physician prescribed care to residents in our communities .all licensed staff will verify and follow the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] This Federal tag relates to Complaint IN 057. 3.1-35(g)(2)

Based on interview and record review, the facility failed to provide the appropriate treatment and services for a resident with a history of UTIs (urinary tract infections) in a timely manner. The facility failed to obtain the collection of a STAT (immediate) urine sample as ordered for a UA (urinalysis) for 1 of 2 residents reviewed for UTIs (urinary tract infections). (Resident 46) Finding includes: On 7/7/22 at 11:50 A.M., Resident 46's clinical record was reviewed. The Quarterly MDS (Minimum Data Set) assessment, dated 6/16/22, indicated Resident 46 was cognitively intact. Resident 46's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/8/22 at 2:00 P.M., a new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . I&O [in and out catheterization by means of a one time non-anchored catheter] cath only. Special instructions: May d/c [discontinue] order once collected. The order stated the start date was 7/8/22 and the time the order was created and verified was 12:37 P.M. On 7/11/22 at 9:15 A.M., Resident 46's electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record lacked documentation that a urine sample had been obtained or that the NP (Nurse Practitioner) or MD had been notified. During an interview on 7/11/22 at 9:30 A.M., LPN 1 indicated that she did not know of any current lab orders pending for Resident 46. LPN 1 then checked the eMAR upon being queried and noted that Resident 46 had a pending UA order. LPN 1 then indicated it was a STAT order when she was queried again. LPN 1 stated that as a STAT lab, the collection of the urine sample should be attempted immediately and that she would try once Resident 46 was back from hemodialysis. On 7/111/22 at 10:30 A.M., Resident 46's clinical record was reviewed. The progress notes included, but was not limited to: -7/10/22 at 11:05 A.M., a nursing progress note indicated that I and O catheterization for Resident 46 had been attempted but nurse was .unable to obtain due to thick mucous in catheter. Encouraged fluids. -7/11/22 at 9:40 A.M., a nursing progress note indicated that Stat urine unable to be obtained. NP notified. keep order and try after returning from [CONDITION(S)][.] -7/11/22 at 10:06 A.M., a progress note from the nurse practitioner stated Writer made aware that staff was unable to obtain urine sample due to HD [hemodialysis] and low urine output. Will order STAT CBC [complete blood count, which monitors hemoglobin, white blood cell count, etc.] for comparison until urine is able to be obtained. On 7/12/22 at 2:35 P.M., the DON provided a urinalysis result, dated 7/12/22, which indicated that Resident 46 was positive for a [CONDITION(S)]. During an interview on 7/11/22 at 9:57 A.M., the DON indicated that the expected time frame for blood draws ordered as STAT should be completed within four hours and that for a UA it would depend on whether it was ordered I and O catheterization or clean catch but that it should be obtained as quickly as possible. On 7/11/22 at 12:35 P.M., the DON provided a policy titled Diagnostic Services, dated 6/6/19, and indicated it was the policy currently in use. The policy stated that .8. Orders for diagnostic services will be promptly carried out as instructed by the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Emergency requests must be labeled STAT to assure that prompt action is taken. 3.1-41(a)(2)

Based on interview and record review, the facility failed to perform [CONDITION(S)] assessments for 1 of 2 residents reviewed for [CONDITION(S)]. Pre and Post [CONDITION(S)] assessments were not completed. (Resident 46) Finding includes: On 7/7/22 at 11:50 A.M., Resident 46's clinical record was reviewed. The Quarterly MDS (Minimum Data Set) assessment, dated 6/16/22, indicated Resident 46 was cognitively intact. Resident 46's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 46 received [CONDITION(S)] treatment three days a week (Monday, Wednesday, and Friday). The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Complete the Pre [CONDITION(S)] Assessment observation before treatment on Mondays, Wednesdays, and Friday, ordered on 4/13/22. - Complete the Post [CONDITION(S)] Assessment observation after treatment on Mondays, Wednesdays, and Fridays, ordered on 4/13/22. On 7/12/22 at 1:15 P.M., Resident 46's pre and post [CONDITION(S)] assessments were reviewed. The following assessments were missing: -4/15/22 (Friday) the clinical record lacked a Post [CONDITION(S)] Assessment. -4/22/22 (Friday) the clinical record lacked a Post [CONDITION(S)] Assessment. -5/6/22 (Friday) the clinical record lacked a Post [CONDITION(S)] Assessment. -5/9/22 (Monday) the clinical record lacked a Post [CONDITION(S)] Assessment. -5/11/22 (Wednesday) the clinical record lacked a Pre and Post [CONDITION(S)] Assessment. -5/13/22 (Friday) the clinical record lacked a Pre and Post [CONDITION(S)] Assessment. -5/16/22 (Monday) the clinical record lacked a Pre and Post [CONDITION(S)] Assessment. -5/18/22 (Wednesday) the clinical record lacked a Pre and Post [CONDITION(S)] Assessment. -5/20/22 (Friday) the clinical record lacked a Pre and Post [CONDITION(S)] Assessment. -5/23/22 (Monday) the clinical record lacked a Post [CONDITION(S)] Assessment. -5/30/22 (Monday) the clinical record lacked a Post [CONDITION(S)] Assessment. -6/24/22 (Friday) the clinical record lacked a Post [CONDITION(S)] Assessment. -6/29/22 (Wednesday) the clinical record lacked a Pre [CONDITION(S)] Assessment. -7/1/22 (Friday) the clinical record lacked a Pre and Post [CONDITION(S)] Assessment. -7/6/22 (Wednesday) the clinical record lacked a Pre and Post [CONDITION(S)] Assessment. -7/8/22 (Friday) the clinical record lacked a Post [CONDITION(S)] Assessment. -7/11/22 (Monday) the clinical record lacked a Post [CONDITION(S)] Assessment. During an interview on 7/11/22 at 9:57 A.M., the DON indicated that some Pre and Post [CONDITION(S)] assessments were missing from Resident 46's clinical record and that they should have been completed. On 7/11/22 at 12:27 P.M., a policy titled Hemodialysis Policy dated 6/4/19 was provided by the Regional Director of Operations; she indicated that this was the policy currently in use. The policy stated that staff caring for residents with [CONDITION(S)] (end-stage [CONDITION(S)]), including residents who are receiving [CONDITION(S)] care shall .4. Complete a pre- and post- [CONDITION(S)] assessment. 3.1-37(a)

Based on observation, interview, and record review the facility failed to ensure food was stored in a sanitary manner for 1 of 2 observations of the resident's snack refrigerator. Food items were not discarded by the manufacturer's pre-printed use by date and the food items lacked a label to indicate whom the items belonged to. (Rehabilitation Unit) Findings include: On 7/6/22 at 10:50 a.m., during the initial facility tour with the Dietary Manager (DM), observed the Rehabilitation Unit resident snack refrigerator, located behind the nurses station. Inside the resident snack refrigerator, the following food items were observed: - One unopened 8 ounce bottle of [MEDICATION(S)] Renal and the manufacturer's pre-printed best by - 7/1/22 date, located near the top of the bottle, was visible. The bottle lacked a resident's name to identify to whom it belonged and was past the manufacturer's use by date. - Three unopened 8 ounce bottles of Nepro with carb steady therapeutic nutrition and the manufacturer's pre-printed best by - 7/1/22 date, located near the top of each bottle, was visible. The bottles lacked a resident's name to identify to whom it belonged and was past the manufacturer's use by date. During an interview at that time, the DM indicated the resident snack refrigerator was for resident food items only and all were to be labeled to indicate to whom the items belonged. All food items were to be monitored and discarded when past the use by date. The Rehabilitation Unit resident snack refrigerator was available for residents residing on that unit. On 7/6/22 at 2:13 p.m., the Corporate Dietary Consultant provided a copy of the Use and Storage of Food/Beverage Brought in for Residents policy, dated 1/30/18, and indicated it was the current policy in use by the facility. A review of the policy indicated, .the food procurement, storage, handling, serving and consumption policies and practices required by local, state, and federal regulation are followed by [NAME] Community .Members of Community staff will be designated to check resident refrigerators for proper temperatures, food containment and quality, and timely disposal of food and beverages per this policy .foods requiring refrigeration will be received by the charge nurse for labeling, dating and storage .staff will examine food for quality (packaging, appearance) to identify any potential concerns . On 7/8/22 at 2:00 p.m., a review of the retail Food Establishment Sanitation Requirements Title 10 IAC 7-24, effective November 13, 2004, indicated .may not exceed a manufacturer's use by date . On 7/8/22 at 3:00 p.m., a review of the retail Food Establishment Sanitation Requirements Title 10 IAC 7-24, effective November 13, 2004, indicated .refrigerated, ready to eat, potentially hazardous food prepared and held in a retail food establishment for more than twenty-four (24) hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises .discarded . 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure a resident with urinary incontinence received incontinence care for 1 of 3 resident reviewed for activities of daily living. (Resident C) Finding includes: During observation on 3/3/22 between 10:16 a.m. until 10:33 a.m., Resident C walked out of her room with her walker. The back of Resident C's pants were visibly wet. Resident C walked back into her room. The call light for Resident C's room and the room directly across the hall were observed to be on. QMA (qualified medication aide) 1 was observed to be passing medications from a cart on that hall approximately 30 feet from Resident C's room. During an interview on 3/3/22 at 10:16 a.m., Resident C indicated she was trying to get help because she had urinated while resting in her bed, so her sheet and her pants were wet. She also indicated she was wearing 2 incontinence briefs because she like wearing 2 briefs. She was unable to remember how long she had been waiting for incontinence care. At that time, Resident C pulled back the flat sheet and exposed a wet incontinence pad, a wet spot on the fitted sheet, and pulled the top edge of her pants down to show she had been wearing 2 incontinence briefs. During an interview on 3/3/22 at 10:33 a.m., LPN 1 indicated there had been a call light on for 16 minutes and a call light on for 60 minutes on that unit. During an interview on 3/3/22 at 10:35 a.m., CNA 1 indicated Resident C chose to wear 2 incontinence briefs at a time and incontinence care should have been provided. The clinical record for Resident C was reviewed on 3/3/22 at 1:15 p.m. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) assessment, dated 2/16/22, indicated Resident C had moderate cognitive impairment and required extensive assistance with dressing, toileting, and personal hygiene. A care plan, dated 1/6/22 and current through 5/25/22, indicated Resident C had urinary incontinence and required assistance with toileting and toileting hygiene. Resident C wore 2 briefs per her preference. The interventions included, but were not limited to, assist with toileting and toileting hygiene and provide incontinence care after every incontinence episode. On 3/4/22 at 11:50 a.m., the facility was unable to provide policy prior to exit regarding incontinence care. This Federal tag relates to Complaint IN 887. 3.1-38(a)(3)

Based on observation, interview, and record review, the facility failed to implement infection control measures to prevent the spread of COVID-19. Staff failed to wear the correct personal protective equipment (PPE) and complete hand hygiene for 4 of 14 residents who resided in a yellow zone reviewed for IC (infection control). (Residents D, E, F, and G) Findings include: On 8/30/21 from 11:45 a.m. to 11:55 p.m., observed a NP (Nurse Practitioner) to enter Resident F's yellow zone room without gowning, gloving, and putting on a face shield prior to entering the room. The NP was observed to not use hand sanitizer or perform hand hygiene after exiting Resident F's room. On 8/30/21 from 12:00 p.m. to 12:25 p.m., CNA 1 (Certified Nursing Assistant) 1 was observed passing lunch trays to residents who resided in the yellow zone. CNA 1 entered Resident D's room without hand sanitizing, gowning, and gloving before bringing Resident D's lunch into their room. Upon exiting, CNA 1 was observed to not use hand sanitizer or perform hand hygiene prior to pushing the lunch cart to the next resident's room. CNA 1 next entered Resident E's room without gowning or gloving. CNA 1 was observed to bring Resident E's lunch back out of the room and place it back on the food cart. CNA 1 then proceeded to pick up a sheet, at the door of Resident E's room, and took it to the soiled utility room. CNA 1 was observed to not change gloves and perform hand hygiene. When CNA 1 came back down hall to continue passing trays at 12:30 p.m., and was interviewed. During the interview CNA 1 indicated she should have gowned and gloved prior to going into rooms as well as using hand sanitizer between each room. On 8/30/21 at 12:35 p.m., Observed 3 family members walk into Resident G's room without hand sanitizing, gowning, and gloving. Interview with QMA 1, on 8/30/21 at 12:40 p.m., indicated Resident G's family members were there on a compassionate care visit and they should have put on gowns and gloves before entering Resident G's room. QMA 1 (Qualified Medication Assistant) was observed to gown up and pull out three (3) gowns from the PPE cart and took them into Resident D's room. On 8/30/21 at 12:50 p.m., 2 of the 3 family members from Resident G's room were observed standing next to QMA 1's medication cart with 1 of the 2 family members still wearing their protective gown, without being asked by QMA 1 to remove it Review of facility's bedboard, on 8/30/21 at 12:50 p.m., indicated the isolation yellow zone had a census of 14 residents, which included Residents D, E, F, and G. On 8/30/21 at 3:30 p.m., the DON (Director of Nursing) provided the Infection Prevention and Control Program policy, dated June 6, 2019, and indicated the policy was the one currently being used by the facility. A review of the policy indicated important facets of infection prevention, included, but not limited to: educating staff and ensuring that they adhere to proper techniques and procedures and following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC). On 8/31/21, at 8:00 a.m., a review of the facility's COVID-19 tool kit, dated 3/9/21, indicated Unknown COVID-19 status (Yellow). that all residents in this category warrant transmission-based precautions ( droplet and contact) HCP (health care providers) will wear single gown per resident, gloves, N95 mask and eye protection (face shield/or goggles). 3.1-18(b)

Based on record review and interview, the facility failed to ensure a resident experiencing abdominal pain received a stat (immediately) medication as indicated by physician order [REDACTED].#79) Findings include: The clinical record of Resident #79 was reviewed on 7/10/15 at 10:17 a.m. [DIAGNOSES REDACTED]. A care plan dated 4/14/15 and current through 7/14/15, indicated Resident #79 was at risk for constipation related to medication use. Approaches included giving laxatives and medications per physician orders. Nurses' notes indicated: 5/9/15 at 2:30 a.m., Resident #79's abdomen was distended and she was complaining of abdominal pain. The physician was notified and ordered an X-ray which was done at 4:31 a.m. The results of the X-ray indicated, Colonic ileus (chronic/long term irritation of bowel immobility) type pattern .may represent clinical constipation. 5/9/15 at 6:20 a.m., Resident #79's physician was notified of the X-ray results. A new order was received for the resident to have only clear liquids for 24 hours and to be given a [MEDICATION NAME] rectal suppository to stimulate a bowel movement. A Medication Administration Record [REDACTED] Further nurses' notes indicated: 5/9/15 at 1:33 p.m., the [MEDICATION NAME] suppository was ineffective and the physician was notified. The physician gave new orders for other laxatives and another suppository. 5/9/15 at 9:25 p.m., the resident had still not had a bowel movement and the physician was contacted. Writer received stat order for (2) (brand name) enemas .writer has faxed order to pharmacy as a stat order and is currently waiting arrival for administration. The next nurse's note, dated 5/10/15 at 6:14 a.m. indicated, Pharmacy delivered enema .writer attempted give enema resident screaming in pain unable to give enema. resident stated send me home or to hospital and let me die . The nurse indicated she had placed a call to the physician's office to notify them of resident being unable to tolerate enema. On 7/15/15 at 2:30 p.m., the DON provided a delivery slip from the facility pharmacy which indicated the enemas had been delivered to the facility on [DATE] at 1:05 a.m. The DON indicated she did not know why the nurse waited until 6:14 a.m., to attempt to administer the enema when it had been ordered stat and delivered by pharmacy at 1:05 a.m. A nurse's note dated 5/10/15 at 6:49 a.m., indicated the physician wanted Resident #79 to be sent to the hospital emergency room . A nurse's note dated 5/10 15 at 7:14 a.m., indicated Resident #79 was taken in an ambulance to the hospital. Hospital emergency room notes, dated 5/10/15 at 7:47 a.m., indicated, Final Impression 1. Abdominal pain 2. Pseudo-obstruction of intestine (the inability of intestines to contract and push food, stool and air through the gastrointestinal tract) . A hospital History and Physical, dated 5/10/15, indicated, .woman .transferred from ECF (extended care facility) in the setting of progressive abdominal distention. She has had difficulty with progressive constipation .for the past 2-3 weeks, now with progressive pain .she is admitted for further care . Resident #79 returned to the facility on [DATE]. On 7/15/15 at 8:55 a.m. the Director of Nursing (DON) provided an undated policy titled, Stat Orders, and indicated it was the policy currently used by the facility. The policy indicated, 4. If a physician prescribes a medication not available in the facility emergency supply, inform the physician that the medication is not readily available. Be sure the physician is aware that his/her order will not be available until it is confirmed with the pharmacy and the timeframe may exceed two-hours. 5. DO NOT FAX a stat order. Call the pharmacy directly to give the stat medication order to the pharmacist . 3.1-48(c)(2)

Based on record review and interview, the facility failed to ensure physician's orders for [MEDICATION NAME]([MEDICATION NAME]-a pain relief medication) were provided to a resident which resulted in the resident to experience excruciating pain for 1 of 3 residents reviewed for pain management in a sample of 3 (Resident #B). Findings include: The clinical record for Resident #B was reviewed on 5/27/15 at 10:00 a.m. [DIAGNOSES REDACTED]. The most current Minimum Data Set assessment (Quarterly 5/19/15), indicated the resident's cognitive status (BIMS-brief interview for mental status) score was 15/15 (intact). Review of Resident #B's physician's orders for May 2015, indicated the resident required [MEDICATION NAME]([MEDICATION NAME]-used for pain relief) 100 milligrams (mg) three times a day (original order date 1/5/15) and to assess the resident's pain level every shift. A nurses note dated 5/6/15 at 2:08 p.m., indicated the resident was not feeling well . was diaphoretic, shaky and pale. Review of the resident's electronic Medication Administration Record [REDACTED] During an interview with the Director of Nursing on 5/28/15 at 8:50 a.m., she indicated she is not sure what happened and why the resident's medications were unavailable. She further indicated she was the new DON and had started an investigation and also began inservicing the nurses. During an interview with Resident #B on 5/28/15 at 10:30 a.m., he indicated he did not get his [MEDICATION NAME] all day 5/6/15, they forgot to reorder it, he started feeling ill and was in a lot of pain that night. He also indicated, his pain level is usually well tolerated when he receives the pain medication as ordered. During an interview on 5/28/15 at 11:20 a.m., with the Director of Nursing and the Nurse Consultant, they indicated they were unable to locate a policy or procedure for reordering medications. This Federal tag relates to complaint IN 943. 3.1-48(c)(2)

Based on record review, observation, and interview, the facility failed to ensure a wheelchair was covered appropriately to prevent a deep skin avulsion (laceration injury) for 1 of 3 residents reviewed for injuries in a sample of 3. (Resident #B) Findings include: The clinical record for Resident #B was reviewed on 12/1/14 at 11:05 a.m. [DIAGNOSES REDACTED]. A care plan dated 11/12/14, indicated the resident was at risk for skin breakdown related to fragile skin and a history of skin tears. The goal for the care plan indicated the resident would be free from injuries and skin tears. A nurses note dated 11/9/14 at 3:06 p.m., indicated the resident was observed in bed with a moderate amount of red blood on the sheet, pant leg and geri stocking. The resident had a laceration to the left calf that measured 6 centimeters (cm) X .2 cm X .2 cm (family and physician notified). A hospital Emergency Department (ED) note dated 11/10/14, indicated the resident sustained [REDACTED]. The wound was cleansed, steri strips and dressing applied. The physician's consult also indicated, "we should avoid closing the laceration due to the extended time since the injury." The hospital "After Visit Summary" dated 11/10/14, indicated the resident discharge information included care instructions for a "Deep Skin Avulsion" (layers of skin or parts of body structures have been torn away). The resident was to follow-up with the physician for re-evaluation of the wound. The physician's orders [REDACTED]. Monitor pedal (foot/below the injury) pulses and change the dressing once daily. The investigation documentation provided by the DON on 12/1/14 at 3:55 p.m., indicated ... the padding, which was in place to prevent skin tears, was wearing down to the wheelchair hook up. During an interview with the DON on 12/1/14 at 4:00 p.m., she indicated there were no protocols in place, at that time, for staff to check on the condition of the padding/covering, which was in place to cover the pedal hooks to prevent skin tears. Observations of the wheelchair indicated the area where the foot rests would be attached was being covered because the foot rests had been removed. This Federal tag relates to Complaint IN 590. 3.1-45(1) 3.1-45(2)

Based on observation, record review, and interview, the facility failed to ensure a resident was safely transferred from one surface to another, which resulted in the resident receiving a 14 centimeter skin tear to her leg, a trip to the emergency room , and 24 staples to close the wound, for 1 of 3 residents reviewed for accidents. (Resident #A) Findings include: The clinical record of Resident #A was reviewed on 6/5/14 at 10:00 a.m. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment, dated 1/30/14, and an annual Minimum (MDS) data set [DATE], both indicated Resident #A was severely cognitively impaired and needed extensive assistance of 2 people for transferring. An Incident Report Form, dated 5/7/14, sent by the facility to the Indiana State Department of Health, indicated on 5/6/14 at 6:30 p.m., a Certified Nursing Assistant (CNA) was transferring Resident #A from her wheelchair to her bed. During the transfer, the resident received a 14 centimeter (cm) laceration (irregular tear of the skin) to her left lower leg. The laceration was cleaned and covered, and Resident #A was sent to an emergency room for evaluation and treatment. The report indicated the resident received 24 staples (a means of fastening tissue/skin to one another) to the area of the laceration on her left lower leg. The report indicated the resident's transfer program, plan of care, and assignment sheet were being reviewed, the bed was padded, cognitively intact residents on the unit were being interviewed regarding their transfers, and the CNA was suspended pending investigation. During an observation on 6/2/14 at 1:00 p.m., Resident A's right leg had a dressing on it. During an interview with Unit Manager #1, and the Director of Nursing, on 6/6/14 at 11:30 a.m., Unit Manager #1 indicated it was Resident #A's right leg, not her left leg, which received the skin laceration. A nurse's note, dated 5/6/14 at 6:30 p.m., indicated, "...called to the room per CNA. CNA reported resident had a skin tear and was bleeding. Upon entering the resident's room, signee observed resident in bed and her right LE (lower extremity) was bleeding from a (large) laceration. ....assessed the area, reported to MD (medical doctor) on unit (MD observed), Laceration is 16 cm in length, 3 cm open with 6 cm skin flap, muscle visible...Resident continues to have...bleeding from laceration. Resident denies pain and is asking questions of what happened and what was wrong. Staff reassured resident." A nurse's note dated 5/6/14 at 6:36 p.m., indicated an ambulance was called as the physician wanted the resident to be evaluated in the emergency room . A nurse's note dated 5/6/14 at 7:00 p.m., indicated the resident was transported to the hospital. A nurse's note dated 5/6/14 at 10:33 p.m. indicated Resident #A returned from the hospital at 10:10 p.m. The note indicated, "She has 24 staples in place to RLE, (right lower extremity) that need to be removed in 14 days...." Review of an Associate Warning Notice, provided by the Director of Nursing on 6/2/14 at 3:10 p.m., indicated, "Employee transferred resident as 1 person assist when assignment sheet states 2 person." During an interview with CNA #2 on 6/4/14 at 3:30 p.m., she indicated Resident #A had been assigned to her on the evening shift, 5/6/14. CNA #2 indicated she wasn't really sure how Resident #A got her skin tear. She indicated her assignment sheet on 5/6/14, evening shift said Resident #A was a 2 person transfer, but she did not enlist the help of another staff person to transfer the resident. During an interview with the Director of Nursing on 6/2/14 at 3:00 p.m., she indicated she wasn't really sure what caused the laceration on Resident #A's leg, but CNA #2 should have used 2 people to transfer the resident. During an interview with Unit Manager #1 on 6/5/14 at 3:00 p.m., she indicated CNA #2 should have used 2 people to transfer Resident #A on 5/6/14. She indicated the resident was inconsistent in her ability to assist with transfers and that was why they made Resident #A, "A 2 person transfer." This Federal tag relates to Complaint IN 896. 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure a resident was safely transferred from one surface to another, which resulted in the resident receiving a 14 centimeter skin tear to her leg, a trip to the emergency room , and 24 staples to close the wound, for 1 of 3 residents reviewed for accidents. (Resident #A) Findings include: The clinical record of Resident #A was reviewed on 6/5/14 at 10:00 a.m. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment, dated 1/30/14, and an annual Minimum (MDS) data set [DATE], both indicated Resident #A was severely cognitively impaired and needed extensive assistance of 2 people for transferring. An Incident Report Form, dated 5/7/14, sent by the facility to the Indiana State Department of Health, indicated on 5/6/14 at 6:30 p.m., a Certified Nursing Assistant (CNA) was transferring Resident #A from her wheelchair to her bed. During the transfer, the resident received a 14 centimeter (cm) laceration (irregular tear of the skin) to her left lower leg. The laceration was cleaned and covered, and Resident #A was sent to an emergency room for evaluation and treatment. The report indicated the resident received 24 staples (a means of fastening tissue/skin to one another) to the area of the laceration on her left lower leg. The report indicated the resident's transfer program, plan of care, and assignment sheet were being reviewed, the bed was padded, cognitively intact residents on the unit were being interviewed regarding their transfers, and the CNA was suspended pending investigation. During an observation on 6/2/14 at 1:00 p.m., Resident A's right leg had a dressing on it. During an interview with Unit Manager #1, and the Director of Nursing, on 6/6/14 at 11:30 a.m., Unit Manager #1 indicated it was Resident #A's right leg, not her left leg, which received the skin laceration. A nurse's note, dated 5/6/14 at 6:30 p.m., indicated, "...called to the room per CNA. CNA reported resident had a skin tear and was bleeding. Upon entering the resident's room, signee observed resident in bed and her right LE (lower extremity) was bleeding from a (large) laceration. ....assessed the area, reported to MD (medical doctor) on unit (MD observed), Laceration is 16 cm in length, 3 cm open with 6 cm skin flap, muscle visible...Resident continues to have...bleeding from laceration. Resident denies pain and is asking questions of what happened and what was wrong. Staff reassured resident." A nurse's note dated 5/6/14 at 6:36 p.m., indicated an ambulance was called as the physician wanted the resident to be evaluated in the emergency room . A nurse's note dated 5/6/14 at 7:00 p.m., indicated the resident was transported to the hospital. A nurse's note dated 5/6/14 at 10:33 p.m. indicated Resident #A returned from the hospital at 10:10 p.m. The note indicated, "She has 24 staples in place to RLE, (right lower extremity) that need to be removed in 14 days...." Review of an Associate Warning Notice, provided by the Director of Nursing on 6/2/14 at 3:10 p.m., indicated, "Employee transferred resident as 1 person assist when assignment sheet states 2 person." During an interview with CNA #2 on 6/4/14 at 3:30 p.m., she indicated Resident #A had been assigned to her on the evening shift, 5/6/14. CNA #2 indicated she wasn't really sure how Resident #A got her skin tear. She indicated her assignment sheet on 5/6/14, evening shift said Resident #A was a 2 person transfer, but she did not enlist the help of another staff person to transfer the resident. During an interview with the Director of Nursing on 6/2/14 at 3:00 p.m., she indicated she wasn't really sure what caused the laceration on Resident #A's leg, but CNA #2 should have used 2 people to transfer the resident. During an interview with Unit Manager #1 on 6/5/14 at 3:00 p.m., she indicated CNA #2 should have used 2 people to transfer Resident #A on 5/6/14. She indicated the resident was inconsistent in her ability to assist with transfers and that was why they made Resident #A, "A 2 person transfer." This Federal tag relates to Complaint IN 896. 3.1-45(a)(2)

Based on interview and record review, the facility failed to supervise and prevent an accident/fall, by not providing stand by assistance while toileting a resident for 1 of 4 residents reviewed for falls resulting in resident A sustaining multiple bruises on multiple extremities, back, and head and a subdural hematoma (bleeding in the brain). (Resident A). Findings include: The clinical record for Resident A was reviewed on 3/27/11 at 3:30 p.m. The [DIAGNOSES REDACTED]. The ER (emergency room )/hospital records, dated 3/11/12, indicated that Resident A presented to the ER with multiple bruises on multiple extremities, back, and head and a subdural hematoma. A hospital critical care progress note, dated 3/11/12, indicated a subarachnoid hemorrhage and right breast hematoma. A facility progress, dated 3/10/12 at 9:20 a.m., indicated "res (resident) (sic) being assisted up for am care, restorative care CNA attempting to get res up and res 'legs just buckled' (sic) res was lowered to the floor via CNA, with gait belt on, res was assesse (sic) and gotten up off the floor with assist of two (sic) res has no red (sic)open or irritated areas noted, all necessary parties notified, res has call light in reach" A facility progress note, dated 3/11/12 at 6:57 a.m., indicated an "aide came down the hall and notified nurse that there was a resident on the ground. When the nurse walked into the room, the resident was lying on the floor holding her head in pain. ROM (range of motion) on all extremities was good. Bruising on right forehead measures 6 cm (centimeter) x 6 cm. No bleeding. Doctor notified. Doctor said to send her out. POA and Pharmacy notified." In an interview with the DoN (Director of Nursing), on 3/29/12 at 12:00 p.m., she indicated stand by assistance is communicated with the staff per the A/B/C Wing Resident Information Sheet. In an interview with PT #2, on 3/29/12 at 12:20 p.m., she indicated while Resident #A was residing in the facility, she needed stand by assistance while on a bedside commode and this type of information is passed on to nursing in daily and weekly meetings. PT #2 also indicated that stand by assistance means within arm's length to provide immediate assistance, if needed. In an interview with OT #3, on 3/29/12 at 12:40 p.m., she indicated while Resident A was residing in the facility, she needed stand by assistance while on a toilet or bedside commode and this type of information is passed on to nursing in daily meetings and weekly meetings. OT #3 also indicated that stand by assistance means within arm's length to provide immediate assistance if needed. The OT (Occupational Therapy)-Therapist Progress Report and Discharge Summary, dated 3/09/12 , indicated, for "Current Level of Function for Self Care: Toileting-General," that Resident A is able to safely perform all toileting tasks utilizing grab bars and required CGA (contact guard assistance). In a interview with OT #3, on 3/29/12 at 1:20 p.m., OT #3 indicated on the Discharge Summary for Resident A, that Resident A still needed stand by assistance with grab bars while toileting, which also means CGA (contact guard assistance). OT #3 reiterated that stand by assistance means that staff is to be within arm's length, to provide assistance, if needed, immediately. The C Wing Resident Information Sheet, no date indicated, indicated Resident A was to be transferred and toileted with 1 assist. There was no further information on assisting resident while toileting to indicate that resident needed stand by assistance while on the toilet per OT and PT's recommendation. In an interview with CNA #1, on 3/29/12 at 3:40 p.m., she indicated she transferred Resident A to a bedside commode and went into bathroom to retrieve washcloths and to start the water to clean the resident up. While the water was running, she heard a bang and found resident on the floor, holding her head. CNA #1 indicated that the resident has been more confused recently and it was reported to her that the resident had an "assisted fall," the previous day. CNA #1 also indicated that she did not know that Resident #A was a stand by assist. In another interview with CNA #1, on 3/30/12 at 12:15 p.m., she reiterated that Resident A has become more confused within the recent days of the 3/11/12 fall. This federal tag relates to Compliant #IN 408. 3.1-45(a)(2)