Every finding on record at Ascension Living Sacred Heart Village

Based on interview and record review, the facility failed to ensure adequate supervision and implement interventions to prevent elopement for 1 of 3 residents reviewed for elopement risk (Resident D).Findings include:A report, dated 8/5/26, alleged Resident D followed a dietary staff member off the secured memory care unit and out to the parking lot.Resident D's record was reviewed on 8/20/26 at 12:49 P.M. Diagnoses included dementia.A physician order, dated 10/14/24, was for Resident D to reside on a locked memory care unit (MCU) for safety. An elopement evaluation, dated 6/2/26, indicated Resident D was ambulatory, cognitively impaired, and had poor decision-making skills. She wore a wander guard to alert staff of exiting from the secured unit. An elopement care plan was to be put in place.A quarterly Minimum Data Set (MDS) assessment, dated 6/8/26, indicated the resident had severely impaired cognition. Resident D used no assistive devices. She required supervision with ambulation and had no wandering behaviors. Care plans, dated 6/12/26, indicated Resident D had memory problems and impaired decision-making abilities. She ambulated independently with supervision. She was at risk for altered moods, wandering, and falls. Interventions included: wander guard for safety, monitor for mood and behavior changes, and follow community elopement evaluation and monitoring process.Resident D's care plan had not indicated she was at risk for elopement off the secured unit. There were no specific person-centered interventions in place to prevent elopement.A nurse progress note, dated 7/24/26 at 2:25 p.m., indicated Resident D had been exit seeking and staff had to redirect her several times. The resident left the unit with kitchen staff and was redirected back to the unit. Her wander guard was in place and checked for function.On 8/20/26 at 12:58 P.M., the Director of Dining Services was interviewed. She indicated, on 7/24/26 after lunch, a new dietary staff member had been leaving the secured MCU, with the large meal tray cart, and hadn't noticed Resident D follow her out. Following the incident, the Director re-educated her staff on checking for residents when leaving the MCU to ensure residents weren't leaving the unit.Dietary Aid 3 was interviewed on 8/20/26 at 1:03 P.M. The Aid indicated, on 7/24/26, she left the MCU with the meal tray cart after lunch. She hadn't seen Resident D walk out behind her and no alarm sounded. She walked down the hallway to the kitchen where she delivered the cart. She had not seen the resident walking in the hallway. Dietary Aid 3 indicated she should have checked for any residents around and behind her when leaving the unit but had not done so. On 8/20/26 at 1:54 P.M., the Assistant Director of Nursing (ADON) was interviewed. She indicated on 7/24/26 after being notified of the incident, the ADON tested the wander guard each resident was wearing on the MCU, a total of 10 residents. All wander guards, including Resident D's, were working when tested. Resident D's wander guard was replaced to prevent further elopement.On 8/20/26 at 2:04 P.M., the Receptionist was interviewed. She indicated on 7/24/26 at 1:25 p.m., she had taken a walk around the outside of the building and sat down outside on the front door patio. She looked up and saw Resident D walking alone in the parking lot coming towards the front door. She assisted the resident to come into the building and back to the MCU. As she brought the resident back into the building, the alarm from the wander guard went off. She indicated she believed Resident D had exited the building where the kitchen hallway was because she had not seen the resident when walking around the building.On 8/20/26 at 3:07 P.M., Registered Nurse (RN) 2 was interviewed. The RN was working on the MCU and caring for Resident D. RN 2 indicated the resident loved to be around other people. She had a habit of attaching herself to other residents or staff and would follow others around. The Administrator was interviewed on 8/20/26 at 3:30 P.M. The Administrator indicated when told of the incident, staff were educated on the elopement policy and use of the wander guard testing tool. Wander guard placement and function was to be checked 2 times per day on day and evening shifts. A current copy of the facility policy, titled Elopement and Wandering Residents, was provided by the Director of Nursing on 8/20/26 at 3:52 P.M. The policy included definitions of the terms wandering and elopement. Wandering was repetitive motion, not usually goal oriented. Elopement was when a resident left the facility or safe area without permission or supervision. The community was equipped with door locks and alarms to avoid elopements but were not a replacement for necessary supervision. Residents were to be assessed for risk of elopement and unsafe wandering upon admission and during their stay by the Interdisciplinary Team (IDT). The IDT would evaluate the unique factors contributing to a resident's risk and develop a person-centered care plan. The person-centered care plan would include interventions to increase staff awareness of the resident's risk and help modify the behavior which could increase the risk for elopement. Adequate supervision was to be provided to prevent elopements.This Citation relates to Intake 3134757.410 IAC (Indiana Administrative Code) 16.2-3.1-45(a)

Based on observation, interview, and record review the facility failed to ensure dishes and equipment were stored in sanitary conditions, unit refrigerators were maintained and were free of expired foods for 99 of 99 residents residing in the facility who consumed food prepared in the kitchen.Findings include:During an observation, on 1/5/26 at 9:16 AM, the following was observed:A nested stack of stainless steel, 6-inch containers had moisture between 3 of 6 pans observed. A dietary staff member was observed taking 6 wet, plate sized, lids out of the dishwashing area and stacking them for storage.During an observation, on 1/05/2026 at 2:00 PM, the Unit B pantry refrigerator had 2 chocolate Glucerna liquid supplements with expiration dates of 8/1/25. 1 vanilla Glucerna shake expired on 1/1/26. A review of the Nursing Unit B Refrigerator Log, on 1/9/26 at 11:10 AM, indicated documentation was missing for ensuring outdated food was discarded and routine weekly cleaning was completed from 1/1/26 to 1/9/26. The log indicated the refrigerator should be checked for outdated food daily and cleaned at least once a week.In an interview, on 1/5/26 at 9:30 AM, the Director of Dining Services indicated items should be dried before storing, nested, or stacked. She indicated 99 residents consumed food prepared in the kitchen. In an interview, on 1/09/2026 11:16 AM, LPN 12 indicated dietary staff were responsible for checking the refrigerator in the common area of Unit B. In an interview, on 1/09/2026 at 11:28 AM, the Director of Dining Services indicated dietary staff sign the unit refrigerator log. She indicated dietary staff had not checked the Glucerna supplements in the refrigerators.A current policy, dated 1/2024, indicated all food contact surfaces including pots, dishes, flatware, and utensils were required to air dry before stacking or storing.A current policy, dated 1/2024, indicated foods that had past the use-by date or expiration date were to be discarded.3.1-21(i)(3)

Based on observation, interview and record review, the facility failed to ensure safe storage of medications for 6 of 15 residents observed (Resident 6, Resident 38, Resident 51, Resident 73, Resident 10, and Resident 4).Findings include:1.During an observation on 01/07/2026 8:51 AM, Registered Nurse (RN) 2 opened the top drawer of a medicine cart positioned outside the main dining room. 3 cups of pills were in a divided compartment of the drawer, positioned together with the cups touching. A cup labeled with Resident 6's first name contained 7 pills. A cup with Resident 38's name contained 8 pills. A cup with Resident 51's name had 10 pills. A cup labeled with Resident 73's name was in the same cart section separated from the others by a box and contained 11 pills. An additional cup of pills was observed in same drawer about 12 inches away from the others. This cup was labeled for Resident 10 and contained 7 1/2 pills. The cups were open to air and not covered. In an interview, on 01/07/2026 8:52 AM, RN 2 indicated she had prepared medications for residents who normally came to the dining room. When the residents did not come to the dining room, she labeled the cup with their first name and placed the cups in the top of the cart. She indicated she should have verified each resident was present prior to preparing their medication. RN 2 indicated she intended to push the cart back to the hall and administer the prepared medications to the residents in their rooms. She indicated cups of medications should not be preset and placed in the medicine cart because medications could be spilled from their cups into the wrong cup or out onto the drawer surface if the cart is bumped while stationary or during transport. Resident 6's record was reviewed on 01/07/2026 11:17 AM. Diagnoses included bipolar disorder, metabolic encephalopathy, and chronic kidney disease. Resident 6's current admission Minimum Data Set assessment (MDS), dated [DATE], indicated Resident 6 had a Basic Interview for Mental Status (BIMS) score of 14 (cognitively intact). Resident 6's current physician's orders included Keppra 750mg 1 tablet by mouth twice daily for seizures, Vimpat 200mg 1 tablet by mouth twice daily for seizures, Vitamin D 125 mcg 1 tablet by mouth daily for supplement, Flexeril 10 mg 1 tablet by mouth three times daily for muscle spasms, probiotic blend 2 billion cell/50 mg 1 capsule by mouth daily for gut health, Requip 1 mg 1 tablet by mouth daily for restless leg syndrome, and divalproex 500mg tablet by mouth daily for restlessness and agitation. A current care plan titled .diseases which are treated with medications, indicated Resident 6 required medications with a goal date of 2/7/2026. The care plan indicated medication administration should be overseen by the nursing and physician team through the duration of Resident 6's stay. Resident 38's record was reviewed on 01/07/2026 11:44 AM. Diagnoses included Parkinson's disease, cerebrovascular disease, and depression. A current quarterly MDS, dated [DATE], indicated Resident 38 had a BIMS score of 14 (cognitively intact). Resident 38's current physician's orders included carbidopa/levodopa 25/250 mg two tablets by mouth twice daily for Parkinson's disease, buspirone 10 mg 1 tablet by mouth daily for anxiety, acetaminophen 325 mg 2 tablets by mouth twice daily for pain, senna-s 8.6-50 mg 1 tablet by mouth daily for constipation, nifedipine 60 mg ER 1 tablet by mouth daily for hypertension, and escitalopram 10 mg 1 tablet by mouth daily for depression. A current care plan titled .diseases which are treated with medications, indicated Resident 38 required medications with a goal date of 2/9/2026. The care plan indicated medication administration should be overseen by the nursing and physician team through the duration of Resident 38's stay. Resident 51's record was reviewed on 01/07/2026 11:48 AM. Diagnoses included type 2 diabetes, normal pressure hydrocephalus, and hypertension. Resident 51's current quarterly MDS dated [DATE] indicated Resident 51 had a BIMS score of 12 (mild cognitive impairment). Resident 51's current physician's orders included bumex 2 mg tablet by mouth twice daily for edema, cinnamon 500 mg 2 capsules by mouth daily, hydrochlorothiazide 50 mg 1 tablet by mouth daily for hypertension, acetaminophen 325 mg 2 tablets by mouth 3 times daily for pain, vitamin D3 50 mcg 1 tablet by mouth daily for supplement, metoprolol succinate ER 1 tablet by mouth twice daily for hypertension, metformin 1000 mg 1 tablet by mouth twice daily for diabetes type 2, hydralazine 100 mg 1 tablet by mouth 3 times daily for hypertension, and benazapril 40 mg 1 tablet by mouth daily for hypertension. Resident 73's record was reviewed on 01/07/2026 11:54 AM. Diagnoses included congestive heart failure and chronic obstructive pulmonary disease. Resident 73's current quarterly MDS dated [DATE] indicated Resident 73 had a BIMS score of 15 (cognitively intact). Resident 73's current physician's orders included allopurinal 200 mg one tablet daily by mouth daily for gout, senna 8.6 mg one tablet daily by mouth for constipation, norco 5/325 mg (a schedule II medication) one tablet three times daily by mouth for pain, carafate 1 gram one tablet twice daily for acid reflux, pantoprazole 40 mg one tablet twice daily by mouth for acid reflux, eliquis 2.5 mg one tablet by mouth every 12 hours for atrial fibrillation, vitamin d3 10 mcg 1 tablet by mouth once daily for supplement, vitamin b12 250 mcg 2 tablets by mouth twice daily for supplement, oxybutinin ER 5 mg 1 tablet by mouth daily for urinary frequency,10) folic acid 1 mg 1 tablet by mouth daily for supplement, and certavite with antioxidants 1 tablet by mouth daily. A current care plan titled .diseases which are treated with medications, indicated Resident 73 required medications with a goal date of 2/21/2026. The care plan indicated medication administration should be overseen by the nursing and physician team through the duration of Resident 73's stay. Resident 10's record was reviewed on 01/07/2026 11:40 AM Diagnoses included myasthenia gravis, major depressive disorder and chronic pain. Resident 10's current annual MDS assessment dated [DATE] indicated Resident 10 had a BIMS score of 15 (cognitively intact). Resident 10's current physician's orders included Claritin 10 mg 1 tablet by mouth daily, Methadone 10 mg (a schedule II medication) 1 1/2 tablets by mouth 3 times daily, Zofran 8 mg 1 tablet by mouth daily, Duloxetine 60 mg 1 capsule by mouth daily, lisinopril 20 mg 1 tablet by mouth, daily, levothyroxine 50 mcg 1 tablet by mouth daily, and Aspirin 81 mg 1 tablet by mouth daily. In an interview, on 01/07/2026 8:58 AM, the Director of Nursing (DON) indicated staff should not preset medications in the medicine carts. She indicated presetting medications in the medication carts increased the risk of medication errors, loss or damage to medications. 2.) During an observation on, 01/08/26 at 1:42 PM, RN 8 acquired Resident 4's dialysis folder from the nurse's workroom. Inside the folder multiple medications were observed. In an opened plastic bag, labeled with Resident 4's name and dated 12/24/25, 3 tablets of midodrine 5 mgs were observed. In an opened plastic bag, labeled with Resident 4's name and dated 01/07/26, 2 tablets of midodrine 5 mg, 2 tablets of gabapentin 100mg, 1 tablet of cyclobenzaprine 10mg, and 2 tablets of Velphoro 500 mg. 2 tablets of zofran 4 mg, and 1 tablet of midodrine 5 mg were observed loose, outside of packaging in the bottom of the dialysis folder pocket. Resident 4's record was reviewed on 01/08/2026 at 1:26 PM. Diagnoses included chronic kidney disease stage 5, dependence on renal dialysis, and type 2 diabetes. Resident 4's current quarterly Minimum Data Set assessment (MDS) dated [DATE] indicated Resident 4 had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). Resident 4's current physician orders included: 1) Dialysis on Monday, Wednesday, and Friday at [NAME] Dialysis 2) The actual times of administration of medication may be adjusted on a daily basis to accommodate resident's request on administration schedule unless contraindicated due to the action of medication. 3) Velphoro Chews 500mg tablet, by mouth three times a day with meals for chronic kidney disease 4) Flexeril, or cyclobenzaprine 10mg tablet, by mouth three times a day for muscle spasms 5) Gabapentin 100 mg capsules, by mouth three times a day for pain 6) Zofran 8 mg tablet, by mouth three times a week for nausea, send with resident to dialysis 7) Midodrine 5 mg tablet, by mouth three times a week for nausea or vomiting, send 3 tablets with resident to dialysis for hypotension. A current policy, titled Medication Storage, dated 7/23/2019, provided by the Administrator on 1/8/26 at 2:31 PM, indicated medications should be stored safely, securely, and properly, only accessible by licensed nursing staff, pharmaceutical staff, or staff members authorized to administer medications. The policy indicated schedule II medications and other drugs subject to abuse should be stored in a separate area under double lock. 3.1-25(m)

Based on observation, interview, and record review the facility failed to ensure ceiling tiles were maintained in 5 of 5 resident rooms reviewed. Findings include:During an observation starting on 01/05/2026 at 9:52 AM, the following was observed: Room A-15 had 2 areas of discolored ceiling tiles. 2 round areas with an irregularly round, brown outline surrounding black centers approximately 1/8th of a ceiling tile.Room A-18 had 6.25 ceiling tiles with 15 round areas of discoloration. In a line parallel to the hallway, 5 areas had round black centers measuring approximately 1-4 inches in diameter. An irregularly round brown outline surrounded the black colored areas of discoloration. One ceiling tile in the middle of the room had 2 large areas, covering the width of the tile and 1/3'd of the length. The two large areas had dark to light brown irregularly shaped round rings decreasing in size to the center gray and brown irregular round shape, approximately 5.5 inches in diameter.Room A-20 had 6 areas of discoloration on 3 ceiling tiles. 1 area had approximately 6 inches in diameter of brown, round rings decreasing to a black center about 3-inch by 4-inches. The second tile had three round areas of brown rings about 4-inches with a 3- inch diameter black center, 3-inch brown ring surrounding a 2-inch speckled black to gray center, and a half circle of brown about 3 inches in diameter surrounding a 2-inch black center.Room A-22 had 3 areas of discoloration on 2 ceiling tiles near an exterior window. 1 area had approximately 7 inches of diameter of brown, round rings decreasing in size to a black center approximately a 4 by 5-inch 3/4 circle stopping at the wall. The second area had a brown about 6 inch ring and a 4-inch diameter black speckled center. The third had a light brown ring, approximately 4 inches.Room A-24 had 5 areas of discoloration on 4 ceiling tiles in a line parallel to the hallway. 2 areas were a light brown ring approximately 3 inches in diameter, with about a 3-inch black center. 1 area had a brown ring, approximately 4.5-inch diameter with a 3-inch black speckled center. The main dining room had 11 ceiling tiles with brown circular or round shaped areas on the tiles next to the shared kitchen wall too numerous to count.In an interview, on 1/5/25 at 9:53, Resident 45 indicated the ceiling tiles in the room are nasty. A review of open work orders on 1/9/26 at 11:30 AM, indicated:An order, created on 10/21/25, indicated all stained ceiling tiles needed replaced on Unit A and in the hallways.An order, created on 12/16/25, indicated room A-15 had ceiling tiles with mold on them.In an interview, on 1/5/26 at 10:24 AM, the Director of Dining Services indicated she had not previously entered a work order for 11 brown discolored ceiling tiles in the dining room.In an interview, on 1/8/26 at 10:06 AM, the Maintenance Director indicated water damage has been an ongoing issue. When mold or mildew were noticed on ceiling tiles, the tiles should be changed right away. Rooms A 18, 20, 22, and 24 did not have specific work orders identifying black ceiling tiles.In an interview, on 1/9/26 at 11:19 AM, Housekeeper 14 indicated they would make a work order for ceiling tiles with water damage. When the tiles become black, Housekeeper 14 indicated a second work order and described how the ceiling looked.A current policy, dated 11/2012, and provided by the Executive Director, titled NIOSH Alert Preventing Occupational Respiratory Disease from Exposures Cause by Dampness in Office Buildings, School, and Other Nonindustrial Buildings, indicated the management should identify and correct all sources of excess building moisture (e.g., roof and window leaks). Regularly sched uled inspections of the building by mainte nance personnel (e.g., focusing on ceilings, dry wall, exterior walls) may help to identify evidence of leaks or dampness. Building materials that show evidence of mold growth or moisture damage should be cleaned and repaired or replaced to minimize the risk of health effects in building occupants.A CDC publication, titled Mold, dated 9/26/2024, indicated if you see or smell mold, you should remove it. You do not need to know the type of mold. If mold is growing in your home, you need to clean up the mold and fix the moisture problem.This citation is related to intake 26738613.1-19(f)(5)

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%. 2 of 14 residents observed were affected (Resident 29 and Resident 7).Findings include: 1.During an observation on 01/07/2026 11:51 AM, Licensed Practical Nurse (LPN) 7 obtained a blood glucose reading of 215 for Resident 29. 9 units of novalog insulin were given by an insulin flexpen. LPN 7 did not prime the novalog flexplen with 2 units of insulin prior to administration. In an interview, on 01/07/2026 11:53AM, LPN 7 indicated she didn't prime the flexpen with 2 units of insulin, and was not sure what the facility policy was for priming. Resident 29's record was reviewed 01/08/2026 12:00 PM. Diagnoses included diabetes mellitus type 2 and long term use of insulin. A current admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident 29 had a Basic Interview for Mental Status (BIMS) score of 10 (moderate cognitive impairment). A current physician's order, dated 12/28/25, indicated Resident 7 should receive novolog insulin coverage as follows:For a blood glucose reading of :151-199 give 2 units200-249 give 4 units250- 299 give 6 units300- 350 give 8 units351-399 give 10 units.For a reading of 215, 4 units of novolog insulin should have been given. A current physician's order dated 12/1/25 indicated Resident should receive 5 units of novolog insulin subcutaneously twice daily for diabetes type 2. In an interview, on 1/8/26 at 9:47 AM, the Director of Nursing (DON) indicated 2 units should be used to prime in the insulin flexpen before giving the dose of insulin to ensure the correct dose was received by the resident. A current policy titled Insulin Administration Policy, dated 6/21/2017, provided by the DON on 01/08/2025 at 10:16 AM indicated nurses should follow manufacturer's instructions on how to properly operate the device containing insulin. The policy indicated many devices required priming prior to administration. Novolog flexpen instructions, provided in video format on the manufacturer's (Novo Nordisk) website (https://www.novomedlink.com/diabetes/products/treatments/novolog/dosing-and-administration.html), indicated after attaching a needle to the correct pen, the dosage dial should be turned to 2 and the activation button should be pushed to reveal a drop of insulin at the end of the needle (priming or airshot). If the drop was not observed, the process should be repeated up to 6 times. If after 6 attempts, no drop is observed, the pen should not be used. The priming or airshot process should be used to ensure no air was present in the portion of the pen use to deliver the correct dose of insulin. 2) During an observation on 1/8/25 at 8:40 AM, Registered Nurse (RN) 3 approached Resident 7 in the dining room with a cup of pills, cup of water, an inhaler, and a unit dose eye drop device. Resident 7 was in the process of eating his breakfast at the time of the observation. After he finished chewing a bite of food and swallowing, RN 3 handed Resident 7 his inhaler. Resident 7 inhaled the dose of medication and handed the inhaler back to RN 3. Resident 7 then picked up his cup of pills, poured them in his mouth and swallowed them. No mouth rinse was completed. RN 3 donned gloves, instructed Resident 7 to tilt his head back and administered eye drops in each eye. Resident 7 then took another bite of food. His remained positioned at the table with his plate of food in front of him throughout the process. In an interview, on 01/08/2026 8:56 AM, RN 3 indicated the inhaler should not have been given during mealtime due to risk of aspiration of food particles. She indicated an oral rinse should have occurred after administration of the inhaler. She indicated eye drops should not have been administered in proximity to the resident's food. 3 medication errors occurred during medication pass observation resulting in an error rate of 10.74%. Resident 7's record was reviewed on 01/08/2026 1:28 PM. Diagnoses included chronic obstructive pulmonary disease and dry eyes. Resident 7's current quarterly MDS assessment dated [DATE] indicate he had a BIMS score of 13 (mild cognitive impairment). A current physician's order, dated 1/28/25, indicated Resident 7 should receive artificial tears eye drops, one drop in both eyes twice daily. A current physician's order, dated 2/13/25, indicated Resident 7 should receive anoro ellipta 62.5/25 mcg, inhale one puff once daily for chronic obstructive pulmonary disease, rinse and spit after each use. In an interview, on 01/08/2026 9:34 AM, The DON indicated inhalers should not be administered during a meal due to risk of aspiration of food particles and an oral rinse should occur after the use of an inhaler when ordered by the physician. The DON indicated insulin pens should be primed with 2 units of insulin to ensure correct dosages were delivered. A current policy titled Administering Medications through a Metered Dose Inhaler, dated 12/17, provided by the Administrator on 1/8/26 at 10:16 AM, indicated gargling solution should be provided to the resident for inhaler administration. The policy did not address safety precautions to prevent aspiration or rinsing procedure. A current policy titled Opthalmic drop administration, dated 12/17, provided by the Administrator on 1/8/26 at 10:16 AM, did not address ensuring medication was not administered in close proximity to food items. Manufacturers guidelines found on the refresh tears (artificial tears) website provided a warning indicated the medication was for external use only and poison control should be consulted in event of ingestion. 3.1-48(c)(1)

Based on observation, interview, and record review the facility failed to follow physician orders related to medication administration for 1 of 18 residents reviewed. (Resident 4)Resident 4's record review began on 01/08/2026 at 1:26 PM. Diagnoses included chronic kidney disease stage 5, dependence on renal dialysis, and type 2 diabetes. Resident 4's current quarterly Minimum Data Set assessment (MDS), dated [DATE], indicated Resident 4 had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact).Resident 4's current physician orders included:Dialysis on Monday, Wednesday, and Friday at an outside dialysis companyThe actual times of administration of medication may be adjusted on a daily basis to accommodate resident's request on administration schedule unless contraindicated due to the action of medication.Velphoro Chews 500mg tablet, by mouth three times a day with meals for chronic kidney diseaseFlexeril, or cyclobenzaprine 10mg tablet, by mouth three times a day for muscle spasmsGabapentin 200 mg capsules, by mouth three times a day for painZofran 8 mg tablet, by mouth three times a week for nausea, send with resident to dialysisMidodrine 5 mg tablet, by mouth three times a week for nausea or vomiting, send 3 tablets with resident to dialysis for hypotension A review of Resident 4's Medication Administration Record (MAR), dated 12/1/25-12/31/25, indicated Resident 4 did not receive the second dose of Flexeril 10 mg, Gabapentin 200 mg, and Velphoro 500mg on 12/1/25, 12/3/25, 12/10/25, 12/12/25, 12/15/25, 12/17/25, 12/19/25, 12/22/25, 12/24/25, 12/26/25, 1/5/26, and 1/7/26. Documentation related to Flexeril 10 mg, Gabapentin 200mg, and Velphoro 500 mg on 12/6/25 was missing for the noon dose.A review of Resident 4's Self-Administration of Medication Assessment, dated 11/15/25, indicated Resident 4 was had trouble holding onto objects, and opening bottles.During an observation, on 1/08/26 at 1:42 PM, an opened plastic bag in the dialysis communication folder, dated 1/7/26, labeled with Resident 4's name, was found to have 2 tablets of midodrine 5 mg, 2 tablets of gabapentin 100mg, 1 tablet of cyclobenzaprine 10mg, and 2 tablets of unpackaged Velphoro 500mg.In an interview, on 1/9/26 at 9:55 AM, Resident 4's Dialysis RN indicated medications sent from the facility were not given at dialysis, except for Midodrine. The facility did not send an order sheet or MAR with Resident 4. The dialysis center had told the facility not to send Resident 4's routine medications multiple times, the last time the dialysis facility communicated with the nursing facility was around November. Resident 4 was unable to open the packets for medications per self. Resident 4 was educated by dialysis staff about their medication administration procedure. In an interview, on 1/9/2026 at 10:29 AM, Qualified Medication Aide (QMA) 5 indicated MAR letters indicated (O) meant the resident was out of the facility. (H) meant the medication was on hold or for hospital stay. (R) meant the resident refused medication or treatment. QMA 5 indicated they had not heard of the dialysis center asking the facility to stop sending medications other than midodrine. In an interview, on 1/9/2026 at 10:38 AM, Registered Nurse (RN) 4 indicated Resident 4 usually returns from dialysis at 1PM. Scheduled medications for noon could be given upon return. The MAR should not have missing documentation for scheduled medication. RN 4 indicated they were not aware when nursing staff had called a physician to clarify noon scheduled medications on dialysis days Resident 4 was not in the building.In an interview, on 1/8/26 at 1:57 PM, the Director of Nursing indicated the facility did not have a policy about sending meds to and from dialysis.A current policy, dated 12/2025, indicated a resident who cannot safely self-administer medications would have nursing staff administer resident's medications. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure safe, sanitary food storage and serving practices for 5 of 5 observations. Food prepared in the kitchen was consumed by 74 of 74 residents who lived in the facility. Findings include: During a continuous observation on [DATE] from 10:16 AM - 11:00 AM the following observations were made: A countertop had open slotted drains and a brown, murky liquid puddle under the countertop. The opened bag of french fries and bread were not dated in Freezer 1. Freezer 2 had whipped cream in a bag not labeled or dated. The whipped cream was unsealed and open to air. The opened bag of macaroni was not dated in the dry pantry. There was a package of swiss cheese, expired ,d+[DATE], located in Refrigerator 1. 2 of 5 stacked metal pans had moisture between them. The stand mixer had dime sized, dry, yellow flaky material on the paddle. During a continuous observation from 11:34 AM-12:25 PM, Dietary Aide 4 donned gloves and started distribution of food to resident plates. She touched brussel sprouts and bread with gloved hands. Dietary Aide 4 held clean bowls against her t-shirt, touched her shirt with her gloved hands and then resumed serving food. Dietary Aide 4 was observed using a pen to write on a meal ticket with her gloved hands and then resumed serving food. Dietary Aide 4 then scooped ice with a cup, and placed the cup onto the meal tray. Dietary Aide 4 did not perform hand hygiene or change gloves during the continuous observation. During the distribution of food, 3 plates from the clean stack were observed with small flecks of dried yellow particles. During an observation on [DATE] at 12:20 PM, Dietary Aide 11 assembled meal trays and covered dessert with plastic wrap. Her hands were gloved. Dietary Aide 11 knocked the plastic wrap box onto the floor. She then picked up the box with her gloved hands from the floor, resumed assembling the meal trays and covering desserts with the same plastic wrap. Dietary Aide 11 did not perform hand hygiene or change her gloves. In an interview, on [DATE] at 10:18 AM, Dietary Shift Supervisor 7 indicated the bread was to be used within one week. She indicated the mixer was now clean and ready to be used. She indicated there should not be dry yellow substance on the mixer. During an observation on [DATE] at 11:44 AM, Unit A's pantry freezer contained prepackaged meals with no date. In an interview on [DATE] at 11:44 AM, Certified Nurse Aide (CNA) 9 indicated the meals should be labeled and dated. During an observation on [DATE] at 11:50 AM, Unit B's pantry refrigerator contained soup with an expiration date of [DATE]. There were also black and brown particles and a popcorn kernel between the refrigerator and the floor. In an interview on [DATE] at 11:50 AM, Registered Nurse (RN) 10 indicated expired food should not be in the refrigerator. In an interview on [DATE] at 11:09 AM, the Director of Nursing (DON) indicated all 74 residents received food that was prepared in the facility kitchen. A current policy, dated ,d+[DATE], titled Food Preparation Area Safety and Sanitation, was provided by DON on [DATE] at 12:45 PM. The policy indicated all counters and equipment should be cleaned and sanitized after each use. A current policy, dated ,d+[DATE], titled Food Purchasing and Storage, was provided by DON on [DATE] at 12:45 PM. The policy indicated food storage areas shall be clean and dry at all times. Food must be date marked if it is prepared on site and refrigerated, or commercially processed after the original container is opened. Food shall be dated with the current date and be used or discarded per State Food Code Regulations. The policy also indicated if potentially hazardous, ready-to-eat food is frozen, the food shall be dated with the current date and used or discarded per State Food Code Regulations. A current policy, dated ,d+[DATE], titled Foods Brought by Resident Representative(s)/Visitors and Personal Refrigerators, was provided by DON on [DATE] at 12:45 PM. The policy indicated perishable foods brought into the community and stored in the kitchenette refrigerators or the resident's room shall be clearly marked with . 2. food items labeled with an expiration date shall be marked with the date opened and stored until the expiration date. The policy also indicated the kitchenette refrigerators shall be monitored by the dining staff for outdated/expired food. A current policy, dated ,d+[DATE], titled Hand Hygiene, was provided by DON on [DATE] at 12:45 PM. The policy indicated hand hygiene should be preformed before and after handling food and the use of gloves did not replace hand hygiene. 3XXX,d+[DATE](i)(3)

Based on interview and record review, the facility failed to ensure ongoing assessment for a change in condition for 1 of 4 residents reviewed (Resident 75) Findings include: Resident 75's record was reviewed 12/27/24 at 10:23 AM. Diagnoses included Cerebral infarction (stroke), diabetes, high blood pressure, and osteoarthritis, A review of progress notes indicated the following: Dated 10/1/24, Resident 75 was afebrile. Orders were obtained for a complete blood count and comprehensive metabolic panel. No reason for the tests or assessment of Resident 75's condition was documented. Dated 10/2/24, Resident 75 was placed on Robitussin. There was no documentation regarding breath sounds, or other condition of the resident. Dated 10/3/24, Resident 75 was placed on an antibiotic Invanz for urinary tract infection symptoms. The resident was afebrile, the urine color was yellow, and there were no complaints of pain on urination. There was no documentation regarding other symptoms of the infection, urine clarity, or presence of pain. Dated 10/4/24, No documentation regarding urinary symptoms was available for review. Dated 10/5/24, Resident 75 was afebrile, and her urine was yellow. Fluids were encouraged. Dated 10/6/24 at 9:21 PM, Resident 75 becomes very confused, the family was notified, urine characteristics were not documented. Dated 10/7/24 at 2:48 AM, Resident 75's urine was amber with sediment documented. Fluids were pushed. There was no documentation the family or physician was notified of the change in the urine characteristics. Dated 10/7/24 at 10:22 PM, Resident 75 was eating only bites and pocketing food. The resident's confusion continued. The family was aware of the resident's condition, but there was no documentation the physician was notified. of the change in urine characteristics. Dated 10/8/24 at 10:20 AM, Resident 75's urine showed signs of blood. The note indicated the resident had been tugging on her catheter. The Nurse Practitioner was notified and the anchored catheter was discontinued. The notes indicated Resident 75's temperature was within normal limits. The note indicated the resident was confused, but did not indicate any other assessment of her condition. Dated 10/9/24 Resident 75's temperature was within normal limits. There was no documentation of her urine characteristics, but an increase in the resident's confusion was documented. Dated 10/10/24 indicated Resident 75 remained confused, did not urinate through the night. When toileted later in the morning, her urine was decreased amount, was amber and clear. Dated 10/11/24 indicated Resident 75 had increased confusion. but there was no documentation of urinary characteristics, color, clarity, or pain. Dated 10/12/24, Resident 75's temperature was 98.0. There was no other documentation regarding the resident's urinary characteristics. A physician's order, dated 10/12/24 at 3:30 PM, indicated to send Resident 75 to emergency room , related to low blood pressure and sepsis. In an interview on 12/17/24 at 11:15 AM, Licensed Practical Nurse (LPN) 8 indicated staff should be assessing the resident for changes in condition that indicate condition improvement or decline. 3.1-37

Based on observation, interview and record review, the facility failed to ensure functional and comfortable positioning for 1 of 3 residents reviewed (Resident 12). Findings include: On 12/15/24 at 12:35 PM, Resident 12 was observed sitting in an adjustable positioning wheelchair (Broda chair) in the dining room. Resident 12 was observed sitting upright with their head leaning forward. Resident 12's chin was observed to be approximately 1 inch from their chest. A staff member was observed lifting Resident 12's head by placing their hand on the resident's forehead. The staff member was observed placing a spoon in Resident 12's mouth while continuing to hold the resident's head up with their hand on the resident's forehead Resident 12's record was reviewed on 12/18/24 at 12:05 PM. Diagnoses included Alzheimer's, hypothyroidism, (underactive thyroid gland) muscle weakness and multiple sites of muscle contractures (tightening that can restrict movement). Resident 12's Quarterly Minimum Data Set, (MDS) dated [DATE], indicated the resident's Brief Interview for Mental Status (BIMS) score was not rated as the resident was seldom or never understood. The MDS indicated Resident 12 was dependent on staff for eating. The MDS indicated Resident 12 was dependent on staff for all position changes. A physician order, dated 10/15/24, indicated Resident 12 could have a Broda chair for positioning and comfort. Resident 12's Care Plan, dated 10/29/24, indicated the resident required extensive or total assistance for all activities of daily living (ADLs). ADLs included eating, toileting, dressing, bathing and positioning. The target goal was for Resident 12 to have their ADL needs met through the next review period. Interventions included a total lift assistive device for transfers, a Broda chair for mobility and a hand roll to their left hand at night. Resident 12's Care Plan, dated 11/6/24, indicated the resident was at risk for further decline in range of motion due to having a contracture to their left hand. The target goal was for Resident 12 to have no further decline or complications to their left hand. Interventions included passive range of motion, hand roll to left hand at night, monitor and notify the nurse of any changes and the nurse was to inform Occupational Therapy (OT) of any issues. The Care Plan did not indicate Resident 12's head leaned forward. Resident 12's Care Plan, dated 118/24, indicated the resident was at risk for further decrease in all their joints due to reduced mobility and advanced dementia. The target goal was Resident 12 would not have a further decline of range of motion through the next review date unless the decline was clinically unavoidable. Interventions included passive range of motion to the upper and lower body, notify the nurse of changes and the nurse was to notify OT of changes. The Care Plan did not indicate Resident 12's head leaned forward. Resident 12's Care Plan, dated 10/29/24, indicated the resident was at risk for impaired nutrition. The target goal was for the resident to have nutritional needs met without significant weight changes through the next review. An intervention was a pureed diet. Interventions dated 11/1124 included providing supplements as ordered and weighing the resident monthly. An intervention dated 12/15/24 indicated Resident 12 needed fed by staff at mealtimes. The Care Plan did not indicate Resident 12's head leaned forward. On 12/18/24 at 12:25 PM, Resident 12 was observed sitting in their Broda chair in the dining room. Resident 12 was sitting upright in the Broda Chair. Resident 12's chin was approximately 1 inch from their chest. The staff member feeding Resident 12 encouraged Resident 12 to lift their head. Resident 12 lifted their head up a minimal amount. The staff member fed Resident 12 a spoonful while the staff member's head was lowered to the level of Resident 12. Resident 12 immediately lowered their head to the prior position of approximately 1 inch from their chest. In an interview on 12/18/24 at 12:41 PM, the Director of Nursing (DON) was made aware of Resident 12's head being manually lifted during lunch on 12/15/24. The DON indicated they were aware of Resident 12's Care Plan to notify OT for concerns. The DON indicated it was not unusual for Resident 12 to sit with their head leaning forward to their chest. The DON indicated Resident 12's head leaning forward was not a new occurrence. In an interview on 12/18/24 at 2:34 PM, the DON indicated Resident 12 had received OT services approximately 30 days ago. The DON indicated they believed OT had focused on Resident 12's head and neck positioning. Resident 12's therapy record was reviewed on 12/18/24 at 2:44 PM. Resident 12's OT start of care was 8/15/24. Resident 12's end of care was 9/24/24. An OT Plan of Care, dated 8/15/24 at 8:08 PM, indicated OT was required to improve Broda chair positioning to reduce fall risk, prevent increased contractures and improve comfort. Resident 12's current level of function was contractures of the neck, the trunk, both arms and both legs. A short-term goal was for Resident 12 to achieve midline head and body alignment using head positioners and lateral support devices by 8/29/24. A long-term goal was for Resident 12 to achieve midline head and body alignment using head positioners and lateral support devices by 10/13/24. An OT progress note dated 8/29/24 at 2:48 PM, indicated a short-term goal was for Resident 12 to achieve midline head and body alignment using head positioners and lateral support devices by 8/29/24. The clinical impression indicated Resident 12's seating had looked better with lateral support devices and staff had been educated for lateral support. An OT progress note, dated 9/12/24 at 2:42 PM, indicated a short-term goal was for Resident 12 to achieve midline head and body alignment using head positioners and lateral support devices by 9/26/24. The clinical impression indicated Resident 12's midline had improved but was still leaning forward into flexion. The progress note indicated a wedge cushion was ordered. An OT progress and discharge summary, dated 9/26/24 at 7:59 AM, indicated a long-term goal of Resident 12 12 to achieve midline head and body alignment using head positioners and lateral support devices had been met. The clinical impression indicated the resident had improved their Broda chair positioning with the use of lateral supports and a high-profile step cushion. The summary indicated staff had been educated for adaptive equipment and Broda chair positioning. In an interview on12/18/24 at 3:15 PM, Certified Nurse Aide (CNA) 12 indicated they were not aware of Resident 12 having any postural positioning devices to assist with lifting their head. Resident 12's CNA worksheet was reviewed with CNA12. Resident 12's CNA worksheet indicated the nurse was to inform OT of any issues. The worksheet indicated Resident 12 was to have passive range of motion of their left hand prior to applying left hand splint, a mat at bedside while in bed, a total lift assistive device and a Broda chair. The CNA worksheet did not indicate Resident 12 had a positional device for their head and neck while in the Broda chair. On 12/19/24 at 10:01 AM, Resident 12 was observed in the beauty shop sitting upright in their Broda chair with their head leaning forward. Resident 12's feet were placed on a triangular shaped cushion. In an interview on 12/19/24 at 10:34 AM, the DON indicated Resident 12's Care Plan did not include the assistive equipment recommended by therapy. The DON indicated the aides were not aware of any assistive equipment recommended by therapy due to the recommendations not being on their CNA worksheets. A current facility policy, dated12/2017, provided by the DON on 12/19/24 at 11:10 AM, indicated each resident's care plan should reflect their specific positioning needs. The policy indicated each resident would be placed be assisted into a comfortable position according to their individualized care plan. A current facility policy, dated 11/2019, provided by the DON on 12/19/24 at 11:10 AM, indicated residents who are unable to feed themselves would be fed by staff with attention to safety, comfort and dignity. 3.1-42(a)(1) 3.1-42(a)(2)

Based on observation, interview, and record review the facility failed to ensure sanitary handling of a catheter bag in 1 of 2 residents reviewed (Resident 36). Findings include: During an observation on 12/15/24 at 10:32 AM, Resident 36 was viewed from the hallway sitting in her room in a wheelchair watching television. A catheter bag was observed attached to the wheelchair frame underneath the seat of the wheelchair. The catheter bag contained about 200 ml of yellow fluid and was in contact with the floor. During an interview on 12/15/24 at 10:36 AM the Weekend Supervisor indicated urine in the catheter bag should be secured to the wheelchair keeping it from contacting the floor. She indicated contact with the floor could increase the risk of infection. Resident 36's record was reviewed on 12/16/24 at 2:52 PM. Diagnoses included obstructive and reflux uropathy, and encounter for attention to other artificial openings of the urinary tract. Resident 36's current Admission Minimum Data Set (MDS) dated [DATE] indicated their Basic Interview for Mental Status (BIMS) score was 6 (cognitively impaired). The MDS indicated Resident 36 needed maximal assistance with lower body activities of daily living. Resident 36's current care plan titled .altered elimination related to uropathy . indicated Resident 36, with a goal date of 2/24/25. Interventions included maintaining a closed drainage system. Physician orders dated 12/11/24 indicated Resident 36 should have a 16 french 10 ml foley catheter for obstructive uropathy. During an interview on 12/16/24 at 3:07 PM, the Director of Nursing (DON) indicated catheter bags should be maintained without contact with the floor. A current policy dated 12/2017 provided by the DON on 12/16/24 at 3:23 PM indicated staff should ensure the catheter tubing and bag were kept off the floor. 3.1-41(a)(2)

Based on observation, interview, and record review the facility failed to ensure privacy of health information for 2 of 18 residents reviewed (Resident 36 and Resident 72). Findings include: 1) During an observation on 12/15/24 at 10:32 AM, Resident 36 was viewed from the hallway sitting in her room in a wheelchair watching television. A catheter bag was observed attached to the wheelchair frame underneath the seat of the wheelchair. The catheter bag contained about 200 ml of yellow fluid. During an interview on 12/15/24 at 10:36 AM the Weekend Supervisor indicated urine in the catheter bag should not be visible from the hallway. Resident 36's record was reviewed on 12/16/24 at 2:52 PM. Diagnoses included obstructive and reflux uropathy, and encounter for attention to other artificial openings of the urinary tract. Resident 36's current Admission Minimum Data Set (MDS) dated [DATE] indicated their Basic Interview for Mental Status (BIMS) score was 6 (cognitively impaired). The MDS indicated Resident 36 needed maximal assistance with lower body activities of daily living. During an interview on 12/16/24 at 3:07 PM, the Director of Nursing (DON) indicated catheter bags should be maintained with a cover so contents cannot be viewed by any passersby. In an interview on 12/19/24 at 11:09 AM, the DON indicated the facility did not have a policy specifying how staff should keep contents of catheter bags from being seen by passersby. 2) During an observation on 12/15/24 at 12:16 PM, Resident 72 was seated in her wheelchair while Certified Nurse Aide (CNA) 2 was pushing her wheelchair out of the main dining room. CNA 2 called loudly to staff members in the assisted dining area across the hall; Resident 72 needed to go to the restroom and she did not know how to assist her. Residents, staff and a family member were all seated in the dining room, positioned to hear what was said. Resident 72's record was reviewed on 12/16/24 at 11:51 AM. Diagnoses included psychotic disorder with delusions due to known physiological conditions, rheumatoid arthritis, and need for assistance with personal care. Resident 72's current quarterly MDS indicated their Basic Interview for Mental Status (BIMS) score was 9 (cognitively impaired). The MDS indicated Resident 72 required supervision or touching assistance with toilet transfers, and partial/moderate assistance with toileting hygiene. Resident 72's current care plan, titled .needs assistance with Activity of Daily Living (ADL) care, with a goal date of 2/3/24 indicated Resident 72 needed limited assistance with one person staff support for toileting activities. In an interview on 12/15/24 at 12:51 PM, Certified Nurse Aide (CNA) 2 indicated staff should not call across the room to communicate resident needs to one another. Staff should speak in low tones in a private area to communicate residents' personal needs to one another. In an interview on 12/16/24 at 3:07 PM, the DON indicated staff should go to a private area to discuss resident needs and not reveal private information about residents in populated areas. A current policy, titled Confidentiality of Information, dated 12/2019, provided by the DON on 12/16/24 at 3:23 PM, indicated all resident information should be treated confidentially. 3-1(p)(5)

Based on observation, record review and interview, the facility failed to ensure physician orders were followed and safe handling of respiratory equipment was completed for 4 of 24 residents reviewed. (Resident 9, Resident 24, Resident 36, and Resident 68). Findings include: 1) During an observation on 1/2/24 at 1:35 PM, Resident 9 was laying in her bed. Her nasal cannula (NC) oxygen tubing (a lightweight tube split into two prongs on one end and placed in the nostrils used to deliver supplemental oxygen) was attached to her oxygen condenser (a medical device that gives you extra oxygen) laying on the oxygen condenser unbagged. The oxygen condenser flow meter was turned to 2 liters per minutes (LPM) delivering oxygen via the NC. Her oxygen condenser was positioned at the upper right side of her bed. The resident's portable oxygen condenser (a lightweight transportable oxygen condenser), not in use at that time, was sitting on the floor with NC oxygen tubing attached. The NC oxygen tubing extended from the portable oxygen unit and laid on the chair unbagged. The oxygen tubings attached to Resident 9's oxygen condenser and portable oxygen condenser were not labeled with the time and date the tubing was changed. During an interview on 1/3/24 at 1:41 PM, Resident 9 indicated she wore oxygen. During an observation on 1/2/24 at 1:41 PM, Licensed Practical Nurse (LPN) 5 put the NC oxygen tubing on Resident 9. Resident 9's record was reviewed on 1/3/24 at 2:20 PM. Diagnoses included chronic obstructive pulmonary disease (COPD), obstructive sleep apnea (OSA), and morbid obesity, Resident 9's current significant change in status Minimum Data Set (MDS) assessment, dated 10/31/23, indicated her Basic Interview of Mental Status (BIMS) score was 8 (mild cognitive impairment). The MDS indicated she had a lower extremity impairment on one side and used a manual wheelchair. The MDS indicated the resident required maximal assistance from staff to roll right to left and lying to sitting on the side of the bed and was dependent on staff to bed-to chair transfers. The MDS indicated the resident had shortness of breath or trouble breathing when laying flat and wore oxygen after arriving to the facility. Resident 9's current care plan titled Impaired Gas Exchange indicated the resident was dependent on oxygen related to COPD and OSA with a goal to be free from cardiac symptoms of respiratory distress. Interventions included to monitor oxygen flow rate and change tubing and bubblers per protocol or as ordered. A physician orders dated 10/19/23 indicated Resident 9's oxygen was to be at 2 LPM via NC and may be titrated to keep oxygen sats above 90%. A physician orders dated 6/19/23 indicated Resident 9's oxygen tubing was to be changed weekly on 3rd shift. Resident 9's Medication Administration Record indicated the oxygen tubing was changed at 5:00 AM on 12/4/23, 12/10/23, 12/17/23, 12/24/23 and 12/31/23 indicating the oxygen tubing for the oxygen condenser and portable oxygen condenser was last changed on Sunday 12/31/23 at 5:00 AM but not labeled. 46756 2) During an observation and interview on 1/2/24 at 9:40 AM, Resident 24 was observed lying in bed with a nasal cannula placed in his nostrils, attached to an oxygen concentrator beside the bed. The oxygen concentrator was turned on and set to deliver 0 liters of oxygen per minute. Qualified Medicine Aide (QMA) 2 indicated the oxygen should have been set at 2 liters per minute and she did not know why it had been turned down to zero. QMA 2 indicated she was unable to verify when the oxygen tubing had been changed because she was unable to find a date on the tubing. Resident 24's record was reviewed on 1/4/24 at 12:56 PM. Diagnoses included multiple sclerosis, sleep apnea, unspecified, and personal history of pulmonary embolism. A review of Resident 24's current quarterly Minimum Data Set (MDS) dated [DATE] indicated he had a Basic Interview for Mental Status (BIMS) score of 14 (cognitively intact). The MDS indicated Resident 24 used oxygen. A review of a care plan titled .has pneumonia, undated and labeled inactive, included an approach indicating oxygen should be administered as ordered. No current care plan pertaining to oxygen use was available for review. A review of physician orders dated 11/6/23 indicated oxygen should be delivered at 2 liters per minute by nasal cannula. A physician's order dated 11/7/23 indicated oxygen tubing should be changed weekly. In an interview on 1/3/24 at 2:45 PM, the Director of Nursing (DON) indicated oxygen should be administered as ordered and tubing should be changed weekly and dated. 3) During an observation and interview on 1/3/24 at 10:52 AM, A respiratory treatment mask and tubing were observed lying on Resident 36's dresser unbagged and undated. Resident 36 was seated in his wheelchair in his room and was not using oxygen. He indicated he had not used oxygen in a while. Resident 36's record was reviewed on 1/3/24 at 10:52 AM. Diagnoses included chronic obstructive pulmonary disease, personal history of pulmonary embolism, hypoxemia, and dependence on supplemental oxygen. A review of Resident 36's current quarterly Minimum Data Set (MDS) dated [DATE] indicated his Basic Interview for Mental Status (BIMS) score was 14 (cognitively intact). A review of Resident 36's care plan, dated 1/22/21, labeled inactive, included an approach to administer oxygen as ordered for shortness of breath. No current care plans mentioning oxygen were available for review. A review of current physician's orders dated 2/14/22 indicated oxygen should be administered at a rate of 2 liters per minute via nasal cannula for shortness of breath. An additional current physician's order dated 2/14/22 indicated oxygen should be administered at a rate of 2 liters per minute via nasal cannula as needed for oxygen saturations less than 90 percent and shortness of breath. In an interview on 1/3/24 at 2:45 PM, the DON indicated Resident 36's oxygen orders should be clarified, and respiratory equipment should be bagged when not in use. 4) During an observation on 1/2/24 at 10:26 AM Resident 68 was observed sitting in his wheelchair in his room. No oxygen was in use at the time of the observation. An oxygen concentrator was observed several feet from the foot of the bed with a nasal cannula lying on top of it, undated and unbagged. A nebulizer machine with tubing and a mask attached to it was lying undated and unbagged on a recliner chair in the room. During an observation on 1/8/24 at 9:39 AM, Resident 68 was observed lying on his bed with the oxygen concentrator positioned across the room and turned off. Resident 68's record was reviewed on 1/3/24 at 9:44 AM. Diagnoses included chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and muscle weakness. A review of Resident 68's current quarterly MDS dated [DATE] indicated his BIMS score was 15 (cognitively intact). In an interview on 1/2/24 at 10:26 AM, Residnet 68 indicated he had not had oxygen on in quite some time A review of current physician's orders included the following orders dated 2/24/23: Change oxygen tubing and humidifier weekly on Sundays. Supplemental oxygen via nasal cannula at 3 liters to keep sats greater than or equal to 90 percent, may titrate. In a review of the Medication Administration Record for January 2024, an order dated 2/24/23, indicating supplemental oxygen via nasal cannula at 3 liters to keep saturations greater than or equal to 90 percent, may titrate, was checked as given on 1/1/24, 1/2/24, and 1/3/24. A review of Resident 68's current care plan titled .at risk for respiratory distress indicated the resident had a problem of shortness of breath, with a goal date of 1/9/24. Interventions included maintain oxygen administration device as ordered. A review of progress notes dated 1/4/24 at 2:44 PM indicated Resident 68 was using continuous oxygen at 3 liters per minute. In an interview on 1/3/24 at 2:45 PM, the DON indicated respiratory tubing should be bagged when not in use and oxygen orders should be followed. A current policy titled Procedure: Administering Medications Through a Small Volume Nebulizer dated 1/24 provided by the DON on 1/3/24 at 2:45 PM indicated respiratory equipment should be cleaned after use and stored in a plastic bag with the resident's name and date. The policy indicated the equipment should be changed every seven days. A current policy titled Procedure: Oxygen Administration dated 12/22 provided by the DON on 1/3/24 at 2:45 PM indicated oxygen tubing should be labeled and dated. 3.1-47(a)(6)

Based on observation, interview, and record review the facility failed to ensure privacy was maintained for 2 of 24 residents reviewed (Resident 24, and Resident 32). Findings include: 1) During an observation and interview on 1/2/24 at 9:48 AM, Resident 24's catheter bag partially filled with yellow liquid was visible from his doorway. Qualified Medicine Aide (QMA) 2 indicated Resident 24's catheter bag should be covered. Resident 24's record was reviewed on 1/2/24 at 11:07 AM. Diagnoses included multiple sclerosis, neuromuscular dysfunction of the bladder, and benign prostatic hyperplasia with lower urinary tract symptoms. A review of Resident 24's current quarterly Minimum Data Set (MDS) dated [DATE] indicated he had a Basic Interview for Mental Status (BIMS) score of 14 (cognitively intact). The MDS indicated Resident 24 used an indwelling catheter. A review of Resident 24's current care plan titled .indwelling catheter for diagnosis of neuromuscular bladder . indicated the resident had a problem of indwelling catheter use, with a goal date of 3/11/24. Interventions included cover catheter bag with a dignity cover. A review of physician orders dated 1/10/19 indicated Resident 24's catheter and drainage bag should be changed as needed based on clinical indicators. In an interview on 1/3/24 at 2:45 PM, the Director of Nursing indicated the catheter bag should have been covered to maintain privacy. A current policy titled Procedure: Catheter Care, Urinary, Last reviewed 12/17, provided by the Director of Nursing on 1/3/24 at 2:45 PM did not indicated the resident's catheter should be covered. 2) During a medication pass observation on 1/4/24 at 8:20 AM, Registered Nurse (RN 3) was observed preparing medications for Resident 32. After preparing the medications, RN 3 walked away from the cart leaving it unattended with the computer screen open. Resident 32's protected health information including her name and medications were visible on the screen to individuals passing by. The cart was situated by the dining room with residents and staff passing within visual range of the cart. During an observation on 1/5/24 at 1:21 PM, RN 3 prepared a cup with pills in it and walked away from her cart with her computer screen open leaving resident information visible. The cart was situated in the hallway with staff and residnets passing within visual range of the cart. During an interview on 1/4/24 at 8:55 AM, RN 3 indicated she should have closed her computer screen prior to leaving the medication cart to ensure privacy. Resident 32's record was reviewed on 1/8/24 at 12:29 PM. Diagnoses included Vascular dementia, moderate with psychotic disturbance, anxiety disorder, and hypertensive heart disease without heart failure. A review of Resident 32's current quarterly MDS dated [DATE], indicated Resident 32 had a BIMS score of 12 (mild cognitive impairment). A current policy titled Ascension Annual Compliance, dated 2023, provided by the Director of Nursing on 1/8/24 at 11:20 AM indicated staff should not walk away from computers while logged in and the screen should have been locked when the staff member was away from the computer. 3-1(p)(5)

Based on observation, interview and record review, the facility failed to ensure the investigation of attempted self-harm for 1 of 3 residents reviewed. (Resident 4). Findings include: In an interview on 1/2/24 at 1:48 PM Resident 4 was observed avoiding eye contact during the interview. Resident 4 did not respond verbally to this writer's greetings and continued to look at the floor. Resident 4's record was reviewed on 1/4/24 at 10:16 AM. Diagnoses included Down Syndrome, anxiety disorder, major depressive disorder, Alzheimer's, unspecified dementia, restlessness and agitation. Resident 4's current quarterly Minimum Data Set (MDS) indicated their Basic Interview for Mental Status (BIMS) score was 1 (severe cognitive impairment). The MDS indicated Resident 4 had not displayed any behaviors. The MDS indicated Resident 4 was able to make themselves understood and was able to understand others. Resident 4's current care plan entry dated 2/9/23 indicated the resident's family had reported a history of suicidal ideations. The target goal was for the resident to have no suicidal ideations through 11/30/23. Interventions included arranging psychiatric services as needed, 1 to 1 staff visits, monitor moods and monitor effectiveness of antipsychotic medications. Resident 4's current care plan entry dated 5/1/23 indicated the resident had displayed behaviors of refusal of care, refusing medications, being combative with staff during care and difficulty with redirection. The target goal was for Resident 4 to have fewer refusals through 11/30/23. Interventions included review of medications, allow choices, monitor and document behaviors, ask for family input and encourage communication. Resident 4's current care plan entry dated 1/24/20 indicated the resident had a life long history of depression and displayed extreme tearfulness and unrealistic fears. Target goals included attendance of 1 new activity weekly and no increase in depression through 11/29/23. Interventions included 1 to staff visits, encourage socialization, allow choices, allow the resident to select dining room seating and monitor effectiveness of medications. A progress note dated 3/4/23 at 11:23 AM indicated Resident 4 had been found holding their call light cord around their neck. Resident 4 did not respond to questions related to the call light cord being around their neck. A progress note dated 3/4/23 at 11:44 AM indicated Resident 4 did not display increased depression symptoms, was pleasant and cooperative and had no thoughts of harming self or thoughts of being better off dead. Resident 4's call light cord was found lying on their bed wrapped loosely numerous times with a loop lying on the bed and wrapped around the bed rail. It was determined Resident 4 most likely got tangled in the call light cord on accident. Resident 4's call light was removed and replaced with a bell. A progress note dated 3/6/23 at 9:33 AM noted as a late entry for 3/4/23 indicated the incident was determined to not be a behavioral incident. In an interview on 1/5/24 at 3:18 PM the Director of Nursing (DON) indicated Resident 4 having been found with their call light cord wrapped around their neck had not been investigated. The DON indicated the event had not been reported to the Indiana Department of Health (IDOH). The DON indicated they did not believe the event was an unusual occurrence. The Assistant Director of Nursing (ADON) indicated Resident 4 had an exceptionally long call light cord. The ADON indicated they did not believe Resident 4 had formulated a plan to harm themselves. The ADON indicated Resident 4 was pleasant, laughing and denied the depression screen question of having thoughts of harming self or thoughts of being better off dead. The DON indicated the facility did not have a policy for suicidal ideation or suicide precautions. A current policy related to reportables dated 12/16 provided by the DON indicated the facility was to report adverse events or unusual occurrences as required by federal or state regulations. 3.1-28(d) 3.1-28(e)

Based on observation, interview and record review the facility failed to ensure MD orders were followed for cervical spine fracture management in 1 of 24 resident reviewed for quality of care. (Resident 181). Findings include: During an observation on 1/2/24 at 1:05 PM, Resident 181 was sitting in his recliner watching television. The resident's cervical collar (C-collar) was in a chair across the room. In an interview on 1/2/24 at 1:08 PM, Resident 181 indicated he was supposed to wear the C-collar, but the staff never puts the C-collar back on. Resident 181's record was reviewed on 1/7/24 at 2:47 PM. Diagnoses included a fall from a motorized mobility scooter resulting in C2 odontoid process fracture, bilateral hearing loss, and mild cognitive impairment of unknown origin. Resident 181's current admission Minimum Data Set (MDS), dated [DATE], indicated his Basic Interview for Mental Status (BIMS) score was 10 (moderate cognitive impairment). The MDS indicated in the last month prior to admission he had a fall with a related fracture. The MDS indicated the resident required supervision/assistance for transfers and ambulation and used a walker or manual wheelchair. The MDS indicated he was receiving occupational and physical therapy. Resident 181's current Care plan, dated 6/26/23, titled Non-compliance with Care and Orders indicated the resident refused to wear his C-collar at times, with a goal he would not have an injury when refusing to wear the C-collar. Interventions included documenting the resident's refusal to wear his C-collar. A physician orders dated 12/26/23 indicated Resident 181's C-collar was to be worn at all times. There was no indication in the nursing progress notes dated 1-1-24 through 1-3-24 the resident refused to wear his C-collar except for a note dated 1/3/24 at 6:30 PM when a nursing note was entered regarding the resident's refusal. In an interview on 1/2/24 at 1:15 PM, LPN 6 indicated Resident 181 was to wear his C-collar when he was up walking around. After a request to check the orders, LPN 6 indicated she was incorrect, and the resident was to have the C-collar on at all times. LPN 6 went to Resident 181's room and immediately placed the C-collar on the resident. In an interview on 1/8/23 at 9:26 AM, the DON indicated Resident 181 was to wear his C-collar at all times. In an interview on 1/8/23 at 9:26 AM, the DON indicated the facility had no policy for ensuring medical devices were in place. No policy was provided by survey exit. 3.1-37

Based on interview and record review the facility failed to ensure fall precaution interventions were made available to direct care staff members for 1 of 2 residents reviewed (Resident 15). This resulted in an injury from a fall that required emergency department intervention for Resident 15. Findings include: On 1/2/24 at 4:00 PM the facility reported Resident 15 had experienced a fall on 1/1/24 at 4:30 PM. The fall resulted in a lip laceration that required sutures. Resident 15's record was reviewed on 1/5/24 at 9:30 AM. Diagnoses included Alzheimer's, major depressive disorder, dementia, restless leg syndrome and contractures to the left hand. A review of Resident 15's most recent annual Minimum Data Set (MDS) dated [DATE] indicated their Basic Interview for Mental Status (BIMS) score was 0 (severe cognitive loss). Resident 15 required maximum assistance to roll left and right in the bed. The resident was dependent on staff to change position from lying in bed to sitting on the side of the bed. The resident was dependent on staff to change position from sitting on the side of the bed to lying in the bed and was dependant for 2 assist with sitting balance. Resident 15 was dependent on staff for transfers from a bed to a chair and from a chair to a bed. A physician orders dated 9/20/21 indicated Resident 15 was to have a Broda (an assistive seating device for fall prevention) chair for proper positioning. Resident 15's current care plan entry dated 4/22/14, revised 11/13/23 indicated the resident was at risk for falls or fall related injuries. The target goal was reduced risk for falls and fall related injuries through 2/2/24. An intervention dated 2/24/20 indicated Resident 15 was to be seated in a reclined position in their Broda chair at all times except during meals. An intervention dated 5/5/20 indicated staff were to assist with all transfers. An intervention dated 1/1/24 indicated Resident 15 was not to be seated on the side of the bed until ready for transfer. Interventions did not specify the assistance of 2 staff members for resident transfer. The interventions did not include a mechanical lift for resident transfer. Resident 15's undated care card (guide to CNA care) for direct care staff members indicated the resident was at risk for falls. Resident 15 required assistance from 1 staff member for bed mobility, required a Broda chair, required a mechanical lift for transfers and was not to be placed in a sitting position on the side of the bed until ready for transfer due to the resident having poor trunk strength (dated 1/1/24). A progress note dated 1/1/24 at 8:04 PM indicated Resident 15 had a witnessed fall at 4:30 PM. The note indicated staff had been preparing Resident 15 to take a shower and had placed the resident up on the bed. The note indicated Resident 15 slid to the left, hit the bedside table splitting her lip. An Interdisciplinary Team (IDT) progress note dated 1/2/24 at 1:19 PM indicated a Certified Nurse Aide (CNA) placed Resident 15 on the side of the bed and turned away to remove items from the closet. The note indicated Resident 15 had poor trunk control. A Resident at Risk Review dated 11/22/23 indicated Resident 15 had a fall risk score of 22 (moderate risk). The review indicated Resident 15 was bed/chair bound and required extensive staff assistance for activities of daily living (bathing, dressing, getting in or out of bed or chair, eating and toileting). Resident 15 required the assistance of 2 staff members for transfers. An Indiana State Department of Health Survey Report dated 1/2/24 indicated Resident 15 had experienced a fall on 1/1/24 at 4:30 PM. The report indicated a CNA placed Resident 15 on the side of the bed and turned away to remove items from the closet. Resident 15 slid to the side and hit their lip on the bedside table. The report indicated Resident 15 had a BIMS score of 0, used a Broda chair for positioning and required staff assistance for transfers. In an interview on 1/5/24 at 12:10 PM the Director of Nursing (DON) indicated according to MDS assessments, Resident 15 was not physically capable of sitting on the side of the bed alone and did not fall during a transfer. The DON indicated Resident 15 was being prepared for transfer to the shower chair when the fall occurred. In an interview on 1/5/24 at 1:03 PM Qualified Medication Aide (QMA) 4 indicated on 1/1/24 Resident 15 had a witnessed fall from the bed to the floor. A CNA had positioned the resident in a sitting position on the side of the bed and the CNA then turned away. The CNA who left the resident sitting on the side of the bed unattended was from a staffing agency. Resident 15 slid from the bed hitting the bedside table before falling to the floor, and should have not been left sitting on the side of the bed unattended. QMA 4 indicated the resident's care card had been updated to include not leaving the resident sitting on the side of the bed unattended on 1/1/24 after the resident fell . QMA 4 indicated Resident 15 was ready for transfer, but another CNA had left the room to retrieve a shower chair. A current policy dated 12/17 provided by the DON indicated the documentation of identified interventions should be maintained in the clinical record and available to the direct care associates. 3.1-45(a)

Based on observation, interview, and record review the facility failed to ensure tube feeding formula was labeled and dated for 1 of 1 resident reviewed (Resident 71). Findings include: During an observation on 1/2/24 at 9:37 AM Resident 71 was observed sitting in the recliner in her room with a translucent bag of about an inch of tan liquid. A tubing engaged in a tube feeding pump was attached to Resident 71's gastric tube. The bag and tubing were not dated or labeled with the formula type or orders for administration. During an observation on 1/4/24 at 3:02 PM, Resident 71 was observed sitting in the recliner in her room visiting with a guest. A tube feeding bag was observed with about 1/2 inch of tan liquid in the tubing draped over the top of the pole holding the tube feeding pump. No date or label was seen on the bag. Resident 71's record was reviewed on 1/4/24 at 3:10 PM. Diagnoses included amyotrophic lateral sclerosis, progressive bulbar palsy, and dysphagia, oropharyngeal phase. A review of Resident 71's significant change Minimum Data Set (MDS) dated [DATE] indicated her Basic Interview for Mental Status (BIMS) score was 15 (cognitively intact). The MDS indicated the resident received a tube feeding. A review of physician orders dated 11/28/23 indicated Jevity 1.5 should be administered at 60 ml per hour via kangaroo pump starting at 10:00 PM and stopping at 10:00 AM. In an interview on 1/5/24 at 9:32 AM, the Director of Nursing (DON) indicated tube feeding bags and tubing should be changed daily, labeled, and dated. She indicated she was unable to confirm this was being done since the bag and tubing were not labeled and dated. A current policy titled Procedure: Enteral Tube Feeding Via Continuous Pump dated 1/24 provided by the DON on 1/5/24 at 11:28 AM indicated the bag should be labeled with initials, date, and time the formula was hung and initials that the label was checked against the order. 3.1-44(a)(2)

Based on observation, interview, and record review the facility failed to ensure insulin in a medication cart was removed when expired for 1 of 29 residents and a medication refrigerator temperature was monitored for 1 of 2 medication rooms reviewed (Resident 16). Findings include: 1. During an observation and interview on [DATE] at 1:21 PM, medication storage was reviewed with Registered Nurse (RN) 3. A lispro insulin pen was in the top drawer of the cart with an open date of [DATE]. The pen was in a plastic bag with a printed label indicating it was for Resident 16. RN 3 indicated the insulin was expired and should have been pulled from the cart and replaced with a new pen. Resident 16's record was reviewed on [DATE] at 12:12 PM. Diagnoses included morbid obesity due to excess calories, pseudocyst of the pancreas, and chronic kidney disease, stage 3. A review of Resident 16's current significant change Minimum Data Set (MDS) dated [DATE] indicated her Basic Interview for Mental Status (BIMS) score was 6 (cognitively impaired). The MDS indicated insulin was given during the reference period. A review of physician orders dated [DATE] indicated insulin lispro was to be given subcutaneously according to a sliding scale as follows: For blood sugar ,d+[DATE] give 2 units, ,d+[DATE] give 4 units, ,d+[DATE] give 6 units, ,d+[DATE] give 8 units, ,d+[DATE] give 10 units, for blood sugar over 400 give 12 units and call provider. In an interview on [DATE] at 1:59 PM, the DON indicated manufacturers recommendations are followed to determine expiration dates. A review of Humalog lispro insulin KwikPen instructions for use, [NAME] Lilly, 2023, indicated manufacturers guidelines include throwing away the insulin pen 28 days after opening. A current policy titled Insulin Administration dated ,d+[DATE] provided by the DON on [DATE] at 10:09 AM indicated expired insulin should be immediately discarded. 2. During an observation and interview on [DATE] at 1:27 PM, a temperature log taped to the front of the medication refrigerator in the medication storage room on unit A was reviewed with RN 3. The temperature log had readings recorded on [DATE] and [DATE] with no further entries. RN 3 indicated temperatures should have been recorded each day and she was unable to guarantee the rerigerator temperatures were consistant for safe med storage. Multiple medications were stored in the refrigerator. A current policy titled Equipment Temperature Monitoring and documentation dated ,d+[DATE] provided by the Director of Nursing (DON) on [DATE] at 2:47 PM indicated refrigerator temperatures should be documented daily. 3XXX,d+[DATE](j)

Based on observation, interview, and record review, the facility failed to ensure signs of a urinary tract infection were promptly reported to a physician or designee for 1 of 1 resident reviewed. (Resident 68). Findings include: During an observation on 1/3/23 at 9:47 AM, Resident 68 was observed seated in a reclining wheelchair in the unit lounge area with his eyes closed. During an observation on 1/3/23 at 2:23 PM, Resident 68 was observed at a table with other residents. Resident 68 frequently closed his eyes and frequently nodded his head forward, showing signs of drowsiness. Resident 68 did not respond to other residents seated at the table who attempted to interact with him. During an observation on 1/4/23 at 11:15 AM, Resident 68's catheter tubing had medium yellow, cloudy urine with whitish sediment. During an observation on 1/5/23 at 10:21 AM, Resident 68's catheter tubing had medium yellow, cloudy urine with whitish sediment. Irregularly shaped whitish matter with a mucous-like appearance was also noted in the tubing. During catheter care observation on 1/6/23 at 11:35 AM, Certified Nursing Assistant (CNA) 6 indicated irregularities in urine odor and appearance should be reported to the nurse when observed. Resident 68 kept his eyes closed throughout the procedure. CNA 6 indicated Resident 68 had been sleepy a lot lately. Urine in catheter tubing was medium yellow with whitish sediment and irregularly shaped whitish matter with a mucous-like appearance. During an interview conducted on 1/6/23 at 11:46 AM, Licensed Practical Nurse (LPN) 7 indicated urine in catheter tubing should be observed each shift and irregularities such as foul odor, cloudiness, abnormal color, or sediment should be reported to the Nurse Practitioner (NP). During a record review conducted on 1/9/22 at 11:01 AM, a Minimum Data Set (MDS) dated [DATE] indicated Resident 68 had diagnoses including hydrocephalus, non-Alzheimer's dementia, and hypertension. A Basic Interview for Mental Status (BIMS) score of 6 indicated Resident 68 was cognitively impaired and unable to be interviewed. A nurse's note dated 12/28/22 at 10:21 PM indicated Resident 68 was unable to be awakened enough to take his medications. No notes or assessments of urine between 12/28/22 and 1/6/22 were available for review. A nurse's note dated 1/6/22 at 12:18 PM indicated Resident 68's urine was malodorous and contained sediment. The NP was notified, and a dip procedure was ordered with a urinalysis and culture and sensitivity to follow if dip results were positive. A nurse's note dated 1/7/22 at 4:07 AM indicated urine was collected for urinalysis. The urine was described as brownish yellow, cloudy, and malodorous. A lab report dated 1/7/22 indicated Resident 68's urinalysis had many abnormal findings, including protein detected, positive nitrite results and 4+ (many) bacteria. The report indicated the urine had been sent to microbiology for culture. A facility policy titled Procedure: Catheter Care, Urinary, last revised 12/2017 indicated caregivers should observe for signs of a urinary tract infection and report them immediately to the physician. 3.1-41 (a)(1)

Based on observation, interview, and record review, the facility failed to ensure safe medication storage for 1 of 1 resident reviewed. (Resident 11). Findings include: During an observation on 1/3/23 at 9:52 AM, Resident 11 was observed lying in bed with her head elevated. A bottle of Refresh tears (eye drops) was observed on Resident 11's overbed table within her reach. A bottle of elderberry gummy supplements was also observed within Resident 11's reach on top of the bedside table. During an observation on 1/3/23 at 2:18 PM, the bottle of Refresh tears and elderberry gummy supplements remained in the same places as observed that morning. During an observation on 1/4/23 at 1:45 PM, Resident 11 was positioned in her wheelchair with her overbed table positioned in front of her. The bottle of Refresh tears was placed on the overbed table in front of Resident 11. The bottle of elderberry gummy supplements was observed sitting on Resident 11's bedside table. During an interview conducted on 1/4/23 at 2:03 PM, Registered Nurse (RN) 2 indicated self-administration assessments should be done to determine appropriateness of any bedside medications. She also indicated any medications deemed appropriate for self-administration must be kept in a locked box and should not be accessible to other residents. During an observation of Resident 11's room with RN 2, she indicated the eye drops and elderberry supplements should not be at the bedside. During an interview conducted on 1/4/23 at 2:26 PM with the Director of Nursing (DON), the DON indicated Resident 11 was not able to correctly self-administer or keep medications at her bedside. During a record review on 1/4/23 at 1:50 PM, a Minimum Data Set (MDS) dated [DATE] indicated Resident 11 had diagnoses including myasthenia gravis, diabetes mellitus, and hypothyroidism. The MDS included a Basic Interview for Mental Status (BIMS) score of 10, indicating Resident 11 was cognitively impaired. A Medication Self-Administration Evaluation dated 11/10/22 indicated Resident 11 was unable to state the proper dosage of medications. The evaluation also indicated Resident 11 was unable to demonstrate secure storage of medication kept in her room. The evaluation deemed Resident 11 unable to safely self-administer medication. A current physician's order for the elderberry gummy supplement was not available for review. A facility policy titled Self-Administration of Medications, last revised 12/2017, indicated if the nurse and physician determined the resident cannot safely self-administer medications, the nursing staff will administer the medications. The policy also indicated self-administered medications must be stored in a safe and secure place. 3.1-25 (m)

Based on observation, interview, and record review, the facility failed to prevent abuse for 1 of 4 residents reviewed for abuse (Resident B). Applying the reasonable person concept, emotional distress and possible fear could occur after physical abuse from staff member. Findings include: On 8/22/22 at 12:42 P.M., Resident B's record was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He resided on the secured memory care unit. MDS (Minimum Data Set) assessments, dated 11/2/21, 1/25/22, and 4/26/22, indicated the resident had severely impaired cognition and mood indicators of depression which were as follows: -Annual MDS 11/2/21-Mood indicators were feeling down (1 day), trouble sleeping, and little energy (2-6 days). He had no behaviors. -Quarterly MDS, dated [DATE] and 4/26/22, indicated his mood had worsened with mood indicators of feeling down (1 day), tired/little energy (7-11 days), poor appetite (2-6 days), and trouble concentrating (7-11) days with no behaviors. Care plans were: -Mood disorder: The goal was for the resident to not experience any increase in his behavioral episodes. Interventions included: monitor changes in his mood and record/monitor patterns of anxiety; determine source of his anxiety and precipitating events; and provide him with reassurance and support. -Anxiety: The goal was for the resident to accept reassurance from staff during episodes of anxiety. Interventions included: approach him warmly and positively at all times; convey acceptance of him; provide opportunities for him to vent his feelings and listen in a non-judgmental manner. -Depression: The goal was the resident would not experience an increase in his depressive symptoms. Interventions were: allow resident to select seating at activities, in the dining room and provide opportunities for increased socialization with others on the unit. -Difficulty finding room and may at times enter others rooms in attempt to find his room: The goal was the resident would be able to find his room by looking at his name plate or sign on his door. Interventions were to give verbal cues/reminders when he was unable to find his room; place familiar items in his room; redirect him when he enters another residents room; approach him positively and with warmth when redirecting him. An Indiana Department of Health report, dated 8/11/22 at 6:01 p.m., indicated a staff member had witnessed CNA 2 (Certified Nurse Assistant) push the resident against a wall. The resident was not found to have any injuries. CNA 2 was suspended pending investigation. A follow up report, dated 8/15/22, indicated the facility's investigation hadn't substantiated the allegation of abuse by CNA 2 who remained suspended pending further review. The allegation of abuse investigation, completed by the facility, was reviewed on 8/22/22 at 10:56 A.M. The investigation indicated on 8/11/22 at 5:50 p.m., Resident B was observed walking in the hallway past his room toward another resident's room. CNA 4 observed this and tried to re-direct him back to the living area. He turned back towards the living area with the CNA. CNA 2 then came down the hallway, yelled and stood in front of the resident which caused him to be agitated. He raised his arms to walk past when CNA 2 pushed him against the wall. He tried to kick CNA 2 while he was against the wall and she grabbed his leg which caused him to fall against the wall a 2nd time. LPN 7 (Licensed Practical Nurse) approached and observed CNA 2 holding the residents wrists with her hands as she told him that he was not going to the end of the hallway to enter another residents room. He raised his right arm in the air and made a fist while the CNA continued to hold his wrist. The nurse intervened and began talking with the resident to distract him. She told the CNAs to walk away and she would care for him. The nurse walked and talked with the resident who said Those girls were trying to jump me. He was assisted to the lounge where he sat and watched television. A psychiatric progress note, dated 8/12/22 at unknown time, indicated Resident B had been visited due to allegations of abuse against the resident. The psychiatric NP (Nurse Practitioner) indicated during the visit, Resident B was seen in the dining area. He had been awake and alert and sitting in a chair. He was calm and not agitated. He denied depression and anxiety but was angry when he stated I've had this deal for about 3 days. He was not able to express what he was speaking about and appeared in distress. He was unable to recall the recent incident. Staff were to continue to assess for changes in his mood and behaviors, provide support to the resident, and encourage social activities. On 8/22/22 at 10:12 A.M., the Administrator, DON (Director of Nursing) and ADON (Assistant Director of Nursing) were interviewed. They indicated CNA 2 had been terminated and no longer worked at the facility. During CNA 2's employment, there were other unsubstantiated allegations of abuse following the facility's investigations and she had been allowed to remain working in the secured memory care unit with dementia residents. The facility's corporate staff had made the decision to terminate the CNA's employment following the latest abuse allegation. On 8/22/22 at 3:30 P.M., CNA 4 was interviewed. She indicated Resident B would often try and go into another's resident room whose room was a few doors down from his. Staff were to intervene and redirect this behavior. She had not ever seen the resident agitated and angry before and he was usually able to be redirected when wandering. When asked, she indicated the resident was initially cooperative and was walking back with her away from the other resident's room and towards the living area. He became agitated when CNA 2 yelled at him and came and stood in front of him. He tried to walk past CNA 2 when the she pushed him against the wall. The resident then tried to kick CNA 2 while he was against the wall and she grabbed his leg which made him fall back into the wall a second time. The nurse came down the hall and starting talking with the resident to calm him down. She and CNA 2 were told to walk away and the nurse would take care of him. She indicated she had never witnessed CNA 2 push a resident before although she'd overheard CNA 2 talking loudly and firmly with residents. On 8/23/22 at 11:25 A.M., LPN 7 was interviewed. She indicated she had heard something going on in the hallway and had overheard CNA 2 trying to redirect Resident B. When she went to where they were standing in the hallway, she saw CNA 2 holding both of the residents wrists. He then raised one of his hands and made a fist while the CNA continued to hold his wrists and told the resident that he wasn't going down to another residents room. She intervened and told CNA 2 and CNA 4 to walk away and she would walk with the resident. The 2 CNAs turned to walk away when CNA 2 turned back and told the resident that he was not going down to the other resident's room. She then repeated for the CNAs to walk away. She walked with the resident towards the lounge while he told her that those girls had been trying to jump him. She reassured him and he sat in the lounge and watched television. She reported the incident to the DON and CNA 2 left the facility as her shift had ended. The facility's current policy, titled Abuse Prevention, provided on 8/22/22 at 10:29 A.M., stated the following: All residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation This Federal tag relates to Complaints IN 787 and IN 890. 3.1-27(a)(b)

Based on observation, interview, and record review, the facility failed to perform a comprehensive assessment, obtain physician order, and consent of the residents legal representative prior to placement of a resident on a locked dementia unit, affecting 1 of 1 residents reviewed (Resident X). This deficient practice resulted in involuntary seclusion for one resident. (Resident X) The Immediate Jeopardy began on 12/1/17 at 7:45 P.M. when the resident was placed onto the locked dementia unit without a comprehensive assessment, physician order, and consent of the resident's legal representative. The Administrator and Director of Nursing were notified of the Immediate Jeopardy at 4:47 P.M. on 12/4/17. The Immediate Jeopardy was removed on 12/7/17, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: On 12/4/17 at 11:58 A.M., Resident X's record was reviewed. [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment, dated 11/14/17, indicated Resident X had a BIMS (Brief Interview Mental Status) score of 13 which signified the resident was not cognitively impaired. The MDS indicated the resident was non ambulatory and required the use of a wheelchair (w/c) and extensive assistance of 1 staff member for locomotion. A Plan of Care, with a problem onset date of 10/7/16, indicated Resident X demonstrated short and long term memory impairment but could make routine daily decisions and was dependent on her POA (Power of Attorney) for major life decisions and finances. On 12/4/17 at 10:18 A.M., during the initial tour, Resident X was observed sitting in a high back w/c in the dining room of the locked memory care unit. The resident had her back away from the rest of the dining room and was facing the wall where music played from a radio. She was observed holding a stuffed dog and was wiping her glasses with her sweater. There was no activity programming in progress on the unit. Resident X indicated she was waiting to move to a new apartment in Fort Wayne and was ready to leave. A census report, provided by the Memory Care Unit Director, on 12/3/17 at 10:20 A.M., did not list Resident X as residing on the Memory Care Unit. The census report indicated the resident's room was located on another unit of the facility that was not locked. The census report also indicated there was not a female bed open on the secured unit. On 12/4/17 at 10:21 A.M., CNA (Certified Nurse Assistant) 2 was interviewed. During the interview, CNA 2 indicated Resident X did not have a room or bed on the locked unit but had been brought to the locked unit on 12/1/17. CNA 2 indicated the resident had been sleeping at night in a recliner chair located in the locked unit's living room area. On 12/4/17 at 10:23 A.M., the locked unit's living room area was observed to have several recliner chairs present. There were no call light cords or emergency call devices located on or near the recliner chairs and living room area. A review of Behavior tracking for November, and December 2017 did not indicate Resident X had been monitored for exit seeking behavior. On 12/4/17 at 11:58 P.M., Nurse notes for Resident X were reviewed and indicated the following: 11/29/17 at 11:29 A.M., the resident was noted to have more frequent confusion/hallucinations and a new order was obtained for a psychiatric consultation. 11/29/17 at 11:57 A.M., the order for a psychiatric consultation was discontinued due to the resident already being seen for psychiatric services and would be visited on 11/30/17 by the psychiatric nurse practitioner. Resident X's chart did not indicate the resident had been visited by the psychiatric nurse practitioner on 11/30/17. 12/1/17 at 1:15 P.M., Resident X was sitting at the back exit door of unit insisting that she is going outside. The resident was informed that it would not be safe for her to go outside by herself and the weather was too cold. Resident continued to sit by the exit door and attempted elopement throughout the afternoon. At 4:23 pm resident attempted going out the exit door and when staff intervened resident began screaming, kicking, and attempted to hit writer. Social service staff was contacted and stated that unit staff will need to watch resident closely or resident may be sent to the ER for evaluation. 12/1/17 at 7:45 P.M., the Director of Nursing documented that Resident X continued to make attempts to exit the facility unattended. The resident believed police were coming to pick her up and take her to a hotel. When staff attempted to redirect the resident, the resident pulled the fire alarm. The resident was moved to our locked dementia unit for the time for her safety. Once on the locked unit, the resident calmed down and has not exhibited further behaviors. The nurse note indicated this behavior was new for the resident and that Dr. (physician) was notified of this behavior and was in this evening to evaluate her. Family have been notified. There were no other interventions attempted prior to placing Resident X on the secured unit. 12/1/17 at 10:34 P.M., indicated the resident continued to exit seek throughout shift and refused care. The resident would not eat, continually tried to go out the doors, and was angry and combative. The resident was placed on F unit (locked memory care unit) where she would spend her days but would return to her room at night to sleep until a bed was available on the locked unit. Dr. (physician) aware of residents behaviors as was on F unit doing rounds. 12/1/17 at 10:38 P.M. indicated the resident remained on F unit at this time r/t (related to) behaviors. 12/2/17 at 3:56 A.M., the resident remained on F unit at this time. 12/2/17 at 6:15 A.M., Res. (resident) is still in F unit at this time. Staff there stated she did well during the night. No behaviors to speak of. 12/2/17 at 2:09 P.M., indicated the resident remained on the locked unit. The resident stated I'm leaving and going to an apartment. 12/2/17 at 8:42 P.M. indicated Resident was still on the locked unit. The resident was agitated and thought the police were outside. The resident indicated she wanted to go home and I can't sleep here because I don't have a bed. There were no further nurse notes completed after 12/2/17 at 8:42 P.M. A Plan of Care, reviewed on 12/4/17 at 11:58 A.M. and 1:15 P.M., did not indicate Resident X was at risk for elopement and there was no care plan that addressed elopement. A review of the record did not indicate an elopement assessment had been completed. On 12/4/17 at 2:03 P.M., CNA 4 was interviewed. During the interview, CNA 4 indicated she usually cared for Resident X. CNA 4 indicated on Saturday 12/2/17 and Sunday 12/3/17 she had worked the evening shift. CNA 4 indicated Resident X slept overnight on the locked memory care unit and that the resident's clothing was taken from her room over to the locked memory care unit for staff to assist her with changing her clothes. On 12/4/17 at 2:06 P.M., the DON (Director of Nursing) was interviewed. During the interview, she indicated Resident X had been placed on the locked unit due to the resident's exit seeking behaviors. The DON indicated the residents physician was made aware of the resident's exit seeking on the evening of 12/1/17 when the physician was in to visit residents on the locked memory care unit. The DON indicated the physician had ordered some lab work to be done, at that time, due to the resident's increased confusion and delusions. The DON was not able to locate a physician progress notes [REDACTED]. Physician orders, dated 12/4/17 at 11:30 A.M., were for Resident X to have labs done for increased confusion/delusions. On 12/4/17 at 2:13 P.M., LPN (Licensed Practical Nurse) 6 was interviewed. During the interview, she indicated she was the nurse assigned to the hall where Resident X's room was located. LPN 6 indicated she had taken Resident X to the locked memory care unit this morning due to her behaviors. On 12/4/17 at 3:34 P.M., the POA (Power of Attorney) for Resident X was interviewed. During the interview, the POA indicated she had not been notified the resident had attempted to leave the facility unattended nor had she been notified that the resident had been placed onto the locked memory care unit. On 12/4/17 at 4:05 P.M., the ADON (Assistant Director of Nursing) was interviewed. During the interview, the ADON indicated the facility did not have a policy for admitting or including residents on the locked memory care unit. She indicated the facility used only two criteria to determine if a resident was appropriate for the locked memory care unit which was a [DIAGNOSES REDACTED]. On 12/4/17 at 4:41 P.M., the Director of Nursing was interviewed and provided a plan of care dated 12/1/2017. The plan of care indicated Resident X was at risk for elopement and wears a wanderguard (alarm that temporarily locks an outside door and sounds an alarm to staff that a resident is attempting to leave the building unattended). Interventions included, but were not limited to, apply wanderguard bracelet on resident's wheelchair and resident to participate in day program on secured unit. During the interview, the Director of Nursing indicated the elopement plan of care was dated 12/1/17 but was written and implemented today, 12/4/17. The Immediate Jeopardy that began on 12/1/17 was removed on 12/7/17 when the facility completed resident assessment on the locked memory care unit for appropriate placement and re-educated staff on involuntary seclusion, but the noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy because all employees had not been inserviced. This Federal tag relates to Complaint IN 141. 3.1-27(a)(4)

Based on observation, record review, and interviews, the facility failed to ensure one resident received timely treatment after a pressure ulcer developed in order to promote healing and prevent infection for 1 of 1 residents reviewed for pressure ulcers (Resident #76). Findings include: The record for Resident #76 was reviewed on 3/7/2014 at 9:15 a.m. and indicated the resident was admitted on [DATE]. [DIAGNOSES REDACTED]. Review of Departmental nursing notes, indicated the following: 12/17/13 Admission assessment completed and indicated an "abraised area on left buttocks 7 cm.(centimeters) by 2.1 cm." The note also indicated the resident was being treated with Mepiflex(a foam dressing for wounds). 12/23/13 Notes indicated an abraised area on the left buttocks covered with Mepiflex dressing. The note indicated the resident had limited range of motion of the bilateral upper extremities due to pain in the bilateral shoulders, and limited range of motion of the left lower extremities due to a fracture. Also the resident was non-weight bearing to the left lower extremity, required extensive assistance to transfer from one surface to another, was able to guide bilateral lower extremities to the edge of the bed but not over the edge of the bed, and was not able to assist to pull his upper torso to the upright position. The note further indicated the resident was dependent for bathing, grooming, and dressing and was not able to feed himself breakfast due to pain in the bilateral shoulders. 12/23/13 A dietary note, electronically signed by the Dietician, indicated the resident was on a No added salt diet, 1200 cubic centimeters (cc) fluid restriction daily, required some assistance with his meals, and also indicated the resident had an abrasion to the left buttock, and it was being treated by nursing. 1/2/14 The note indicated the abraised area to the buttocks was dry, with no signs of infection, and measured 3 cm. by 1.8 cm., and Mepiflex continued. 1/9/14 A wound assessment report, dated 1/9/14, and electronically signed by RN #5, indicated the abrasion to the left buttock had improved, had scant serosanguinous drainage, no signs of infection, and measured 2.80 cm. by 2.00 cm., with no depth. 1/12/14 A note, electronically signed by LPN #6 indicated the old dressing was removed from the left buttock, the wound bed was soft black eschar (necrotic tissue) with yellow slough (dead cells which had accumulated in the fluid of the wound) in the center, the peri wound was pink, and a new dressing was applied. The note indicated the resident was encouraged when in bed to allow staff to reposition him from his back. There was no documentation the physician was notified regarding the worsening condition of the wound. The next entry regarding the wound was documented on 1/16/14 at 1:53 a.m., and indicated the area to the left buttocks measured 3.5 cm. by 3 cm. by 0.1 cm. The area had a moderate amount of serous drainage, a foul odor, and slough to the upper wound. A new dressing was applied, and the resident was encouraged to lay on his side. The resident indicated he could not lay on his side for long due to his shoulders. Another departmental nursing note, dated 1/16/14, at 1:23 p.m., indicated per the wound team, the Stage 3 wound area was to be washed with wound wash, Santyl applied to the slough, then Zeroform, and a dry dressing applied. Also the note indicated the physician was notified . A fax to the physician, dated 1/16/14, indicated the resident was admitted with an abrasion to the left buttocks. This past week, it had a significant change, increased in size, had a foul odor, and a moderate amount of serous drainage. The note indicated a foam dressing was being used, the resident had a poor appetite, and did not like to lay on his sides. New orders on the fax indicated a low pressure mattress was ordered. Another fax to the physician, dated 1/16/14, indicated the physician approved the wound care teams treatment for [REDACTED]. 1/17/14 a nursing note indicated the low pressure mattress was to be delivered today. 1/20/14 The wound dressing was changed, and a wound care team member was present. The stage 3 wound measured 3.0 by 1.5 by 0.6 centimeters, with a blanchable peri wound bed, small amount of slough removed from the wound, and the area under the wound was dark red in color. Santyl was applied to the wound, safegel applied , and the area was packed with aqua cell and a foam dressing was applied. A sacral dressing was applied to help prevent further breakdown. The note further indicated therapy had placed a roho cushion in the wheelchair, and the resident was currently on a low pressure mattress. Also it was recommended the dressing be changed every other day and with any soiling. 1/23/14 Stage 3 wound measured 4.0 by 2.0 by 0.5 centimeters, was blanchable peri wound bed, and the middle of wound dark red in color. The note further indicated the physician was updated weekly. The most recent departmental nursing note, dated 3/6/14, indicated a healing Stage 3 pressure area which measured 1.8 cm. by 0.5 cm., by 0.1 cm. Resident #76 was interviewed, at 10:00 a.m., on 3/7//14, and indicated he was going to [MEDICAL TREATMENT] three times a week, and was currently on a regular diet with no fluid restrictions and was doing well. He indicated both of his shoulders were "bad" and he received pain medication for the pain in his shoulders. He indicated he was admitted to the facility because he had a [MEDICAL CONDITION] so also had some pain in his hip and had received therapy for the [MEDICAL CONDITION], and was currently in restorative therapy. A care plan, dated 12/30/13, indicated the resident was at risk for impaired skin integrity due to decreased bed mobility and overall low Braden score. Approaches included, but were not limited to: Daily skin inspection, report any changes in skin or signs of possible skin breakdown or redness; Encourage/assist to turn at least every 2 hours when in bed; pressure reducing mattress on bed, and a pressure reducing pad in the wheelchair; Nutritional support based on assessment and physician orders, and a lift sheet/slip sheet was to be used to reposition to decrease friction and shear. Another care plan, dated 1/16/14, indicated the resident had a stage 3 pressure area to the left buttock, and the Braden assessment score indicated the resident was at risk for pressure sores. Additional interventions included, but were not limited to: Monitor daily Treatment as ordered Measure weekly Turn and reposition every 2 hours and as needed Air flow mattress Cushion in wheelchair and magic cup. Physician orders,dated 1/17/14, also indicated the resident was on a regular diet, Pro-mod 1 scoop twice a day, and a magic cup was ordered daily. Resident #76's pressure area was observed, with RN#5 present, at 9:17 a.m., on 3/10/14. A dressing, dated 3/10/14, was partially removed by RN#5 and a pressure area, was observed on the upper left buttocks, approximately 2 cm. by .5 cm., with little depth, and no drainage. The DNS, RN#5, and RN#4 were Interviewed, at 10:37 a.m., on 3/10/14, regarding the pressure area. RN#4 indicated she worked on the rehab unit, and the resident was originally admitted to the rehab unit, due to a [MEDICAL CONDITION], was receiving Physical therapy, but was not very compliant. She indicated he was admitted with an abrasion to the left buttocks which he had incurred due to a fall at [MEDICAL TREATMENT], prior to admission. She indicated at first the resident was transferring with an assist of 2-3 staff members, but then started using a sling lift because he could not stand to bear weight. She indicated at one of the morning staff meetings, they discussed his progress and determined he needed to be moved to a long term care unit where more care could be provided. She indicated he was moved on 12/23/13. The DNS indicated when LPN #6 assessed the wound on 1/12/14, and the wound contained black eschar and yellow slough, the LPN should have contacted the physician due to the worsening condition of the wound. The DNS indicated she was not aware of this change in the wound until 1/16/14, and had not spoken to LPN#6 regarding this wound. The DNS indicated there were 3 certified wound nurses in the building, but they didn't get involved unless there was a question about a skin condition, or if there was a pressure sore. She indicated the wound nurses should have been involved for Resident #76 on 1/12/14, when the wound worsened. The DNS indicated a low pressure air mattress was ordered on [DATE], and prior to the air mattress, the resident had a pressure redistributing (reducing) mattress. The DNS indicated prior to getting the low pressure air mattress, it was more difficult for the resident to turn due to pain in his shoulders, but with the low pressure air mattress, it was easier for him to turn. The policy for Pressure Ulcer Treatment, dated 11/11/10, and provided by the DNS, at 1:50 p.m., on 3/10/14, was reviewed at 2:15 p.m., on 3/10/14. The policy indicated residents with pressure ulcers would have appropriate assessment, intervention and evaluation of treatment implemented. Physicians would be notified of all pressure ulcers. 3.1-40(a)(1) 3.1-40(a)(2)