Every finding on record at Aperion Care Arbors Michigan City

Based on observation, record review, and interview, the facility failed to ensure residents received the necessary care and treatment related to oxygen not administered as ordered for 1 of 3 residents reviewed for respiratory care. (Resident C)Finding includes:On 7/15/26 at 12:29 p.m., Resident C was observed sitting up in bed. An oxygen concentrator was next to the bed with tubing attached in a bag. The concentrator was turned off. The resident indicated she only used oxygen at night.On 7/15/25 at 3:05 p.m., Resident C was observed lying in bed. The oxygen concentrator next to the bed was still turned off.Record review for Resident C was completed on 7/15/26 at 2:28 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease, and chronic respiratory failure.A Physician's Order, dated 6/13/26, indicated to administer oxygen at 3 liters continuous every shift. A Care Plan, dated 6/15/26, indicated the resident had oxygen therapy. An intervention included to administer oxygen as ordered. The admission Minimum Data Set assessment, dated 6/19/26, indicated the resident was cognitively intact. The resident was dependent on staff for transfers. The resident received oxygen therapy.During an interview on 7/15/26 at 3:07 p.m., LPN 1 indicated the resident was supposed to have the oxygen on at 3 liters at all times. The resident would sometimes remove the oxygen herself and turn off the concentrator.There was a lack of documentation to indicate the resident had been removing her oxygen and turning off the concentrator.An oxygen policy was not provided by the facility.This citation relates to Intake 3029017.410 IAC (Indiana Administrative Code) 16.2-3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure pain medications were available and administered as ordered when residents complained of pain for 2 of 3 residents reviewed for pain. (Residents B and D)Findings include:1. A closed record review for Resident B was completed on 7/15/26 at 10:20 a.m. Diagnoses included, but were not limited to, difficulty walking, chronic obstructive pulmonary disease, anxiety, and depression. The resident was admitted to the facility on [DATE] and discharged home on 5/17/26.The admission Assessment, dated 5/16/26, indicated the resident arrived from the hospital on 5/16/26 at 1:38 p.m. The resident was alert and oriented. The resident had mild pain everywhere and was to receive acetaminophen (pain/fever reducer) 650 milligrams (mg) every 4 hours PRN (when necessary), and Norco (pain medication) 10-325 mg every 6 hours PRN. The Pain Care Plan in the assessment indicated the resident had pain. An intervention included anticipating the resident's need for pain relief and responding immediately to any complaint of pain.The May 2026 Physician's Order Summary (POS) indicated the following orders:- pain assessment every shift- Norco 10-325 mg, administer 1 tablet every 6 hours as needed for moderate pain of 4-6 on pain scaleThere was a lack of documentation to indicate a Physician's Order for the PRN acetaminophen.The May 2026 Medication Administration Record (MAR) indicated the resident had complained of pain of a 4 on 5/17/26 at 8:00 a.m. No PRN Norco was administered.There was a lack of documentation to indicate the doctor had been notified the resident had complained of pain and they had not received the PRN Norco or had an order for PRN acetaminophen.A Nurses Note, dated 5/17/26 at 6:43 p.m., indicated the resident's family came in to the facility around 4:50 p.m. The family indicated they were taking the resident home because the facility was not taking care of the resident's pain. The resident left the facility against medical advice. A Concern Form, dated 6/1/26, indicated the resident's family had called the facility with concerns related to oxygen and narcotic medications unavailable. The Administrator and Director of Nursing (DON) indicated the concerns were partially substantiated. They found the medications could have been timelier. The corrective action taken was initiating telehealth medicine for all new residents to ensure medications were in place and training was initiated. During an interview on 7/15/26 at 2:21 p.m., the DON indicated they had changed pharmacies and were having trouble with the new one. The nurse should have called the telehealth doctor to inform him the Norco had not been delivered and asked if they wanted to order any other medications or pull the medication from the Emergency Drug Kit. 2. On 7/15/26 at 12:29 p.m., Resident D was observed lying in bed. He indicated when he was admitted to the facility, he kept asking for pain medication and didn't receive any for multiple days. Record review for Resident D was completed on 7/15/26 at 2:15 p.m. Diagnoses included, but were not limited to, arthritis and heart failure. The resident was admitted to the facility on [DATE].A Physician Progress Note, dated 7/6/26 at 6:06 p.m., indicated the resident was seen and examined. The resident reported left knee pain of a 4-5 that morning before he received his pain medication. The resident indicated the pain typically improved to about 3 after the medication. The plan was to continue his PRN Norco.A Care Plan, dated 7/6/26, indicated the resident was on pain medication. An intervention included administering pain medications as ordered by the physician.The admission Minimum Data Set assessment, dated 7/10/26, indicated the resident was cognitively intact. The resident received PRN pain medication and had occasional pain of 4.The July 2026 POS indicated the following orders:- pain assessment every shift- Norco 5-325 mg, give 1 tablet every 6 hours PRN for moderate pain of 4-6 on pain scale, ordered 7/5/26 The July 2026 MAR indicated the resident had complained of pain of a 5 on 7/8/26 at 8:00 a.m., and again of a 4 on 7/9/26 at 8 a.m. No PRN Norco was administered on 7/8/26. A PRN Norco was not administered until 10:45 a.m., on 7/9/26. There was a lack of documentation the resident had received any PRN Norco until 7/9/26. The resident had complained of pain on 7/6, 7/8, and 7/9/26.A Concern Form, dated 7/9/26, indicated the resident had a concern that he had not received any pain medication since he was admitted and had asked for them daily. The DON found the concern partially substantiated. The pharmacy didn't send the medication. The pharmacy was called and an order was placed in the medication bank.During an interview on 7/15/26 at 2:21 p.m., the DON indicated they had changed pharmacies and were having trouble with the new one. The nurse should have called the telehealth doctor to inform him the Norco had not been delivered and get an order to pull the medication from the Emergency Medication Kit timelier.A facility policy titled, Physician Orders - Entering and Processing and received as current from the Administrator on 7/15/26, indicated, .3. Notify the resident's physician (if not the prescribing physician), for verification if applicable .4. If the medication is needed immediately, it will be removed from the Emergency Drug Kit (EDK) .This citation relates to Intake 3029017.410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on observation and interview, the facility failed to maintain comfortable and home like environment for 1 of 3 residents reviewed for environment. (Resident B)Finding includes:On 5/12/26 at 10:55 a.m., Resident B was observed lying down in bed. The resident had indicated he was lying on a broken old bed and his new bed had been sitting in the hallway and was the wrong bed. The resident rolled over and showed he had no headboard on his bed.During an interview at the time, Resident B indicated he had not had a headboard for months and the facility knew about it. The headboard was broken and maintenance just came and ripped it the rest of the way off the bed. The resident indicated he was almost 600 pounds and the facility ordered him the wrong bed.Resident B's record was reviewed on 5/12/26 at 10:45 a.m. Diagnoses included, but were not limited to, high blood pressure, heart failure, COPD (Chronic Obstructive Pulmonary Disease) and respiratory failure.The Quarterly Minimum Data Set (MDS) assessment, dated 2/11/26, indicated the resident was cognitively intact for daily decision making. The resident required supervision for bed mobility.During an interview on 5/12/26 at 11:05 a.m., the Maintenance Director indicated when his staff tried to put the new bed in Resident B's room when it was delivered, the resident refused the bed. When the staff tried again a few minutes ago, the resident refused the bed again. The resident indicated that they had the wrong bed. The resident had broken 3 beds and he had broken the headboard before as well because he used it to help himself get out of bed. He had told the Administrator and they ordered a new bed.During an interview on 5/12/26 at 11:35 a.m., the Administrator provided the order form for the bed that was ordered for Resident B. He indicated the maximum weight for the bed was 550 pounds and the resident weighed 571 pounds. He understood the concern with the resident not having a headboard and that the bed ordered would not accommodate the resident's weight. A new bariatric bed would be ordered by the end of the day.During an interview on 5/12/26 at 12:57 p.m., the Administrator indicated Maintenance found a bariatric bed in the facility. They would be moving the resident to that bed when he was ready to get up for the day.This citation relates to Intake 2992284.410 IAC (Indiana Administrative Code) 16.2-3.1-19(h)

Based on record review and interview, the facility failed to initiate effective resident-specific interventions and provide adequate supervision to prevent the elopement from the facility of a resident with a diagnosis of dementia, a history of exit-seeking behaviors and a wanderguard (door alarm bracelet) in place for 1 of 3 residents reviewed for elopement risk. The resident exited the building without the knowledge of the staff working in the facility and was found the next day by the local police department and was taken to the hospital Emergency Room. (Resident B)The Immediate Jeopardy began on [DATE], when the facility was unaware that the resident had exited the facility without supervision. The resident walked independently and was found over 24 hours later by local police, and Emergency Services transported the resident to the hospital. The Administrator, Director of Nursing (DON), and [NAME] President of Clinical Operations were notified of the immediate jeopardy on [DATE] at 3:55 p.m. The immediate jeopardy was removed and the deficient practice corrected on [DATE], prior to the start of the survey, and was therefore past noncompliance. Finding includes:The record for Resident B was reviewed on [DATE] at 10:11 a.m. Diagnoses included, but were not limited to, dementia, anxiety, unspecified psychosis, adult failure to thrive, personal history of traumatic brain injury, bipolar disorder, cognitive communication deficit, difficulty walking, and depression. The Quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident had severe cognitive impairment for daily decision making. The resident required supervision for all activities of daily living (ADLs) and transfers. An Elopement Risk and Community Survival Skills assessment, dated [DATE], indicated the resident should be placed on elopement risk protocol.A Care Plan, dated [DATE], indicated the resident required supervision when out in the community. An approach was for a survival skills assessment to be conducted quarterly to determine safety when outside in the community.A Care Plan, dated [DATE], indicated the resident resided on a secured unit related to dementia diagnosis. Approaches were to validate the resident's fears and concerns through listening and explain all care and reasons before beginning.A Care Plan, dated [DATE], indicated the resident had a history of exit-seeking and wandering and was at risk for elopement. Approaches were to anticipate care needs and provide them before the resident became overly stressed, administer medications and observe for side effects and attempt to redirect.An Elopement Risk and Community Survival Skills assessment, dated [DATE], indicated the resident should be placed on elopement risk protocol.A Social Service Note, dated [DATE] at 2:26 p.m., indicated a message was left with the resident's daughter related to a decision to transition the resident off memory care to a regular Long-Term care bed per her request. The interdisciplinary team agreed and the transfer was scheduled for [DATE] to room [ROOM NUMBER]. A Wanderguard would be placed during transition for safety.A Nurse's Note, dated [DATE] at 1:16 p.m., indicated the resident had transitioned from memory care unit to a less restrictive unit within the facility. The daughter was present at time of transfer, and the resident tolerated the move without distress. Upon arrival to the new unit, the resident had adjusted appropriately to his new environment. No concerns were noted and would continue to monitor for ongoing adjustment and safety.A Social Service's Note, dated [DATE] at 9:09 a.m., indicated a wanderguard was placed on the resident's left ankle.A Nurse's Note, dated [DATE] at 9:00 p.m., indicated the resident was outside of the facility and a code pink was announced. Nurses and aides looked in rooms and outside the building.An Indiana Department of Health (IDOH) facility reported incident, dated [DATE], indicated Resident B had left the facility without notifying staff. The Administrator and Director of Nursing (DON) went to the facility and initiated the investigation. The local police department was notified and assisted with search of the resident. The next day on [DATE] at 1:50 p.m., the resident was found by police and was transported to the hospital for evaluation. No injury was reported.The facility's investigation follow up indicated all staff had been educated on elopement and wander guards, an audit was completed on wander guard residents by the Director of Nursing over 72 hours, the wanderguard system was inspected and found to be in correct working order, written statements by all staff who worked on [DATE], a timeline of events, and an abatement plan were included in the investigation binder.A written statement on [DATE] by Activity aide 1 indicated she had let Resident B out for a 1:00 p.m. smoke break. The resident had not seemed annoyed or on edge and he enjoyed the weather. He had gone back inside the building shortly after his smoke break.A written statement on [DATE] by QMA 1 indicated her statement served as a search and rescue /recovery effort that was initiated at 7:50 p.m. on [DATE] and ongoing. From 7:50 p.m.-11:30 p.m., she had coordinated an intensive search with another CNA. They performed multiple sweeps of the facility's interior, courtyard, and exterior perimeter. They drove through Michigan City for three hours or longer checking local landmarks, intersections, and areas the resident was known to frequent. All staff and management were looking for the resident. Law enforcement was notified, and the nurse contacted the Power of Attorney (POA).A written statement from CNA 1 on [DATE] indicated she had not seen the resident from room [ROOM NUMBER] (Resident B) at all on her 2:00p.m. to 10:00 p.m. shift.A written statement by LPN 2 on [DATE] indicated he was at the nurse's station when an aide came up to him and said she thought she had seen a resident outside. I went to look and did not see a resident and came back in and informed the DON. I then made an announcement to look for the resident.A written statement by Social Services on [DATE] indicated she placed a brand new wanderguard to the resident's left ankle, it was not expired, it was brand new from the package.A written statement by CNA 2 on [DATE] indicated at 9:10 p.m. on [DATE] a code pink was called. She had seen QMA 1 coming down the hall and she had said she was going to drive around and look for the resident. CNA 2 offered to go with her and drive. They looked around the whole building and the building next door, then they drove around to stores, gas stations, and parks.A Police Report, obtained on [DATE] at 1:33 p.m., indicated a police officer was dispatched to the facility on [DATE] at 10:01 p.m. because a resident had left the facility unattended. The executive director explained that the resident had been at the facility since [DATE] and had dementia. Staff were able to get in contact with the resident's daughter via telephone and she had reached out to the resident's friends who lived in the area. One of the residents' friends indicated Resident B had come to her house on a nearby street at approximately 1:30 p.m. and left at approximately 5:30 p.m. She had given the resident $20.00, and the resident indicated he was going to get a hot dog. On Thursday [DATE] at 9:40 a.m., a K9 officer responded to an attempt to locate the resident. A scent article was obtained from the resident's belongings to assist in the K9 search. Due to resident B's condition and an approaching storm reported for the area, assistance was requested from a nearby county Search and Rescue. The local County deputies and another nearby city police force deployed [NAME] to search for Resident B. At approximately 1:47 p.m., Resident B was seen walking out from a nearby wooded/dead end area. The resident was in the same clothing he was reported missing in and was stumbling, covered in dirt/moss and disoriented. He was unable to identify where he was from. He made statements that indicated confusion including that he had no blood left in his heart and could not eat. The resident refused medical treatment and indicated he would not go back to the facility. The resident's daughter/ power of attorney (POA) requested the resident be transported to the hospital for evaluation. The resident was placed under emergency detention for evaluation.A Physician's Order, dated [DATE] at 3:00 p.m., indicated to observe wanderguard on left ankle for placement every shift.A Nurse's Note, dated [DATE] at 1:49 p.m., indicated Resident B was located by police officers and taken to the hospital for evaluation.The Medication Administration Record for [DATE] indicated the wanderguard was signed out on [DATE] for the evening shift. There was no written plan for the safe adjustment of Resident B from the locked memory care unit to an unsecured unit. The record lacked 15-minute safety checks and there was no 72-hour charting or assessments initiated to document safety and adjustment.The resident's care plan related to exit-seeking and wandering had not been updated to reflect new interventions or the room change off of the locked memory care unit.During an interview on [DATE] at 10:57 a.m., the Administrator indicated Resident B was originally admitted to the 400 unit for rehab in December. Staff had noticed the resident was wandering in the hallways and exit-seeking, so they made the decision to move him to the secure memory care unit in January. He was on the secured unit with no exit-seeking behaviors and had a good mentation. The POA/resident's daughter works in health care and indicated her dad had rights and the facility was stifling his psychosocial development by keeping him on the secured unit. They had noticed no exit-seeking behaviors for the last 3 months, so they graduated him out of the secured unit. The resident moved out of the secured unit on [DATE].During an interview on [DATE] at 11:11 a.m., the DON indicated the wanderguard alarms did not go off because the resident had removed the wanderguard prior to exiting the facility. They had been searching for the wanderguard but had not located it. She had the alarm system tested and everything was working properly.During an interview on [DATE] at 1:18 p.m., CNA 1 indicated she had been working as an aide on the 200 unit, but Resident B was not in her line up. She had seen the resident around lunchtime as he was walking toward the dining room. She had not noticed any exit-seeking behavior at the time. She did not check for a wanderguard because she did not know he had one until after the fact. She found out the next day after he had already left the building.During an interview on [DATE] at 1:28 p.m., CNA 2 indicated she was working as an aide on the 200 unit. She indicated that Resident B was in her line up, but she had not received shift report and did not know there was a new resident in room [ROOM NUMBER]. She had not seen Resident B at all her entire shift, she did not even know what he looked like. Resident B's roommate stays out of his room all day until it is time for bed and he does not like going back to his room. The first time she stepped into room [ROOM NUMBER] was about 8:30 p.m. when she was putting Resident B's roommate to bed. That was when she realized there was an unmade bed and a cell phone. She asked LPN 1 about the resident's wherabouts and he told her the resident had a wanderguard on. They then began searching for the resident throughout the building. She had to look up the resident's picture because she had no idea what he looked like.QMA 1 and LPN 2 were unavailable for interview during the survey.On [DATE] at 3:44 p.m., video surveillance was reviewed with the Administrator. Resident B was seen returning to the facility in a silver car and exited the passenger's side of the car at 11:20 a.m. The resident remained in the front of building and then at approximately 11:24 a.m., the resident was seen walking away from the building toward the street wearing the same clothing that matched the description given to police.During an interview at the time, the Administrator indicated there was no video surveillance of the resident returning inside the facility or initially leaving. He also pointed out that there was no wanderguard on the resident's left leg and noted it would be bulky around the ankle since the tag sticks out. He indicated that was how it had normally looked on the resident. The police were given the details on the silver car and had no update on who the car belonged to. The administrator was unsure if the resident exited initially from the front door or a different door, but another resident could have given him the passcode. All doors are locked and require a passcode for entry and exit.During an interview on [DATE] at 3:55 p.m., the Administrator and Regional Nurse Consultant indicated they understood the immediate jeopardy concerns and said there should have been more safety checks initiated for Resident B after being moved off of the locked memory care unit.On [DATE] at 10:00 a.m., the Wanderguard alarm system at the front door was checked with the Maintenance Director, DON, Administrator and Resident E (wanderguard resident) and the alarm sounded. The Administrator indicated the doors were always locked so a lock mechanism did not need to engage. All points of entry to the facility had a keypad to enter and exit. The alarm sounds at the front door and at the 200 nurse's station when activated. Initially the alarm did not go off at the nurse's station because the button got stuck on the alarm, but it was quickly fixed. When released, both alarms worked properly. All doors were checked, they all alarmed when triggered. The wander guard system was in working order.During an interview on [DATE] at 1:09 p.m., Activity Aide 1 indicated she had personally taken the resident out during the 1:00 p.m. smoking break on [DATE]. He was calm and was enjoying the weather and looking at the sky. He had a short smoke break, he took about 10 minutes and went back inside the building. She did not see the resident for the 4:00 p.m. or 6:30 p.m. smoke breaks and the resident was not in his room during those times. She had worked 11:00 a.m. to 7:00 p.m. that day. She was not aware the resident was wearing a wanderguard or was an elopement risk. During an interview on [DATE] at 1:15 p.m., the Administrator confirmed that the resident was seen on the video system returning to the front of the facility in a car at 11:20 a.m. and was also seen inside the building at 1:00 p.m. by the Activity Aide for a scheduled smoking break. The resident was not seen by any staff member after the smoke break, was not seen exiting the facility at any time that day, and the wanderguard should have not been signed out for evening shift. During an interview on [DATE] at 1:23 p.m., the Social Service Director (SSD) indicated when the resident had first transferred to the facility back in December, he was observed to have confusion and was wandering. His room was closer to the exit than to the nurses' station and since he was confused and wandering, they thought he would be safer on the memory care unit. The daughter/POA had called the ombudsman because her father was on memory care and she had felt that was inappropriate placement. The daughter/POA had emailed her that her father was not flourishing in memory care and she wanted him transferred out. After three months, she asked if they could revisit the conversation and try to transfer her father to a regular unit since he had no incidents of exit-seeking in the memory care unit. The daughter/POA would tell the nurses her dad does not have dementia, she would ask for verbiage to use to get her dad admitted to an assisted living. She had then wanted him transferred to two other skilled facilities so he could flourish in an appropriate environment. The POA liked remodeled properties and felt that would suit him better. The SSD discussed with her that her dad was doing well in memory care, he was making friends and was coming out of his shell, but she would not hear of it, she wanted him out of memory care. She had been educated on [DATE] that as an interdisciplinary team, they would review and put proper safety systems in place at the time of his transfer from memory care such as 15 minute checks for 48 hours, she was educated on code Pink and the new nurse rounding protocol. They added picture grids to all of the elopement binders and there was a binder on each unit and one at the reception desk. The current facility policy, titled, Code Pink-Missing Resident/Elopement was provided by the Administrator on [DATE] at 10:32 a.m. The policy indicated interventions for elopement risks were . a. wanderguard bracelet b. increased monitoring such as 15-minute visual checks, 1:1 supervision c. evaluate for secured unit if available and appropriate.The past noncompliance immediate jeopardy began on [DATE]. The immediate jeopardy was removed and the deficient practice corrected on [DATE] after the facility implemented a systemic plan that included the following actions: the facility immediately had a quality assurance meeting with the department heads and implemented a new protocol for residents at elopement risk, especially newly transferred residents. All staff were then inserviced on code pink protocol for a missing person, elopement risk, wanderguards, new purposeful rounding for nursing staff, and 15-minute checks for 48 hours on any transferred residents. All staff observed and interviewed throughout the survey were aware of the newly implemented plan and proper procedures. This citation relates to Intake 2965919. 410 IAC (Indiana Administrative Code) 16.2-3.1- 45(a)(2)

Based on record review and interview, the facility failed to provide treatments as ordered and did not complete a skin assessment upon readmission for 1 of 3 residents reviewed for pressure ulcers. (Resident B)Finding includes:The record for Resident B was reviewed on 2/9/26 at 8:55 a.m. Diagnoses included, but were not limited to COPD, respiratory failure, diabetes, arthritis, heart failure, and pressure ulcer.A Care Plan, dated 11/10/25, indicated the resident had a pressure ulcer to left buttock, right buttock, left ischial tuberosity related to immobility, incontinence, obesity, fragile skin, and history of pressure ulcers. Interventions were to provide treatment as ordered, supplements as ordered to promote wound healing and assist with offloading bilateral lower extremities.The 12/11/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and was dependent with toileting, showering and lower body dressing. The resident needed substantial to maximum assistance for bed mobility and transfers. Sit to stand, chair to bed, and shower transfers required dependent assistance. The resident had a pressure ulcer and used a wheelchair.A Physician's Order, dated 12/11/25, indicated clean left buttock with soap/water, pat dry, apply zinc barrier cream mixed with antifungal ointment, and cover with bordered gauze every night shift for wound care.A Physician's Order, dated 12/11/25, indicated clean right buttock with soap/water, pat dry, apply zinc barrier cream mixed with antifungal ointment, and cover with bordered gauze every night shift for wound care.The December 2025 Treatment Administration Record (TAR) indicated the treatment was not signed out for the left and right buttock on December 20, 21, and 22, 2025.A Nurse's Note, dated 1/1/26 at 3:00 p.m., indicated the resident arrived to the facility via stretcher and was able to make needs known.A Nurse's Note, dated 1/1/26 at 3:00 p.m., indicated wounds/skin concerns presented with no changes in skin integrity.A Physician's Order, dated 1/2/26, indicated clean with Dakin's, pat dry, apply Dakin's-soaked gauze to wound bed, apply calcium alginate, and cover with bordered gauze every night shift for wound care.The January 2026 Treatment Administration Record (TAR) indicated the treatment was not signed out on January 2, and 3, 2026.During an interview on 2/10/26 at 8:50 a.m., the Director of Nursing (DON) indicated the nurse did not perform a skin assessment on 1/1/26, but she did perform it on 1/2/26 and identified the wound and ordered treatments to begin.During an interview on 2/10/26 at 9:00 a.m., the DON indicated she understood the concern and the skin assessment should have been completed on the day of readmission and not the next day and treatments should have been signed out.This citation relates to Intake 2716013. 3.1-40(a)(2)

Based on observation, record review, and interview, the facility failed to ensure activities of daily living (ADLs) were completed for dependent residents related to the removal of facial hair, dirty fingernails, and hair care for 3 of 7 residents reviewed for ADLs. The facility also failed to ensure a dependent resident received a sack lunch to take with him to dialysis for 1 of 1 resident reviewed for dialysis. (Residents 5, 11, 6 and 7)Findings include: 1.On 12/1/25 at 11:15 a.m., Resident 5 was seated in his wheelchair, he had an accumulation of facial hair. During an interview at that time, the resident indicated he preferred to be clean shaven. On 12/2/25 at 3:47 p.m., the resident was seated in his wheelchair in his room. He remained unshaven. On 12/3/25 at 9:22 a.m. and 1:27 p.m., the resident remained unshaven. During an interview on 12/3/25 at 1:30 p.m., the resident indicated he could use a shave. On 12/4/25 at 11:00 a.m., the resident's facial hair remained. At 11:08 a.m., CNA 2 was taken into the resident's room. The CNA asked the resident if he would like a shave and the resident indicated he needed one. The CNA indicated she would get the resident shaved. At 1:07 p.m., the resident was in his room watching television and had not been shaved. The record for Resident 5 was reviewed on 12/4/25 at 9:01 a.m. Diagnoses included, but were not limited to, altered mental status and mild intellectual disabilities. The Annual Minimum Data Set (MDS) assessment, dated 9/29/25, indicated the resident was moderately impaired for daily decision making and he required supervision or touching assistance for personal hygiene and partial to moderate assistance with bathing. A current Care Plan indicated the resident had an ADL self-care performance deficit related to impaired balance, limited mobility, chronic obstructive pulmonary disease (COPD), and weakness. Interventions included, but were not limited to, one person staff assistance for bathing and personal hygiene. During an interview on 12/4/25 at 3:30 p.m., the Director of Nursing indicated the resident should have been shaved per his request and she would check into it. 2. During an interview on 12/2/25 at 11:01 a.m., Resident 11 indicated her hair was not routinely washed every week as she preferred to have a complete bed bath versus a shower. She would like her hair washed at least three times a week. The record for Resident 11 was reviewed on 12/3/25 at 12:00 p.m. Diagnoses included, but were not limited to, CHF, cellulitis lower limbs, chronic ulcers of the skin, panic disorder, adult failure to thrive, anxiety, major depressive disorder, and fibromyalgia (a chronic condition causing widespread body pain). The 11/7/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and was dependent on staff for bathing and hair washing. The resident had scheduled and prn (as needed) pain medication for occasional pain. Her pain was five out of 10. She received an opioid medication. A Care Plan, revised 4/11/25, indicated the resident had an ADL self care deficit. A Care Plan, revised on 11/10/25, indicated the resident was non-compliant/resistive to care with with showers, wound care, and daily care. Shower sheets for 10/2025 and 11/2025, indicated the resident received a bed bath on 10/7, 10/10, 10/14, 10/17, 10/21, 10/24, 10/31, 11/4, 11/7, 11/14 and 11/25/25, however, for the section hair washed it was blank and not completed. For bed baths completed on 11/18, 11/21, and 11/28/25, the section hair washed was coded No. There was no documentation in nursing notes or on the shower sheets where the resident refused to have her hair washed. During an interview on 12/4/25 at 10:40 a.m., ADON 3 indicated the resident's hair should be washed as needed. During an interview on 12/4/25 at 11:00 a.m., the Director of Nursing indicated she has talked and tried to convince the resident to take a shower, however, she was afraid of the shower bed/chair. She was aware the resident did refuse baths and showers, however, staff needed to document the refusals of for her hair being washed. 3. During an observation on 12/1/25 at 11:10 a.m. Resident 6 was observed sitting in his wheelchair. At that time, he had a large amount of facial hair on his chin and neck. The resident's left hand fingernails were dirty with a brown-like substance underneath them. The resident indicated at that time, he preferred to be shaved. During random observations on 12/2/25 at 10:05 a.m., on 12/3/25 at 9:12 a.m., 9:55 a.m., and 2:41 p.m., and on 12/4/25 at 9:25 a.m., the resident was observed with a large amount of facial hair and his right hand fingernails were dirty. During an observation on 12/3/25 at 9:50 a.m. the resident was pushed out of the shower room with wet hair. He was not shaved nor were his nails cleaned. During an observation on 12/4/25 at10:16 a.m., CNA 3 was in the resident's room. At that time, the CNA observed the resident's fingernails and indicated they were in need of cleaning. She also indicated male residents were usually shaved on their shower days. The record for Resident 6 was reviewed on 12/3/25 at 9:20 a.m. Diagnoses included, but were not limited to, stroke, anxiety, adult failure to thrive, vascular dementia, major depressive disorder, dementia, long term use of anticoagulants, and atrial fibrillation. The Quarterly Minimum Data Set (MDS) assessment, dated 9/3/25, indicated the resident was not alert and oriented for daily decision making and was dependent on staff for personal hygiene and bathing. A Care Plan, revised on 4/22/25, indicated the resident had an ADL self-care/mobility performance (functional abilities) deficit. The November 2025 shower sheets indicated nail care was completed for the resident on 11/1, 11/15, 11/19, and 11/22/25. There was no documentation of the resident being shaved. A skin/shower sheet provided on 12/4/25 at 10:55 a.m. by the Director of Nursing (DON) indicated the resident was last shaved on 11/26/25 and nail care was also provided. During an interview on 12/4/25 at 10:58 a.m., the DON indicated the CNA that showered him yesterday said she did shave him, and told her the razors they used were terrible. She indicated the resident's nails should have been cleaned and he should have been shaved as needed. 4. During an interview on 12/2/25 at 11:44 a.m., Resident 7 indicated he went to dialysis on Monday, Wednesday, and Fridays. On those days, he missed lunch. The facility did not always pack him a lunch and he would have to wait to eat until supper. The record for Resident 7 was reviewed on 12/03/25 at 8:43 a.m. Diagnoses included, but were not limited to, chronic kidney disease and diabetes. The Quarterly Minimum Data Set (MDS) assessment, dated 11/4/25, indicated the resident was cognitively intact for daily decision making, required assistance with activities of daily living (ADLs), and was on dialysis. A Care Plan, revised on 5/4/24, indicated the resident had a potential nutritional problem. Interventions included to provide and serve diet as ordered. During an interview on 12/8/25 at 11:45 a.m., PT 1 indicated the resident came to therapy after he returned from dialysis on Monday, Wednesday, and Friday. She indicated he was not regularly getting a lunch to take with him to dialysis. There were times he did not feel well, and she gave him food she had to eat in the therapy gym. She indicated she and the rehab director communicated with the kitchen about sending a lunch with the resident, but he would often come to therapy from dialysis hungry. During an interview on 12/8/25 at 3:15 p.m., the Director of Nursing (DON) was informed of the finding. No additional information was received. 3.1-38(a)(2)(D) 3.1-38(a)(3)(B) 3.1-38(a)(3)(D) 3.1-38(a)(3)(E)

Based on observation, record review, and interview, the facility failed to ensure follow up documentation after a fall was completed for 1 of 4 residents reviewed for accidents. The facility also failed to ensure a treatment to a skin tear was completed as ordered, areas of bruising and skin lesions were assessed and monitored, and geri-sleeves and/or long sleeves were in use for 5 of 6 residents reviewed for skin conditions non-pressure related. The facility also failed to monitor and assess edema for 2 of 2 residents reviewed for edema. (Residents 6, 9, 70, 14, and 28)Findings include:1. During an observation on 12/1/25 at 11:10 a.m., Resident 6 was observed sitting in his wheelchair next to the bed. At that time, the resident's right hand was wrapped in a kerlix bandage. During an observation on 12/3/25 at 9:12 a.m., the resident was in bed wearing a short sleeved hospital gown. He had a large red and purple bruise to his left elbow. At 9:29 a.m., the resident was taken to the shower room for a bath. At 9:50 a.m., he was wheeled out of the shower room wearing a short sleeve shirt. During a treatment observation on 12/3/25 at 2:41 p.m. the Wound Nurse Consultant removed the old bandage from the right hand. At that time there was a gauze sponge over the wound and when removed, there were 2 pieces of Xeroform dressing on top of the skin tear. During an interview at that time, the Wound Nurse Consultant indicated that was not the treatment order. The Xeroform bandage should not have been placed on the skin tear. During an observation on 12/4/25 at 9:25 a.m., the resident was sitting in his wheelchair next to his bed wearing a short sleeve shirt. On 12/4/25 at 10:16 a.m., CNA 2 entered the resident's room and was asked if she knew the resident was to wear long sleeves, geri sleeves or tubi grips. She indicated she was not aware of that information. She then checked the computer and there was no information the resident was to be wearing long sleeves due to fragile skin. During an observation on 12/4/25 at 10:35 a.m., ADON 3 entered the resident's room. At that time, she indicated she was aware of the bruising to the resident's left hand, however she was not aware of the bruise to the left elbow. The record for Resident 6 was reviewed on 12/3/25 at 9:20 a.m. Diagnoses included, but were not limited to, stroke, anxiety, adult failure to thrive, vascular dementia, major depressive disorder, dementia, long term use of anticoagulants, and atrial fibrillation. The Quarterly Minimum Data Set (MDS) assessment, dated 9/3/25, indicated the resident was not alert and oriented for daily decision making and was dependent on staff for personal hygiene and bathing. A Care Plan, revised on 6/12/25, indicted the resident was at risk for bruising related to anticoagulant use. The approaches were to asses for bruises. A Care Plan, revised on 6/12/25, indicated the resident had the potential for skin impairment and had a history of picking at his skin. The approaches were to encourage the resident to be compliant with interventions to protect the skin, including long sleeves, geri sleeves, or tubi grips to bilateral arms. A Physician's Order, dated 12/1/25, indicated to cleanse the skin tear with normal saline, apply bacitracin to the wound bed, cover with gauze and wrap with kerlix every Monday, Wednesday and Friday. The skin tear measurements, dated 12/1/25, indicated the area measured 4.5 centimeters (cm) in length and 0.20 cm in width. During an interview on 12/4/25 at 10:40 a.m., ADON 3 indicated she would assess the new bruises. During an interview on 12/4/25 at 10:55 a.m., the Director of Nursing (DON) indicated the wound nurse should have followed the physician orders and bruises were to be reported and monitored as needed. 2. The record for Resident 9 was reviewed on 12/4/25 at 1:10 p.m. Diagnoses included, but were not limited to, dementia, psychotic disorder with delusions, anxiety disorder, heart disease, major depressive disorder, and heart failure. The 11/27/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making and had minimal difficulty hearing with no hearing aides. She needed partial to moderate assistance with sitting to stand and transfers from the bed to the chair and vice versa. She had a history of one fall with no major injury since the last assessment and has no oral problems. A Care Plan, revised on 11/17/25, indicated the resident had the potential for falls. The approaches were to place anti skid strips next to the bed. An Initial Fall Occurrence Report, dated 11/14/25 at 6:27 a.m., indicated the resident had an unwitnessed fall in her room self transferring. The resident stated that she was sleep walking when asked how she ended up on the floor. The resident was observed with with swelling and bruising to her face. There was documentation of fall follow up on 11/14 and 11/15/25, however, there was no documentation of any fall follow up assessments or vital signs checked on 11/16/25. A 72 hour charting note, dated 11/15/25 at 11:15 p.m., indicated the resident was observed with deep purple facial, neck, and chest bruising. The Weekly Skin Observation assessment, dated 11/19/25 indicated there were new skin concerns observed. If new, section three was to be completed. Section three was blank and there was no documentation of assessment of bruised areas sustained from the fall on 11/14/25. A Physician's Order, dated 11/24/25 (10 days after the fall), indicated to monitor bruising to the face and chest for any abnormal enlargement until reabsorbed. During an interview on 12/8/25 at 11:20 a.m., ADON 3 indicated she was unaware the order was put in to monitor the bruises on 11/24/25 and indicated nursing staff should have been monitoring it right after the fall. She was unaware the weekly skin observation sheet, dated 11/19/25, was not completed correctly and did not identify the new bruises and swollen face. During an interview on 12/8/25 at 1:07 p.m., the Director of Nursing (DON) indicated fall follow up was to be completed every shift for 72 hours. During an interview on 12/8/25 at 2:07 p.m., the DON indicated the bruises and swollen face were monitored on 11/14, 11/15, and 11/17/25 on the 72 hour fall follow up, however, the bruises were not documented and monitored until the order was put in on 11/24/25. 3. During random observations on 12/1/25 at 10:56 a.m., 12/3/25 at 1:28 p.m., and 12/4/25 at 10:20 a.m., Resident 70's legs were very swollen. She was wearing non-slip socks that were deeply indented into her ankles. The record for Resident 70 was reviewed on 12/4/25 at 9:06 a.m. Diagnoses included, but were not limited to, cellulitis of the left leg, dementia, and edema. The Quarterly Minimum Data Set (MDS) assessment, dated 9/25/25, indicated the resident had moderate cognitive impairment and required moderate assist with activities of daily living (ADLs) and transfers. Weekly Skin Observations, dated 11/18/25 and 11/25/25, indicated the resident had edema to her legs. The 12/2/25 assessment did not indicate edema. A Nurse Practitioner assessment, dated 12/3/25, indicated 2+ edema to the right lower leg and 3+ edema to the left lower leg. A Care Plan, revised on 1/15/25, indicated the resident was at risk for decreased cardiac output. Interventions included observing for edema. On 12/8/25 at 1:38 p.m., ADON 1 observed the resident's ankles and immediately removed the indenting socks, indicated they were too small and she would get larger socks for the resident. During an interview on 12/8/25 at 9:00 a.m., the Director of Nursing (DON) indicated edema should be documented on the weekly skin assessment. 4. During random observations on 12/1/25 at 11:38 a.m., 12/3/25 at 9:22 a.m., 12/4/25 at 10:23 a.m., and 12/8/25 at 10:55 a.m. Resident 14's ankles were visibly swollen. The resident's record was reviewed on 12/03/25 at 9:34 a.m. Diagnoses included, but were not limited to fluid overload. The Medicare-5 Day Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and required moderate assist with activities of daily living (ADLs) and transfers. Weekly Skin Assessments, dated 11/19/25 and 11/26/25, did not indicate edema. A Care Plan, revised on 8/20/25, indicated the resident was at risk for decreased cardiac output. Interventions included observing for edema. During an interview on 12/8/25 at 9:00 a.m., the Director of Nursing (DON) indicated edema should be documented on the weekly skin assessment. 5. During a random observation on 12/2/25 at 9:37 a.m., an area of several small open, red, bloody areas were observed to Resident 28's left upper arm. There was a large bruise on his left forearm. The resident's record was reviewed on 12/03/25 at 1:46 PM. Diagnoses included, but were not limited to, dementia and adult failure to thrive. The Medicare-5 Day Minimum Data Set (MDS) assessment, dated 11/22/25, indicated the resident had severe cognitive impairment, required supervision assistance with activities of daily living, and moderate assistance with transfers. Weekly Skin assessments, dated 11/24/25, 12/1/25, and 12/8/25, lacked documentation of the left upper arm lesions and the bruise to the left forearm. A Physician's Order, dated 11/17/25, indicated weekly skin assessment on Mondays during the day shift. A Care Plan, dated 11/18/25, indicated the resident had a potential for impaired skin integrity. Interventions included assessing/recording changes in skin status. On 12/8/25 at 1:29 p.m., ADON 1 observed the scabbed areas to the resident's left upper arm, and the bruise to the left forearm. She indicated she did not know what they were from, but they should be monitored & documented. A policy titled, Skin Condition Assessment & Monitoring, received from the VP of Clinical Services as current on 12/9/25 at 10:35 a.m., indicated, . Non-pressure skin conditions (bruises / contusions, abrasions, lacerations, rashes, skin tears, surgical wounds, etc.) will be assessed for healing progress and signs of complications weekly . 3.1-37(a)

Based on observation, record review, and interview, the facility failed to maintain clinical records that were complete and accurately documented related to documentation of food consumption for 2 of 2 residents reviewed for nutrition. The facility also failed to ensure documentation was completed on the medication and treatment records as well as in the nursing progress notes related to medication administration and oxygen use for 1 of 5 residents reviewed for unnecessary medications and 1 of 3 residents reviewed for oxygen. There was also no discharge note completed for a resident who left the facility against medical advice (AMA) for 1 of 3 closed records reviewed. (Residents 59, 8, 74, 11, 12, and 123)Findings include: 1.The record for Resident 59 was reviewed on 12/2/25 at 4:01 p.m. Diagnoses included, but were not limited to, adult failure to thrive and edema. The Quarterly Minimum Data Set (MDS) assessment, dated 9/11/25, indicated the resident was cognitively intact. He required supervision or one person physical assistance with eating. A Care Plan, dated 7/3/25, indicated the resident had a nutritional problem or potential nutritional problem related to chronic obstructive pulmonary disease (COPD) and hypertension. Interventions included, but were not limited to, provide and serve diet as ordered. On 10/6/25, the resident weighed 166 pounds. On 11/11/25, the resident weighed 154 pounds. The food consumption monitoring located in the Task section of the electronic medical record indicated no breakfast or lunch was documented for the resident on 11/16, 11/24, and 11/30/25. No dinner intake was documented on 11/5, 11/8, 11/9, 11/10, and 11/22/25. During an interview on 12/8/25 at 2:13 p.m., the Director of Nursing indicated the resident's food consumption should have been documented. 2. The record for Resident 8 was reviewed on 12/4/25 at 3:41 p.m. Diagnoses included, but were not limited to, Parkinson's disease, dementia with behavioral disturbance, anxiety disorder, and fracture of the neck of the right femur. The Significant Change Minimum Data Set (MDS) assessment, dated 9/16/25, indicated the resident was cognitively impaired for daily decision making and he received opioid medications. The December 2025 Physician's Order Summary (POS) indicated the resident was to receive Lorazepam concentrate (an anti-anxiety medication) 2 milligrams (mg) per milliliter (ml) every six hours as needed (PRN) for anxiety for 14 days and Morphine Sulfate (an opioid pain medication) oral solution 20 mg/ml give 0.25 ml every two hours PRN for pain or dyspnea (difficulty breathing). The October 2025 Medication Administration Record (MAR) indicated QMA 1 administered the PRN Morphine to the resident on 10/15/25 at 9:08 a.m. and on 10/31/25 at 8:25 a.m. and 12:24 p.m. On 10/25/25 at 2:32 p.m., QMA 4 administered the resident's PRN Morphine. On 10/26/25 at 5:52 p.m., QMA 5 administered the resident's PRN Morphine. There was no documentation indicating the QMAs received authorization from the licensed nurse prior to giving the medication. The November 2025 MAR indicated QMA 3 administered the resident's PRN Lorazepam on 11/25/25 at 1:08 p.m. Again, there was no documentation indicating the QMA received authorization from the licensed nurse prior to giving the medication. The December 2025 MAR indicated QMA 2 administered the resident's PRN Morphine on 12/6/25 at 4:34 p.m. and his PRN Lorazepam on 12/6/25 at 10:00 p.m. There was no documentation indicating the QMA received authorization from the licensed nurse prior to giving the medication. During an interview on 12/8/25 at 2:58 p.m., the Director of Nursing indicated the QMAs were to document in the nursing progress notes that they received approval from the nurse to administer PRN medications. 3. On 12/1/25 at 10:30 a.m., Resident 74 was observed in her room in bed. Oxygen by the way of a nasal cannula was in use at two liters. On 12/2/25 at 3:42 p.m., 12/3/25 at 9:10 a.m. and 1:23 p.m., and 12/4/25 at 9:58 a.m., the resident remained in her room in bed with the oxygen in use. The record for Resident 74 was reviewed on 12/4/25 at 11:45 a.m. Diagnoses included, but were not limited to, epilepsy, hypertension, and aphasia (difficulty speaking) following a stroke. The Quarterly Minimum Data Set (MDS) assessment, dated 11/11/25, indicated the resident was cognitively impaired for daily decision making. There was no care plan related to the oxygen use. A Physician's Order, dated 12/1/25, indicated oxygen at two liters was to be applied per nasal cannula as needed (PRN) for shortness of breath. Notify the physician if the resident's oxygen saturation was below 90%. The December 2025 Medication Administration Record (MAR) indicated the resident's oxygen was not signed out as being in use 12/1-12/4/25. During an interview on 12/4/25 at 3:22 p.m., the Director of Nursing indicated if the oxygen was in use, it should have been signed out as being in use on the MAR. During an interview on 12/8/25 at 8:45 a.m., the Director of Nursing indicated the oxygen use for 12/1, 12/2 and12/3/25 was documented in the nursing progress notes but not on the MAR. 4. The record for Resident 11 was reviewed on 12/3/25 at 12:00 p.m. Diagnoses included, but were not limited to, CHF, cellulitis lower limbs, chronic ulcers of the skin, panic disorder, adult failure to thrive, anxiety, major depressive disorder, and fibromyalgia (a chronic condition causing widespread body pain). The 11/7/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and was dependent on staff for bathing and hair washing. The resident had scheduled and prn (as needed) pain medication for occasional pain. Her pain was five out of 10. She received an opioid medication. A Physician's Order, dated 8/6/25, indicated, Oxycodone 10-325 milligrams (mg) give one tablet every six hours as needed for pain. The 10/2025 Medication Administration Record (MAR) indicated the Oxycodone was signed out as being administered 20 times at different times of the day. The Controlled Drug Administration Record indicated the Oxycodone was signed out being administered to the resident 61 times at different times of the day. The 11/2025 MAR indicated the Oxycodone was signed out as being administered 18 times at different times of the day. The Controlled Drug Administration Record indicated the Oxycodone was signed out as being administered to the resident 51 times at different times of the day. During an interview on 12/4/25 at 10:40 a.m., ADON 3 indicated nursing staff needed to sign the medication out on the MAR as well as the narcotic sheets. During an interview on 12/4/25 at 11:00 a.m. the Director of Nursing indicated nursing staff were to sign the medication out on the MAR. 5. The record for Resident 12 was reviewed on 12/3/25 at 10:25 a.m. Diagnoses included, but were not limited to, fracture of the left femur, Alzheimer's disease, anxiety, chronic kidney disease, high blood pressure, and depression. The 10/21/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making and a significant weight loss. The meal consumption logs under the CNA task section indicated there was no documentation for breakfast on 10/5, 10/7, 10/9, 10/10, 10/13, 10/14, 10/17, 10/19, 10/21, 10/23, 11/4, 11/16, 11/24, 11/30, and 12/3/25. There was no documentation for lunch on 10/5, 10/7, 10/9, 10/10, 10/13, 10/14, 10/16, 10/17, 10/19, 10/21, 10/23, 11/16. 11/24, 11/28, 11/30, and 12/3/25 and no documentation for dinner on 10/1, 10/21, 10/23, 10/26, 11/3, 11/4, 11/8, 11/9, 11/10, 11/22, and 11/26/25 During an interview on 12/8/25 at 11:15 a.m., ADON 3 indicated a lot of times her family will bring in food for her to eat or she will door dash food in, however, they still should be completing food consumption for her. During an interview on 12/8/25 at 11:30 a.m., CNA 2 indicated sometimes the family will eat with her in the dining room. She indicated whatever the resident ate she was to document the amount in the computer. The current and undated Food Intake policy, provided by the Director of Nursing on 12/8/25 at 2:05 p.m., indicated food intake will be recorded by assigned staff. 6. Closed record review for Resident 123 was completed on 12/8/25 at 10:31 a.m. Diagnoses included, but were not limited to, coronary artery disease, hypertension, and hyperlipidemia. The resident was admitted to the facility on [DATE]. A Nurse's Note, dated 9/4/25 at 4:33 p.m., indicated the resident arrived at the facility by private car. The resident was alert and oriented. A Nurse's Note, dated 9/4/25 at 7:04 p.m., indicated the resident went home in his private car with all his personal belongings against medical advice. The Nurse Practitioner, Director of Nursing, and the Assistant Director of Nursing was informed. The resident signed a form he was leaving the facility against medical advice on 9/4/25 at 6:01 p.m. The form included to check mark if the resident was provided with any discharge planning. There were no checkmarks completed on the form for any discharge planning completed. There was a lack of documentation to indicate any type of discharge planning was attempted with the resident, that included his current treatment and medication regimens before he left the facility. There was a lack of documentation to indicate the resident's emergency contact was notified the resident had decided to leave the facility against medical advice. During an interview on 12/8/25 at 11:08 a.m., the Director of Nursing (DON) indicated the resident was only in the facility a few hours before he left against medical advice. There was no documentation to indicate any discharge planning was attempted with the resident before he left the facility. A policy titled, AMA Discharge Guidelines – (Against Medical Advice) and received as current from the facility on 12/8/25, indicated, .Procedure: 1. If the resident has made their desire to discharge against medical advise known, the following should be attempted prior to the resident leaving the facility: a. Discharge planning must identify the discharge destination, and ensure it meets the resident's health and safety needs, as well as preferences.3. The nurse on duty will provide the resident and/or legal guardian of information regarding the resident's current treatment and medication regimens.9. In the event the resident is signing him/herself out AMA, his/her legal representative and/or family member will be notified by facility personnel. 3.1-50(a)(1)3.1-50(a)(2)

Based on random observations, record review and interview, the facility failed to ensure infection control practices were in place and implemented related to the storage of urinals and wash basins for 3 of 4 units throughout the facility. The facility also failed to ensure the glucometer was disinfected correctly for 1 of 1 glucometer observed as well as nursing staff dispensing pills into their bare hand for 1 of 11 residents observed during medication administration. (Residents 59, 88, and 10, the 100, 200, and 300 units)Findings include:1.On 12/2/25 at 10:05 a.m., Resident 59 was observed in his room in his bed. The head of the bed was elevated and his urinal was positioned on the quarter side rail with urine in it. On 12/3/25 at 1:25 p.m., the resident was observed in bed and his urinal was again hanging from the side rail with urine in it. On 12/4/25 at 11:00 a.m., the resident was observed in bed and his urinal was again hanging from the side rail with urine in it. The record for Resident 59 was reviewed on 12/2/25 at 4:01 p.m. Diagnoses included, but were not limited to, adult failure to thrive and edema. The Quarterly Minimum Data Set (MDS) assessment, dated 9/11/25, indicated the resident was cognitively intact. There was no care plan related to the resident hanging his urinal from the bedside. During an interview on 12/8/25 at 2:58 p.m., the Director of Nursing indicated the resident's urinal shouldn't be hanging from the side rail with urine in it. 2. During the Environmental tour on 12/9/25 at 9:30 a.m., with the Maintenance Director and the Housekeeping Supervisor, the following was observed: 100 Unit a. room [ROOM NUMBER] - there was an uncontained pink wash basin on the top of the counter in the bathroom. There were two residents who shared the bathroom. 200 Unit: a. room [ROOM NUMBER] - there was an uncontained pink wash basin on the floor next to the toilet in the bathroom. There were two residents who shared the bathroom. b. room [ROOM NUMBER] - there was an uncontained toothbrush laying on the counter in the bathroom. There were two residents who shared the bathroom. c. room [ROOM NUMBER] - there was an uncontained toothbrush and two razors on the bathroom counter. There were two residents who shared the bathroom. 300 Unit a. room [ROOM NUMBER] - there was one uncontained wash basin on top of the counter in the bathroom. There were two residents who shared the bathroom. b. room [ROOM NUMBER] - there were two uncontained wash basins on top of the counter in the bathroom. There were two residents who shared the bathroom. c. room [ROOM NUMBER] - there was one uncontained pink wash basin on the floor underneath the sink and one uncontained basin on top of the counter in the bathroom. There were two residents who shared the bathroom. d. room [ROOM NUMBER] - there were 2 uncontained pink wash basins stacked on top of each other and one uncontained urinal on the bathroom counter. There were two residents who shared the bathroom. e. room [ROOM NUMBER] - there was one uncontained pink wash basin on top of the counter in the bathroom. There was one resident who used the bathroom. h. room [ROOM NUMBER] - there were four uncontained pink wash basins stacked on top of each other on the floor in the bathroom. There were two residents who shared the bathroom. During an interview on 12/8/25 at 10:00 a.m., the Maintenance Director and Housekeeping Director indicated the basins were to be stored in plastic bags. The 1/16/18 and current Cleaning-Sanitizing Bedside Equipment policy, provided by the [NAME] President of Clinical Services on 12/9/25 at 10:35 a.m., indicated bedside equipment such as bedpans, wash basins, and urinals may be stored in separate plastic bags in shared resident bathroom and appropriately labeled with resident names, otherwise these items should be placed in plastic bags and stored in the bedside cabinet or closet. 3. On 12/3/25 at 10:37 a.m., RN 1 was observed to complete blood sugar testing on Resident 88. She removed the glucometer out of the medication cart and proceeded to wipe the glucometer with an alcohol wipe. She then went into Resident 88's room and performed blood sugar testing with the glucometer. She then went back to the medication cart where she proceeded to clean the glucometer once again with an alcohol wipe. During an interview with RN 1 at the time of the observation, she indicated she had cleaned glucometers with alcohol wipes since she had been a nurse. When asked if she had been instructed on the facility's policy and procedure for cleaning glucometers, she indicated yes, she had been instructed. A policy titled, Glucometer Cleaning and provided by the Director of Nursing (DON) on 12/3/25 indicated, .The blood glucose monitor should be cleaned and disinfected between each resident test. Procedure 4. wipe meter with 1:10 solution bleach wipe/towel until all surfaces of the glucometer are visibly wet. 4. On 12/4/25 at 9:16 a.m., RN 2 was observed preparing to administer a medication to Resident 10. She popped two acetaminophen 325 mg (milligram) tablets into her hand from the medication card before putting them in the medicine cup. During an interview with RN 2 at the time of the observation, she indicated she should have popped them into a medicine cup and not put them in her hand. She went on to administer the medication. During an interview on 12/4/25 at 9:32 a.m., the Assistant Director of Nursing (ADON) 4, indicated the nurse should have popped the medication into the cup and not into her bare hands. During an interview on 12/4/25 at 9:35 a.m., Nurse Consultant 1 indicated the nurse should have worn gloves and not touched the medication with her bare hands. A policy titled, Medication Administration General Guidelines and received as current from the facility on 12/4/25, indicated, .Preparation.3. Examination gloves are worn when necessary. 3.1-18(b)

Based on observation and interview, the facility failed to keep the resident's environment clean and in good repair related to marred walls and door frames, dirty ceiling vents, walls, windows, and closet shelves, warped floor tile, missing paper towel covers, rusted toilet bolts and missing covers, stained toilets, and broken medication drawers on the medication carts for 3 of 4 units. (Units 100, 200, and 300)Findings include:1. During the Environmental tour on 12/9/25 at 9:30 a.m., with the Maintenance Director and the Housekeeping Supervisor, the following was observed: 100 Unit a. room [ROOM NUMBER] - the bathroom wall was marred and the ceiling vent was dirty and dusty. There were two residents who shared the bathroom. b. room [ROOM NUMBER] - the room walls were dirty as well as the over bed table. The toilet bolts were rusty and missing covers and the ceiling vent was dirty and dusty. There were two residents who resided in the room and shared the bathroom. c. room [ROOM NUMBER] - the hinge was broken on the closet door exposing a sharp screw. The bathroom ceiling vent was dirty and dusty. There was 1 resident who resided in the room and 2 residents shared the bathroom. 200 Unit: a. room [ROOM NUMBER] - there was corrosion around the faucet in the bathroom. The ceiling vent was dirty and dusty. There were two residents who shared the bathroom. b. room [ROOM NUMBER] - there were cobwebs at the base of the window behind the head of the bed. There was no cover for the paper towel holder. The toilet bolts were exposed on each side of the toilet, There were two residents who resided in the room and four residents shared the bathroom. c. room [ROOM NUMBER] - the wall behind the head of bed and the base of the closet was gouged and marred. There was no cover on the paper towel dispenser in the bathroom and the ceiling vent was dirty and dusty. There were two residents who resided in the room and two residents shared the bathroom. d. room [ROOM NUMBER] - there was no drain plug in the bathroom sink. The bolts at the base of the toilet were exposed on each side and there was no cover on the paper towel dispenser in the bathroom. The ceiling vent was dusty and dirty. There was 1 resident who used the bathroom. e. room [ROOM NUMBER] - there was no drain plug in the bathroom sink and the bolts at the base of the toilet were exposed on each side. There was no cover on the paper towel dispenser in the bathroom and the floor tile was warped under the bathroom sink and on the side of the toilet. There were rust stains inside the toilet bowl and the ceiling vent was dust and dirty. There was a large amount of dust on the fan blades and grate on a fan that was on bedside stand. There were two residents who resided in the room and four resident shared the bathroom. f. room [ROOM NUMBER] - The walls were marred and gouged behind the head of the bed. The floor mat next to the bed was stained. The bathroom and closet doors were marred. There was no cover for the paper towel dispenser and the toilet seat was too small and did not completely cover the toilet. The ceiling vent was dusty and dirty. There was one resident who resided in the the room and two residents shared the bathroom. g. room [ROOM NUMBER] - there was no drain stop in the bathroom sink and the toilet bowl had rust stains inside. There was one resident who resided in the room and two residents shared the bathroom. 300 Unit a. room [ROOM NUMBER] - the floor tile in the bathroom was warped and the panel on the bathroom door was buckled. The toilet had brown stains on the inside and the ceiling vent was dirty and dusty. There were 2 residents who shared the bathroom. b. room [ROOM NUMBER] - the bathroom ceiling vent was dirty and dusty. c. room [ROOM NUMBER] - there was a clump of a dried brown substance on the wall. The floor tile in the bathroom was warped and the ceiling vent was dusty and dirty. There were 2 residents who resided in the room and shared the bathroom. d. room [ROOM NUMBER] - the bathroom and resident room doors were marred. The walls were marred in the bathroom and the ceiling vent was dirty and dusty. There were two residents in the room and shared the bathroom. e. room [ROOM NUMBER] - the base of the over bed table was dirty and top had a piece missing. There were two residents who resided in the room. f. room [ROOM NUMBER] - the floor tile in the bathroom was warped and peeling away from the base of the toilet. There were two residents who shared the bathroom. g. room [ROOM NUMBER] - the bathroom floor tile was warped behind the toilet and there were brown stains inside the toilet bowl. The ceiling vent was dirty and dusty. There was one resident who used the bathroom. h. room [ROOM NUMBER] - the cover over an outlet was cracked and missing in places. The floor tile in the bathroom was peeling away from the wall and warped around the toilet. The ceiling vent was dusty and dirty. There were two residents who resided in the room and used the bathroom. During an interview on 12/8/25 at 10:00 a.m., with the Maintenance Director and Housekeeping Director all of the above was in need of cleaning and/or repair. 2. Medication Storage observation was completed on 12/8/25 at 3:38 p.m. - 3:53 p.m. with facility staff. The following was observed: a. 300 Unit Team 1 Medication Cart and Team 2 Medication Cart observed with RN 3: Both the carts had a cut out, broken area to the top lip area of the second drawers. The RN indicated she was unsure how long there had been broken areas to the drawers. b. 300/400 Unit Medication Cart 2 was observed with Agency LPN 1: The cart had a cut out, broken area, to the top lip area of the second drawer. When the cart was locked, the surveyor was still able to pull the drawer out a little and slide half of a hand into the cut out broken area and touch the medication cards. The Agency LPN indicated that it was the first time she was on the cart and was unaware of the broken areas to the drawer. c. 200 Unit Medication Cart 2 was observed with QMA 1: The cart had a cut out, broken area to the top lip area of the second drawer. The QMA indicated she was unsure how long there had been broken areas to the drawer. d. 100 Unit Medication Cart 1 was observed with LPN 1: The cart had a cut out, broken area to the top lip area of the second drawer. The LPN indicated the drawer had a broken cutout area for a long time. During an interview on 12/8/25 at 4:05 p.m., the Director of Nursing (DON) indicated the staff should have reported the drawers had broken pieces. She would call the pharmacy right away and have them replaced. A policy titled, Equipment and Supplies for Administering Medications and received as current from the facility on 12/9/25, indicated, .Procedures 1. The following equipment and supplies are acquired and maintained by the facility for the proper storage, preparation, and administration of medications. a. Lockable medication carts, cabinets, drawers.4. The charge nurse or in accordance with facility policy, is notified if supplies are inadequate or equipment fails to work properly. The charge nurse reports equipment and supply deficiencies to the Director of Nursing. 3.1-19(f)

Based on observation, record review, and interview, the facility failed to ensure each resident's dignity was maintained related to not offering a resident a snack while others were eating around him and a resident's abdomen being exposed during an activity for 2 of 5 residents reviewed for dignity. (Residents 8 and 93)Findings include:1. During a random observation on 12/3/25 at 9:18 a.m., Resident 8 was observed seated in a broda chair (a specialty chair used for positioning) in the 300 hall activity room. The resident's chair was positioned at a table with six other residents. The resident's eyes were open and music was playing. At 9:36 a.m., the other residents were drinking coffee in front of him and an activity aide was serving the other residents donuts. The activity aide stopped by the resident and stated, he can't have one, he's a pureed diet. The activity aide did not attempt to find the resident anything else to eat. After the donuts were consumed, the activity aides gave the residents a cup of soda. Again, the resident was not offered anything. The record for Resident 8 was reviewed on 12/4/25 at 3:41 p.m. Diagnoses included, but were not limited to, dysphagia (difficulty swallowing), Parkinson's disease, and dementia without behavioral disturbance. A Significant Change Minimum Data Set (MDS) assessment, dated 9/16/25, indicated the resident was cognitively impaired for daily decision making and he required partial to moderate assistance with eating. A Care Plan, last reviewed on 9/17/25, indicated the resident's activity preferences were pet interaction, family/friend visits, listening to music, sensory, snacks, poker, movies, Happy Hour, live entertainment, exercise, and going outside when the weather was nice. During an interview on 12/4/25 at 3:21 p.m., the Director of Nursing indicated the resident should have been offered pudding or something else. 2. During a random observation on 12/3/25 at 9:54 a.m., Resident 93 was seated in his broda chair (a specialty chair used for positioning) in the 300 hall activity room. The resident's chair was positioned at the table with six other residents. The resident's shirt was lifted up and his abdomen was exposed. At 10:44 a.m., the resident remained in the activity room and his shirt continued to be lifted up. No staff in the area attempted to pull down the resident's shirt. The record for Resident 93 was reviewed on 12/9/25 at 8:45 a.m. Diagnoses included, but were not limited to, dementia with behavior disturbance, psychosis, and anxiety disorder. The Quarterly Minimum Data Set (MDS) assessment, dated 12/1/25, indicated the resident was cognitively impaired for daily decision making and required partial to moderate assistance with upper body dressing. A Care Plan, reviewed on 12/1/25, indicated the resident had an ADL (activities of daily living) self-care mobility performance deficit that may fluctuate with activity throughout the day related to impaired balance and limited mobility. Interventions included, but were not limited to, partial to moderate assistance with upper body dressing. During an interview on 12/4/25 at 3:21 p.m., the Director of Nursing indicated the resident's shirt should have been pulled down. 3.1-3(t)

Based on record review and interview, the facility failed to report allegations of resident-to-resident abuse to the State Agency for 1 of 1 resident reviewed for abuse. (Resident 117)Finding includes:The record for Resident 117 was reviewed on 12/02/25 at 3:29 p.m Diagnoses included, but were not limited to, depression, dementia, and unspecified psychosis.The Quarterly Minimum Data Set (MDS) assessment, dated 9/15/25, indicated the resident had severe cognitive impairment, required moderate assist with activities of daily living (ADLs) and supervision or touching assistance with transfers.A Nurse's Note, dated 11/29/25, indicated, . CNA observed this resident loose [sic] balance and fall to floor. CNA advised that just prior to falling this resident [Resident 117] had been pushed by another resident . Resident c/o [complained of] discomfort to the left radial hand, prn [as needed] pain med given . No edema [swelling], redness, or bruising noted to left hand, fingers, arm, shoulder . The note indicated the resident's Nurse Practitioner, responsible party, on call nurse, and Director of Nursing (DON) were informed. An x-ray was taken of the resident's left hand, wrist, and shoulder. In a fall occurrence note, dated 11/29/25, LPN 1 indicated, . when asked what happened resident stated 'I don't know he pushed me' .A list of reportable incidents received from the Administrator on 12/4/25 indicated no incidents had been reported to the State Agency since 8/29/25. During an interview on 12/4/25 at 2:40 p.m., the Administrator indicated the DON informed him of the incident, but he believed they did not need to report it to the State Agency because there was no injury and they could not prove there was intent. The Administrator indicated he had not read the nurse's notes regarding the incident.During an interview on 12/4/25 at 3:39 p.m., CNA 1 indicated she saw Resident 117 on the floor and the other resident with their hands up in a position like they had just recoiled from pushing Resident 117. She reported the incident immediately to LPN 1.During an interview on 12/4/25 at 3:48 p.m., LPN 1 indicated both CNA 1 and Resident 117 indicated the unnamed resident pushed Resident 117 and he fell to the floor. She indicated she gave the resident ibuprofen because he said his hand hurt after the fall. During an interview on 12/8/25 at 9:00 a.m., the DON indicated after LPN 1 informed her of the incident, she discussed it with the Administrator and they did not believe it needed to be reported because there was no injury and they could not prove the resident's intent. A policy titled, Abuse Prevention and Reporting - Indiana, received from the [NAME] President of Clinical Services as current on 12/9/25 at 10:35 a.m. indicated, . Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, or punishment with resulting physical harm, pain, or mental anguish to a resident . The term willful in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Any allegation of abuse or any incident that results in serious bodily injury will be reported to the Department of Public Health immediately, but not more than two hours after the allegation of abuse. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours .3.1-28(c)

Based on record review and interview, the facility failed to ensure a resident with hearing loss, was seen by an Audiologist for 1 of 1 resident reviewed for vision and hearing. (Resident 9)Finding includes:During an interview on 12/1/25 at 10:38 a.m., Resident 9 indicated she had asked to see an Audiologist a long time ago because she was having trouble hearing. The record for Resident 9 was reviewed on 12/4/25 at 1:10 p.m. Diagnoses included, but were not limited to, dementia, psychotic disorder with delusions, anxiety disorder, heart disease, major depressive disorder, and heart failure. The 11/27/25 Quarterly Minimum Data Set (MDS) assessment, indicated the resident was moderately impaired for daily decision making and had minimal difficulty hearing with no hearing aides. She needed partial to moderate assistance with sitting to stand and transfers from the bed to the chair and vice versa. She had a history of one fall with no major injury since the last assessment and has no oral problems. There was no care plan for any hearing difficulties the resident may have had. The resident signed a consent to be seen by the Audiologist on 1/20/23, however as of 12/4/25, the resident had not seen one. During an interview on 12/8/25 at 1:45 p.m., the Social Service Director indicated the resident has never seen an Audiologist and they have been in the building several times since she signed the consent in 2023. 3.1-39(a)(1)

Based on observation, record review, and interview, the facility failed to ensure fall precautions were in place for a resident with a history of falls for 1 of 4 residents reviewed for accidents. (Resident 9)Finding includes:During an interview on 12/1/2025 at 10:45 a.m., Resident 9 indicated she had a recent fall where she was trying to transfer herself out of bed into her wheelchair. She landed on the floor and bruised her face and chest area. During an observation at that time, the resident pulled down her shirt and her upper chest was still red in color from the fall. The non-skid strips that were located by the bed were observed to be missing in several spots. On 12/8/25 at 11:10 a.m., ADON 3 was in the resident's room. At that time, she was asked about the non-skid strips next to the bed. She indicated they were missing in areas and needed to be replaced. The record for Resident 9 was reviewed on 12/4/25 at 1:10 p.m. Diagnoses included, but were not limited to, dementia, psychotic disorder with delusions, anxiety disorder, heart disease, major depressive disorder, and heart failure. The 11/27/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making and had minimal difficulty hearing with no hearing aides. She needed partial to moderate assistance with sitting to stand and transfers from the bed to the chair and vice versa. She had a history of one fall with no major injury since the last assessment and has no oral problems. A Care Plan, revised on 11/17/25, indicated the resident had the potential for falls. The approaches were to place anti-skid strips next to the bed. An Initial Fall Occurrence Report, dated 11/14/25 at 6:27 a.m., indicated the resident had an unwitnessed fall in her room self transferring. The resident stated that she was sleep walking when asked how she ended up on the floor. The resident was observed with with swelling and bruising to her face. A Nurse's Note, dated 11/14/25 at 11:15 p.m., indicated the resident sustained bruising to the face, neck, and upper chest from the fall. An IDT fall note, dated 11/15/25, indicated the root cause was the resident indicated she just rolled out of bed. The resident frequently sits on the side of the bed and leans over. The resident utilized crocs as shoes and they were new, but worn as clogs. The resident leaned to far to the side when sleeping, and it caused her shoes to slip leading to her falling off the bed. During an interview on 12/8/25 at 1:07 p.m., the Director of Nursing indicated she had thought they told maintenance to put down new non-skid strips next to her bed, as she indicated they needed to be replaced. 3.1-45(a)

Based on record review and interview, the facility failed to ensure signs and symptoms of a urinary tract infection (UTI) were treated in a timely manner for 1 of 1 resident reviewed for urinary tract infections. (Resident 8)Finding includes: The record for Resident 8 was reviewed on 12/4/25 at 3:41 p.m. Diagnoses included, but were not limited to, dysphagia (difficulty swallowing), Parkinson's disease, and dementia without behavioral disturbance. The Significant Change Minimum Data Set (MDS) assessment, dated 9/16/25, indicated the resident was cognitively impaired for daily decision making. The resident required partial to moderate assistance with eating and was incontinent of urine. A late entry documented in the nursing progress notes, dated 11/25/25 at 8:12 p.m., indicated the resident was observed with blood-tinged urine in his brief. The hospice agency was contacted and they indicated they would speak with the nurse practitioner and the resident's sister to inquire about obtaining a urine specimen. A Hospice Progress Note, dated 11/26/25 at 1:10 p.m., indicated the unit was visited for a urine dipstick test (a urine screen for UTI). The nurse reported she was unable to collect a sample and the resident had no further blood in the urine. The nurse practitioner and the resident's sister were contacted. The resident's sister declined the straight catheter collection and was agreeable to observe for any further changes on the next scheduled visit. The resident's sister had concerns that he was not drinking water due to not being able to hold it. A late entry documented in the nursing progress notes, dated 11/26/25 at 1:30 p.m., indicated the hospice nurse was at the facility to follow up related to blood in the urine. The resident had no more episodes of hematuria (blood in urine) that shift. The hospice nurse spoke with the resident's sister and all parties agreed to further discuss the concern and possibly obtaining a urine specimen on 11/28/25. A Nurse's Note, dated 11/27/25 at 5:32 a.m., indicated the resident had decreased urine output with pus and blood present. Hospice was notified and they indicated they would contact the resident's sister to see if they could proceed with a straight catheterization. The next entry in the nurse's notes was a weekly skin assessment dated [DATE]. A Hospice Progress Note, dated 11/28/25, indicated the nurse was able to obtain a small amount of urine for a urine dipstick. The resident had thick red odorous urine with pus. The urine dipstick was unable to be read. The nurse practitioner was notified and orders were received and faxed to the pharmacy. A Physician's Order, dated 12/5/25, indicated the resident was to receive Nitrofurantoin oral suspension (an antibiotic) 25 milligrams (mg) per milliliter (ml), give 20 ml twice a day for five days for UTI.During an interview on 12/8/25 at 4:30 p.m., the Corporate Infection Preventionist indicated the antibiotic should have been started on 11/28/25.

Based on observation, record review, and interview, the facility failed to ensure residents received proper treatment and care related to following physician's orders for oxygen administration, and the lack of pre and post nebulizer assessments for 2 of 3 residents reviewed for respiratory care. (Residents 127 and 14) Findings include:1. On 12/1/25 at 11:00 a.m., Resident 127 was observed lying in bed. The resident had oxygen in place via nasal cannula. The oxygen concentrator flow rate was set between 2 and 2.5 liters. The resident indicated he was supposed to be on 3 liters. On 12/1/25 at 2:57 p.m. and again on 12/2/25 at 10:49 a.m., Resident 127 was observed sitting in the hallway in a wheelchair outside of his room. The resident was not wearing any oxygen. There was not a portable oxygen tank attached to the wheelchair. On 12/2/25 at 3:46 p.m., Resident 127 was observed lying in bed. The resident had oxygen in place via nasal cannula. The oxygen concentrator flow rate was set between 2 and 2.5 liters. Record review for Resident 127 was completed on 12/2/25 at 3:30 p.m. Diagnoses included, but were not limited to, chronic respiratory failure with hypoxia, and chronic obstructive pulmonary disease. An admission Observation Assessment, dated 11/26/25, indicated the resident was cognitively intact. The resident required extensive assistance for bed mobility and total assistance for transfers. The resident received oxygen at 3 liters per nasal cannula. A Care Plan, dated 11/28/25, indicated the resident received oxygen therapy. An intervention included administering oxygen as ordered. The December 2025 Physician's Order Summary (POS) indicated an order for oxygen at three liters via nasal cannula every shift. During an interview on 12/2/25 at 4:02 p.m., the Assistant Director of Nursing (ADON) 3 indicated the resident was supposed to be on 3 liters of oxygen. Nursing should have made sure the resident was administered oxygen at all times per the physician's order. 2. During a random observation on 12/3/25 at 9:00 a.m., Resident 14 was sitting in his wheelchair near the nurse's station. At that time, he indicated he had not gotten his nebulizer treatment yet that morning. On 12/3/25 at 9:29 a.m., QMA 1 brought the resident to his room, initiated the nebulizer treatment, and left the room. When the treatment was completed, the resident turned off the nebulizer machine. LPN 2 arrived, removed the mask and put it in a bag. No assessments were observed before or after the nebulizer was administered. The resident's record was reviewed on 12/03/25 at 9:34 a.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD) and fluid overload. The Medicare-5 Day Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making, and required moderate assist with activities of daily living (ADLs) and transfers. A Physician's Order, dated 11/24/25, indicated ipratropium - albuterol solution, inhale orally every 4 hours. A Physician's Order, dated 9/30/25, indicated pre-nebulizer and post-nebulizer assessments: obtain pulse, respirations, and O2 saturations prior to and after each treatment. The record lacked documentation of pre and post-nebulizer assessments. During an interview on 12/8/25 at 3:00 p.m., the Director of Nursing (DON) indicated assessments should be done before and after each nebulizer treatment. A policy titled, Oral Inhalation Administration, received as current from the VP of Clinical Services on 12/9/25 at 10:35 a.m., indicated the following instructions when administering a nebulizer, . Obtain a baseline pulse, respiratory rate, and lung sounds . When treatment is complete . obtain post-treatment pulse, respiratory rate, and lung sounds and document findings on the MAR [medication administration record] or in the resident's medical record . 3.1-47(a)(6)

Based on observation, record review, and interview, the facility failed to ensure a resident received routine dental services and a denture follow up appointment had been completed for 2 of 2 residents reviewed for dental services. (Residents 5 and 9)Findings include:1.On 12/1/25 at 11:15 a.m., Resident 5 was observed with multiple areas of missing teeth. The resident indicated it had been a long time since he had seen the dentist. The record for Resident 5 was reviewed on 12/4/25 at 9:01 a.m. Diagnoses included, but were not limited to, altered mental status and mild intellectual disabilities. The Annual Minimum Data Set (MDS) assessment, dated 9/29/25, indicated the resident was moderately impaired for daily decision making. A Physician's Order, dated 6/27/25 and listed as current on the December 2025 Physician's Order Summary (POS), indicated the resident could receive dental care as needed. There was no documentation of any dental visits for the resident since the order was obtained on 6/27/25. Documentation provided by the Social Service Director indicated the dentist had visited the facility on 6/27, 7/30, 8/27, 9/24, 10/29, and 11/21/25. The dental hygienist visited the facility on 6/12, 7/23, 8/29, 9/26, 10/15, and 11/21/25. During an interview on 12/8/25 at 10:00 a.m., the Social Service Director indicated the resident refused his last dental visit but neither she nor the contracted dental group had a date for that visit. The Social Service Director indicated she put the resident on the list to be seen on 12/10/25. 2. During an interview on 12/1/25 at 10:34 a.m., Resident 9 indicated she had her teeth removed six months ago and she still had no dentures. The record for Resident 9 was reviewed on 12/4/25 at 1:10 p.m. Diagnoses included, but were not limited to, dementia, psychotic disorder with delusions, anxiety disorder, heart disease, major depressive disorder, and heart failure. The 11/27/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making and had minimal difficulty hearing with no hearing aides. She needed partial to moderate assistance with sitting to stand and transfers from the bed to the chair and vice versa. She had a history of one fall with no major injury since the last assessment and has no oral problems. A Care Plan, revised on 9/4/25, indicated the resident had dental problems. The following was a timeline of events leading up to the resident's extractions: - 11/14/24 a dental note which indicated the resident would like to have her teeth removed a couple at a time. The recommendations were to have an x-ray after all root tips were removed and full upper and lower dentures. - 4/15/25 a dental note indicated suggested to resident removing a tooth or two at at time, however the resident wanted to hold off for now. - 4/21/25 the resident signed a consent for dental extraction. - 4/22/25 10 teeth were extracted. - 5/23/25 more teeth were extracted. - 6/27/25 a dental note indicated she still had two more root tips to be removed. The resident indicated she would discuss with social services and go outside of the facility to see and oral surgeon. - 11/21/25 a dental note indicated the resident still had two root tips to be removed. The resident wanted to discuss dentures, however her posterior maxillary arch has a moderate level of bone loss, anteriorly approximately six centimeters of bone remained before the base of her nose was breached. The bone level was not sufficient for dentures. The resident would need implants if she still wanted dentures due to the lack of bone. A Social Service Progress Note, dated 9/25/25 at 11:44 a.m., indicated they left a message asking for follow up on dental services for resident and were awaiting a response. A Social Service Progress Note, dated 12/8/25 at 10:34 a.m., indicated the resident had an appointment with an outside dentist to inquire about dental implants. The dentist had been in the facility on 6/27, 7/30, 8/27, 9/24, and 10/29/25 and did not see the resident. During an interview on 12/8/25 at 2:00 p.m., the Social Service Director indicated the resident had most of her teeth extracted in April and May 2025 with a couple of root tips that remained. She was unaware the resident had told the dentist on 6/27/25 that she was going to consult her for help on getting her to an oral surgeon, as the dentist did not leave any of that information after the visit. She followed up with the dentist on 9/25/25 and also reached out to them on 11/25/25 to see what kind of insurance would cover the implants. She had someone else working on the ancillary services during this time, however, that person no longer worked at the facility. 3.1-24(a)(1) 3.1-24(a)(3)

Based on record review and interview, the facility failed to ensure a dependent resident's family or representative was notified of changes related to a dislodged gastrostomy tube (g-tube; a tube inserted through the skin into the stomach to provide nutrition and mediations) and antibiotic orders for 1 of 3 residents reviewed for g-tubes. (Resident C)Finding includes:Resident C's record was reviewed on 10/8/25 at 9:34 a.m. Diagnoses included, but were not limited to, flaccid hemiplegia affecting the right side, aphasia (a language disorder that affects communication), dysphagia (swallowing difficulty) and g-tube status.The Quarterly Minimum Data Set assessment, dated 8/4/25, indicated the resident had severe cognitive deficits and was dependent for bed mobility and transfers.A care plan dated 11/14/21, indicated the resident had impaired cognition related to impaired short term and long-term memory and decision making. The family manages her care.The resident's profile indicated she was her own responsible party. Her family members were listed as emergency contacts.A Nurse Note, dated 9/1/25 at 5:56 a.m., indicated the resident's g-tube had become dislodged. The Nurse Practitioner (NP) had been notified, there was no documentation family had been notified.A Nurse Note, dated 9/1/25 at 9:15 a.m., indicated the NP had given orders to cleanse the g-tube site with normal saline, pat dry and cover with a dry dressing daily and as needed. The resident was her own responsible party and aware.A Nurse Note, dated 9/11/25, indicated the Physician had given an order for amoxicillin-pot clavulanate (an antibiotic) 875-125 milligrams (mg), twice daily for ten days and doxycycline hyclate (an antibiotic) 100 mg, twice daily for ten days related to an infection of the g-tube site. The resident was her own responsible party and aware.A Nurse Note, dated 9/22/25, indicated the NP had given an order for Levaquin (an antibiotic) 500 mg, daily for seven days related to an infection of the g-tube site. The resident was her own responsible party.During an interview on 10/8/25 at 1:20 p.m., the Nurse Consultant indicated the resident should not be listed as her own responsible party as the family managed her care.The citation relates to Intake 2632273.3.1-5(a)(3)

Based on record review and interview, the facility failed to ensure residents received the necessary care and treatment related to antibiotics not given as ordered, wound treatments not provided as ordered and incomplete wound assessments for 3 of 3 residents reviewed for infections. (Residents C, B and D)Findings include:1. Resident C's record was reviewed on 10/8/25 at 9:34 a.m. Diagnoses included, but were not limited to, flaccid hemiplegia affecting the right side, aphasia (a language disorder that affects communication), dysphagia (swallowing difficulty) and g-tube status. The Quarterly Minimum Data Set assessment, dated 8/4/25, indicated the resident had severe cognitive deficits and was dependent for bed mobility and transfers. A Physician's Order, dated 9/11/25, indicated to give amoxicillin-pot clavulanate (an antibiotic) 875-125 milligrams (mg), twice daily for ten days and doxycycline hyclate (an antibiotic) 100 mg, twice daily for ten days related to an infection of the g-tube site. The September 2025 Medication Administration Record indicated the medications had not been given on the evening of 9/20/25. There were no progress notes or medication notes that indicated why the medications were not given. During an interview on 10/8/25 at 2:00 p.m., the Nurse Consultant indicated she did not know why the medications were not signed out, there was no additional information provided. 2. Resident B's record was reviewed on 10/8/25 at 9:57 a.m. Diagnoses included, but were not limited to, fracture of the left acetabulum (part of the pelvis). The resident admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment, dated 9/24/25, indicated the resident was cognitively intact. A Care Plan, dated 9/18/25, indicated the resident had a surgical incision/wound. Interventions included, but were not limited to, keep incision site clean and dry, monitor for signs or symptoms of infection, and treatment as ordered. The Wound Assessment Details Report, dated 9/18/25 at 2:15 p.m., indicated the resident had a surgical incision present on admission to the left hip. There was a non-removable dressing in place. There was moderate serous exudate (drainage from wound). There was no other documentation included in the assessment. The Wound Assessment Details Report, dated 9/26/25 at 2:36 p.m., indicated the left hip surgical incision had a non-removable dressing in place. There was moderate serous exudate. There was no other documentation included in the assessment. The photograph of the wound showed visible staples as the dressing had been removed. The Wound Assessment Details Report, dated 10/6/25 at 11:28 a.m., indicated the left hip surgical incision had 95% intact skin and 5% slough loosely adherent tissue. There was light serous exudate. The periwound (surrounding tissue) was reddened in color and macerated (breakdown of skin due to prolonged exposure to moisture) There were signs of infection present, and the resident was on antibiotics. The wound was 23 centimeters (cm) long by 0.30 cm wide. The Nurse to Nurse Transfer Report, dated 9/18/25, indicated the resident had a surgical wound with left hip incision with a treatment Mepilex (absorbent foam dressing) to be changed every 5 days. A Long Term Care – admission Orders, dated 9/18/25, indicated Physician Orders.21. Treatment & wound care change dressing every 5 days or PRN for drainage/soiled dressing. A Physician's Order, dated 9/18/25, indicated to monitor the non-removable dressing to the left hip. Notify the physician if any increased redness or swelling occurs, dressing dislodgment/damage, or any other signs or symptoms of possible infection every shift. The order was discontinued on 9/23/25. The September 2025 Treatment Administration Record (TAR) indicated the non-removable dressing to the left hip was monitored as ordered. A Physician's Order, dated 9/30/25, indicated to cleanse the left hip with normal saline/wound wash, pat dry, and cover with dry dressing every Tuesday and Friday and may replace dressing PRN for damage, soilage, or dislodgement. The September 2025 Treatment Administration Record (TAR) indicated the order for the left hip was completed on Tuesday 9/30/25. There were no other treatments to the left hip administered per the September 2025 TAR. A Nurse Practitioner Progress Note – Follow Up, dated 10/3/25, indicated the chief complaint was redness to the surgical site. The resident had some redness and pain to the lower part of the surgical site. The staples were embedded in the lower half of the incision. During an interview on 10/8/25 at 2:03 p.m., the Nurse Consultant indicated the physician's orders for the dressing changes were not followed and documented as ordered. The wound assessments were to be completed weekly. A facility policy titled, Skin Condition Assessment & Monitoring – Pressure and Non-Pressure, indicated, .Non-pressure skin conditions (bruises/contusions, abrasions, lacerations, rashes, skin tears, surgical wounds, etc. will be assessed for healing progress and signs of complications or infection weekly.7. Physician ordered treatments shall be initialed by the staff on the electronic Treatment Administration Record after each administration. 3. Resident D's record was reviewed on 10/8/25 at 11:22 a.m. Diagnoses included, but were not limited to, surgical aftercare following surgery on the digestive system and peritoneal abscess. The admission Minimum Data Set (MDS) assessment, dated 9/30/25, indicated the resident was cognitively intact and was receiving antibiotics. A Care Plan, dated 9/25/25, indicated the resident was on intravenous antibiotic therapy for an abdominal abscess. Interventions included, but were not limited to, administer antibiotic medications as ordered by the physician. A Physician's Order, dated 9/25/25, indicated meropenem intravenous solution reconstituted, 500 milligrams (mg) intravenously every 6 hours until 10/6/25. A Physician's Order, dated 10/6/25, indicated meropenem intravenous solution reconstituted, 500 milligrams (mg) intravenously every 6 hours until 10/20/25. The September and October 2025 Medication Administration Record indicated the meropenem antibiotic was not administered as ordered on 9/25/25 at 6:00 a.m., 10/5/25 at 12:00 p.m. and 10/7/25 at 12:00 a.m. During an interview on 10/8/25 at 2:15 p.m., the Nurse Consultant indicated she had no further information to provide. This citation relates to Intake 2632273. 3.1-37(a)

Based on record review and interview, the facility failed to ensure activities of daily living (ADLs) were completed for a dependent resident related to lack of showers provided twice a week for 1 of 3 residents reviewed for ADLs. (Resident B)Finding includes:The record for resident B was reviewed on 7/29/25 at 2:04 p.m. Diagnoses included, but were not limited to, diabetes, adult failure to thrive, and chronic non-pressure ulcer of skin. The 5/20/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and required maximal assistance with ADLs and transfers.The Care Plan, revised on 4/11/25, indicated the resident had an ADL self-care performance deficit and required the assistance of 1-2 staff members to shower. The Tasks section of the resident's record indicated the resident was to receive a bath or shower on Tuesday and Friday evenings. The record lacked documentation of the resident being bathed from 7/1/2025 to 7/29/25. There was no bathing documented or refused for 7/4/25, 7/22/25, and 7/25/25. There were no documented attempts to re-schedule bathing refused by the resident on 7/1/25, 7/8/25, and 7/11/25, or when the resident was not available on 7/15/25. During an interview on 7/29/25 at 3:55 p.m., when informed of the findings, the Director of Nursing indicated staff needed to be educated about documentation and offered no additional information.This citation relates to Complaint 2566923.3.1-38(a)(3)

Based on observation, record review, and interview, the facility failed to ensure interventions to provide effective pressure relief to the coccyx were implemented for a resident readmitted with a stage two (a partial thickness loss of skin) pressure injury on the coccyx and failed to ensure the physician was notified when the wound deteriorated. (Resident F) This deficient practice resulted in the wound deteriorating to a stage four pressure injury (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) that required two surgical debridements. The facility also failed to ensure treatments were signed out as being completed, antibiotics for a wound infection were started promptly, the physician was notified of treatment refusals, and turning and repositioning a resident with a pressure ulcer was completed for 5 of 10 residents reviewed for pressure ulcers. (Residents F, E, T, O, and H) Findings include: 1. On [DATE] at 9:30 a.m., the Wound Nurse was observed changing the bandage to Resident F's pressure ulcer. The bandage was removed from the resident's coccyx area and the wound was foul smelling with a large amount of bloody drainage. There was slough (necrotic tissue) observed inside and around the wound, which was red and pink in color. The record for Resident F was reviewed on [DATE] at 11:55 a.m. Diagnoses included, but were not limited to, acute kidney failure, type 2 diabetes, major depressive disorder, atrial fibrillation, cardiac pacemaker, heart disease, anemia, depression, high blood pressure, and dementia without behaviors. The [DATE] Quarterly Minimum Data Set (MDS) assessment, indicated the resident was cognitively intact for daily decision making and needed substantial to maximum assistance for bed mobility and transfers. The resident had no pressure ulcers. The resident returned to the facility on [DATE] after being hospitalized . A Stage 2 (a partial thickness loss of skin) pressure ulcer was present to the coccyx that measured 1.30 centimeters (cm) in length by 1 cm in width and had 100% pale pink non-granulating tissue (a smooth, moist, red or pink tissue that appeared in wounds that were not healing). While in the hospital, the resident tested positive for Clostridioides difficile (C-diff) and was readmitted on transmission-based precautions (contact isolation). She was being treated for the C-diff with the antibiotic of Vancomycin 125 milligrams (mg) four times a day for six days. Physician's Orders, dated [DATE], indicated Stage 2 Wound Site: cleanse coccyx with normal saline, apply skin prep barrier and wipe around periwound. Apply Hydrocolloid (used to treat wounds by creating a moist environment that promotes healing and protects new tissue) dressing every Monday, Wednesday and Friday one time a day. A Care Plan, initiated upon readmission to the facility, indicated the resident was at risk for pressure ulcers and had a stage 2 pressure ulcer. Interventions included turning and repositioning, good nutrition, and treatments as ordered. A coccyx wound measurement, dated [DATE], indicated the wound measured 1.5 cm in length by 1 cm in width and had 100% pink or red non-granulating tissue. The presence of odor or drainage was not addressed. A coccyx wound measurement, dated [DATE], indicated the wound now deteriorated and measured 2 cm in length by 3 cm in width and was classified as an unstageable (full thickness tissue loss that was covered by necrotic tissue) pressure ulcer with 100% loosely adhered slough. The presence of odor or drainage was not addressed. There was no documentation that the physician was notified of the wound deterioration and the increase in size. There was no documentation that a physician had assessed the wound when the deterioration was identified. The Treatment Administration Record (TAR) for ,d+[DATE] and ,d+[DATE] indicated the Hydrocolloid dressing was signed out as being completed as ordered from ,d+[DATE]-[DATE] and on [DATE]. The TARs indicated a hydrocolloid dressing was applied to the unstageable wound three times a week on 4 of 4 days between [DATE] and [DATE]. A Wound Physician initial note, dated [DATE], indicated the resident had an unstageable wound on the coccyx that measured 2.8 cm in length by 3.8 cm in width with 80% thick adherent necrotic tissue. There was a moderate amount of serous drainage observed to the wound. Post-debridement assessment of this previously unstageable necrotic wound has revealed the underlying deep tissue at the muscle/fascia level, which had been obscured by necrosis prior to this point. This wound has now revealed itself to be a Stage 4 (damage through all layers of the skin) pressure injury. The etiology (cause) was identified as pressure. A Wound/Skin Note, dated [DATE] at 1:02 p.m., indicated the resident was seen by the Wound Physician for the coccyx wound. Surgical debridement was done, which the resident tolerated well, and a new order was obtained for the treatment to be changed. A Physician's Order, dated [DATE], indicated cleanse the coccyx wound with normal saline, apply calcium alginate (a wound dressing material that absorbs excess moisture and promotes healing) and cover with dry dressing twice a week every Monday and Friday. A Physician's Order, dated [DATE], indicated a low air loss mattress (an air mattress covered with tiny holes designed to let out air very slowly, which helps keep the skin dry and [NAME] away any moisture) The ,d+[DATE] TAR indicated the treatment of the calcium alginate was not signed out as being done on [DATE], which was 1 of 4 treatments from ,d+[DATE]-[DATE] A Wound Nurse Note, dated [DATE] at 10:15 p.m., indicated the resident was seen by the Wound Physician on [DATE]. The pressure ulcer had increased in size, so a new treatment was obtained as well as a low air loss mattress was now in place. The RD (Registered Dietitian) was notified as the resident had lost 11.6% weight in the last 6 months, and new labs were ordered. A [DATE] RD note indicated the resident was seen due to a decline in a pressure ulcer and an unplanned weight loss of 11.9% in 6 months. Megace was in place to enhance appetite, and the RD reviewed the plan of care with the treatment nurse. Protein modular may not be indicated at this time secondary to fragile kidney function. The plan of care was appropriate; however, disease progression may make the wound decline and weight loss unavoidable. Please add a house nutritional supplement three times a day. A Care Plan, revised on [DATE], indicated the resident had a pressure ulcer to the coccyx area related to immobility. The approaches were to follow facility policies/protocols for the prevention/treatment of skin breakdown and to monitor/document/report as needed any changes in skin status such as appearance, color, wound healing, infection, wound size stage and report results to the physician and follow up as indicated. A Physician's Order, dated [DATE], indicated Complete Blood Count, Chemical Metabolic Panel, a pre-albumin and a glycosylated hemoglobin was to be obtained from lab services. The Progress Notes and Care Plan [DATE]-[DATE] did not include interventions for pressure relief to the coccyx. A Wound Physician Note, dated [DATE], indicated the wound measured 4.8 cm by 3.2 cm by not measurable. There was 30% thick necrotic tissue, 20% slough, and 20% granulation tissue. The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, curette was used to surgically excise 7.68cm^2 of devitalized tissue and necrotic subcutaneous level tissues along with slough and biofilm were removed at a depth of 0.4 cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 50 percent to 0 percent. Hemostasis was achieved and a clean dressing was applied. The etiology (cause) was identified as pressure. A Wound/Skin Note, dated [DATE] at 11:11 a.m., indicated the resident was seen by the Wound Physician and another surgical debridement was completed. During an interview on [DATE] at 11:55 a.m., the Wound Nurse indicated the regular Wound Physician was on vacation for two weeks so there was a sub who performed telehealth medicine on [DATE], however, the physician did not see Resident F's wound that day. The Wound Nurse measured and assessed the wound herself and placed the Hydrocolloid bandage on the wound as ordered. She did not notify the resident's doctor for a treatment change or the decline in wound status after the wound had deteriorated. The first time a physician saw the wound was on [DATE] and the treatment was changed at that time. Laboratory tests, implementation of the low air loss mattress, and the RD notification were all done after [DATE]. Nothing had been completed on [DATE] when the wound initially deteriorated. During an interview on [DATE] at 3:00 p.m., the Director of Nursing indicated the resident's physician and family were notified today of the worsening pressure ulcer. The resident had a bacterium Clostridioides difficile (C-diff) infection when she returned from the hospital and the pressure ulcer was only a Stage 2 at that time. The treatment should have been changed when it had become an unstageable ulcer. The change in treatment, mattress, laboratory tests and RD consultation were all ordered after the wound physician had seen the resident on [DATE]. The current and revised Pressure Injury and Skin Condition Assessment policy, provided by the Director of Nursing as current on [DATE] at 8:40 a.m., indicated care givers were responsible for promptly notifying the charge nurse of skin breakdown. When there were weekly changes which required physician and responsible party notification, documentation of findings will be made in the clinical record. Physician and responsible party will be documented in the clinical record. These changes include, but were not limited to, new onset of purulent drainage, new onset of odor, significant increase in wound measurements and onset of new ulcers. The attending physician shall be notified within seven to 14 days of the resident's lack of response to treatment. 2. The closed record for Resident E was reviewed on [DATE] at 9:33 a.m. Diagnoses included, but were not limited to, stroke, peg tube (a tube inserted directly into the stomach for nutrition), vascular dementia, dysphasia (difficulty swallowing), major depressive disorder, anxiety, pain, and bilateral amputee. The resident expired in the facility on [DATE]. The [DATE] Significant Change Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making and had one unstageable pressure ulcer. The Care Plan, revised on [DATE], indicated the resident had an impairment of skin integrity related to a pressure ulcer to the sacrum. A Physician's Order, dated [DATE], indicated to cleanse the sacrum pressure ulcer with normal saline, gently pat periwound dry, apply calcium alginate to wound bed and cover with Island dressing every day shift. The Wound Physician Note, dated [DATE], indicated a Stage 4 Pressure Ulcer to the coccyx that measured 9 centimeters (cm) by 15 cm by 0.5 cm with undermining of 1.0 cm at 9 o'clock. There was heavy drainage noted and 30% thick adherent devitalized necrotic tissue, 20% slough, and 10%granulation tissue. The wound progress has exacerbated and worsened. The plan and new treatment was to add Metronidazole (an antibiotic) sprinkled on top of the wound once daily for 30 days with the Calcium Alginate. A Nurse's Note, dated [DATE] at 6:53 p.m., indicated the resident was seen by the Wound Physician and a new order was obtained for Metronidazole to be sprinkled on wound daily and calcium alginate with island dressing daily. A Physician Order, dated [DATE], indicated Metronidazole powder apply to coccyx one time a day. A Nurse's Note, dated [DATE] at 10:59 a.m., indicated medication was not available. A Nurse's Note, dated [DATE] at 12:41 p.m., indicated the order was clarified per pharmacy recommendations. A Physician Order, dated [DATE], indicated Metronidazole 500 milligrams (mg), apply to coccyx wound topically one time a day. The Treatment Administration Record (TAR) for ,d+[DATE] indicated the antibiotic had not been initiated until [DATE] (three days after it was ordered). During an interview on [DATE] at 2:33 p.m., the Wound Nurse indicated the pharmacy told them they did not have the powder form of the antibiotic, so they had to wait for the pill form to be delivered. During an interview on [DATE] at 11:28 a.m., the Director of Nursing indicated the pharmacy did not have the powder and they recommended the sprinkles, however, that alternative was not sent until later. There was no documentation from nursing regarding the conversations with pharmacy and the change from powder to sprinkles. The medication was not initiated timely. 10326 3. The record for Resident T was reviewed on [DATE] at 2:11 p.m. Diagnoses included, but were not limited to, dementia without behavioral disturbance, Alzheimer's disease, major depressive disorder, and stress incontinence. The Quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident was cognitively impaired for daily decision making. She required partial to moderate assistance with rolling left and right in bed and had one Stage 2 (a partial thickness loss of skin) pressure ulcer, one Stage 4 (damage through all layers of the skin) pressure area, and one Unstageable (full thickness tissue loss that is covered by necrotic tissue) pressure ulcer. A Care Plan, dated [DATE], indicated the resident had a pressure ulcer to her right and left hip and right knee related to history of ulcers, immobility, and progression of disease process. Interventions included, but were not limited to, administer treatments as ordered and monitor for effectiveness. The [DATE] Physician's Order Summary (POS) indicated the pressure ulcers to the resident's right and left hips were to be cleansed with normal saline, packed with Iodoform (a wound packing) packing strips, and cover with a dry dressing daily and as needed (PRN) for dislodgement or soiling. The [DATE] Treatment Administration Record (TAR) indicated the treatment to the right and left hips were not signed out as being completed on [DATE], [DATE], and [DATE]. The [DATE] TAR indicated the treatment to the right and left hips were not signed out as being completed on [DATE]. During an interview on [DATE] at 3:15 p.m., the Director of Nursing indicated the treatments should have been signed out as being completed. 32664 4. On [DATE] at 11:05 a.m., Resident O was observed sitting in her room. During an interview at that time, the resident indicated she was admitted with a pressure ulcer wound to her coccyx. She had problems with the bandage always falling off and the nursing staff did not do her treatments when they were supposed to. Record review for Resident O was completed on [DATE] 3:33 p.m. Diagnoses included, but were not limited to, heart failure, hypertension, and arthritis. The Admission MDS assessment, dated [DATE], indicated the resident was cognitively intact. The resident was independent for bed mobility. The resident had an unstageable pressure ulcer on admission to the facility. A Care Plan, dated [DATE] and revised [DATE], indicated the resident had a pressure ulcer to the coccyx. Interventions included to assess/record and monitor for wound healing and report improvements and declines to the physician. If the resident refused treatment, confer with the resident, IDT (interdisciplinary team) and family to determine why and try alternative methods to gain compliance. The [DATE] Physician's Order Summary (POS) indicated an order to cleanse the open area to the coccyx with normal saline, pat dry, and apply a foam dressing one time a day on Mondays, Wednesdays, and Fridays and every 24 hrs as needed for soilage or dislodgement. A Wound Rounds Assessment, dated [DATE], indicated the resident had an unstageable pressure ulcer to the coccyx. The wound measured 3.5 cm (centimeters) x 1.5 cm. The wound was covered in 100% slough (dead tissue). The wound was present on the resident's admission. Wound Rounds Assessments, dated [DATE] and [DATE], indicated the resident had refused treatment and picture of the wound. The resident indicated the dressing came off frequently and there was no need for it. The [DATE] Treatment Administration Record (TAR) indicated the resident refused treatment for the coccyx on ,d+[DATE] and [DATE]. The [DATE] TAR treatment for the pressure ulcer indicated, on [DATE], the resident left the facility for an appointment and the treatment was not completed. The TAR was blank on [DATE], and on [DATE], the TAR indicated the resident did not receive treatment and had refused. There was a lack of documentation to indicate the Physician had been notified of the resident's refusal of wound treatments or that education about the importance of the treatments was provided to the resident. During an interview on [DATE] at 9:11 a.m., the 200 Unit Assistant Director of Nursing (ADON) indicated the Wound Nurse had told her the resident had refused her wound treatment that day. During an interview on [DATE] at 10:28 a.m., the Director of Nursing indicated she was unaware the resident had been refusing her pressure ulcer treatments. She would expect the staff to provide education to the resident about the importance of the treatments and to notify the Physician about the refusals. During an interview on [DATE] at 11:30 a.m., the Social Services Director indicated she had a Care Plan Conference with the resident on [DATE]. The resident did not express to her anything related to her pressure ulcer treatments. Nursing did not inform her the resident had been refusing her wound treatments. During an interview on [DATE] at 1:09 p.m., the Wound Nurse indicated she had not documented the resident had been refusing her wound treatments or that education was provided. She had not measured the resident's wound since the first Wound Round Assessment, dated [DATE]. 43293 5. During observations at the following times, Resident H was observed lying flat on his back in bed: [DATE] at 11:22 a.m., 2:16 p.m., 2:35 p.m. and 3:30 p.m.; [DATE] at 2:16 p.m. and 3:30 p.m.; [DATE] at 8:34 a.m., 11:00 a.m., 2:03 p.m. and 2:57 p.m.; and [DATE] at 10:48 a.m. The record for Resident H was reviewed on [DATE] at 3:27 p.m. Diagnoses included, but were not limited to, quadriplegia, urinary tract infection, pressure ulcer of sacrum stage 4, gastrostomy status (a feeding tube inserted through the abdomen into the stomach), dysphagia (difficulty swallowing), and neuromuscular dysfunction of bladder. The [DATE] Annual Minimum Data Set (MDS) assessment indicated the resident was cognitively intact and dependent in activities of daily living. A Care Plan, revised on [DATE], indicated the resident had a pressure ulcer on his coccyx due to immobility, and the CNAs were to turn and reposition the resident at regular intervals as he allowed/ tolerated. During an interview on [DATE] at 2:16 p.m., the resident indicated the staff only turned him when cleaning him up or performing wound care. During an interview on [DATE] at 10:48 a.m., the resident indicated the staff used to turn him regularly and had used wedges to keep him on his side. He did not know why they stopped repositioning him, but he was agreeable to resuming it. During an interview on [DATE] at 3:30 p.m., the Director of Nursing (DON) was informed of the findings and offered no further information. This citation relates to Complaints IN00446198 and IN00447156. 3XXX,d+[DATE](a)(2)

Based on record review and interview, the facility failed to promptly notify the Physician of abnormal laboratory findings, resulting in a delay in treatment for which the resident was hospitalized for septic shock and required intubation and ultimately death for 1 of 4 residents reviewed for a change in condition. (Resident E) Finding includes: The closed record for Resident E was reviewed on [DATE] at 4:35 p.m. Diagnoses included but were not limited to, COPD, respiratory failure, acute kidney failure, peg tube, epilepsy, anxiety, and heart failure. There was Minimum Data Set (MDS) assessment available for review. The Admission Nursing Assessment, dated [DATE], indicated the resident was observed with pursed lip breathing and his lung sounds on both sides were clear, diminished with rales. No equipment for respiratory status was checked on the form. A Physician's Order, dated [DATE], indicated to obtain labs: a CBC (Complete Blood Count) with differential and platelets, a CMP (Comprehensive Metabolic Panel), a Glycohemoglobin A1C, a Lipid panel, a renal function panel, a thyroid profile with a T4 and TSH, and a PSA. The lab results were obtained on [DATE] and reported to the facility on [DATE] at 10:24 p.m., however, there was no documentation the Physician was ever notified of the abnormal results. The lab results were as follows: - CBC Hemoglobin was 10.3 grams (gm) (normal 14.0 - 18.0) Hematocrit was 33.7% (normal 42.0 - 52.0) - CMP Blood Urea Nitrogen (BUN) was 132 (normal ,d+[DATE]) Creatinine was 4.02 (normal 0XXX,d+[DATE].32) Sodium was 164 (normal ,d+[DATE]) Glucose was 230 (normal ,d+[DATE]) The lab had suggested the BUN and Sodium be repeated if necessary. The resident's vital signs on [DATE] were documented at 10:37 a.m. The resident's blood pressure was ,d+[DATE] and the oxygen saturation was 97% on room air. A Nurses' Note, dated [DATE] at 12:20 p.m., indicated resident is not responding, BP is ,d+[DATE],o2 is 80/min, respi is 16/min, blood sugar is 347. writer sent him in ER. notified to DON and family. [sic] A Nurses' Note, dated [DATE] at 1:20 p.m., indicated report was given to the emergency room (ER) at the hospital. A signed document by the Paramedic, dated [DATE], indicated EMS (Emergency Medical Service) was dispatched to the extended care facility for a sick person. The patient had been unconscious for over an hour. The patient was not on any oxygen. The patient's dialysis port was uncovered and not secured to the patient. The patient had multiple sores to his body. A History and Physical by the ER Physician, dated [DATE] at 12:33 p.m., indicated .Patient presents to ED via EMS from (nursing home name) for altered mental status and shortness of breath. Patient was hypoxic down to the 80's per EMS without any oxygen which improved on nonbreather. Patient has a dialysis catheter in his right subclavian that is no longer sutured down. EMS reportedly place a tegaderm over the dialysis catheter to help stabilize it in place. It is unclear how long symptoms have been going on for. A physical exam indicated the patient was ill-appearing and did not respond or follow any commands. The patient had decreased breath sounds bilaterally. At 1:30 p.m., the resident was intubated due to hypoxemia and respiratory failure. Labs were obtained which indicated the resident tested positive for COVID-19. The BUN was 199, Creatinine was 6.2, Sodium was 156, Potassium was 5.8 (normal 3XXX,d+[DATE].0) Glucose was 382, and White Blood Cells were 15.50 (normal 4XXX,d+[DATE].8). A Lactic Acid lab test was obtained which was 3.4 (normal 0XXX,d+[DATE].0. A high lactic acid meant that body tissues were not getting enough oxygen). The resident was diagnosed with Severe Sepsis/Septic Shock (Severe sepsis develops when the infection caused organ damage. Septic shock was the most severe form in which the infection causes low blood pressure, resulting in damage to multiple organs). The resident expired in the hospital on [DATE]. Interview with the Director of Nursing on [DATE] at 11:30 a.m., indicated the Physician was not notified of the critical lab results drawn and received on [DATE]. This Federal tag relates to Complaint IN00401271. 3XXX,d+[DATE](a)(3)

Based on record review and interview the facility failed to protect a resident's right to be free from neglect related to the failure of monitoring/assessing a dialysis perma catheter, lack of Physician notification of abnormal lab results and failure to administer oxygen for a resident in respiratory distress which resulted in a hospitalization for septic shock and required intubation and ultimately death for 1 of 3 residents reviewed for neglect (Resident E) Finding includes: The closed record for Resident E was reviewed on [DATE] at 4:35 p.m. Diagnoses included but were not limited to, COPD, respiratory failure, acute kidney failure, peg tube, epilepsy, anxiety, and heart failure. There was Minimum Data Set (MDS) assessment available for review. The resident was admitted directly to the facility on [DATE] from another Long Term Care facility. Ancillary Physician's Orders on the transfer information, dated [DATE], indicated the resident was receiving oxygen continuously at 2 liters via nasal cannula and had a dialysis perma catheter to the right chest that was to be checked/assessed every shift. The resident had discontinued dialysis treatment on [DATE]. A Nurses' Note, dated [DATE] at 2:01 p.m., indicated the resident arrived via ambulance transport accompanied by two ambulance transporters. Nursing tried to acclimate the resident to the room, call light, surrounding areas and the television, however, the resident did not respond. Vital signs were checked and within normal limits. A rapid COVID-19 test was administered with negative results. The remainder of the new admission process was passed to the oncoming shift. A Nurses' Note, dated [DATE] at 7:34 p.m., indicated all medication was verified with the Physician and entered into the electronic Medication Administration Record (MAR). The Admission Nursing Assessment, dated [DATE], indicated the resident was observed with pursed lip breathing and his lung sounds on both sides were clear, diminished with rales. No equipment for respiratory status was checked on the form. Under the section of Intravenous (IV) therapy, nothing was checked as well for the dialysis perma catheter. Physician's Orders, dated ,d+[DATE]-[DATE], indicated there were no orders for oxygen or to check/assess the dialysis perma catheter to the right chest. Physician's Orders, dated [DATE], indicated the resident was NPO and was to receive an enteral tube feeding of Glucerna 1.5 at 65 cubic centimeters (cc) from 10:00 a.m., until 6:00 a.m. The peg tube was to be flushed with 180 milliliters (ml) of water every 4 hours. A Physician's Order, dated [DATE], indicated to obtain labs: a CBC (Complete Blood Count) with differential and platelets, a CMP (Comprehensive Metabolic Panel), a Glycohemoglobin A1C, a Lipid panel, a renal function panel, a thyroid profile with a T4 and TSH, and a PSA. The lab results were obtained on [DATE] and reported to the facility on [DATE] at 10:24 p.m., however, there was no documentation the Physician was ever notified of the abnormal results. The lab results were as follows: - CBC Hemoglobin was 10.3 grams (gm) (normal 14.0 - 18.0) Hematocrit was 33.7% (normal 42.0 - 52.0) - CMP Blood Urea Nitrogen (BUN) was 132 (normal ,d+[DATE]) Creatinine was 4.02 (normal 0XXX,d+[DATE].32) Sodium was 164 (normal ,d+[DATE]) Glucose was 230 (normal ,d+[DATE]) The lab had suggested the BUN and Sodium be repeated if necessary. The resident's vital signs on [DATE] were documented at 10:37 a.m. The resident's blood pressure was ,d+[DATE] and the oxygen saturation was 97% on room air. A Nurses' Note, dated [DATE] at 12:20 p.m., indicated resident is not responding, BP is ,d+[DATE],o2 is 80/min, respi is 16/min, blood sugar is 347. writer sent him in ER. notified to DON and family. [sic] A Nurses' Note, dated [DATE] at 1:20 p.m., indicated report was given to the emergency room (ER) at the hospital. A signed document by the Paramedic, dated [DATE], indicated EMS (Emergency Medical Service) was dispatched to the extended care facility for a sick person. The patient had been unconscious for over an hour. The patient was not on any oxygen. The patient's dialysis port was uncovered and not secured to the patient. The patient had multiple sores to his body. A History and Physical by the ER Physician, dated [DATE] at 12:33 p.m., indicated .Patient presents to ED via EMS from (nursing home name) for altered mental status and shortness of breath. Patient was hypoxic down to the 80's per EMS without any oxygen which improved on nonbreather. Patient has a dialysis catheter in his right subclavian that is no longer sutured down. EMS reportedly place a tegaderm over the dialysis catheter to help stabilize it in place. It is unclear how long symptoms have been going on for. A physical exam indicated the patient was ill-appearing and did not respond or follow any commands. The patient had decreased breath sounds bilaterally. At 1:30 p.m., the resident was intubated due to hypoxemia and respiratory failure. Labs were obtained which indicated the resident tested positive for COVID-19. The BUN was 199, Creatinine was 6.2, Sodium was 156, Potassium was 5.8 (normal 3XXX,d+[DATE].0) Glucose was 382, and White Blood Cells were 15.50 (normal 4XXX,d+[DATE].8). A Lactic Acid lab test was obtained which was 3.4 (normal 0XXX,d+[DATE].0. A high lactic acid meant that body tissues were not getting enough oxygen). The resident was diagnosed with Severe Sepsis/Septic Shock (Severe sepsis develops when the infection caused organ damage. Septic shock was the most severe form in which the infection causes low blood pressure, resulting in damage to multiple organs). The resident expired in the hospital on [DATE]. Interview with the Administrator on [DATE] at 3:30 p.m., indicated the LPN who admitted the resident was asked about the dialysis perma catheter at the time of admission. The LPN indicated she had seen the catheter and it was covered. The Administrator indicated the LPN was fired from the facility. Interview with the Director of Nursing on [DATE] at 11:30 a.m., indicated the Physician was not notified of the labs drawn on [DATE]. There was no documentation/assessment of the dialysis perma catheter and there was no documentation of any oxygen administered when the resident started to have a change in condition before he was sent to the hospital. They had no further information for review. This Federal tag relates to Complaints IN00398992 and IN00401271. 3XXX,d+[DATE](a)(3)

Based on observation, record review, and interview, the facility failed to ensure a resident received appropriate care and services including new admission follow up nursing assessments and lack of oxygen after a change in condition which resulted in a hospitalization for septic shock and intubation for 1 of 4 residents reviewed for a change in condition (Resident E). The facility also failed to ensure follow up assessments were completed after falls and bruises were monitored until healed for 2 of 3 residents reviewed for falls and 1 of 3 residents reviewed for abuse. (Residents L, J and N) Findings include: 1. The closed record for Resident E was reviewed on [DATE] at 4:35 p.m. Diagnoses included but were not limited to, COPD, respiratory failure, acute kidney failure, peg tube, epilepsy, anxiety, and heart failure. There was no Minimum Data Set (MDS) assessment available for review. The resident was admitted directly to the facility on [DATE] from another Long Term Care facility. Ancillary Physician's Orders on the transfer information, dated [DATE], indicated the resident was receiving oxygen continuously at 2 liters via nasal cannula. A Nurses' Note, dated [DATE] at 2:01 p.m., indicated the resident arrived via ambulance transport accompanied by two ambulance transporters. Nursing tried to acclimate the resident to the room, call light, surrounding areas and the television, however, the resident did not respond. Vital signs were checked and within normal limits. A rapid COVID-19 test was administered with negative results. The remainder of the new admission process was passed to the oncoming shift. A Nurses' Note, dated [DATE] at 7:34 p.m., indicated all medication was verified with the Physician and entered into the electronic Medication Administration Record (MAR). The Admission Nursing Assessment, dated [DATE], indicated the resident was observed with pursed lip breathing (helps assist with shortness of breath) and his lung sounds on both sides were clear, diminished with rales (abnormal rattling sound in the lungs). No equipment for respiratory status was checked on the form. There were no further nursing assessments documented either as a new admission or as a follow up to the abnormal admission respiratory assessment. Physician's Orders, dated ,d+[DATE]-[DATE], indicated there were no orders for oxygen. A Nurses' Note, dated [DATE] at 12:20 p.m., indicated resident is not responding, BP is ,d+[DATE],o2 is 80/min, respi is 16/min, blood sugar is 347. writer sent him in ER. notified to DON and family. [sic] A Nurses' Note, dated [DATE] at 1:20 p.m., indicated report was given to the emergency room (ER) at the hospital. A signed document by the Paramedic, dated [DATE], indicated EMS (Emergency Medical Service) was dispatched to the extended care facility for a sick person. The patient had been unconscious for over an hour. The patient was not on any oxygen . A History and Physical by the ER Physician, dated [DATE] at 12:33 p.m., indicated .Patient presents to ED via EMS from (nursing home name) for altered mental status and shortness of breath. Patient was hypoxic down to the 80's per EMS without any oxygen which improved on nonbreather . It is unclear how long symptoms have been going on for. A physical exam indicated the patient was ill-appearing and did not respond or follow any commands. The patient had decreased breath sounds bilaterally. At 1:30 p.m., the resident was intubated due to hypoxemia and respiratory failure. Labs were obtained which indicated the resident tested positive for COVID-19. A Lactic Acid lab test was obtained which was 3.4 (normal 0XXX,d+[DATE].0. A high lactic acid meant that body tissues were not getting enough oxygen). The resident was diagnosed with Severe Sepsis/Septic Shock (Severe sepsis develops when the infection caused organ damage. Septic shock was the most severe form in which the infection causes low blood pressure, resulting in damage to multiple organs). The resident expired in the hospital on [DATE]. Interview with the Director of Nursing on [DATE] at 11:30 a.m., indicated there was no documentation of any follow up assessments or oxygen administered when the resident started to have a change in condition before he was sent to the hospital. They had no further information for review. 2. The record for Resident L was reviewed on [DATE] at 10:00 a.m. Diagnoses included, but were not limited to, COVID-19, heart disease, atrial fibrillation, high blood pressure, and angina. The [DATE] Quarterly Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for decision making. The resident had a history of 2 or more falls since the last assessment and 1 with a minor injury. A Care Plan, revised on [DATE], indicated the resident was at risk for falls. A Fall Initial Occurrence Note, dated [DATE] at 10:43 a.m., indicated the resident had an unwitnessed fall on [DATE] at 9:05 a.m. in her bathroom. The resident was observed on the floor outside of the bathroom. The resident indicated she did not lift her walker up far enough and fell . The resident was assessed for injuries and none were noted at the time. The resident had no pain and was picked up from the floor with 2 staff members. 72 hour Charting following the fall was completed on [DATE] at 4:35 p.m., [DATE] at 7:20 p.m., [DATE] at 5:00 a.m. and 9:51 a.m., and the last documented fall follow up was on [DATE] at 5:02 a.m. The 72 hour Charting on [DATE] at 4:35 p.m., indicated the resident's temperature, pulse, respirations, and blood pressure were all taken from [DATE] at 11:50 a.m. The 72 hour Charting on [DATE] at 7:20 p.m., and [DATE] at 5:00 a.m., indicated the resident's temperature, pulse, respirations, and blood pressure were all taken from [DATE] at 11:50 a.m. Interview with the Nurse Consultant on [DATE] at 3:30 p.m., indicated residents were to be assessed for 72 hours every shift post fall. Interview with the Director of Nursing on [DATE] at 2:00 p.m., indicated staff were to initiate 72 hour charting for every shift after a fall. There was no further information to review. 32582 3. Resident J's record was reviewed on [DATE] at 1:45 p.m. Diagnoses included, but were not limited to, dementia, dysphagia and Diabetes Mellitus. The Annual Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident had significant cognitive impairment and required extensive staff assistance for bed mobility and transfers. A Nurses' Note, dated [DATE] at 10:29 p.m., indicated the resident had been found next to his bed on the floor. The resident was assessed and no injury was noted. On [DATE] at 7:58 a.m. and 4:00 p.m., a 72 hour Charting progress note had been completed related to the fall. There were no additional 72 hour assessments related to the fall. Interview with the Nurse Consultant on [DATE] at 3:30 p.m., indicated residents were to be assessed for 72 hours every shift post fall. 45666 4. Resident N's record was reviewed on [DATE] at 2:06 p.m. Diagnoses included, but were not limited to, dementia with behavioral disturbance, Alzheimer's disease, generalized anxiety disorder, and psychosis. The Annual Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident was severely cognitively impaired. The resident displayed behavioral symptoms not directed towards others such as physical symptoms like hitting or scratching self, pacing, or verbal/vocal symptoms like screaming or disruptive sounds. A Nurses' Note, dated [DATE] at 4:24 p.m., indicated the resident had deep purple and reddish-purple bruising noted to both arms. A Nurses' Note, dated [DATE] at 7:52 p.m., indicated the resident had reddish-purple bruising noted to both arms. A Nurses' Note, dated [DATE] at 10:51 a.m., indicated the resident had deep purple and reddish-purple bruising noted to both arms. A Nurses' Note, dated [DATE] at 4:10 p.m., indicated the resident had deep purple and reddish-purple bruising noted to both arms. A Nurses' Note, dated [DATE] at 1:25 p.m., indicated the resident had deep purple and reddish-purple bruising noted to both arms. A Nurses' Note, dated [DATE] at 12:15 p.m., indicated the resident had reddish-purple, green, and yellow bruising noted to both arms. A Nurses' Note, dated [DATE] at 8:32 p.m., indicated the resident had reddish-purple, green, and yellow bruising noted to both arms. A Nurses' Note, dated [DATE] at 3:46 p.m., indicated the resident had deep purple, and reddish-purple, and green bruising noted to both arms. There were no further notes documented. Interview with the Director of Nursing on [DATE] at 1:55 p.m., indicated the bruising should have been monitored until healed. A Policy titled Skin Condition Assessment & Monitoring - Pressure and Non-Pressure and noted as current indicated .Guidelines . Non-pressure skin conditions (bruises/contusions, abrasions, lacerations, rashes, skin tears, surgical wounds, etc.) will be assessed for healing progress and signs of complications or infection weekly . When bruises are healing without complications as indicated on the above table, the nurse will monitor the site weekly. At the point of signs of healing, approximately ,d+[DATE] days, or when the bruise has turned color to green, yellow, brown, the nurse will document a last entry indicating that the normal healing process has taken place without complications, and no further follow-up will be needed. This Federal tag relates to Complaint IN00396040, IN00401271, and IN00401730. 3XXX,d+[DATE](a)

Based on record review and interview, the facility failed to protect a resident's right to be free from physical abuse by a staff member which resulted in a cognitively impaired resident sustaining a fractured skull and head laceration requiring staples for 1 of 3 residents reviewed for abuse. (Resident B) The immediate jeopardy began on 9/11/22 when the physical abuse of a QMA punching a resident occurred to Resident B. The Executive Director was notified of the immediate jeopardy at 1:37 p.m., on 11/30/22. The immediate jeopardy was removed and the deficient practice was corrected by 9/13/22, prior to the start of the survey, and was therefore past noncompliance. Finding includes: The record for Resident B was reviewed on 11/29/22 at 1:20 p.m. Diagnoses included, but were not limited to, type 2 Diabetes Mellitus, history of falling, major depressive disorder, adjustment disorder with mixed anxiety and depressed mood, and dementia without behaviors. The Annual Minimum Data Set (MDS) assessment, dated 11/1/22, indicated the resident was not cognitively intact. He was a limited assist with 1 person physical assist with bed mobility, transfers, dressing, toileting, and personal hygiene. The resident had 1 fall with major injury since the last assessment. A Care Plan, dated 9/13/22, indicated the resident had the potential for falls related to confusion, incontinence, diagnosis of dementia, and impaired mobility. A Care Plan, dated 7/13/22, indicated the resident had a close friendship with a co-resident. The resident may be seen walking in the hallways holding hands with co-resident. The resident had the potential to get upset when staff attempted to separate them. The interventions were to approach the resident calmly and speak clearly and slowly using short sentences, avoid reality orientation with the resident, redirect the resident to common areas to spend time with friend and staff should not intervene when residents were holding hands. A Fall Initial Occurrence Note, dated 9/11/22 at 7:15 p.m., indicated the resident had a witnessed fall on 9/11/22 at 7:15 p.m., by the nurse's station. The resident was resisting and fell with QMA 1 to the floor. A Behavior Progress Note, dated 9/11/22 at 7:32 p.m., indicated the resident was attempting to lure a female to his room. The QMA noticed a female resident needed personal attention. The QMA informed the resident he could not take her to the room because she needed personal care. The male resident was holding the female resident's hands tightly and she was yelling You are hurting me. Let me go. The QMA pulled his hands loose from hers and the male resident began pulling the QMA's hair. At that time, the male resident and QMA fell to floor. The resident had a contusion to the back of the head that was bleeding. The Physician was called by the LPN. The POA (Power of Attorney) was notified and requested the resident be sent to the hospital. A Nurses' Note, dated 9/11/22 at 11:38 p.m., indicated at 7:15 p.m., the nurse was requested on 100 unit. Upon entering, the resident was sitting on the floor with blood on his clothing and the floor. The blood was coming from his head. There were 2 nurses at his side rendering first aid. This nurse did begin necessary documentation and assisted nurses with necessary notifications. The QMA stated that resident had female resident by the hands and was directing her toward his room. QMA noticed resident needed incontinent care and informed male resident that he can't take female resident to his room because she needs care. He would not release female residents hands. Female resident called out it hurt was hurting her hands [sic]. QMA stated that she took his hands from resident and at that time he pulled QMA hair and he fell to floor and QMA fell on top of him. The resident was sent out 911. An investigation by the Executive Director on 9/12/22, indicated the staff member to witness the incident was QMA 1. The QMA's statement indicated the resident pulled her hair and she fell on top of him. The Executive Director asked the QMA why did she think the resident would want to pull her hair. The QMA indicated she was trying to take the female resident that was with Resident B to the restroom, but Resident B became combative and pulled her hair. All staff working on the unit were questioned and interviewed and all deny witnessing the incident. The Executive Director reviewed video surveillance cameras for the 100 nurses' station. There was an altercation with QMA 1 and Resident B observed. In the video, QMA 1 gets up and walks over to Resident B and another resident and they quickly grab a hold of one another. Resident B fell backwards and the QMA was observed striking the resident on the right side of the face twice. The video had no sound, and the Executive Director did not hear the conversation. The police were notified and came to the facility to view the video and started a report. The QMA was notified she was under investigation for physical abuse related to the incident with Resident B. A hospital History and Physical, dated 9/11/22 at 9:13 p.m., indicated Resident B was brought in by EMS from the nursing home. The patient lost his balance, fell , and hit his head. The patient did not recall most of the fall and has a history of dementia. Approximately 3 centimeters (cm) to 4 cm laceration to the to the posterior head was noted. A Cat Scan (CT) of the head indicated there was a right posterior scalp hematoma with underlying occipital fracture without evidence of acute intracranial hemorrhage. The laceration was repaired with staples to the back of the head. The resident's discharge diagnoses were scalp laceration, skull fracture, and acute head injury. Interview with the Executive Director on 11/29/22 at 2:00 p.m., indicated after she was notified the resident had fallen and sustained a skull fracture, she wanted to know how that could have possibly happened because he had never had any falls in the past. She interviewed the QMA over the phone and was told the same story regarding her hair being pulled and how the resident fell backwards and hit his head on the floor. She then reviewed the video cameras after the interview with QMA 1 and saw the entire incident of physical abuse with the QMA striking the resident in the face two times. She phoned the QMA again and informed her what she saw the video did not correlate with the story she had told her about her hair being pulled. The QMA never admitted she hit the resident and stuck to her story that her hair was pulled. The police were notified on 9/12/22, came to the facility, reviewed the video, and a police report was initiated. A warrant for QMA 1's arrest was obtained as well. A QAPI meeting was held on 9/12/22 with all department heads to develop an immediate plan of action. Staff inservices began immediately on all types of abuse, staff burn out, and how to approach dementia residents. If staff were not in the facility, they were called. A house wide skin audit was completed and all residents with a Brief Interview of Mental Status greater than 8 were interviewed regarding abuse. The current and updated 10/28/22, Abuse Prevention and Reporting policy, provided by the Nurse Consultant on 12/1/22 at 11:30 a.m., indicated the facility affirms the right of the residents to be free from abuse. The facility therefore, prohibits abuse and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of the policy was to assure the facility was doing all that was within its control to prevent occurrences of abuse. Physical abuse was the infliction of injury on a resident that occurred other than by accidental means and required medical attention. Physical abuse included, hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. The past noncompliance immediate jeopardy began on 9/11/22. The immediate jeopardy was removed and the deficient practice corrected by 9/13/22 after the facility implemented a systemic plan that included the following actions: The facility conducted skin assessments on all residents, inserviced all staff on the abuse policy, staff burnout and dementia, interviewed staff and residents regarding abuse, audited resident charts, audited grievance logs and audited employee background checks. This Federal tag relates to Complaints IN00393256 and IN00395083 3.1-27(a)(1)

Based on record review and interview, the facility failed to complete a laboratory test, failed to monitor a resident's blood sugars which resulted in hospitalization for [CONDITION(S)] (low blood sugar) and failed to increase monitoring of a resident with low hemoglobin (carries oxygen from the respiratory organs to the rest of the body) laboratory results and on antibiotic therapy for 2 of 4 residents reviewed for discharge. (Residents C and L) Findings include: 1. Resident C's closed record was reviewed on 4/14/22 at 9:04 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS (Minimum Data Set) assessment, dated 3/31/22, indicated the resident was cognitively intact and required extensive assistance with activities of daily living. A Care Plan indicated the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nurse Practitioner Note, dated 2/9/22 at 8:48 p.m., indicated the resident had been experiencing low blood sugars in the morning. She reported experiencing nausea, dizziness, lightheadedness, and diaphoresis when her blood sugars were low. She also complained of diarrhea all day, every day for the past 3 days. The Nurse Practitioner's plan included a decrease in [MEDICATION(S)] (insulin) to 28 units at bedtime, monitor blood sugars before meals and at bedtime, and to test the resident's stool for C. diff ([CONDITION(S)], a bacteria that causes severe diarrhea). A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no HS (bedtime) blood sugar monitoring results documented. A Progress Note, dated 2/10/22 at 2:22 p.m., indicated the resident was to have a CMP (comprehensive metabolic panel, lab test to monitor electrolytes) drawn on 2/11/22 and needed a stool sample to be collected for testing of C.diff. There was lack of any further documentation the stool sample had been collected and the C. diff testing had been completed as ordered by the Nurse Practitioner. A Progress Note, dated 2/11/22 at 7:09 p.m., indicated the resident's glucose at 5:00 a.m. per the CMP lab results was 24. The Nurse Practitioner was notified, and the [MEDICATION(S)] was decreased to 20 units at bedtime. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no HS (bedtime) blood sugar monitoring results documented. A Progress Note, dated 2/23/22 at 7:00 a.m., indicated the resident was unresponsive and her blood sugar was 33. She was given orange juice with sugar and 40% glucose. The resident remained unresponsive, and her blood sugar remained low. The Nurse Practitioner was notified and 911 was called. The resident was transported to the hospital at 7:15 a.m. A Progress Note, dated 2/23/22 at 6:42 p.m., indicated the resident had been admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was readmitted to the facility on [DATE]. A Nurse Practitioner Note, dated 2/28/22 at 3:12 p.m., indicated the resident had been admitted to the hospital for altered mental status and [CONDITION(S)]. All her insulin had been discontinued while in the hospital and she also tested positive for [CONDITION(S)]. Interview with the Interim Director of Nursing (DON) and the Administrator on 4/14/22 at 3:50 p.m., indicated the Nurse Practitioner would put her own orders in the computer. She had not decreased the [MEDICATION(S)] to 20 units on 2/11/22 as the Progress Note indicated. She had just added the parameters to hold the [MEDICATION(S)] if the resident's blood sugar was below 150. They were unable to provide any documentation of HS blood sugar monitoring for the resident. They indicated the lab test for C. diff had not been completed until the resident was in the hospital. 2. The record for Resident L was reviewed on 4/19/22 at 8:50 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS), dated [DATE], indicated the resident was moderately cognitively impaired and had received anticoagulants and antibiotics over the last 7 days. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The February Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The March MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nurse Note, dated 3/5/22 at 4:47 p.m., indicated the resident had a low hemoglobin level of 6.8 -low (normal range 14.0-18.0 grams/deciliter). The physician was notified and new orders were placed to repeat the CBC (complete blood count) again on 3/6/22 and 3/7/22 and call the physician with results. A Nurse Note, dated 3/6/22 at 3:14 p.m., indicated the hemoglobin level was 6.6. Physician was notified and orders were given to repeat the CBC again the next morning. The resident and resident representative were aware. A Nurse Note, dated 3/8/22 at 8:00 a.m., indicated the hemoglobin level was 7.2. The physician and representative were aware and new orders were given to test for occult blood (blood found in stool). A Nurse Note, dated 3/12/22 at 9:05 p.m., indicated the resident was sent to the hospital due to low hemoglobin and blood in stool. The Infection/Antibiotic Charting indicated the resident had daily monitoring due to having an infection and had received antibiotic therapy. On each shift from 3/8/22-3/12/22, the resident's blood pressure document as 136/80 from 3/7/22 at 5:23 p.m. The record lacked an accurate documentation that the resident was being monitored via blood pressures for 3 consecutive laboratory test results for low hemoglobin levels as a Nursing measure. Interview with the Interim Director of Nursing (DON) on 4/19/22 at 1:38 p.m., indicated if a resident had abnormal labs such as a low hemoglobin, the nursing staff would be expected to do a full assessment more often, including taking a current blood pressure. Interview with the Assistant Director of Nursing (ADON) on 4/19/22 at 1:51 p.m., indicated if a resident had an infection or was on antibiotic therapy, the nursing staff were to chart using the Infection/Antibiotic Charting. The charting generated a template which should guide the staff to know what vital signs and assessments to do. The template included, but was not limited to, an updated blood pressure, temperature, respirations, and pulse. The staff should have assessed and monitored the resident's blood pressure with each of the assessments completed. This Federal Tag relates to Complaint IN 002. 3.1-37(a)

Based on observation, record review and interview, the facility failed to ensure adequate supervision and assistance was provided to maintain safety related to residents needing assist of 2 staff being transferred with only one staff for 3 of 3 residents reviewed for falls. (Residents B, V and T) This resulted in hospitalization and a fractured left leg tibia and fibula for 1 of the 3 residents. (Resident B) Findings includes: 1. The record for Resident B was reviewed on 8/20/19 at 9:20 a.m. [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment, dated 8/7/19, indicated the resident was not cognitively intact. The resident needed extensive assist with 2 person physical assist for transfers and bed mobility. There were no range of motion limitations to upper or lower extremities. The Care Plan, revised on 3/16/18, indicated the resident had an Activities of Daily Living (ADL) deficit or potential for as evidenced by, needed assistance or was dependent in transfer. The approaches were to transfer the resident with 2 assist. The Care Plan, revised on 2/23/18, indicated the resident had a history and potential for falls related to required extensive assist with transfers. Nurse's Notes, dated 8/8/19 at 7:00 a.m., indicated the resident had a witnessed fall on 8/8/19 at 7:00 a.m. The writer was called upon by a CN[NAME] The CNA indicated the resident was lowered to the ground. The resident was assessed for injury and then assisted back to the wheelchair and brought near the writer for further observation. Nurse's Notes, dated 8/8/19 at 7:00 a.m., indicated the resident's family was unable to be reached. The resident indicated the pain was a 10. The Physician's office had not returned the phone call. An x-ray of the left femur, knee, tibia, fibula, and ankle was requested stat. Nurse's notes, dated 8/8/19 at 10:45 a.m., indicated the resident was in bed and pain medication had been administered. The resident still had complaints of leg pain. Awaiting x-ray (technician's) arrival. Nurse's Notes, dated 8/8/19 at 11:30 a.m., indicated the mobile x-ray had arrived. Nurse's Notes, dated 8/8/19 at 1:30 p.m., indicated x-ray results returned. A fracture to the left tibia and fibula (lower leg) was noted. Left urgent message for Nurse Practitioner at Physician's office to return call for new orders. Nurse's Notes, dated 8/8/19 at 3:15 p.m., (1 hour and 45 minutes later), writer spoke with Physician and new orders to send the resident to the emergency room for further evaluation was obtained. Nurse's Notes, dated 8/8/19 at 3:25 p.m., indicated the paramedics arrived to facility to take the resident to the hospital. An incident report, dated 8/8/19 and provided by the Administrator on 8/20/19 at 9:00 a.m., indicated the following: It was reported to the nurse by aide that resident slid from the side of the bed toward the floor and aide lowered to floor. Nurse assisted aide to put resident back to bed and resident complained of pain in leg. Notified physician & family, x-ray ordered for left leg. X-ray results returned indicated fracture to left tibia and fibula, order received to send out to ER (emergency room ). The investigation was completed and indicated CNA 1 had assisted the resident to sit on the side of the bed then lowered her to the floor after she had begun to slide off the bed. Resident was on a low air loss mattress and CNA 1 indicated she was aware the resident required assistance of 2 staff for transfers. Two staff members assigned to the resident's unit indicated they had assisted the resident earlier in the shift and CNA 1 had not ask for assistance with the resident before assisting her alone. CNA 1 was counseled, corrective action completed including a suspension after the occurrence. CNA 1 has since resigned from her position with the facility and will not be returning. Resident B remained in the hospital at this time. Interview with the Director of Nursing (DON) on 8/20/19 at 9:46 a.m. indicated she had interviewed staff who worked that day and who had worked the previous shifts. The DON was hearing conflicting stories from CNA 1 so she suspended her until the investigation was completed. After interviewing other staff members, it was concluded, CNA 1 had transferred the resident with 1 assist rather than 2 assist, she slid off the bed and was lowered to the floor. The resident required a 2 person assist and the CNA attempted to transfer the resident by herself. Interview with LPN 1 on 8/20/19 at 1:37 p.m., indicated she arrived at work at 6:00 a.m. on 8/8/19. She started passing medications shortly thereafter. She saw CNA 1 walk out of Resident B's room. She acted like she was looking for someone to help her, however, she never asked her for help. The CNA walked back into the resident's room and closed the door. Minutes later, CNA 1 walked out of the room and said Hey can you help me? LPN 1 indicated the CNA did not tell her the resident was on the floor. When she walked into the room and she saw the resident on the floor, she asked CNA 1 what happened. CNA 1 told LPN 1 she had lowered the resident to the floor cause she was sliding out of bed. LPN 1 indicated the entire story did not make sense to her. 2. On 8/19/19 at 4:45 a.m., CNA 6 was observed combing Resident V's hair. The resident was sitting in her wheelchair next to the bed. The CNA indicated he had just transferred the resident by himself from the bed to the wheelchair. The record for Resident V was reviewed on 8/20/19 at 1:00 p.m. [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment, dated 6/2/19, indicated the resident was not alert and oriented. She was an extensive assist with a 2 person physical assist for transfers and had no history of falls since the last assessment. The Care Plan, revised on 1/28/19, indicated the resident needed extensive assist for transfers. The approaches were to provide a 2 person assist for all transfers. A transfer list, posted at the 200 Nurse's station, indicated Resident V was a 2 person assist for all transfers. Interview with the Director of Nursing (DON) on 8/20/19 at 10:50 a.m., indicated she had just inserviced staff regarding the new transfer list for residents who needed 1 person or 2 person assist. Resident V was a 2 person assist for transfers. 3. On 8/19/19 at 4:50 a.m., CNA 6 was observed providing morning care for Resident T. The resident was already dressed but in bed. The CNA assisted the resident to the side of the bed. He reached under her arms and picked her up to a standing position. The resident was not able to stand completely on her own. The CNA instructed the resident to stand and pivot and seated her in the wheelchair. CNA 6 did not use a gait belt nor did he have another staff member assisting him. The record for Resident T was reviewed on 8/20/19 at 12:35 p.m. [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment, dated 6/25/19, indicated the resident was not alert and oriented and she was an extensive assist with a 2 person physical assist for transfers. There was no history of falls since the last assessment. Nurse's Notes, dated 8/9/19 at 12:24 p.m., indicated the resident was found on the floor in the bathroom. The Care Plan, revised on 12/31/18, indicated the resident had a potential for falls related to poor safety awareness and impaired cognition. The approaches were to provide extensive to total assist with transfers. Interview with the Director of Nursing (DON) on 8/20/19 at 10:50 a.m., indicated she had just inserviced staff regarding the new transfer list for residents who needed 1 person or 2 person assist. Resident T was a 2 person assist for transfers. This Federal tag relates to Complaints IN 432 and IN 545. 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to provide adequate supervision related to not providing care in pairs during a transfer resulting in a laceration requiring sutures for 1 of 3 residents reviewed for accidents. (Resident E) Finding includes: The closed record for Resident E was reviewed on 1/30/17 at 9:23 a.m. [DIAGNOSES REDACTED]. The Admission MDS (Minimum Data Set) assessment, completed on 12/13/17, indicated Resident E required extensive assistance of two staff members for bed mobility, transfer, dressing, and toileting. The resident's cognitive skills for decision making were moderately impaired. A Fall Risk Assessment, completed on 12/6/17, indicated the resident's score was (13) meaning the resident was at risk for falls. A Care Plan, initiated on 12/6/17, indicated the resident had an ADL (Activities of Daily Living) self-care deficit related to a [DIAGNOSES REDACTED]. Interventions included, but were not limited to, bed in lowest position, mats on the side of the bed, Care in pairs (initiated on 1/3/18), and call light in reach. An Other Skin Condition Report, completed on 1/8/18, indicated a laceration to the resident's left lower leg was noted. The laceration measured 10.5 cm x 2 cm. Review of a Skin Tear/Bruise of Unknown Origin Investigation, completed on 1/9/18, indicated the resident sustained [REDACTED]. The resident was being transferred from the wheel chair to his bed by a CNA. His leg had gotten cut on the bed frame. The final conclusion on the investigation indicated the resident was transferred with one assist and two assist for transfers was required. Statements from two LPN's were reviewed. Both LPN's indicated the CNA transferred the resident by herself and the resident sustained [REDACTED]. Nursing Progress Notes, dated 1/8/18 at 8:00 p.m., indicated the resident was being transferred to bed and the resident's legs gave out. The resident obtained a laceration to the left lateral calf area. A pressure dressing was applied and the Physician was notified. New orders were obtained. 911 was called to transport the resident to the hospital. A 1/8/18 After Visit Summary from the hospital indicated an appointment was to be made with the Physician for suture removal. During an interview on 1/30/18 at 11:34 a.m., Unit Manager 3 indicated the CNA transferred the resident with one assist. The CNA got the resident on the bed and he was not sitting far enough and the CNA went to pick the resident up and sit him back further and he sustained a skin tear to the leg. An investigation was initiated the next day. The Nurses were interviewed. It was determined the CNA was the only staff in the room. Disciplinary action was taken and the CNA was terminated. During an interview on 1/30/18 at 2:50 p.m., the Director of Nursing indicated Care in Pairs was initiated due to the resident's behaviors with staff. Therapy indicated the resident was a 1-2 person transfer. This Federal tag relates to Complaint IN 670. 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to implement effective interventions in a timely manner to maintain resident room and common area temperatures at or below 81 degrees F (Fahrenheit), placing residents at risk for adverse reactions to the high temperatures. This had the potential to affect the 31 residents who resided on the affected 300 & 400 Halls. The Immediate Jeopardy began on 6/12/17 at 9:15 a.m. when temperatures on the 300 and 400 Halls were measured above 81 degrees F by the Maintenance Director. Effective interventions were not put in to place in a timely manner at the time temperatures were above 81 degrees F. Facility temperatures rose to over 86 degrees F at 12:30 p.m. Outside temperatures were forecasted for above 90 degrees F. The Administrator, Director of Nursing, and Nurse Consultant were notified of the Immediate Jeopardy on 6/12/17 at 12:45 p.m. The Immediate Jeopardy was removed on 6/12/17 at 4:15 p.m., but noncompliance remained a lower scope and severity of pattern, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Finding includes: Room temperatures on the 300 Hall were observed on 6/12/17 at 9:05 a.m. The following temperatures were recorded: Nursing Station: 83.7 F Hallway across from the Nursing station: 83.5 F. Five residents were seated in wheel chairs in this area. Additional room temperatures were taken with the Maintenance Staff 1 on 6/12/17 at 9:15 a.m. The following temperatures were recorded by Maintenance Staff at this time on the 300 hall and short hall portion of the 400 unit: Nursing Station: 81.1 F room [ROOM NUMBER]: 82.5 F room [ROOM NUMBER]: 82.4 F room [ROOM NUMBER]: 82.5 F room [ROOM NUMBER]: 83.3 F room [ROOM NUMBER]: 83.1 F During an interview on 6/12/17 at 9:15 a.m., the Maintenance Director indicated the company had started installing a new air conditioner unit for the above sections of the building last week and had not finished at this time. Temperatures were not checked on the 300 Unit on this past Saturday (6/10/17) or Sunday (6/11/17), even though he had been in the building on the evening of 6/11/17 for an issue with the AC and warm temperatures on the 200 unit, which was corrected at that time. On 6/12/17 at 11:05 a.m., Resident M was observed in a room on the 300 Hall. Room temperatures on the 300 Hall were between 81- 83.3 degrees F. Resident M was observed in bed and was covered with a blanket. The resident was awake and responded when spoken to. The resident shook her head yes when she was asked if she was hot. Pearls of sweat were visible under the resident's eyes and on her upper cheeks. There was no fan blowing on the resident to assist in cooling. No staff was present in the room. The record of Resident M was reviewed on 6/12/17 at 2:40 p.m. The [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set) assessment, completed on 4/4/17, indicated Resident M required assistance of two staff members for bed mobility and personal hygiene and was dependent on two staff members for transfers. Impairment in range of motion was present on both upper and both lower extremities. A Nursing Skilled Charting Note, dated 6/7/17 at 8:59 p.m., indicated the resident was alert and oriented to person, her hearing was adequate, and was dependent on staff for dressing and personal hygiene. Current Care Plans were reviewed. The resident was at risk for Dehydration and may not be able to recognize thirst. Interventions included, but were not limited to, provide diet as ordered, tube flushes per Physician orders, and provide diet as ordered. Room temperatures were checked again by the Maintenance Director on 6/12/17 at 12:30 p.m. The following temperatures were recorded: Nursing Station 300 hall: 84.9 F room [ROOM NUMBER]: 85.6 F. The resident in Bed A stood from her wheel chair and began taking off her shirt. room [ROOM NUMBER]: 85.8 F. A fan was on in the room. room [ROOM NUMBER]: 86.3 F. The resident in Bed A stated, it's too da** hot room [ROOM NUMBER]: 87.2 F room [ROOM NUMBER]: 87.8 F 300 Activity Room (one of the rooms identified as a cooling station): 85.6 F. Three residents were in the Activity Unit. A Portable Air Conditioning unit was on. The temperature was set to be at 65.0 F. The AC unit reading showed the area temperature reading of 84.9 F. Internet reported temperatures in Michigan City, IN were 79 degrees F in the morning on 6/12/17 and the temperature at 1:32 p.m. was recorded at 89 degrees F. As of 4:00 p.m. on 6/12/17, the AC repair company had arrived, worked on the AC unit, and left without the air conditioning being fixed. At 4:15 p.m. on 6/12/17, all residents from the 300 & short 400 halls were observed to have been relocated to other units of the facility. The survey team observed the 300 Hall and 400 short hall remained closed on 6/13/17. Staff members were interviewed related to safe care and monitoring of residents during predicted temperature elevations and procedures related to reporting any concerns to the Administration. The Immediate Jeopardy that began on 6/12/17 at 9:15 a.m. was removed on 6/12/17 at 4:15 p.m. when the facility completed physical assessments which included vital signs and relocated residents from the 300 hall and the 400 short hall to other units in the facility. Inservicing was provided to staff related to monitoring for sign and symptoms of dehydration and interventions to be implemented. The Immediate Jeopardy was removed but noncompliance remained at a lower scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, because maintenance was still working on attaining full functioning of the AC system. This Federal tag relates to Complaints IN 997 and IN 509. 3.1-19(f)

Based on record review and interview the facility failed to ensure residents remained free of physical, verbal, and emotional abuse related to a CNA spraying water on a and using profanity towards a cognitively impaired dependent resident who was undressed in the shower. The CNA recorded a video of the resident in the resident being sprayed with water and the profanity used. The video was posted on social media for 1 of 3 residents reviewed for allegations of abuse. This resulted in an Immediate Jeopardy. (Resident #E) The Immediate Jeopardy began on 1/18/16 when CNA #1 posted a video of Resident #E on social media (Snap Chat). The video revealed the resident in the shower with no clothing on and CNA # 1 spraying water on the resident and using profanity. Two other staff members saw the video and reported the above to Administration. The Administrator, Director of Nursing, and Nurse Consultant were notified of the Immediate Jeopardy on 1/21/16 at 12:49 p.m. The Immediate Jeopardy was removed on 1/22/16, but noncompliance remained at the lower scope and severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Finding includes: On 1/21/16 at 9:32 a.m., Resident #E was observed sitting in a wheel chair in the hallway in front of a lounge/TV room. The resident was awake, alert, and calm. The resident was dressed in clean clothes. A staff member was talking with the resident and explaining the exercises she was going to assist them with. The clinical record for Resident #E was reviewed on 1/19/16 at 9:40 a.m. The resident's [DIAGNOSES REDACTED]. Review of the 12/8/15 Minimum Data set (MDS) annual assessment indicated the resident's BIMS (Brief Interview for Mental Status) score was (3). A score of (3) indicated the resident's cognitive patterns were severely impaired. The assessment indicated the resident had physical behaviors 1-3 days during the reference periods. The assessment indicated the resident required extensive assistance of two staff members for transfers and extensive assist of one staff member for bed mobility and personal hygiene. Resident #E's Care Plans were reviewed. A Care Plan initiated on 4/13/14 indicated the resident was non compliant and resistive to care with ADL's, showers, eating, and medication administration. Care plan intervention included to encourage the resident to be compliant, explain all procedures before initiating them and leave resistant resident alone and reapproach as needed. The Care Plan was last revised on 12/29/15. A Care Plan initiated on 3/3/2014 indicated the resident had a behavior problem. Behaviors included: Verbally Abusive- yelling and swearing at others and threatening to kill self. Physically Abusive - biting scratching, pinching staff during ADL's (Activities of Daily living, attempts to bite staff. Socially inappropriate- throws items, fecal smearing, and throws soap on aides during showers. A Social Service note completed on 12/8/15 at 10:10 a.m., indicated on 12/3/15 the resident was very combative kicking, biting, and punching in the shower. The resident also attempted to hit a CNA while she was getting her dressed. A Social Service note completed on 1/5/16 at 9:29 a.m., indicated the resident was pinching, scratching, kicking, and biting during care and the behavior ended when care was completed. A Social Service note completed on 1/7/16 at 9:24 p.m., The note indicated the resident was verbally and physically aggressive in her room. The resident became combative while the Nurse was administering her insulin. The resident was flailing her hands and broke a nail on her thumb. A Social Service note completed on 1/18/16 at 4:12 p.m. The note indicated the Social Service Director spoke with the resident related to an incident that had occurred earlier in the day. The resident stated she thought she may have had a shower but was not sure. The resident displayed no signs of distress and was cheerful during the conversation. A Physician's Progress note dated 11/10/2015 indicated the resident did not want to be examined or touched. The note also indicated the resident seemed a little agitated. Review of the 11/25/15 Behavioral Health Follow up Progress note indicated the resident's mood was calm. The note indicated staff had reported the resident did have episodes of aggression during care. Review of a report and investigation of an allegation of Abuse for Resident #E indicated on 1/18/16 at approximately 11:45 a.m., CNA#2 was on her way back from her lunch break and and was looking at Snap Chat on her phone. She opened a video sent by CNA #1. CNA #3 was with CNA #2 at the time, the video was played and heard by both of the CNA's. The video was of Resident #E naked in the shower room with CNA #1. Both CNA #2 and CNA#3 reported the event to a manager immediately after viewing the video. CNA #1 was escorted to the Administrator's office and was immediately suspended. The local Police were called. A written statement from CNA #3 on 1/18/16 was reviewed. The statement indicated the CNA was coming from lunch and looking at her Snap Chat and observed CNA #1 had a Snap Chat showing Resident #E in the shower room. The resident was naked while the staff member was spraying the resident with water. The statement indicated the video was sent to her personally but it was for public viewing. A written statement from CNA #2 on 1/18/16 was reviewed. The statement indicated CNA #1 had a video on Snap Chat and Resident #E was naked in a shower chair and CNA #1 said look at his crazy b---h she doesn't like taking showers. A written statement from CNA #1 on 1/18/16 was reviewed. The statement indicated the CNA she took a picture of Resident #E's face while she was in the shower room. When interviewed on 1/21/16 at 10:20 a.m., the facility Administrator indicated an incident of possible abuse was reported. CNA #1 took a picture of Resident #E with her cell phone and posted it on Snap Chat. CNA #1 sent the video to CNA#3. CNA #3 was coming back from break with CNA #2. The two CNA's watched the video. They immediately looked for someone to report it to. CNA #1 was located and escorted out of the facility at this time. Statements were then obtained from both CNA #2 and CNA #3 and the facility security cameras were reviewed. The security video did show CNA #4 had walked into the shower when CNA #1 was in the room with the resident. This CNA stepped in the room with a bag of trash and exited in approximately 2-3 minutes. They other person seen on the video going in or out of the shower room at this time was CNA #5 who was seen stepping in for approximately a minute and walking out. The Nurse went in to help transfer the resident and perform a skin check at the end of the shower. The Administrator indicated they noted a 10 minute gap of time that CNA #1 was in the shower room alone with Resident #E. Continued interview with the Administrator indicated CNA#1 was asked to write a statement and was then escorted out of the building. CNA #1 admitted to posting a picture of Resident #E on Snap Chat and stated she meant to post it privately, not publicly. CNA #1 also first stated it was just a picture and not a video. The Administrator indicated CNA #3 was interviewed and stated she received a message that CNA#1 had sent to her on Snap Chat and she clicked on it and it was a video of CNA #1 talking and spraying water on Resident #E who was naked in the shower room. The Administer indicated she also spoke with CNA #2 who stated she saw the video and heard CNA #1 saying Look at this crazy b----h she doesn't like taking showers. The Administrator indicated the Social Service Director then assessed the resident and asked the resident if she had taken a shower and the resident answered yes to her. Continued interview with the Administrator indicated the facility policy was for staff not to have any cell phones on the unit when they were working on the floor. The Administrator indicated the local Police were called and came to the facility that evening. CNA #1 was not in the facility when the Police arrived as they had escorted her out of the building as soon as the other two CNA's reported the incident. The Administrator indicated CNA #3 and CNA #2 were interviewed separately and they both stated the occurrence was seen as a video and not a picture even though CNA #1 stated she had taken a picture of the resident in the shower and not a video. The Administrator indicated CNA #1 stated she had deleted the photo. CNA #2 was interviewed on 1/21/16 at 11:20 a.m. The CNA indicated she and CNA #3 were coming back from their break and CNA # 3 received a Snap Chat message from CNA #1. CNA #2 indicated it was a video and it started with seeing CNA #1 and ended with Resident #E. CNA #2 saw Resident #E completely naked in the shower and trying to splash water on CNA#1. CNA #1 was waving the hose over the resident and it seemed like CNA#1 was trying to get a reaction from (Resident #E's name). CNA #2 indicated she did not hear the resident say anything. Continued interview with CNA #2 indicated she had taken care of Resident #E before and the resident tended to get physical and would tell you I'm gonna hit you and she sometime made clawing like gestures, yelled and screamed. The CNA indicated the resident required one person assistance for showers but she herself always made sure she had someone else in the room when she took care of the resident. CNA #3 was interviewed on 1/21/16 at 12:00 p.m. The CNA indicated she and CNA #2 were coming back from their breaks and she noted a video from CNA #1 was on her phone. The CNA said it was a video of Resident #E in the shower naked an CNA #1 was spraying water on the resident and the resident was doing a fanning motion with her hands. CNA #3 indicated there was a caption that read like I thought we were friends and CNA #1 saying look and this crazy b----h. CNA #3 states both she and CNA #2 were shocked to see that. CNA #3 indicated she had never seen anything like that before. When interviewed on 1/21/16 at 12:25 p.m., the facility Administrator indicated she had received a screen shot that another CNA (CNA #7) provided her. A friend of CNA#7 had seen the video and took a screen shot of it and sent it to the CNA. This CNA showed the Administrator the shot. The picture was of Resident #E naked on a shower chair and the caption on the photo read she F-----G hates showers. The facility protocols for the Use of Recording Devices and Personal Telephone Calls were reviewed on 1/21/16 at 1:00 p.m. The facility Administrator provided the protocols from the Employee Handbook. The protocol for Personal Telephone Calls indicated cell phone usage was not permitted during working hours. The protocol for Recording Devices indicated each facility resident should be free of any fear that he or she will be photographed or video taped, or have his or her voice recorded, copied or transmitted improperly. The protocol also indicated employees were prohibited from possessing or using, or assisting any other persons to use or process any recording devices while on the facility premises. The protocol also indicated the term recording device meant any camera, videotape recorder, tape recorder, computer disc or tape drive, cellular telephone, or any other recording device to record or transmit visual images, sound, or electronic information. The facility Abuse policy was reviewed on 1/21/16 at 11:00 a.m. The policy indicated residents had the right to be free from verbal, sexual, physical, and mental abuse. The policy indicated residents were not to be subjected to abuse by anyone. The policy indicated resident rights were to be protected by providing a method to investigate and report allegations of abuse, neglect, and mistreatment. The Immediate Jeopardy that began on 1/18/16 was removed on 1/22/16 when. statements made by staff present at the time were obtained and reviewed. The involved staff member had been removed from the facility and the resident's physical and psychosocial well being was assessed. Inservicing began on 1/18/16 and were done in person and 1:1 or in small groups. The Inservicing covered cell phone usage, the elder justice act, HIPPA (Health Insurance portability and Accountability Act), and Abuse/reporting for all employees who were currently in the building. All employees were given the chance to ask questions related to the information. On 1/18/16 the facility notified ISDH (Indiana State Department of Health), the local Police Authority, and the resident's family. Surveillance footage outside the involved shower room was reviewed. Several additional residents were interviewed for concerns. A Police Offer arrived at the facility on 1/18/16. Further interviews with several other staff members were completed on 1/20/16 and 1/21/16. Staff assessed the resident's skin and emotional status again on 1/21/6. Staff completed resident interviews to assure no other resident concerns were identified. The facility again reviewed all injuries of unknown occurring in the past 30 days. On 1/18/16 continued inservicing continued and Department Heads were assigned to do observation rounds on varying shifts and days to monitor for compliance and observed staff /resident interactions. The Immediate Jeopardy was removed but the noncompliance remained at a lower scope and severity level of No actual harm with potential for more than minimal harm that is not Immediate Jeopardy as continued monitoring of the interventions was to be continued to evaluate the effectiveness of the removal plan to ensure abuse does not occur. The survey team completed various round throughout the facility on 1/22/16 and observed Department Heads present on the units. Staff members from different departments were interviewed related to the the facility policy for cell phone use, social media use, and reporting allegations immediately and response were as in the facility polices and procedures. This Federal tag relates to Complaint IN 307. 3.1-27(a)(1) 3.1-27(b)

Based on observation, record review and interview, the facility failed to provide adequate supervision while toileting two residents resulting in a resident falling and obtaining a kneecap fracture, and a resident falling with no injury for 2 of 4 residents reviewed for accidents of the 5 who met the criteria for accidents. (Resident's #C and #B) Findings include: 1. On 12/18/15 at 10:12 a.m., Resident #C was observed sitting in a wheelchair in her room. The resident was observed to have a personal alarm clipped onto the back of her shirt. On 12/21/15 at 11:10 a.m., Resident #C was observed sitting in a wheelchair in the therapy gym participating in therapy. Record review for Resident #C was completed on 12/18/15 at 8:54 a.m. The resident's [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment completed on 9/25/15, indicated the resident had a BIMS (Brief Interview for Mental Status) score of 12 which indicated the resident's cognition was moderately impaired. The assessment indicated the resident required extensive assistance of 1 person for transfers and toileting. The assessment indicated the resident was not steady and only able to stabilize with staff assistance for moving on and off the toilet. A Nursing Care Plan dated 8/24/15 indicated the resident had an ADL (Activity of daily Living) self care deficit or potential for as evidenced by needing assistance or was dependent in: oral/dental care, bed mobility, transfers, walking, locomotion, dressing, toilet use, personal hygiene, bathing and was at risk for developing complications associated with decreased ADL self-performance related to weakness and a pelvic fracture. A Nursing Care Plan dated 8/20/15 indicated the resident had a history of [REDACTED]. The resident required assistance with transfers. A Social Service Care Plan dated 8/21/15 and revised on 9/11/15 indicated the resident had impaired cognition as evidenced by expressive problems, receptive problems and hearing problems related to hard of hearing, and dementia. A Social Service Care Plan dated 8/21/15 indicated the resident had impaired cognition as evidence by Short Term Memory (STM) impairment related to dementia. A nursing intervention included to maintain and establish consistency in the resident's daily routine when able. A Fall Risk Assessment completed on 8/15/15 indicated the resident had intermittent confusion, had a history of [REDACTED]. The assessment indicated the resident was at risk for falls. A Skilled Medicare Assessment completed on 9/27/15 indicated the resident was oriented to person and had a STM impairment. The resident had weakness and unsteady gait requiring supervision with ADLs. A Nurse's Note completed on 11/14/15 at 10:30 a.m., indicated the resident was found lying on the bathroom floor in her room. The resident was assessed and assisted into her wheelchair. The resident had indicated she was trying to adjust herself on the toilet. A Nurse's Note completed on 11/4/15 at 11:16 a.m., indicated the physician had been notified and the resident had been sent to the ER to be evaluated. A Nurses's Noted completed on 11/5/15 at 4:53 p.m., indicated the Fall IDT (Interdisciplinary Team) Note: summary of fall was the resident was on the toilet and attempted to get up unassisted and fell . The resident had indicated she should have used the call button for the nurse. The root cause of the fall was the resident stood and went to turn and fell to the floor. The resident had an unassisted transfer. The intervention was staff education completed. An ER visit summary completed on 11/4/15 indicated the resident was evaluated for a fall from standing and a Right Patellar Fracture (kneecap fracture). A state reportable dated 11/4/15 indicated, .Resident was assisted by the staff into the restroom and instructed to use the call light when done. Resident attempted to self stand and fell forward. Was sent to ER for evaluation. Noted to have a fractured right patella. Follow up added on 11/6/15 indicated, Resident was scored not at risk for falls on the assessment done in August. Resident requires assist of one to transfer. CNA assisted resident into the bathroom and instructed her to use the call light when she was ready to get up. CNA exited the restroom to grab a new incontinent brief for resident. Resident attempted to adjust her position on the toilet by standing and fell (per resident). Resident stated she should have used the call button when asked about the incident. Resident has a BIMS of 12 on most recent MDS A Fall Investigation Worksheet completed by the facility on 11/4/15 indicated the resident had a fall in the bathroom. Activity at the time of the fall: resident adjusting self on toilet. The CNA statement indicated she had helped the resident onto the toilet and stepped out for her to use the bathroom. She indicated she then heard a noise and saw the resident on the floor. The resident had complained of knee pain. The recommended intervention was staff education. The conclusion/root cause analysis indicated: the resident was assisted onto the toilet and required assistance off the toilet. She indicated she did not use her call light because she thought she could do it without assistance. A Fall Assessment completed after the fall on 11/4/15 indicated the resident had intermittent confusion and was at risk for falls. An Inservice completed with the CNAs and Nurses on 11/4/15 indicated, .A rule to follow if you assist a resident onto the toilet, into a shower chair you must stay with them and assist them out of the chair or off the toilet. If a resident requires assistance it's because they are not physically able to do so by themselves and or they are not cognitively able to be safe or both. Failure to stay with a resident that requires assistance on or off a surface will result in disciplinary action An interview completed on 12/18/15 at 10:12 a.m., with Resident #C indicated the CNAs usually stood by the door when she used the restroom but that time the CNA was not there so she thought she could get up on her own. She indicated when she had fallen the CNA was not able to get to her in time before she fell . She further indicated she believed it was an accident. An interview with the Assistant Director of Health Services 2 (ADHS2) on 12/18/15 at 10:31 a.m., indicated the CNA was supervising the resident to use the restroom. She indicated the resident was a 1 assist with transfers but sometimes she was able to transfer herself from the wheelchair to the toilet independently by using the grab bars. She indicated the CNAs were there to provide supervision in case she needed assistance because the resident had a weak knee that would sometimes give out on her. She indicated the CNA had gone out to the hallway while the resident was using the restroom and instructed her to use her call light when she was finished. She indicated the CNA was in the hall less than a minute when she had went back into the bathroom and found the resident on the floor. She indicated it was the expectation of the CNAs that if a resident needs assistance with toileting they were to stay close by while the resident was on the toilet. She indicated the CNA should have stayed with the resident while she was in the restroom instead of going to the hallway. She indicated the CNA could have given the resident privacy by slightly closing the bathroom door and standing there instead of being out in the hallway. She further indicated the resident had her days when she would be slightly confused and may not remember to use the call light for assistance. She indicated a whole house Nursing Inservice had been completed after the residents fall on staying with residents when assisting them to the restroom. An interview with CRCA #3 was completed on 12/18/15 at 1:45 p.m., indicated she took care of the resident before she had fallen. She indicated the resident was able to transfer herself on and off the toilet but she always stood close by to see if the resident needed assistance. She indicated she would not have left the resident alone in the bathroom and gone out into the hallway. Interview with the Social Service Director (SSD) #1 on 12/18/15 at 1:56 p.m., indicated the resident's cognition could fluctuate on a daily basis. She indicated on some days the resident may not remember to use a call light for assistance. Interview with LPN #1 on 12/18/15 at 2:02 p.m., indicated she did not take care of the resident before her fall and was unaware of how she was supposed to transfer prior to her fall. 2. The closed record for Resident #B was reviewed on 12/17/2015 at 11:42 a.m. The resident's [DIAGNOSES REDACTED]. cancer, thyrotoxicosis, metabolic [DIAGNOSES REDACTED], and dementia. The 11/4/15 30-Day Minimum Data Set (MDS) assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 5, indicating the resident was severely impaired for decision making and had severe cognitive impairment. The resident was an extensive assist with a physical assist of two people for transfers and toilet use. The resident had one fall since admission or prior assessment. The current and updated plan of care dated 9/2015 indicated the resident was at risk for falls related to weakness, recent abdominal surgery, and requiring assistance with transfers. The Fall Investigation Worksheet dated 10/25/15 provided by the Director of Health Services (DHS) on 12/16/15 at 3:00 p.m., was reviewed. The activity at the time of the fall indicated the resident was on the toilet attempting to get paper towels off a table that she thought was toilet paper and fell . The intervention at the time was to replace the call button with a touch pad calling device. Interview with the Director of Health Services, Assistant Director of Health Services #2, and the Care Plan Coordinator #1 on 12/17/15 at 12:53 p.m., indicated the resident was confused, she was oriented to self and knew she was not at home. On 10/25/15 the resident was placed on her bedside commode by two nursing staff, they exited the room, leaving the resident unattended, and informed the resident's CNA she would need to be assisted off the commode. When the CNA entered the room the resident was observed on the floor. Continued interview indicated the resident had a bed side stand next to the commode and there were paper towels on the stand, the resident reached for the towels thinking it was toilet paper and she fell to the floor which resulted in no injury. The DHS further indicated the resident's call light was within reach, however, she does not know if the resident was cognitively able to use the call light, she should not have been left alone. This Federal Tag relates to Complaint IN 990. 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure a resident was transferred correctly and was not moved before being assessed by a Licensed Nurse after a fall for 1 of 3 residents reviewed for falls in the sample of 7 resulting in a hip fracture. (Resident # E), (RN #1), (CNA #2) Findings include: On 8/11/14 at 10:45 a.m., Resident #E was observed sitting in a wheelchair. An alarm was in place to the wheelchair. The record for Resident #E was reviewed on 8/11/14 at 10:15 a.m. The resident's [DIAGNOSES REDACTED]. The resident was admitted to the hospital on [DATE] and returned to the facility on [DATE]. Review of the current Physician orders [REDACTED]. These orders were obtained on 6/5/14. There were also Physician orders [REDACTED]. These orders were also obtained on 6/5/14. A physician's orders [REDACTED]. The order also indicated the resident was to be given a one time dose of Norco (a narcotic pain medication) 5/325 milligrams. A physician's orders [REDACTED]. Review of the 5/5/14 Minimum Data Set (MDS) Quarterly Assessment indicated the resident's BIMS (Brief Interview for Mental Status) score was (6). A score of (6) indicated the resident's cognitive patterns were severely impaired. The MDS Assessment also indicated the resident required extensive assistance (resident involved in activity, staff provide weight-bearing support) of two or more staff for transfers and was totally dependent on staff for bathing. The assessment also indicated the resident had one fall with injury since admission or the last prior assessment. The assessment indicated the resident had impairment of range of motion in one upper extremity and was not steady moving on and off the toilet, not steady moving from a seated to a standing position, and not steady transferring surface to surface such as between bed and chair. A Fall Risk Assessment completed on 2/28/14 indicated the score was (21). A score of 10 or above indicated the resident was at high risk for falls. A Fall Risk completed on 7/5/14 indicated the resident's score was (11). The resident's Care Plans were reviewed. A Care Plan initiated on 3/5/14 indicated the resident was at risk for falls/injury as evidenced by a history of falls and the potential for falls related to depression and high blood pressure. The Care Plan had a goal date of 10/30/14. Care plan interventions included for the resident's bed to be in the lowest position, floor mats to be in place, call light to be left in reach, and to lock brakes on the chair and bed when transferring the resident. A Care Plan initiated on 3/5/14 indicated the resident had an ADL (Activities of Daily Living) Self- Care deficit or potential for as evidenced by need for supervision assistance with transfers, toilet use, personal hygiene and locomotion. The Care Plan also indicated the resident had weakness, depression, pain, and a total knee replacement. The Care Plan was last updated with a goal date of 10/30/14. Care Plan interventions included for the resident to be transferred with (2) assists. The resident's Care Card (card with care interventions for each resident) for Resident #E was reviewed on 8/11/14 at 3:55 p.m. The Care Card was received from the ADON (Assistant Director of Nursing) at this time. The ADON indicated the interventions in this Care Card were in be in place at the time of the 7/5/14 fall. Interventions included to encourage the resident to stay in a common area, to be transferred by two staff members using a gait belt ( a belt used to assist residents to a standing position and with transfers), and the resident was not to be left in the bathroom unattended, and not to be left in room in her wheelchair unattended. The July 2014 electronic Progress Notes were reviewed. An entry made on 7/5/14 at 1:13 p.m. indicated the entry was made related to to fall. The entry indicated the time of the fall was 9:10 a.m. and the fall occurred in the Shower Room bathroom when the resident "began to slide to floor and CNA assisted by lowering to floor and res (resident) sat down." The entry also indicated the resident complained of discomfort with movement to the left leg and was alert and orientated. The resident was returned to bed, given Tylenol as ordered, and alarms were in place. The Physician and POA (Power of Attorney) were called. This entry was completed by RN #1. A hand written "Nurse's Note" dated 7/5/14 at 9:10 a.m. indicated a CNA notified the writer (RN #1) that the resident slid to the floor while in the shower bathroom and sat on her buttock, and was "assisted per CNA to W/C (wheelchair)..." The Nurse's Note also indicated the resident was "returned to bed" with an evaluation done with the resident complaining of discomfort to the left leg and no redness or rotation noted. Review of Radiology Report of the 7/7/14 left hip X-Ray indicated there was a" left subcapital fracture with moderate displacement." The results also indicated mild degenerative changes were seen. Diffuse osseous demineralization was also noted. The report indicated the X-Ray was read by the Radiologist on 7/8/14 at 12:27 a.m. Resident #E's July 2014 hospital records were reviewed. A History and Physician report indicated the resident was transferred to the emergency room because of complaints of left hip pain. The report indicated the resident had fallen on Saturday (7/5/14) and had vague complaints of aches and pain and no specific X-rays were done at that time. The report also indicated the night Nurse (7/7/14) noted there was leg length discrepancy and when the Nurse tried to move the resident's leg the resident complained of pain and therefore an X-ray of the left hip was then done in the night and showed a fracture of the of the left hip. The resident was transferred to the emergency room . A subcapital fracture was confirmed and the resident was then admitted to the hospital for further treatment. The "Review of Systems" section of the History and Physical noted the resident recognized the Physician by knowing his name and complained of pain in the left hip from a fall on Saturday. The "Impression" section of the History and Physical indicated the resident had an "accidental fall resulting in left subcapital femur fracture." This section also noted the resident had a history of [REDACTED]. A hospital Operative Report was reviewed. The report indicated a "Cemented bipolar hemiarthroplasty, left hip" was performed on 7/10/2014. The report indicated the resident had a completely displaced femoral neck fracture. A 7/18/14 Physicians Progress Note indicated the resident had been admitted to the hospital on [DATE] for a subcapital left hip fracture secondary to fall. The Progress Note also indicated the resident had left hip surgery for [REDACTED]. The ADON (Assistant Director of Nursing) and the DON (Director of Nursing) were interviewed on 8/11/14 at 2:19 p.m. related to Resident #E's fall on 7/5/14. The ADON indicated the fall was investigated and staff members were interviewed. The ADON indicated the staff Nurse working at the time of the fall interviewed the CNA who was with the resident at the time of the fall and she (the staff Nurse) was told the CNA was in the bathroom with the resident and the resident stood up to pull her pants up and the resident's knees began to buckle and she was lowered to the floor. The ADON indicated the on-call manager was called and at that time it was being viewed as an assisted fall based on the above information. The ADON indicated she worked on 7/7/14 and started a complete investigation of the fall. The ADON indicated she did talk to the resident and staff members on 7/7/14. The ADON indicated when the resident was asked about the fall the resident told her she stood up to pull up her pants and was alone in the bathroom at the time. The ADON indicated she then started re-interviewing the staff CNA and staff Nurse who were taking care of the resident at the time of the fall. The ADON indicated CNA #2 was the CNA who took the resident to the toilet in the Shower Room on 7/5/14 and the during this interview the CNA indicated she lowered the resident to the floor. The ADON indicated the CNA did confirm in an interview that no one else was present when she transferred the resident to toilet and she transferred the resident to the toilet and then back up from the floor onto to the chair after the resident was lowered to the floor and took the resident to the Nurses Station and met the Nurse. The ADON indicated the CNA confirmed the resident's Care Card noted the resident was to be a two person transfer and was to be transferred with a gait belt and this was not done. Continued interview with the ADON indicated she interviewed RN #1 (the Nurse caring for the resident at the time of the fall on 7/5/14) on 7/8/14. The RN indicated she did not assess the resident in the Bathroom. The ADON indicated the resident was to be a two person transfer with the use of gait belt and staff should have transferred the resident with two staff members using a gait belt. The ADON also indicated CNA #2 was suspended and no longer was employed by the facility. RN #1 was also suspended and returned to work after being educated as she did not immediately inform management of CNA #2 moving the resident back into a chair without calling for the Nurse to assess the resident before moving her. This Federal tag relates to Complaint IN 714. 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure adequate supervision was provided to prevent accidents and hazards related to staff not utilizing the required assistance during a transfer resulting in the resident being sent to the hospital Emergency Roon and receiving staples to a laceration on the leg. (Resident #B) (CNA #1) The facility also failed to ensure open spaces in between bars of side rails were no larger then the recommended dimension to prevent possible injury for 1 of 1 resident observed with large openings in the side rails in the sample of 8. (Resident #H) Findings include: 1. On 7/1/13 at 1:51 p.m., Resident #B was observed in bed. The resident's bed was in the low position and side rails on each side of the bed were padded with cushions. The record for Resident #B was reviewed on 7/1/13 at 1:00 p.m. The resident's [DIAGNOSES REDACTED]. An "Incident/Accident Investigation" dated 6/7/13 at 1:10 a.m., indicated the LPN was called to the resident's room by a CNA and the CNA stated the resident had received a skin tear when the resident's left leg hit the side rail during a transfer. A 8.5 cm (centimeter) x 10 cm laceration was noted on the resident's left calf. Steri strips (thin bandage strips) were applied to hold the wound together and to stop the bleeding. The Physician was notified and new orders were obtained to send the resident to the hospital for an evaluation and treatment. The 6/2013 Nurses' Notes were reviewed. An entry made on 6/7/13 at 2:00 a.m. indicated a laceration was noted on the resident's left calf area and steri strips and a dressing were applied to hold the wound together and to control the bleeding. The Physician was notified and orders were received to transfer the resident to the hospital emergency room for an evaluation and treatment. An entry made on 6/7/13 at 6:00 a.m. indicated the resident returned from the hospital emergency room at 4:30 a.m. The entry indicated the resident was assessed with [REDACTED]. The 4/17/13 Minimum Data Set (MDS) quarterly assessment indicated the resident's BIMS (Brief Interview for Mental Status) score was (3). This indicated the resident's cognitive patterns were severely impaired. The MDS assessment also indicated the resident required extensive assistance (resident involved in activity with staff providing weight- bearing support) of two or more persons for transfers. The MDS assessment also indicated the resident's balance in moving from a seated position to a standing position was not steady and the resident was only able to stabilize with the assistance of staff. The MDS assessment also indicated the resident demonstrated impairment in functional range of motion on both lower extremities. The resident's current care plans were reviewed. A care plan initiated on 12/3/12 and last updated with a goal date of 7/30/13 indicated the resident had a ADL (Activities of Daily Living) self-care deficit. The care plan indicated the resident needed assistance or was dependent for bed mobility and transfers. When interviewed on 7/1/13 at 2:10 p.m., the Unit Manager indicated the resident received a laceration to the leg during a transfer on 6/7/13. The Unit Manager indicated she initiated an investigation of the injury and the CNA (CNA #1) who transferred the resident was interviewed. The CNA indicated she transferred the resident by herself without the assistance of another staff member or the use of a gait belt (a strap secured around the resident waist to assist in transferring a resident). The Unit Manager indicated the resident's transfer status was for the resident to be transferred with the assistance of two staff members. The Unit Manager indicated the CNA Care Card (written document which included information and instructions on the care for each resident) at the time indicated the resident was to be transferred by two staff members. The Unit Manager indicated CNA #1 was terminated after the investigation related to transferring the resident by herself. 2. During Orientation Tour on 7/1/13 at 8:34 a.m., Resident #H was observed in bed. The resident was awake. The side rails on the both side of the upper part of the resident's bed were in the up position. There was no padding or covering on either of the side rails. One of the open gap areas between a section of the bars on the side rails appeared to be approximately 5 inches by 5 inches. On 7/1/13 at 10:50 a.m., the Maintenance Director measured the above area on the bed side rails. The open gap measured 7 inches across and 7 1/2 inches high. The record for Resident #H was reviewed on 7/1/13 at 3:15 p.m. The resident's [DIAGNOSES REDACTED]. The 6/17/13 Monthly Summary indicated the resident utilized two half bed rails. The Monthly Summary did not indicate if the rails were used as an enablers. The 5/9/13 Minimum Data Set (MDS) quarterly assessment indicated the resident BIMS (Brief Interview for Mental Status) score was (15). This score indicated the resident's cognitive patterns were not impaired. The assessment also indicated the resident required extensive assistance (resident involved in activity with staff providing weight-bearing support) of two or more persons for bed mobility and transfers. When interviewed at this time, the Maintenance Director indicated the resident's bed was a specialty bed and not the facility's bed. The Maintenance Director indicated there were no other beds of this type in the building. When interviewed on 7/1/13 at 11:30 a.m. the facility Administrator indicated the open area on the bed side rails was larger then the recommended measurement and the Maintenance Director was now replacing the resident's bed and mattress and the other bed was to be removed from the facility. When interviewed on 7/1/13 at 11:15 a.m., the Director of Nursing indicated the resident had the bed and mattress for a long time. The Director of Nursing indicated there had been no reported incidents of the resident sustaining any injury related to the use of this bed or side rails. The 3/10/2006 FDA (Food and Drug Administration) "Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment" indicated the space between bars of bed side rails were recommended to be less than 4 3/4 inches. The facility policy titled "Guidelines For The Use of Side Rails" was reviewed on 7/1/13 at 10:35 a.m. There was no date on the policy. The Director of Nursing provided the policy and identified the policy as current. The policy indicated" an assessment will be made using the Admission/Monthly or Skilled Nursing Assessment data to determine the resident's symptoms or reason for using the side rails." The policy also indicated "when side rail usage is appropriate, the facility will assess the space between the mattress and the side rails to reduce the risk for entrapment." This federal tag relates to Complaint IN 446. 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, record review and interview, the facility failed to ensure restorative nursing services were provided for 1 of 1 residents reviewed who met the criteria of Contracture Without Range of Motion or Splint Device and for 2 of 2 residents reviewed who met the criteria for Lack of Community Discharge, which resulted in a decline in Resident #193's ability to transfer to and from the wheelchair. The resident's transfer status declined from requiring the assist of one person to requiring the assist of two persons. (Residents #116, #193 and #226). Findings include: 1. Resident #193 was observed on 7/13/11 at 9:00 a.m. seated in his wheelchair in his room. Interview with the resident at that time indicated he had a stroke in January. He indicated he still could not walk because his left leg was too weak. He indicated he was currently in therapy to improve his function. On 7/18/11 at 8:57 a.m., the resident was observed being transferred from his wheelchair to a commode, to be toileted. CNA #3 and CNA #4 assisted the resident with the transfer. Both CNAs placed their arms under the resident's axilla's. The resident held the grab rail in front of him with his right hand. He stood up with the assistance of both of the CNAs. CNA #3 moved the wheelchair away and pulled a commode behind the resident's legs. The resident was then placed down on the commode. The resident was positioned too far forward in the commode. Both CNAs then placed one hand behind each of the resident's thighs and one arm under his axilla and lifted the resident. They then positioned him further back on the commode. Neither of the two CNA's used a gait belt or any mechanical left during the transfer. CNA #3 was interviewed after the transfer. She indicated the resident was able to transfer with a one person assist after his PT (Physical Therapy) had been completed. Then when he was no longer receiving PT, he began to decline and required 2 persons for the transfer. He was then referred back to PT and was now receiving PT services. The record for Resident #193 was reviewed on 7/13/11 at 9:17 a.m. The resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The 1/26/11 admission physician orders [REDACTED]. PT (Physical Therapy) 5 x week OT (Occupational Therapy) 5 x week ST (Speech Therapy) 5 x week The form titled, "Occupational Therapy Initial Plan of Care" and dated 1/27/11 was reviewed. It indicated the goal for the resident was increased independence in ADL (Activity of Daily Living) with transfers and mobility." The resident received OT until 4/27/11. The form titled "Occupational Therapy Discharge Summary" and dated 4/27/11 was reviewed. It indicated the discharge plan was: "d/c (discharge) to nursing staff with restorative program." The form titled, "Physical Therapy Initial Plan of Care" and dated 1/27/11 was reviewed. It indicated the goal for the resident was to progress towards the goal of increased mobility, reduced risk of falls and to return to prior level of function." The resident received PT until 4/23/11. The form titled "Physical Therapy Discharge Summary" and dated 4/23/11 was reviewed. It indicated the discharge plan was: "patient d/c (discharged ) to restorative." The form titled "Restorative/Functional Maintenance Program Plan" and dated 4/28/11 was reviewed. It indicated the restorative nursing program was as follows: From Physical therapy: Program was for upper and lower extremity, range of motion/strength Goal: resident will maintain range of motion/strength of upper an lower extremities. Interventions: Participate in upper/lower extremity range of motion/strength in all planes group or individual- 20 repetitions x 10 sets Special precautions: patient is flaccid in left upper extremity - patient can move left lower extremity with help of right lower extremity From Occupational Therapy: Program: sit to stand Goal: continue with minimum to moderate assist of 1-2 for sit to stand Interventions: patient to participate with repeated sit to stand Special precautions: flaccid left upper extremity, needs to be seen in morning The forms titled, "Restorative Nursing Care Report" for 5/8/11 through 6/25/11 were reviewed. The reports indicated the number of days per week the resident received nursing restorative services. The resident received the following: -Active range of motion and transfers 4 x during the week of 5/8/11 through 5/14/11 -Active range of motion and transfers 3 x during the week of 5/15/11 through 5/21/11 -Active range of motion and transfers 3 x during the week of 5/22/11 through 5/28/11 -Active range of motion and transfers 2 x during the week of 5/29/11 through 6/4/11 -Active range of motion and transfers 3 x during the week of 6/5/11 through 6/11/11 -Active range of motion 1 x on the week of 6/12/11 through 6/18/11 -Active range of motion 2 x and transfers 1 x during the week of 6/19/11 through 6/25/11 Interview with Restorative CNA #1 on 7/13/11 at 2:51 p.m., indicated she was providing restorative nursing for the resident. She indicated restorative nursing services are to be provided at least 6 days per week. She indicated restorative was not being completed for the resident 6 days per week because there was not enough staff. She also indicated the resident declined in his transfer ability and he was referred back to Physical Therapy. A physician order [REDACTED]." Review of the "Physical Therapy Initial Plan of Care" dated 6/23/11 indicated the reason for the referral to Physical Therapy was due to, "Patient demonstrated a significant decline in functional transfers and mobility. Patient referred to skilled therapy for transfers and mobility in preparation to returning home." The Functional assessment: Transfers: Bed to and from Chair: prior level Maximum Assist, current level Maximum assist of 1-2 Wheelchair to and from commode prior level Maximum Assist, current level Maximum Assist of 1-2 The Physical Therapy Manager was interviewed on 7/13/11 at 10:30 a.m. He indicated therapy sets up the restorative programs for the residents at the time of discharge. He indicated the restorative CNAs are trained to complete the program. The Acting 400 Unit Supervisor was interviewed on 7/14/11 at 8:30 a.m. She indicated she was very familiar with Resident #193. She indicated she was on the resident's unit from January 2011 through June 2011. She indicated the resident did not have a medical change in April, May or June, 2011. She indicated there were no infections or signs of additional [MEDICAL CONDITION]. She did not think there was a medical reason for the resident's functional decline. Review of the record indicated there were no "Change of Condition" reports noted for April, May and June 2011 available. Interview on 7/13/11 at 2:45 p.m., with the Physical Therapy Manager, indicated Resident #193 had declined in function after his discharge from therapy services in April 2011. He stated the restorative staff informed him of the resident's decline. He also indicated that restorative nursing services were not always provided to the resident 6 days per week. 2. The record for Resident #226 was reviewed on 7/13/11 at 11:04 a.m. The resident's [DIAGNOSES REDACTED]. The Physical Therapy Discharge Summary dated 6/13/11, indicated the resident continued to require minimal assist with mobility and transfers. The resident also required verbal cues for energy conservation techniques secondary to shortness of breath with exertion. The discharge plan was to discontinue therapy and refer to the restorative nursing program. There was no documentation in the resident's record to indicate restorative therapy had been initiated from 6/13/11 through 7/13/11. Interview with Restorative CNA #2 on 7/14/11 at 10:40 a.m., indicated if a resident was referred to restorative therapy, it was usually communicated by the Unit Manager. She further indicated the resident had been missed and he was picked up by restorative therapy on 7/13/11 and she was planning on working with the resident on 7/15/11. Interview with LPN #4 on 7/18/11 at 9:50 a.m., indicated when a resident was referred to restorative therapy, they are now supposed to put the order in the computer and restorative will pick up the resident. She further indicated this had been a problem in the past but a new system was recently put into place. 3. On 7/14/11 at 10:20 a.m., Resident #116 was observed in bed. The last three fingers on the resident's right hand were bent. At this time, the 300 Unit Manager asked the resident if he was able to open the fingers on his right hand that were bent down. The resident was unable to open them on his own. The Unit Manager attempted range of motion on the resident's three fingers and was able to open the three fingers until the resident complained of pain. The resident's fingers were opened with over 50 % of full range of motion. The record for resident # 116 was reviewed on 7/13/11 at 7:50 a.m. The resident's [DIAGNOSES REDACTED]. There were no Restorative Nursing notes in the resident's clinical record. An Occupational Therapy Discharge Summary for therapy services from 12/22/10 thru 2/25/11 indicated the resident was discharged from Occupational Therapy on 2/26/11. The Discharge Summary indicated the resident was discharged from skilled Occupational therapy to Restorative Nursing. A Restorative/ Functional Maintenance Program Plan was completed by a Physical Therapy Aide on 2/23/11. The plan indicated services were to be provided by Restorative Therapy. Interventions included for the resident to perform upper body and lower body exercises. When interviewed on 7/13/11 at 9:31 a.m., Restorative CNA #1 indicated Resident #116 was not currently receiving Restorative services. When interviewed on 7/13/11 at 9:45 a.m., the Therapy Director indicated the resident was not on the list of residents receiving Restorative services. The Therapy Director indicated the resident last received skilled therapy services in 2/2011 and should have received Restorative Nursing at that time as recommended by the therapy staff. When interviewed on 7/14 at 12:35 p.m., the 300 unit MDS (Minimum Data Set) nurse indicated per the computer tracking record it shows that the resident did not receive Restorative Nursing services in March 2011. When interviewed on 7/14/11 at 2:30 p.m., the Interim Director of Nursing indicated a Restorative Nursing Program was not started after the resident was discharged from skilled therapy on 2/26/11. 3.1-38(a)(2)(A) 3.1-38(a)(2)(B)