Every finding on record at Brickyard Healthcare - Elkhart Care Center

Based on observation, interview and record review, the facility failed to ensure hot coffee was served at a safe temperature for 1 of 3 residents reviewed for accidents, resulting in a resident sustaining skin burns when coffee was spilled on her lap, (Resident B). This deficient practice had the potential to affect 112 of 112 residents who could choose to receive daily hot coffee from the facility kitchen.Findings include:On 4/29/26 at 9:56 A.M., Resident B's clinical record was reviewed. The resident was admitted to the facility with diagnoses that included but were not limited to metabolic encephalopathy and vascular dementia.Resident B's most recent comprehensive annual Minimum Data Set, (MDS) Assessment, completed on 3/17/26, indicated the resident had severe cognitive impairment and required supervision for eating.A review of the resident's Nursing Progress Notes included the following: On 3/19/26 at 5:30 P.M., a Certified Nursing Assistant brought Resident B back from the dining room and indicated the resident had spilt coffee in her lap. The resident was noted to have redness with fluid filled blisters to her groin and bilat thigh areas and complained of mild discomfort. The Nursing Progress Note indicated that the resident's responsible party was notified and they had requested the facility send Resident B to the local emergency room (ER) for treatment and evaluation.Resident B's ER report, dated 3/19/26 at 7:55 P.M., indicated the resident had presented to the local ER for a burn obtained when the resident was drinking coffee and had spilt it onto her lap. She had sustained partial burns with blistering to the left thigh. The burn was cleansed and antibiotic ointment was applied. The differential diagnoses included but were not limited to: superficial burn, partial-thickness burn, and full-thickness burn.A review of the Wound Nurse's documented skin check assessment, dated 3/25/2026 at 2:30 P.M., indicated Resident B had a new wound described as full thickness burn acquired at the facility that measured 8.5 cm long x 4 cm wide to the right thigh. The skin check assessment also indicated another new wound, described as a full thickness burn acquired at the facility, that measured 4 cm long x 3.5 cm wide. The burns to Resident B's bilateral inner upper thighs near the groin region were described as full thickness in that they presented with mild redness and fragile skin surrounding both wounds.A Physician's Progress Note dated 4/6/26, indicated Resident B's physical exam had included abnormal skin with injuries/Bruises were noted and burns to both her right and left inner thighs. The note indicated that the presence of burns to the bilateral inner thighs required ongoing skin surveillance to prevent secondary complications and delayed healing.Resident B's physician's orders, related to the treatment and care of the resident's burns, included but were not limited to;Silvadene External Cream 1 % to apply to groin and bilateral upper thighs, dated 3/19/26 through 3/20/26.Silvadene External Cream 1 % to apply to groin and bilat upper thighs, 3/20/2026 through 3/25/26.Gently cleanse wound to right inner thigh with normal saline, pat dry, apply a thin even layer of Thera honey Gel to slough on wound bed, then place calcium alginate with silver. Apply Skin prep surrounding skin. Cover with 6x6 silicone super absorbent dressing. Change daily and as needed if soiled, dated 3/26/26 through 3/27/26.Gently cleanse wound to left inner thigh with normal saline, pat dry, apply a thin even layer of Thera honey Gel to slough on wound bed, then place calcium alginate with silver. Apply Skin prep surrounding skin. Cover with 6x6 silicone super absorbent dressing. Change daily and as needed if soiled, dated 3/26/26 through 3/27/26.Gently cleanse wound to right inner thigh with normal saline, pat dry, apply a hydrogel honey sheet to slough, cover with 6x6 Silicone bordered gauze dressing, change daily and as needed if soiled dated 3/28/26 with no end date.Gently cleanse wound to left inner thigh with normal saline, pat dry, apply a hydrogel honey sheet to slough, cover with 6x6 Silicone bordered gauze dressing, change daily and as needed if soiled dated 3/28/26 with no end date.On 4/29/26 at 11:40 A.M., the Dietary Manager provided the Coffee/Hot Water Temperature monthly logs from 1/1/26 to 4/29/26. The coffee temperatures were recorded at 195 F every breakfast, lunch, and dinner in the logs provided. The Coffee/Hot Water Temperature log form indicated to maintain coffee temperature at 150 F to 160 F.On 4/29/26 at 12:30 P.M., during meal service, the coffee maker in the kitchen was observed to be a BUNN PN53200.0101 Twin SST Tall. The LCD display window indicated, Ready to brew temp: 195 F. During an interview on 4/29/26 at 12:25 P.M., the Dietary Manager indicated it was Dietary Aide 3's responsibility to manually check the temperature of the coffee after it was brewed and before it was served to the residents with a temperature probe. The Dietary Manager indicated Dietary Aide 3 indicated she had not manually checked the coffee temperatures but instead had recorded the LCD display temperature on the coffee maker as the current coffee temperature. The Dietary Manager indicated she was aware the coffee temperatures documented had been too hot but was never directed to adjust or check the maintenance of the coffee maker. The Dietary Manager indicated the coffee temperatures had obviously not been checked with a temperature probe because it was not reasonable to expect that the coffee temperature would have been 195 F every time they were documented as checked since 1/1/26. The Dietary Manager indicated there was no way to know what the actual coffee temperature had been since 1/1/26 and that coffee should have been served between 150 F and 160 F.On 5/1/26 at 8:30 A.M., the Administrator provided the policy titled, Hot Liquid Safety, dated 2022, and indicated it was the current facility policy. The policy indicated, .Hot liquids are to be served at proper (safe and appetizing) temperatures using appropriate safety precautions.'Proper (safe and appetizing)temperature' means both appetizing to the resident and minimizing the risk for scalding and burns.'Scalding' is a burn caused by spills.and hot beverages.Regulate temperature of hot liquids to which residents have direct access.Literature reference: https://pubmed.ncbi.nlm.nih.gov/18226454/ .Hot beverages such as tea, hot chocolate, and coffee are frequently served at temperatures between 160 degrees F (71.1 degrees C) and 185 degrees F (85 degrees C). Brief exposures to liquids in this temperature range can cause significant scald burns.The preferred drinking temperature of coffee is specified in the literature as 140+/-15 degrees F. Literature reference: https://pubmed.ncbi.nlm.nih.gov/31294834/ Hot beverages are served ubiquitously in the food-service industry as well as at residences and other venues. Coffee and tea beverages, in particular, are brewed at temperatures that are sufficiently high to cause immediate and serious risk for scald injuries. On the other hand, numerous research studies have been performed to identify the preferred consumption temperatures for hot beverages. The outcome of these mutually reinforcing studies is that the preferred drinking temperatures are significantly below the often-encountered brewing temperatures ( 200 F). Consequently, there is great need to distinguish brewing temperatures from serving temperatures. Serving consumers beverages at very high temperatures is not only unnecessary (from a preference standpoint) but also unsafe. An appropriate range for service temperatures is (130 to 160 F). PRACTICAL APPLICATION: Often times, hot beverages are served at temperatures near their brewing temperature; far hotter than preferred by consumers. This practice creates unnecessary risk to the consumer. A more rationale recommended range of service temperatures is 130 to 160 F. This recommendation balances a range of consumer preferences and safety.This citation relates to Complaint 2977527.410 IAC (Indiana Administrative Code)16.2-3.1-45(a)(1).

Based on record review and interview, the facility failed to ensure an unusual occurrence was reported to the State Agency, when 1 of 3 residents reviewed for accidents was burned by hot coffee when the resident spilled the coffee in her lap, (Resident B).Findings include:On 4/29/26 at 9:56 A.M., Resident B's clinical record was reviewed. The resident was admitted to the facility with diagnoses that included, but were not limited to, metabolic encephalopathy and vascular dementia.Resident B's most recent comprehensive Minimum Data Set, (MDS) Assessment, an annual assessment dated [DATE] indicated the resident had severe cognitive impairment and required supervision for eating.A review of the resident's Nursing Progress Notes included the following: On 3/19/26 at 5:30 P.M., a Certified Nursing Assistant brought Resident B back from the dining room and indicated the resident had spilt coffee in her lap. The resident was noted to have redness with fluid filled blisters to the groin and bilat thigh area and had complained of mild discomfort. The Nursing Progress Note indicated that the resident's responsible party was notified and requested the facility send Resident B to the local emergency room (ER) for treatment and evaluation.Resident B's ER report, dated 3/19/26 at 7:55 P.M., indicated the resident had presented to the local ER for a burn obtained when the resident had been drinking coffee and had spilled it onto her lap. She had sustained partial burns with blistering to the left thigh. The burn was cleansed and antibiotic ointment was applied. The differential diagnoses included but were not limited to: superficial burn, partial-thickness burn, and full-thickness burn.A review of the Wound Nurse's documented skin check assessment, dated 3/25/2026 at 2:30 P.M., indicated Resident B had new wounds described as a full thickness burn acquired at the facility that measured 8.5 cm long x 4 cm wide to the right thigh. The skin check assessment also indicated a new wound described as a full thickness burn acquired at the facility that measured 4 cm long x 3.5 cm wide. The burns to bilateral inner upper thighs near the groin region were documented as full thickness in that they presented with mild redness and fragile skin surrounding both wounds.A Physician's Progress Note, dated 4/6/26, indicated Resident B's physical exam included abnormal skin with injuries/Bruises noted and burns to both of her right and left inner thighs. The note indicated the presence of burns to the Resident's bilateral inner thighs required ongoing skin surveillance to prevent secondary complications and delayed healing.Resident B's physician's orders related to the treatment of the burns, included but were not limited to;Silvadene External Cream 1 % to apply to groin and bilateral upper thighs, dated 3/19/26 through 3/20/26.Silvadene External Cream 1 % to apply to groin and bilat upper thighs, 3/20/2026 through 3/25/26.Gently cleanse wound to right inner thigh with normal saline, pat dry, apply a thin even layer of Thera honey Gel to slough on wound bed, then place calcium alginate with silver. Apply Skin prep surrounding skin. Cover with 6x6 silicone super absorbent dressing. Change daily and as needed if soiled, dated 3/26/26 through 3/27/26.Gently cleanse wound to left inner thigh with normal saline, pat dry, apply a thin even layer of Thera honey Gel to slough on wound bed, then place calcium alginate with silver. Apply Skin prep surrounding skin. Cover with 6x6 silicone super absorbent dressing. Change daily and as needed if soiled, dated 3/26/26 through 3/27/26.Gently cleanse wound to right inner thigh with normal saline, pat dry, apply a hydrogel honey sheet to slough, cover with 6x6 Silicone bordered gauze dressing, change daily and as needed if soiled dated 3/28/26 with no end date.Gently cleanse wound to left inner thigh with normal saline, pat dry, apply a hydrogel honey sheet to slough, cover with 6x6 Silicone bordered gauze dressing, change daily and as needed if soiled dated 3/28/26 with no end date.On 4/29/26 at 11:40 A.M., the Dietary Manager provided the Coffee/Hot Water Temperature monthly logs from 1/1/26 to 4/29/26. The coffee temperatures were recorded at 195 F every breakfast, lunch, and dinner in the logs provided. The Coffee/Hot Water Temperature log form indicated to maintain coffee temperature at 150 F to 160 F.On 4/29/26 at 12:30 P.M., during meal service, the coffee maker in the kitchen was observed to be a BUNN PN53200.0101 Twin SST Tall. The LCD display window indicated, Ready to brew temp: 195 F. During an interview on 4/29/26 at 12:25 P.M., the Dietary Manager indicated it was Dietary Aide 3's responsibility to manually check the temperature of the coffee after it was brewed and before it was served to the residents with a temperature probe. The Dietary Manager indicated Dietary Aide 3 indicated she had not manually checked the coffee temperatures but instead had recorded the LCD display on the coffee maker as the current coffee temperatures. The Dietary Manager indicated she was aware the coffee temperatures were too hot but had never been directed to adjust or check the maintenance of the coffee maker. The Dietary Manager indicated the coffee temperatures were obviously not checked with a temperature probe because it was not reasonable to expect that the coffee temperature would have been 195 F every time since 1/1/26. The Dietary Manager indicated there was no way to know what the actual coffee temperature had been since 1/1/26 and that the coffee should have been served between 150 F and 160 F.On 5/1/26 at 8:30 A.M., during an interview, the Administrator indicated he did not have a specific policy regarding the reporting or investigating procedures for accidental burns. The Administrator indicated he had not realized he was required to report Resident B's burn to the State Agency since the treatment required only basic first aid. The Administrator indicated that through communication with the facility's corporate consultant, he was made aware that he should have reported Resident B's burn to the State Agency, due to the severity of the burn. The Administrator indicated the facility failed to fully investigate the root cause of the burn, and if a complete investigation had taken place, perhaps the facility would have learned that the hot coffee temperatures in the kitchen had not been manually checked as required. The Administrator indicated the facility followed the Indiana State Department of Health's guidelines for reporting.Review of the Indiana Department of Health's Long-Term Care Abuse and Incident Reporting Policy, with an effective date of 12/8/22 to 9/1/27, indicated, .To facilitate compliance with state and federal law and regulation, as applicable, related to reporting of abuse and incidents in licensed long-term care facilities in Indiana.Alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor, or other health care provider, or others but has not yet been investigation and, if verified, could be noncompliance with the federal requirements.Rules and Regulations Related to Incident Reporting.Types of Incidents Reportable Under Federal and State Rules.Major accidents.Burns greater than first degree.This citation relates to Complaint 2977527.410 IAC (Indiana Administrative Code)16.2-3.1-28(c).

Based on record review and interview, the facility failed to notify a personal representative at the request of the resident of new orders and a change of condition for 1 of 3 residents reviewed for notification of changes. (Resident B)Finding includes:A record review for Resident B was completed on 1/12/2026 at 9:30 A.M. Diagnoses included, but were not limited to: congestive heart failure, chronic kidney disease stage 3, diabetes mellitus type 2 and acute metabolic acidosis.An admission Minimum Data Set (MDS) assessment, dated 11/6/2025, indicated Resident B was cognitively intact. The 11/7/2025 3:28 P.M. Resident preferences evaluation indicated it was very important for the Resident to have their family or a close friend involved in their care.A Social Services note, dated 11/11/2025 at 4:39 P.M. indicated the resident had stated she wanted her granddaughter to be her emergency contact. Although the admission MDS assessment indicated the resident was cognitively intact, nursing progress notes on the following dates and times indicated the resident was exhibiting confusion and her confusion was chronic: 11/13/2025 at 4:09 P.M., 11/15/2025 at 4:11 P.M., 11/18/2025 at 3:37 P.M., 11/22/2025 at 7:18 P.M., 11/23/2025 at 12:41 A.M., 11/30/2025 AT 11:40 P.M. , 12/6/2025 at 7:37 P.M., 12/7/2025 at 6:17 P.M. and 12/21/2025 at 5:00 A.M.A General Nursing Progress Note, on 11/6/2025 at 8:56 A.M., indicated new orders had been obtained from the facility nurse practitioner for labs, melatonin 5 milligrams daily at bedtime and acetaminophen 325 milligrams two tablets daily at bedtime. Resident B's personal representative had not been notified of the new orders.An Alert Nursing Progress Note, on 11/13/2025 at 9:05 A.M., indicated new orders had been received for acetaminophen 325mg two tablets every six hours as needed for pain, metformin 1000 milligrams twice daily, lispro insulin four units before meals, prednisone 10 milligrams daily for COPD (chronic obstructive pulmonary disease) and Robitussin DM 10 milliliters every six hours for cough. Resident B's personal representative had not been notified of the new orders.A Physician's Note, on 11/25/2025 at 1:26 A.M., indicated Resident B had been seen for an acute visit for dehydration related to an increased laboratory result of a bun urea nitrogen (BUN). The physician ordered two liters of normal saline.An Alert Nursing Progress Note, on 11/25/2025 at 8:46 A.M., indicated new orders had been received for normal saline intravenously for two liters at 157 milliliters per hour related to high Bun results. Resident B's personal representative had not been notified of the new orders.An Alert Nursing Progress Note, on 11/26/2025 at 6:03 P.M., indicated urinalysis results had been received and new order for Macrobid 100 milligrams twice daily for five days related to a urinary tract infection. Resident B's personal representative had not been notified of the new orders.An Alert Nursing Progress Note, on 12/4/2025 at 8:26 A.M., indicated Keflex 500 milligrams every six hours for seven days related to cellulitis of the right leg. Resident B's personal representative had not been notified of the new orders.An Alert Nursing Progress Note, on 12/4/2025 at 6:59 P.M., indicated normal saline per hypodermoclysis 50 milliliters per hour for two liters due to a high BUN laboratory result. Resident B's personal representative had not been notified of the new orders.A General Nursing Progress Note, on 12/15/2025 at 4:39 P.M., indicated a new order for furosemide 40 milligrams daily due to excessive fluid seeping from bilateral lower extremities. Resident B's personal representative had not been notified of the new orders.A General Nursing Progress Note, on 12/16/2025 at 4:54 P.M., indicated new orders had been received for an increase in Lantus insulin to 15 units twice daily. Resident B's personal representative had not been notified of the new orders.A General Nursing Progress Note, on 12/17/2025 at 3:10 P.M., indicated Resident B had complained of chest pain. A new ordered had been obtained for nitroglycerin 0.4 milligrams every two hours as needed for chest pain. An initial dose had been given. Resident B's personal representative had not been notified of the change in condition or the new orders.A General Nursing Progress Note, on 12/17/2025 at 3:37 P.M., indicated a new order for a two-view chest x-ray. Resident B's personal representative had not been notified of the new orders.During an interview, on 1/12/2026 at 2:31 P.M., Resident B's emergency contact indicated she had not been informed of her grandmother's changes of condition nor updated on new orders received by the facility. She indicated her grandmother had periods of confusion and would not understand the orders that had been ordered for her conditions.During an interview, on 1/14/2026 at 9:46 A.M., the Assistant Director of Nursing indicated the family of Resident B should have been updated on any change of condition.A policy was provided, on 1/16/2026 at 11:44 A.M., by the Executive Director. The policy titled, Notification of Change, indicated, .The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician and notifies, consistent with his or her authority, the resident's representative when there I a change requiring notification.Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification.3. Circumstances that require a need to alter treatment. That may include: a. New treatment.Additional considerations: 1. Competent individuals a. The facility must still contact the resident's physician and notify resident representative, if known. B, A family member that wishes to be informed would designate a member to receive calls. C. When a resident is medically competent, such a designated family member should be notified of significant changes in the resident's health status because the resident may not be able to notify them personally, especially in the case of sudden illness or accident.This citation relates to Intake 27044933.1-4(l)(4)(A)(i)

Based on record review and interview, the facility failed to ensure physician's orders regarding blood pressure medications were followed for 1 of 3 residents reviewed for quality of care. (Resident B)Finding includes:A record review for Resident B was completed on 1/12/2026 at 9:30 A.M. Diagnoses included, but were not limited to: congestive heart failure, chronic kidney disease stage 3, diabetes mellitus type 2 and acute metabolic acidosis.An admission Minimum Data Set (MDS) assessment, dated 11/6/2025, indicated Resident B was cognitively intact.A Physician's order, dated 11/5/2025, indicated the resident was to receive metoprolol 25 milligrams twice daily for hypertension. The order indicated the medication was to be held for a systolic blood pressure reading of less than 110 mm/Hg (millimeters of Mercury) or a pulse less than 60 beats per minute.A Medication Administration Record (MAR), for the month of November 2025 indicated the metoprolol medication had been administered on 11/22/2025 even though the resident's blood pressure was 102/42 mm/Hg.A MAR for the month of December 2025 indicated metoprolol had been administered on 12/20/2025 even though the resident's blood pressure was 102/80 mm/Hg. The medication was also administered on 12/21/2025 even though the resident's blood pressure was 104/73 mm/Hg.During an interview, on 1/16/2026 at 11:26 A.M., the Assistant Director of Nursing indicated nursing staff should have followed the physician's orders.A policy, titled, Provisions of Physician Ordered Services, was provided on 1/16/2026 at 11:41 A.M. The policy indicated, .The purpose of this policy is to provide a reliable process for the proper and constituent provision of physician ordered services according to professional standards of quality .This citation relates to Intake 27044933,1-37

Based on interview and record review, the facility failed to ensure a resident was free from verbal abuse, for 1 of 3 residents reviewed for abuse and neglect. (Resident B).Finding includes:On 10/1/25 at 12:16 P.M., Resident B's clinical record was reviewed. Diagnoses included but were not limited to multiple sclerosis, mild cognitive impairment, depression, epilepsy, anxiety, and mood disorder. Review of the resident's most recent Minimum Data Set (MDS), dated [DATE] for a Quarterly Assessment, indicated the resident was mildly cognitively impaired, had demonstrated verbal behaviors directed at others and had other behaviors not directed at others for 1 to 3 days of the assessment 7 day look back period. In addition, the assessment indicated Resident B utilized a motorized wheelchair independently for locomotion and was dependent on others for transferring, toileting, and bathing.A Nursing Progress Note, dated 7/4/25 at 9:00 A.M., indicated CNA 5 had answered Resident B's call light and was then was observed and heard coming out of the resident's room screaming. CNA 5 indicated that Resident B had ran over their foot with her motorized wheelchair, which caused the CNA pain. The Nursing Progress Note indicated Resident B immediately came out of the room in the motorized wheelchair, at a high rate of speed , coming right behind CNA 5. The resident indicated CNA 5 had hit her in her throat and pushed her into her chair. The Nursing Progress Note went on to indicate that a verbal altercation had ensued between CNA 5 and Resident B and multiple staff members had intervened to de-escalate the verbal altercation. Resident B and CNA 5 were immediately separated, and CNA 5 was asked to clock out and leave the facility premises. Resident B was taken back to her room for a full body assessment. Resident B's physical assessment was negative for injuries with no signs of swelling, bruising, or scratches found on her neck or chest though she complained of neck pain. The resident's physician, Administrator, Director of Nursing, and responsible parties were notified about the interaction at the time of the incidentAn Incident Report, completed by the local police department dated 7/4/25 at 1:09 P.M., indicated Case #2025-0704-015 incident dated involved, Battery Person Having Care Against Person with Disability. The report indicated the case was cleared with no prosecution.Review of the Indiana State Department of Health Incident Number 591 report, dated 7/4/25, was submitted by the facility on 7/4/25. The incident report indicated on 7/4/25 at 9:01 A.M., Resident B came out of her room on her power chair and ran over CNA 5's foot with her chair. CNA 5 then raised her voice at Resident B and Resident B alleged that CNA 5 hit her in the front of her neck while attempting to provide care. The resident was assessed immediately with no findings though she complained of discomfort to the front of her neck. All parties were notified. CNA 5 was removed from the facility and suspended pending an investigation, and then terminated for failure to provide customer service to Resident B.On 10/2/25 at 10:00 A.M., the Administrator provided the policy titled Abuse, Neglect and Exploitation, dated 2022, indicating it was the current facility policy. The Policy indicated, .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse.Abuse means the willful infliction of injury.It includes verbal abuse.This citation relates to Intake 26183923.1-27(b)

Based on observation and interview, the facility failed to dispose of expired foods in a timely manner within the main kitchen's walk-in cooler. This deficient practice had the potential to affect 112 of 114 residents who consumed food from the kitchen.Finding includes:During an initial tour of the kitchen, on 8/4/2025 at 9:44 A.M., the following was observed in the walk-in cooler:-A container of corn dated 7/29/2025 with a use by of 7/31/2025-A container of chicken dated 7/3/2025-7 individualized cartons of yogurt in a cardboard box with use by date of 8/1/2025 -A serving bin with ice had 2 outdated yogurts -6 one-half gallon jugs of lime juice with a use by date of 7/14/2025 During an observation and interview on 8/4/2025 at 9:54 A.M. with the Regional Certified Dietary Manager of the walk- in cooler, she indicated the foods should have been disposed within the expiration dates. A policy was provided, on 8/4/2025 at 11:27 A.M., by the Regional Certified Dietary Manager. The policy, titled, Date Marking for Food Safety, indicated, .The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety of food .1. Refrigerated, ready-to-eat, time/temperature control for safety food [i.e. perishable food] shall be held at a temperature of 41 [degrees Fahrenheit] or less for a maximum of 7 days. 2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded .5. The discard day or date may not exceed the manufacturer's use-by-date, or four days, which ever is earliest. The date of opening or preparation counts as day 1. [For example, food prepared on Tuesday shall be discarded on or by Friday]. 6. The Head Cook, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly. 7. The Dietary Manager, or designee, shall spot check refrigerators weekly for compliance, and document accordingly. Corrective action shall be taken as needed 3.1-21(i)(2)

Based on record review and interview, the facility failed to ensure medications were available and administered as ordered (Resident B) and failed to ensure a residents reviewed for medications was assessed for potential adverse side effects. (Resident 13) This deficient practice affected 2 of 7 residents reviewed for medications. (Resident B and 13) Findings include: 1.The closed record for resident B was reviewed on 8/8/2025 at 7:52 A.M. Diagnoses included: diabetes, kidney transplant, epilepsy, atrial fibrillation, gastro esophageal reflux disease and depression. The resident was re-admitted to the facility on [DATE] and was discharged on 6/24/2025. Resident B's May and June medications included the following: Apixaban 5 mg (milligram) 1 tablet twice a day; Glipizide 10 mg 1 tablet every day; Pantoprazole 40 mg 1 tablet twice a day and Pregabalin 50 mg 1 tablet once a day. A Nurse's Progress Note, dated 5/10/2025 at 9:07 P.M. indicated the Apixaban medication was unavailable and was not administered. A Nurse's Progress Note, dated 5/10/2025 at 9:08 P.M., indicated the Pantoprazole medications was unavailable and was not administered. A Nurse's Progress Note, dated 5/10/2025 at 10:02 P.M., indicated the Pregabalin medication was unavailable and was not administered. A Nurse's Progress Note, dated 5/11/2025 at 5:35 A.M , indicated awaiting from pharmacy of the Pregabalin medication and was not administered. A Nurse's Progress Note, dated 5/11/2025 at 1:27 P.M., indicated awaiting from pharmacy of the Pregabalin medication. A Nurse's Progress Note, dated 5/11/2025 at 9:01 P.M., indicated the Pregabalin medication was unavailable and was not administered. A Nurse's Progress Note, dated 5/11/2025 at 9:13 P.M., indicated awaiting from pharmacy of the Pregabalin medication. A Nurse's Progress Note, dated 5/11/2025 at 10:02 P.M., indicated the Pregabalin medication was on order and the nurse was notified. A Nurse's Progress Note, dated 5/16/2025 at 10:20 A.M., indicated the Glipizide medication was not in the cart and was not administered. On 8/11/2025 at 10:24 A.M., the Director of Nursing provided the list of emergency medications that would have been available in the emergency drug storage. The following medications were listed: Eliquis (Apixaban) 5mg tablets; Pantoprazole 40 mg tablets; Pregabalin 50 mg tablets and Glipizide 5 mg tablets. During an interview, on 8/12/2025 at 2:45 PM., the Director of Nursing indicated the medications should have been pulled from the emergency drug supply and administered as ordered. During an interview, on 8/12/2025 at 3:30 P.M., the Director of Nursing indicated she could not provide a policy regarding utilizing the facility's emergency drug supply. 2. A record review was completed for Resident 13 on 8/7/2025 at 2:27 P.M. Diagnoses included, but were not limited to: dementia with agitation, delirium due to known physiological condition and generalized anxiety disorder. A Physician's Order, initiated on 12/12/2024 and discontinued on 12/23/2024 indicated Seroquel (an antipsychotic medication) 100 mg (milligrams), 1.5 tablets by mouth at bedtime was to be administered. A Physician's Order, initiated on 5/13/2025 and discontinued on 6/10/2025 indicated quetiapine fumarate (an antipsychotic medication) 100 mg, one tablet by mouth at bedtime was to be administered. A Physician's Order, initiated on 6/10/2025 and discontinued on 7/6/2025 indicated Seroquel 75 mg give one tablet by mouth at bedtime was to be administered. A Physician's Order, initiated on 7/7/2025 indicated quetiapine fumarate 100 mg give one tablet by mouth at bedtime was to be administered. There was only one Abnormal Involuntary Movement Scale (AIMS) assessment, dated 6/23/2025, completed for Resident 13 in the past 12 months. During an interview, on 8/11/2025 at 8:50 A.M., the DON indicated Resident 13 should have had more than one AIMS assessment in the last 12 months and there was no other documentation Resident 13 had been assessed for adverse side effects related to the use of antipsychotic medications. On 8/8/2025 at 1:09 P.M., the ED provided the policy titled, Use of Psychotropic Medications no date and indicated it was the policy currently being used by the facility. The policy indicated, .13. Residents who receive and antipsychotic medication will have an Abnormal Involuntary Movement Scale (AIMS) test performed on admission, quarterly, or PRN This citation relates to Complaint 1547766 3.1-25(a) 3.1-25(b)(2)

Based on observation, record review and interview, the facility failed to ensure interventions were implemented to prevent contractures for 1 of 3 residents reviewed for range of motion. (Resident 95)Finding includes:During an observation and interview on 8/5/2025 at 11:04 A.M., Resident 95 indicated she had an orthosis for her left hand, but did not know were the orthosis was located in her room. The resident was not wearing any orthosis on her left hand. During observations, on 8/6/2025 at 9:22 A.M., 8/6/2025 at 11:53 A.M., 8/7/2025 at 9:55 A.M., 8/7/2025 at 2:04 P.M., 8/8/2025 at 1:20 P.M. and 8/12/2025 at 9:45 A.M., Resident 95 was lying in bed with her left hand in a fisted position. She did not have an orthosis in place. A record review for Resident 95 was on 8/6/2025 at 11:16 A.M. Diagnoses included, but were not limited to: hemiplegia, lymphedema, diabetes mellitus type 2 and neuromuscular dysfunction of the bladder. A Quarterly Minimum Data Set (MDS) assessment, dated 7/20/2025, indicated Resident 95 was cognitively intact, was dependent for bed mobility and transfers, had range of motion impairment on one side of the body and had received occupational therapy from February 18, 2025 through March 17, 2025. A Physician's Order, dated 3/12/2025, indicated, .Place hand orthosis on in the morning and remove at bedtime An Occupational Therapy Discharge summary, dated [DATE] at 4:11 P.M., included a long term goal of: .Patient will tolerate opponens (opponent muscle])inflate hand orthosis [NAME] (inflatable splint) on discharge from occupational therapy, The notes indicated Resident 95 had been tolerating the [NAME] placements throughout the day with device removed at nighttime. A Nursing Progress Note, on 7/18/2025 at 2:23 P.M., indicated Resident 95 had upper and lower extremity impairment due to hemiplegia and staff assisted her with dressing, grooming, bathing, skin care, toileting/hygiene, transfers, bed mobility, and nutrition/fluid needs. There was no Care Plan addressing the resident's hemiplegia or the use of the orthosis. During an interview, on 8/12/2025 9:48 A.M., CNA 3 indicated Resident 95 had had an orthosis the prior year, but had not worn the orthosis recently. During an interview, on 8/12/2025 at 9:52 A.M., RN 4 indicated Resident 95 wore the orthosis when she was out of bed and in her wheelchair. However, during morning and afternoon observations, Resident 95 was always in her bed. A policy for orthosis use and range of motion was requested on 8/12/2025 at 12:42 P.M. The DON indicated, on 8/12/2025 at 2:44 P.M., a policy was not available for orthosis use or range of motion. 3.1-42(a)(2)

Based on record review and interview, the facility failed to ensure a care plan related to pressure ulcers was initiated timely for 1 of 3 residents reviewed for pressure ulcers. (Resident 7) In addition, the facility failed to ensure a comprehensive plan of care initiated for post traumatic stress disorder had personalized interventions for 1 of 1 residents reviewed .for post traumatic stress disorder (Resident 46) 1.A record review for Resident 7 was completed, on 8/6/2025 at 11:11 A.M. Diagnoses included, but not limited to, cardiac arrest, ischemia of lower extremity resulting in left leg gangrene and amputation, right leg extensive debridement and resulting foot drop, cardiomyopathy, sarcoidosis of the heart, type 2 diabetes, atrial fibrillation and sleep apnea. A weekly skin check, dated 4/23/25, indicated the resident had developed a new, unstageable deep tissue injury, on the right lateral forefoot near the 5th digit. The wound measured 0.4 centimeters wide by 1.6 centimeters deep. On 4/25/2025, the facility physician examined the resident's right foot wound and recommended to continue Betadine treatment. On 4/29/2025, an order was received for ProT Gold twice daily. On 5/7/2025, weekly skin check records indicated the wound measured 0.4 cm wide by 0.7 deep. On 5/19/2025, nursing progress notes indicated the resident had returned from a doctor appointment with new orders to cleanse the right lateral foot wound, stop the Betadine and apply Medihoney and cover with gauze daily. On 5/28/2025, weekly skin check forms indicated the right foot wound measured 1 cm wide by 1.2 cm deep. An order was received, on 5/30/2025, to refer the resident to a wound center. On 6/4/2025, nursing progress notes indicated the referral had been faxed to a local wound clinic, and the facility was waiting on the wound clinic to call back with a scheduled appointment for the resident. On 6/4/2025 an order for fortified foods for nutritional support was entered in the medical record. On 6/11/2025, per the weekly skin check record, the right foot wound measured 0.8 cm wide by 0.9 cm deep. On 6/12/2025, a care plan was created for the right foot wound which included the following interventions: following facility protocols for treatment of injury, monitor and document location, size and treatment of skin injury and providing a pressure relieving/reducing mattress to protect skin while in bed. During an iinterview, on 08/11/2025 8:52 AM, the Director of Nursing indicated a care plan for the right foot wound should have been created when the wound was identified in April. 2. A record review was completed for Resident 46 on 8/8/2025 at 8:55 A.M. Diagnoses included, but were not limited to: post-traumatic stress disorder and behavioral disturbance. A Care Plan, initiated on 5/10/2017 indicated Resident 46 had a diagnosis of personal history of adult physical and sexual abuse, personal history of physical and sexual abuse in childhood, and post traumatic stress disorder that may contribute to behaviors. Interventions included and were limited to: encourage participation from resident who depends on others to make own decisions, if I'm upset, please re-direct the conversation or task as able, offer me step-by-step instructions and give me visual and verbal cues throughout care. Resident 46's care plan lacked person centered interventions. During an interview, on 8/8/2025 at 9:37 A.M., LPN 5 indicated loud noises and overstimulation were triggers for Resident 46's post traumatic stress disorder. She indicated doing one on one time, offering the resident drinks or snacks and taking the resident to a new area were interventions that worked for the resident. She indicated Resident 46's care plan was not person centered and the interventions that helped the resident should have been added to her care plan. On 8/11/2025 at 12:02 P.M., the DON provided the policy titled Comprehensive Care Plans, no date and indicated it was the policy currently being used by the facility. The policy indicated, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All care areas triggered by the MDS will be considered in the developing the plan of care. 3. The comprehensive care plan with describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. 3G. Individualized interventions for trauma survivors that recognizes the interrelation between trauma and symptoms of trauma, as indicated . Trigger-specific interventions will be used to identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the triggers on the resident. 3.1-35 3.1-35(b)(1) 3.1-35(c)(1)

Based on record review and interview, the facility failed to ensure medication orders were followed correctly regarding administering blood pressure medications and insulin and blood glucose assessments for 5 of 7 residents whose medications were reviewed. (Residents 87, 122, 2, 53 and 13) 1. The record for Resident 87 was completed on 8/4/2025 at 11:48 A.M. Diagnoses included, but were not limited to end stage renal disease, orthostatic hypotension, hypertension and aortic valve stenosis. Resident 87's Physician's Order, dated 7/21/2025, indicated to administer Midodrine (medication to treat low blood pressure) 10 milligrams (mg), 1 tablet three times a day for hypotension. The order indicated the following parameter: Do not give if SBP (systolic blood pressure) is greater than 100. The Medication Administration Record (MAR) from July 22- 29, 2025, indicated the following: -on 7/23 at 8:00 A.M., the blood pressure (B/P) was documented as 126/45 mmHg and the medication had been administered. -on 7/23 at 2:00 P.M., the B/P was documented as 126/45 mmHg and the medication had been administered. -on 7/24 at 2:00 P.M., the B/P was documented as 104/61 mmHg and the medication had been administered. -on 7/26 at 8:00 A.M., the B/P was documented as 121/73 mmHg and the medication had been administered -on 7/26 at 10:00 P.M., the B/P was documented as 107/75 mmHg and the medication had been administered. -on 7/27 at 10:00 P.M., the B/P was documented as 133/59 mmHg and the medication had been administered. -on 7/28 at 10:00 P.M., the B/P was documented as 134/63 mmHg and the medication had been administered. A Physician's Order, dated 7/29/2025, indicated Midodrine 5 mg, 1 tablet three times a day for hypotension. The order included the following parameter: Do not give if SBP is greater than 110. The Medication Administration Record (MAR) for July 30 - 31, 2025, indicated the following: -on 7/30 at 2:00 P.M., the B/P was documented as 126/47 mmHg and the medication had been administered. -on 7/30 at 10:00 P.M., the B/P was documented as 102/64 mmHg and the medication had been administered. The MAR for August 2025 indicated the following: -on 8/1 at 10:00 P.M., the B/P was documented as 111/58 mmHg and the medication had been administered. -on 8/2 at 2:00 P.M., the B/P was documented as 108/58 mmHg and the medication had been administered. -on 8/4 at 8:00 A.M., the B/P was documented as 117/55 mmHg and the medication had been administered. -on 8/4 at 2:00 P.M., the B/P was documented as 104/43mmHg and the medication had been administered. -on 8/4 at 10:00 P.M., the B/P was documented as 114/50 mmHg and the medication had been administered. -on 8/5 at 2:00 P.M., the B/P was documented as 124/50 mmHg and the medication had been administered. -on 8/6 at 8:00 A.M., the B/P was documented as 120/51 mmHg and the medication had been administered. During an interview, on 8/8/2025 at 11:54 A.M., the Director of Nursing indicated the medication should have been held on the days the blood pressure was out of the parameters. 2 A record review for Resident 122 was completed on 08/11/2025 at 9:29 A.M . Diagnoses included, but were not limited to: Chronic Obstructive Pulmonary Disease, Type 2 Diabetes , Chronic Kidney Disease stage 3, muscle weakness, history of Pulmonary embolism, Congestive Heart Failure, heart valve disease, and atrial fibrillation. A Physician's order, dated 6/11/2025, indicated Midodrine 2.5 milligrams, 1 tablet by mouth three times a day for low BP (blood pressure) for 2 weeks was to be administered. In addition, the following parameter was ordered: Hold for a systolic BP < (sic) 110* A review of the June Medication Administration Record (MAR) indicated the following: 6/11/25 PM Blood Pressure 104/52 mmHg , Midodrine 2.5 mg administered. 6/12/25 AM Blood Pressure 121/56 mmHg , Midodrine 2.5 mg administered 6/12/25 Noon Blood Pressure 108/60 mmHg , Midodrine 2.5 mg administered 6/13/25 Noon Blood Pressure 102/64 mmHg , Midodrine 2.5 mg administered 6/14/25 AM Blood Pressure 96/53 mmHg , Midodrine 2.5 mg administered 6/14/2025 Noon Blood Pressure 90/51mmHg , Midodrine 2.5 mg administered, 6/14/2026 PM Blood Pressure 89/56 mmHg , Midodrine 2.5 administered 6/15/25 AM Blood Pressure 90/50 mmHg , Midodrine 2.5 administered 6/15/25 Noon Blood Pressure 90/51 mmHg , Midodrine 2.5 administered 6/15/25, PM Blood Pressure 93/58 mmHg , Midodrine 2.5 administered 6/16/25 AM Blood Pressure 109/75 mmHg, Midodrine 2.5 administered 6/16/25 Noon Blood Pressure 98/54 mmHg , Midodrine 2.5 administered 6/16/25 PM Blood Pressure 97/58 mmHg , Midodrine 2.5 administered 6/17/25 AM Blood Pressure 98/60 mmHg , Midodrine 2.5 mg administered 6/17/25 Noon Blood Pressure 96/66 mmHg , Midodrine 2.5 administered 6/18/25 AM Blood Pressure 95/66 mmHg , Midodrine 2.5 mg administered. Resident122 was then discharged to an acute hospital for gastrointestinal bleeding. During an interview, on 08/12/2025 at 9:55 AM, the DON reviewed the June MAR and July MAR for the inconsistency of the midodrine administration due to the incorrect use of the < symbol. The DON agreed that the < sign was wrong and should have been >. The DON indicated the facility did not have a policy regarding the use of symbols in charting. 3. A record review for Resident 2 was completed on 8/7/2025 at 10:33 A.M. Diagnoses included, but were not limited to: diabetes mellitus type 2, borderline intellectual functioning and schizophrenia. A Quarterly Minimum Data Set (MDS) assessment, dated 5/29/2025, indicated Resident 2 had moderate cognitive impairment and received insulin injections. A current Care Plan, initiated on 3/21/2025, indicated Resident 2 had diabetes mellitus and was at risk for complications. Interventions included, but were not limited to: to give diabetes medications as ordered by the physician and monitor/document/report PRN (as needed) any signs/symptoms of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing (a deep, labored and sometimes gasping type of breathing associated with metabolic acidosis), acetone breath (smells fruity), stupor or coma A Physician's Order, dated 5/14/2025, indicated the resident was to receive Lispro Injection Solution (short acting insulin) 100 units per milliliters (unit/ml) inject 10 units subcutaneously before meals for hyperglycemia. A Physician's Order, dated 7/13/2025, indicated the resident was to receive Glargine Subcutaneous Solution (long acting insulin) 100 unit/ml inject 20 units one time a day for diabetes mellitus type 2. A blood glucose assessment, obtained, on 7/14/2025 at 5:20 P.M. had a result of 563 mg/dL (milligrams per deciliter) and was reported to the on-call Physician's Assistant. A Physician's Assistant Triage Note, dated 7/14/2025 at 5:42 P.M., indicated the facility was to give 16 units of Lispro Injection Solution, ensure the Resident 2 ate dinner, push oral fluids and recheck the resident's blood sugar in 1 hour and if the blood sugar was greater than 450 mg/dL , they were to call for additional instructions. However, review of the clinical record for Resident 2 indicated there was no documentation that the newly ordered amount of Lispro Injection Solution had been given, on 7/14/2025 or that the blood sugar had been rechecked an hour after the insulin was given. During an interview, on 8/12/2025 at 11:35 A.M., the Director of Nursing (DON) indicated there was no documentation the orders given by the Physician Assistant, on 7/14/2025 in regards to a one time dose of Lispro insulin, pushing fluids or rechecking the resident's blood sugar after an hour had been followed. The DON indicated, on 8/12/2025 at 11:53 A.M., that the nurse on duty on 7/14/2025 indicated she had not documented the orders as having been completed. A policy for following physician orders was requested on 8/12/2025 at 12:42 P.M. The DON indicated, on 8/12/2025 at 2:44 P.M., a policy was not available for following physician orders. 4. A record review was completed for Resident 53 on 8/6/2025 at 11:16 A.M. Diagnoses included, but were not limited to: hypertension and hypotension. An admission Minimum Data Set (MDS), dated [DATE] indicated Resident 53's cognition was severely impaired. A Physician's Order, dated 6/6/2025 indicated to give Propranolol hydrochloride 10mg (milligrams) one tablet by mouth three times a day for hypertension. Additional instructions included were to Hold Propranolol hydrochloride if systolic blood pressure was less than 110 mmHg (millimeters of mercury) or if heart rate was less than 60 bpm (beats per minute). A Physician's Order, dated 5/15/2025 indicated to give Midodrine hydrochloride 5mg tablet by mouth three times a day for hypotension. Additional instructions were to: Hold Midodrine hydrochloride if systolic blood pressure was greater than 120 mmHg. A review of Resident 53's Medication Administration Record (MAR) indicated Propranolol hydrochloride 10mg one tablet by mouth was administered to the resident on the following dates with the corresponding blood pressures readings: -On 6/11/2025 Resident 53's blood pressure result was 109/73 mmHg. -On 6/21/2025 Resident 53's blood pressure result was 98/52 mmHg. -On 7/5/2025 Resident 53's blood pressure result was 98/74 mmHg. -On 7/10/2025 Resident 53's heart rate was 56 bpm. -On 7/20/2025 Resident 53's blood pressure result was 102/68 mmHg. -On 7/30/2025 Resident 53's blood pressure results were 109/72 mmHg and 101/68 mmHg. A review of Resident 53's MAR indicated Midodrine hydrochloride 5mg tablet by mouth was administered to the resident on the following dates with the corresponding blood pressures: -On 5/17/2025 Resident 53's blood pressure result was 128/74 mmHg. -On 5/19/2025 Resident 53's blood pressure results were 126/76 mmHg and 122/70 mmHg. -On 5/23/2025 Resident 53's blood pressure results were 132/82 mmHg and 136/78 mmHg. -On 5/27/2025 Resident 53's blood pressure results were 150/82 mmHg and 132/82 mmHg. -On 5/28/2025 Resident 53's blood pressure results were 142/72 mmHg and 126/74 mmHg. -On 5/30/2025 Resident 53's blood pressure result was 128/72 mmHg. -On 5/31/2025 Resident 53's blood pressure result was 130/78 mmHg. -On 6/1/2025 Resident 53's blood pressure results were 146/88 mmHg and 134/82 mmHg. -On 6/2/2025 Resident 53's blood pressure results were 146/74 mmHg and 130/70 mmHg. -On 6/6/2025 Resident 53's blood pressure results were 128/64 mmHg and 124/82 mmHg. -On 6/9/2025 Resident 53's blood pressure result was 124/78 mmHg. -On 6/10/2025 Resident 53's blood pressure results were 132/68 mmHg and 124/62 mmHg. -On 6/12/2025 Resident 53's blood pressure result was 128/72 mmHg. -On 6/14/2025 Resident 53's blood pressure results were 138/60 mmHg and 122/60 mmHg. -On 6/15/2025 Resident 53's blood pressure results was 142/82 mmHg. -On 6/18/2025 Resident 53's blood pressure result was 124/62 mmHg. -On 6/19/2025 Resident 53's blood pressure result was 124/70 mmHg. -On 6/20/2205 Resident 53's blood pressure results were 128/66 mmHg and 130/74 mmHg. -On 6/22/2025 Resident 53's blood pressure result was 131/66 mmHg. -On 6/23/2025 Resident 53's blood pressure results were 124/80 mmHg and 132/84 mmHg. -On 6/24/2025 Resident 53's blood pressure results were 153/88 mmHg and 142/72 mmHg. -On 6/25/2025 Resident 53's blood pressure results were 138/74 mmHg and 148/88 mmHg.-On 6/26/2025 Resident 53's blood pressure results were 130/62 mmHg and 160/93 mmHg. -on 6/28/2025 Resident 53's blood pressure results were 130/76 mmHg and 136/80 mmHg. -On 6/29/2025 Resident 53's blood pressure results were 130/76 mmHg and 128/60 mmHg. -On 6/30/2025 Resident 53's blood pressure result was 126/78 mmHg. -On 7/1/2025 Resident 53's blood pressure result was 128/72 mmHg.-On 7/2/2025 Resident 53's blood pressure result was 128/72 mmHg. -On 7/4/2025 Resident 53's blood pressure results were 130/76 mmHg and 144/62 mmHg. -On 7/8/2025 Resident 53's blood pressure result was 128/82 mmHg. -On 7/10/2025 Resident 53's blood pressure result was 140/76 mmHg. -On 7/12/2025 Resident 53's blood pressure results were 132/74 mmHg, 124/66 mmHg and 128/68 mmHg. -On 7/13/2025 Resident 53's blood pressure results were 138/96 mmHg and 134/92 mmHg. -On 7/16/2025 Resident 53's blood pressure result was 128/72 mmHg. -On 7/18/2025 Resident 53's blood pressure results were 122/74 mmHg and 128/64 mmHg. -On 7/23/2025 Resident 53's blood pressure results were 154/90 mmHg and 122/65 mmHg. -On 7/26/2025 Resident 53's blood pressure result was 126/68 mmHg. -On 7/27/2025 Resident 53's blood pressure results were 122/86 mmHg, 124/72 mmHg and 125/75 mmHg. -On 8/1/2025 Resident 53's blood pressure results were 130/94 mmHg, 124/88 mmHg and 130/82 mmHg. -On 8/5/2025 Resident 53's blood pressure result was 152/90 mmHg. -On 8/7/2025 Resident 53's blood pressure result was 129/83 mmHg. 5. A record review was completed for Resident 13 on 8/7/2025 at 2:27 P.M. Diagnoses included, but were not limited to: hypotension. A Physician's Order, dated 7/14/2025 indicated Midodrine hydrochloride 5mg give one tablet by mouth three times a day for hypotension. Additional instructions included to hold Midodrine hydrochloride 5mg tablet when the systolic blood pressure was greater than 125 mmHg. A review of Resident 13's MAR indicated Midodrine hydrochloride was administered to the resident on the following dates with the corresponding blood pressures: -On 7/16/2025 Resident 13's blood pressure result was 128/72 mmHg. -On 7/17/2025 Resident 13's blood pressure result was 126/78 mmHg. -On 7/18/2025 Resident 13's blood pressure results were 130/68 mmHg and 128/76 mmHg. -On 7/21/2025 Resident 13's blood pressure result was 127/76 mmHg. -On 7/22/2025 Resident 13's blood pressure results were 150/96 mmHg and 134/82 mmHg. -On 7/23/2025 Resident 13's blood pressure results were 142/76 mmHg and 132/74 mmHg. -On 7/24/2025 Resident 13's blood pressure result was 128/68 mmHg. -On 7/26/2025 Resident 13's blood pressure result was 126/72 mmHg. -On 7/27/2027 Resident 13's blood pressure results was 128/92 mmHg. -On 7/28/2025 Resident 13's blood pressure result was 128/72 mmHg. -On 7/30/2025 Resident 13's blood pressure result was 128/74 mmHg. -On 7/31/2025 Resident 13's blood pressure results were 134/82 mmHg and 130/70 mmHg. -On 8/1/2025 Resident 13's blood pressure results were 150/98 mmHg, 136/82 mmHg and 133/78 mmHg. -On 8/5/2025 Resident 13's blood pressure results were 126/70 mmHg and 140/88 mmHg. -On 8/9/2025 Resident 13's blood pressure results were 126/70 mmHg, 130/72 mmHg and 132/68 mmHg. -On 8/10/2025 Resident 13's blood pressure result was 140/86 mmHg. During an interview, on 8/11/2025 at 8:50 A.M. the DON indicated Residents 53 and 13 should not have been receiving the Midodrine or the Propranolol if their vital signs were outside the ordered parameters. On 8/11/2025 at 12:02 P.M., the DON provided the policy titled, Medication Administration, no date and indicated it was the policy currently being used by the facility. The policy indicated, 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters This citation relates to Complaints 1547766 and 1547767 3.1-37

Based on record review and interview, the facility failed ensure 2 of 6 residents reviewed for medications were free from unnecessary medications related to having an appropriate diagnosis for the use of an antipsychotic medication and a PRN (as needed) antianxiety medication used for greater than 14 days without adequate documentation. (Resident 125 and 72).1. The closed record for Resident C was completed on 8/10/2025 at 2:45 P.M. Diagnoses included but were not limited to: fracture to the left femur, diabetes, end stage renal disease, depression and anxiety. Resident C's medication orders included Olanzapine (an antipsychotic medication) Oral Tablet 5 MG, 1 tablet by mouth at bedtime for Depression. During an interview, on 8/11/2025 at 12:10 P.M., the Director of Nursing indicated depression was not an appropriate diagnoses for the medication. There was no other diagnosis or medical symptom to support the use of Olanzapine for Resident C. 2. A record review was completed for Resident 72 on 8/7/2025 at 10:49 A.M. Diagnoses included ,but were not limited to: anxiety disorder and dementia. A Physician's Order, initiated on 12/18/2025 and discontinued on 1/18/2025 indicated Resident 72 had been prescribed lorazepam 0.5 mg (milligrams) one tablet by mouth as needed for anxiety and agitation. Resident 72's electronic medical record lacked documentation from the physician for the use of an antianxiety medication for greater than 14 days. During an interview, on 8/11/2025 at 2:36 P.M., the DON indicated Resident 72 should not have been on the lorazepam for greater than 14 days. On 8/8/2025 at 1:09 P.M., the ED provided the policy titled Use of Psychotropic Medications, no date and indicated it was the policy currently being used by the facility. The policy indicated, 2. Psychotropic medications are to be used only when a practitioner determines that the medication is appropriate to treat a resident's specific, diagnosed and documented condition and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication. 16a. PRN orders for psychotropic medications, excluding antipsychotics, shall be limited to no more than 14 days, unless the attending physician or prescribing practitioner believes it is appropriate to extend the order beyond the 14 days. The medical record should include documentation from the physician or prescriber for the rationale for the extended time period and indicate a specific duration This citation relates to Complaint 1547766 3.1-26

Based on observation, record review and interview, the facility failed to ensure a clean, sanitary and comfortable environment was maintained on 2 of 4 units. (400 hall and 500 hall).Findings include: 1. During an interview and observation, on 8/4/2025 at 10:18 A.M., Resident 56 complained of gnats and flies in her room. The resident indicated it had been going on for the past 2-3 weeks. The wall by the resident's bed had dark colored liquid speck marks and the privacy curtains were stained with dark colored specks. 2. During an observation, on 8/4/2025 at 10:41 A.M., several live flies were observed in room [ROOM NUMBER]. 3. During an interview, on 8/4/2025 at 11:07 A.M., Resident 95 indicated she still had flies in her room. She stated, We have them (flies) bad. 4. During an observation, on 8/4/2025 at 11:52 A.M., the wall behind Resident 87's bed was gouged and had black scuff marks. 5. During an observation of the memory care unit on 8/5/2025 at 8:38 A.M., there were several fruit flies seen throughout the unit. Resident 77 indicated, they (flies) were in his room and everyone else's. 6. During an observation, on 8/5/2025 at 10:10 A.M. in room [ROOM NUMBER], a foam fall mat on the floor next to Resident 3's bed had dark circular stained areas, the window blind was broken in numerous places and the trim around the window was cracked in two places.7. During an observation, on 8/5/2025 at 11:24 A.M., several flies were noted on Resident 17's bed linens. During a tour of the facility with the Administrator, on 8/12/2025 at 3:01 P.M., the following was observed:-flies were observed flying in the hallway leading to the 400 hall.-the floor in room [ROOM NUMBER]smelled of urine and floor was sticky -the 500 hall shower room had dead bugs in the sink and gnats flying around the sink, there was equipment stored in the tub and the tub had a dried brown substance in the bottom, there was also a bucket from a bed side commode that had a dark brown substance dried to the bottom surface. -the 400 hall lounge area had an accumulation of food crumbs on the rug, cob webs behind a love seat, a dried dark substance, bed linens and an empty snack bag on the floor. During an interview, on 8/12/2025 at 3:29 P.M., the Administrator indicated the dirty items, walls and broken items should be fixed and cleaned. He indicated the shower room was not being used as a shower room at this time. He indicated there should be a lock on the door to keep any resident out of the shower room. He indicated the facility followed the state guidelines on cleaning. On 8/12/2025 at 3:45 P.M., the Administrator provided the policy titled, Preventative Maintenance Program, undated, and indicated the policy was the one currently used by the facility. The policy indicated . A Preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff and the public . 2. The Maintenance Director shall assess all aspects of the physical plant to determine if Preventative Maintenance (PM) is required . 3. If preventative maintenance is required, the Maintenance director shall decide what tasks need to be completed and how often to complete them This citation relates to complaints IN00462615 and IN00461580. 3.1-19(f)

Based on interview and record review, the facility failed to implement their policy related to reporting an allegation of abuse for 1 of 3 residents reviewed for abuse. (Resident B) Finding includes: During an interview on 1/22/25 at 12:45 P.M., Resident B indicated one night the previous week, Employee 3 entered her room to assist with changing her brief. Resident B indicated Employee 3 commented the odor was strong and sprayed her buttocks with room deodorizer and then pushed the spray can into her rectum. Resident B indicated on 1/20/25, at an unknown time, she was in the lobby of the facility and reported the incident to Employee 6. Resident B indicated on 1/22/24 during morning physical therapy, she reported the allegation to Employee 2. During an interview on 1/22/25 at 1:15 P.M., the Administrator indicated he was made aware of an allegation of abuse for the first time from Employee 2 on 1/22/25 at 12:30 P.M. The Administrator indicated he immediately suspended Employee 3, pending an investigation, reported the allegation to the State Agency, and initiated an investigation. The Administrator indicated the allegation of abuse should have been reported to him by Employee 6 immediately and that Employee 6 had been trained regarding the requirement to report all allegations of abuse to the Administrator and Director of Nursing immediately. During an interview on 1/23/25 at 1:25 P.M., Employee 6 indicated sometime in the evening of 1/20/25, Resident B was in the lobby of the facility and reported to her that sometime in the night on 1/16/25, Employee 3 entered her room to change her brief and and sprayed her with room spray and made remarks about the way she smelled and that the employee practically sodomized her with the can of room spray. Employee 6 indicated she should have reported the allegation immediately to the Administrator but did not. On 1/23/25 at 10:20 A.M., the Administrator provided a policy titled, Abuse, Neglect and Exploitation, dated 2024, and indicated it was the current facility policy. The policy indicated, .The facility will .implement written policies and procedures .Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies .not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . This citation relates to Complaint IN00451700. 3.1-28(c)

Based on observation, record review and interview, the facility failed to ensure food was served at palatable temperatures in 1 of 1 kitchens observed (Main Kitchen). This deficient practice potentially affected 110 of 120 residents who consumed food from the main kitchen. Finding includes: During a meal observation with [NAME] 1 in the Main Kitchen, on 10/1/24 at 12:00 P.M., the food temperatures of hot foods on the steam table were a follows: pureed corn 105 F (Fahrenheit), cream corn 123 F, pureed beef 118 F, beef gravy 128 F, pepper steak 123 F, whole corn 141 and sweet potato 140 During observation of room trays on the 500 hall, conducted on 10/1/24 at 12:37 P.M., meals were transported to the unit, from the kitchen on metal covered, noninsulated carts. The last tray to be served, at 12:37 P.M., had the following food temperatures at the point of service: pepper steak 80 F, sweet potatoes 85 F and whole corn 85*F. During an interview on 10/1/24 at 12:05 P.M., [NAME] 1 indicated hot food temps should be held at or above 140 F while on the steam table. During an interview on 10/1/24 at 12:24 P.M. the Dietary Manager indicated hot foods were to be temperature checked at the steam table and should be held at at least 135 F. During an interview on 10/1/24 at 12:49 P.M., Resident E indicated the hot food was always cold when served. During an interview, on 10/1/24 at 12:52 P.M. in the dining room, Resident G and Resident H both indicated the food was often served cold and needed to be warmer. On 10/1/24 at 12:00 P.M., during food service distribution, in a hot food temps check with [NAME] 1, [NAME] 1 check the food temps and agreed that the following foods tempt out at: Pureed corn: 105 F, Cream corn 123, whole corn 141, pureed beef 118, beef gravy 128, pepper steak 123, sweet potato 140 During an interview on 10/1/24 at 12:58 P.M., the Administrator indicated hot foods should be served at appropriate temperatures and not below. On 10/1/24 at 2:32 P.M., the Director of Nursing provided the policy titled, Maintaining a Sanitary Tray Line, dated 12/17 and indicated it was the current facility policy. The policy indicated the priority of food service was to ensure foods were handled safely and held at proper temperatures and to periodically monitor food temperatures throughout the meal service to ensure hot foods were maintained at or above 135 F. This citation relates to Complaint IN00443191. 3.1-21(a)(2)

Based on observation, interview, and record review, the facility failed to ensure food was handled appropriately, foods were sealed appropriately, and failed to date foods when opened. This had the potential to affect 114 residents of 115 residents who received meals from the kitchen. Findings include: 1. An initial walk through of the kitchen with the Dietary Manager was completed on 7/29/2024 at 9:35 A.M. The following were observed: in the dry storage area was an opened/undated box of lasagna noodles not sealed, a gallon of vanilla with an opened date of 4/15/2023. In the walk-in cooler was an undated container of gravy and 3 health shakes with an expiration date of 7/23/2024, and an opened and undated box of Cream of Wheat cereal. 2. During a meal observation, on 7/29/2024 at 12:35 P.M., CNA 17 was observed to have her thumb extending over the plates' rim onto the food surface of the plate when serving 2 different residents. During an interview, on 7/29/2024 at 12:50 P.M., CNA 17 indicated her thumb should be underneath the plate. 3. During an observation, on 7/29/2024, CNA 18 was observed to hold the meal tray on her shoulder with one hand underneath the tray. While she was moving and walking, her hair was observed touching the top of the tray. During an interview, on 7/29/2024 at 12:58 P.M., CNA 18 indicated she should not put the tray on her shoulders. On 8/2/2024 at 12:18 P.M., the Director of Nursing provided the policy titled, Date Marking for Food Safety, dated 2024, and indicated the policy was the one currently used by the facility. The policy indicated .2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. 3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. 4. The marking system shall consists of the day/date of opening, and the day/date the item must be consumed or discarded .6. The Head Cook, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly A policy was requested on meal tray delivery, but one was not provided prior to the survey exit. 3.1-21(i)(3)

Based on record review and interview, the facility failed to ensure baseline care plans were initiated for a resident receiving dialysis, a resident with falls and edema, and a resident with a wound, and failed to ensure baseline care plans were completed timely for a resident with an enteral feeding tube, for 4 of 27 residents reviewed for baseline care plans. (Residents 36, 107, 14 and 99) Findings include: 1. The record for Resident 36 was completed on 8/01/2024 at 8:48 A.M. Diagnoses included, but were not limited to, end stage renal disease, neurogenic bladder, viral hepatitis, and diabetes. An Admission Minimum Data Set (MDS) assessment, dated 6/13/2024, indicated Resident 36 was receiving dialysis. A Baseline Care Plan form, dated 6/7/2024, indicated the resident required dialysis. The form lacked any goals, interventions, and any special needs to to address the resident's current needs to properly care for the resident. During an interview, on 8/2/2024 at 2:58 P.M., the Director of Nursing indicated the resident had a baseline care plan, but it did not have all the information in it from the chart. 45120 2. During an observation of Resident 107, on 7/29/2024 at 10:00 A.M., a bottle of Glucerna 1.5 was infused at 60 milliliters per hour via a tube feeding. A record review for Resident 107 was completed on 7/31/2024 at 1:57 P.M. Diagnoses included, but were not limited to, cerebral infarction, dysphagia, and diabetes mellitus type 2. He was admitted on [DATE]. An Admission Minimum Data Set (MDS) assessment, dated 7/9/2024, indicated Resident 107 received tube feeding, and had moderate cognitive impairment. Physician's Orders, dated 7/3/2024, indicated for Glucerna 1.5 to infuse via a gastrostomy tube at 60 milliliters per hour (ml/hr). A Care Plan, dated 7/18/2024, indicated Resident 107 received nutrition/hydration via a gastrostomy tube. All goals and interventions were dated 7/18/2024. During an interview, on 8/1/2024 at 3:13 P.M., LPN 2 indicated the baseline care plan was dated 7/9/2024. 38121 3. A record review for Resident 14 was completed, on 8/2/24 at 9:35 A.M. Diagnoses included included, but were not limited to major depressive disorder, heart disease, edema, type 2 diabetes, hypertension, muscle weakness, chronic pain syndrome and absence of left and right leg below knee. An Admission MDS (Minimum Data Set) assessment, dated 7/12/24, indicated Resident 14 has intact cognition. A baseline care plan, completed on 7/15/24, indicated Resident 14 had a history of falls prior to admission and as ordered psychotropic medication. During an interview on 8/2/24 at 1:34 P.M., the Director of Nursing (DON) indicated a baseline care plan should have been completed within 48 hours of admission, it was late and should have been completed timely. 4. A record review for Resident 99 was completed on 7/30/24 at 2:10 P.M. Diagnoses included, but were not limited to, diabetes, dementia, pressure ulcer, muscle weakness and diabetes. A Significant Change MDS assessment, dated 5/17/24, indicated Resident 99 has moderate cognitive impairment. A baseline care plan, completed on 4/29/24, indicated Resident 99 was admitted with a pressure ulcer. During an interview on 8/1/24 at 2:52 P.M., the DON indicated a baseline care plan should have been completed for her wounds within 48 hours of admission. On 8/2/24 at 1:16 P.M., the Executive Director provided the policy titled, Baseline Care Plan, dated 2/2023, and indicated the policy was the one currently used by the facility. The policy indicated .1. The baseline care plan will: a. Be developed within 48 hours of a resident's admission. b. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: i. Initial goals based on admission orders. ii. Physician orders. iii. Dietary orders. iv. Therapy services. v. Social Services. vi. PASARR recommendation, if applicable 3.1-30(a)

Based on record review and interview, the facility failed to ensure comprehensive person-centered plans of care were created related to behaviors, a urinary tract infection, constipation, impaired vision and edema for 5 of 23 residents reviewed for comprehensive care plans. (Residents 28, 10, 14, 66 & 215) Findings include: 1. The record for Resident 28 was reviewed on 7/31/2024, at 9:15 A.M. Diagnoses included but were not limited to: hemiplegia and hemiparesis, cerebral infarction, unspecified dementia, atrial fibrillation, cardiomegaly, hypertension, and anxiety disorder. Resident 28's current medications included Zyprexa (antipsychotic) 10 milligrams (mg) 1 tablet by mouth at bedtime for dementia with agitation. A Care Plan, dated 7/28/2024, indicated the resident had target behaviors of paranoia and agitation. Interventions included, but were not limited to, assess for pain, monitor for side effects of antipsychotics and report to the physician, monthly pharmacy review of the medication regimen, offer to call the resident's wife, offer to sit and talk about the resident's wife, provide medications as ordered and evaluate for effectiveness, psychotropic risk/benefit and reduction plan as recommended by the physician and pharmacist, and reassure the resident of his safety. Resident 28's record lacked person-centered Care Plan interventions for behaviors. During an interview, on 7/31/2024 at 1:43 P.M., CNA 4 indicated all behaviors exhibited by the residents were charted in the electronic medical record system. The CNA indicated any interventions attempted by the CNA's were charted in electronic medical record system and were not individualized to the specific resident, the interventions were the same for every resident. During an interview, on 8/1/2024, at 2:41 P.M., the Memory Care Director indicated the interventions were individualized for the anxiety portion but not the antipsychotic portion of the care plan. She indicated that all parts of the care plan should be patient-centered. 11492 2. The record for Resident 10 was reviewed on 7/30/2024 at 2:20 P.M. Diagnoses included, but were not limited to, Alzheimer's disease, schizoaffective disorder, bipolar disorder, mild cognitive impairment and anxiety. During an interview with Resident 10, on 7/29/2024 at 9:30 A.M., she indicated she could not see very well and her eye glasses were not working. The resident was not wearing her glasses, but a hard covered eyeglass case was noted by the television. The resident indicated she did not think she had seen an eye doctor recently. The Quarterly Minimum Data Set (MDS) assessment, completed 6/19/2024, indicated her vision was adequate without corrective lenses. There was no current care plan for Resident 10 related to impaired vision and the need for eye glasses and/or any other intervention to address the resident's impaired vision. The most recent LTC (Long Term Care) facility evaluation, completed on 7/14/2024 indicated the resident's vision was adequate and she did not utilize corrective lenses. During an interview, on 7/31/2024 at 1:45 P.M. QMA 13 indicated she had not observed Resident 10 wearing eyeglasses. During an observation and interview, on 7/31/24 at 1:45 P.M., Resident 10's eyeglass case, located on the dresser in front of her television, was opened and a pair of prescription eyeglasses that looked like bifocals was observed. The resident indicated she was not wearing the glasses because they were not working for her. During an interview with the MDS coordinator, on 7/31/2024 at 2:00 P.M. she indicated the Social Service Director had completed the section of the MDS pertaining to vision and had inaccurately marked no corrective lenses. The MDS coordinator confirmed Resident 10 did have eyeglasses and the resident had been seen by the in-house eye doctor in March of 2024 and was prescribed bifocal eye glasses. The resident was not due to be seen again for 12 - 15 months from that time. 3. During an observation and interview on 7/29/2024 at 11:34 A.M., alert and oriented Resident 14 indicated he was admitted to the facility with edema to his bilateral below the knee amputation stumps. His prosthetic leg appliances were observed leaning against the wall in his room. He indicated his legs were too swollen to wear the prosthetic legs. The resident's lower thighs, knees and stump areas were observed to be swollen and looked similar in circumference to his upper thighs. A bandage was noted on the bottom of the left stump. The record for Resident 14 was reviewed on 7/31/2024 at 11:31 A.M. He was admitted to the facility on [DATE] with diagnoses including but not limited to, major depressive disorder, recurrent severe, pressure ulcer stage 3 right lateral hip, chronic pain syndrome, lack of coordination, muscle weakness, type 2 diabetes, insomnia, obsessive-compulsive disorder, history of acquired absence of the left leg and right leg below knee. The physician's orders for medication included an order, dated 7/29/2024 to administer Lasix (a diuretic medication) 40 mg tablet at bedtime for Inflammation for 3 days. A subsequent order, dated 8/1/2024, indicated the resident had received Lasix 40 mg one tablet at bedtime for Edema. The Admission MDS assessment, completed on 7/12/2024, indicated the resident was alert and oriented, utilized a wheelchair independently for mobility and required moderate assistance for lower body dressing. The current care plans for Resident 14 did not include a care plan to monitor the resident's edema to his bilateral lower extremity edema. A care plan to address the resident's coronary artery disease diagnosis included an intervention to monitor the resident for edema and other potential complications of the disease. 38845 4. During an interview, on 7/30/2024 at 9:07 A.M., Resident 66 indicated he had a urinary tract infection. A record review was completed on 8/1/2024 at 8:48 A.M. Diagnoses included, but were not limited to, hypertension, end stage renal disease, neurogenic bladder, Viral hepatitis, and diabetes. Resident 66's current Physician Orders, dated 7/29/2024, included Cephalexin (antibiotic) 500 mg (milligram) - Give 1 capsule orally every 12 hours for UTI (urinary tract infection) for 5 days. The record lacked a care plan for the urinary tract infection. During an interview, on 8/2/2024 at 2:48 P.M., the Director of Nursing indicated there should have been a UTI Care Plan on the chart. 5. During an interview, on 7/29/2024 at 3:03 P.M., Resident 215 indicated he had not had a bowel movement (BM) in 14 days. The record for Resident 215 was completed on 7/30/2024 at 11:00 A.M. Diagnoses included, but were not limited to: Neurogenic bladder, anxiety, and depression. A Quarterly Minimum Data Set (MDS) assessment, dated 4/29/24, indicated the resident received opioid medications and received scheduled pain medications. The documentation for bowel continence, dated July 2024, indicated Resident 215 had no bowel movement documented from July 16 on the night shift to July 22 on the night shift. The clinical record lacked a person centered care plan for constipation. During an interview, on 8/5/2024 at 10 :11 A.M., the Director of Nursing indicated there should have been a care plan for constipation. On 8/2/2024 at 1:11 P.M., the Director of Nursing provided the policy titled,Comprehensive Care Plans, dated 2023, and indicated the policy was the one currently used by the facility The policy indicated . It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident right's, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . 1. The care planning process will include and assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally-competent and trauma-informed .3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well being . 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress 3.1-35(a)

Based on interview and record review, the facility failed to ensure resident funds were available on the same day of the request and for the desired amount for 4 of 4 residents reviewed for facility-managed personal funds. (Residents 18, 5, 31 and 8) Findings include: During an interview on 7/29/24 at 10:15 A.M., Resident 18 indicated he was able to obtain money from his facility account between the hours of 9 A.M. and 4 P.M. weekdays, and not at all on Saturday and Sunday. During an interview on 7/29/24 at 10:54 A.M., Resident 5 indicated he was only able to get five dollars from his facility account on the weekends. During an interview on 7/30/24 at 9:42 A.M., Resident 31 indicated she could only get money from her facility account until 4 P.M. weekdays, and not at all on Saturday and Sunday. During an interview on 7/30/24 at 1:15 P.M., Resident 8 indicated she was unable to get money from her facility account after 4 P.M. During an interview on 7/31/24 at 2:27 P.M., LPN 13 indicated the residents had a five dollar limit that they could take out of their facility accounts. During an interview on 7/31/24 at 2:13 P.M., the Business Office Manager (BOM) indicated the residents should not have a five dollar withdrawal limit for their facility accounts. During an interview on 8/2/24 at 2:14 P.M., the Executive Director (ED) indicated he was unaware that staff was telling the residents they had a 5 dollar limit to withdraw from their facility accounts. On 8/1/24 at 2:32 P.M., the Director of Nursing provided a policy titled, Availability of Resident Funds-After Business Office Hours no date, and indicated the policy was the one currently used by the facility. The policy indicated .During non-business office hours (e.g., nights, weekends, and holidays), the Business Office Manager, or designee, provides the Nurse Supervisor on duty at the time the business office closes a residents' fund petty cash box 3.1-6(a)

Based on record review and interview, the facility failed to ensure a surety bond sufficiently covered the total monies in the Resident Fund account. This had the potential to affect the 56 residents who had resident fund accounts managed by the facility. Finding includes: During an interview and record review of Resident Fund accounts, with the Business Office Manager (BOM) and the Executive Director, on 8/2/2024 at 8:25 A.M., the total amount in the Resident Fund accounts was $286,128.00. The BOM indicated the amount was higher than usual due to a closed account with funds from a home sale for which she was waiting on verification before sending the funds back to Medicaid. Review of the facility's Surety Bond insurance rider to cover Resident Fund monies, dated April 1, 2020, indicated the covered amount had been increased to $250,000. During an interview with the Executive Director (ED) on 8/5/2024 at 9:40 A.M. he indicated he did not know why the Corporation had not raised the Resident Fund Surety Bond amount higher. He confirmed the total amount noted on 8/2/2024 was unusually high for that account. The current facility policy titled Surety Bond Requirements provided by the ED on 8/5/2024 at 9:00 A.M., included the following: .The surety bond, or alternative to a surety bond, must be equal to or greater than the total amount of residents' funds, as of the most recent quarter . 3.1-6(j)

Based on record review and interview, the facility failed to provide accurate orders for resuscitative wishes for 2 of 3 resident reviewed for advanced directives. (Residents 94 & 36) Findings include: 1. A record review for Resident 94 was completed on 7/31/2024 at 11:19 A.M. Diagnoses included, but were not limited to: cerebral infarction, chronic obstructive pulmonary disease (COPD), congestive heart failure, atrial fibrillation, epilepsy, and diabetes mellitus type 2. An Admission Minimum Data Set (MDS) assessment, dated 6/7/24, indicated Resident 94 had severe cognitive impairment. A Physician Orders for Scope of Treatment (POST) form, dated 6/1/2024, and signed by the nurse practitioner on 6/27/2024, indicated to not attempt resuscitation. A Physician's Order, dated 6/10/2024, indicated Resident 94 was a full code, indicating cardiopulmonary resuscitation to was to be completed. A Care Plan, dated 6/13/2024, indicated Resident 94 had an advanced directive of a full code. The goal, dated 6/13/2024, indicated that Resident 94's wishes would be honored. The interventions include cardiopulmonary resuscitation would be honored, and to review code status quarterly. During an interview, on 7/31/2024 at 12:19 P.M., LPN 3 indicated Resident 94 had an order to be a full code. The POST form indicated his wishes to be a do not resuscitate. LPN 3 indicated the physician's order, care plan and the POST form conflicted related to the wishes of Resident 94. 38845 2. The record for Resident 36 was completed on 7/31/2024 at 9:54 A.M. Diagnoses included, but were not limited to: diabetes, hypertension, anxiety, depression, epilepsy, and Schizophrenia. Physician's orders, dated 8/1/2024- 8/31/2024, lacked documentation of physician's orders for code status preferences. During an interview, on 7/31/2024 at 12:10 P.M., LPN 13 indicated the resident should have had an order for his code status. On 28/1/2024 at 12:25 P.M., the Director of Nursing provided the policy titled,Communication of Code Status, dated 2/2023, and indicated the policy was the one currently used by the facility. The policy indicated .It is the policy of this facility to adhere to residents' rights to formulate advanced directives .When an order is written pertaining to a resident's presence or absence of an Advanced Directive, the directions will be clearly documented in designated sections of the medical record. Examples of directions to be documented include, but are not limited to: a. Full Code. b. Do Not Resuscitate. c. Do Not Intubate. d. Do Not Hospitalize. 3. The nurse who notates the physician order is responsible for documenting the directions in all relevant sections of the medical record. 4. The designated sections of the medical record are: Active order, copy of code status uploaded into electronic file.8. The resident's code status will be reviewed as least quarterly and documented in the medical record 3.1-4(f)(7)

Based on record review and interview, the facility failed to provide the appropriate supervision and the appropriate textured diet for 1 of 3 residents reviewed for mechanically altered diets that resulted death. (Resident B) Finding includes: A record review was completed for Resident B on [DATE] at 4:33 P.M. Diagnoses included, but were not limited to: Parkinson's disease, hemiplegia, dementia, and atrial fibrillation. A Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], indicated Resident B had severe cognitive impairment. He was able to be understood and understand others. He required meal set-up with supervision for eating. Resident B received a mechanically altered diet. A Physician's Order, dated [DATE], indicated, .Direct supervision for entirety consumption of food and liquids On [DATE], a Physician's Order indicated, .Resident has exhibited coughing or choking during meals or when swallowing medications A Care Plan, initiated on [DATE], and resolved on [DATE], indicated Resident B was at risk for coughing and or choking during meals or when swallowing medication. The goal was for Resident B to remain free of adverse effects associated with coughing/choking during meals or when swallowing medications. A Physician's Order dated [DATE], indicated a regular diet, mechanical soft/easy to chew texture diet. A Nurse's Note, dated [DATE] at 6:32 P.M., indicated Resident B finished eating his dinner, stood up from the table, and placed his hands next to his throat. The Heimlich maneuver was done. Resident B was sitting on the floor with an occasional breath. Resident B's mouth was swept and small pieces of diced fruit was removed from his mouth. Resident B's lips were turning blue and 911 was called. Oxygen was placed and suctioning was attempted with no success. On [DATE] at 6:39 P.M., a Nurse's Note indicated, 911 arrived and took over care. Cardiopulmonary resuscitation (CPR) was initiated for approximately twenty minutes before the time of death was called. On [DATE] at 9:27 A.M., the facility provided a folder that contained the investigation information for the incident on [DATE]. A form titled Alleged Incident Statement, dated [DATE], CNA (certified nursing assistant) 3's statement indicated on [DATE] at 6:20 P.M., .I was sitting at a table feeding a resident turned around notice the resident [Resident B] was looking like he was choking I called [name of QMA 4] he ran over started the hemlich [Heimlich] maneuver then I preceded to call the nurses.Injury? Death Another Alleged Incident Statement, dated [DATE], handwritten by QMA (qualified medication assistant) 4 indicated .Resident [Resident B] was eating and I noticed him grasping for and trying to get our attention, Realizing he was choking I conducted Heimlich maneuver while calling for nurse .Resident [Resident B] was eating mechanical [ground] hamburger chips and peaches .Injury? Not certain though it appeared resident was choking An Alleged Incident Statement, dated [DATE], handwritten by QMA 5 indicated .While counting and getting report, got a scream from the dining room from a CNA that a resident is choking. I run and helped to with the Heimlich Maneuver and I put a glove and sweep out his mouth and found in mouth. Then the nurse took over and helped him more and proceeded to call 911 and paperwork and authorities .Injury? Death A typed interview, dated [DATE], Cook 6 indicated he would know the type of diet a resident should receive, by observing the ticket. Cook 6 then explained the mechanical soft diet for the evening meal on [DATE] was .Chopped hamburger with a slice of cheese on a bun. Spiced apricots that were cut up into small pieces. And Cheetos Cheese Puffs Cook # 6 statement indicated the meals are loaded onto a cart, then delivered to the unit's dining room. The mechanical soft diets were checked by the dietary staff who loads the cart. Cook # 6 indicated the fruit in a mechanical soft diet, would be served cut up, into small pieces. A document titled, Interview [LPN 2] for incident on [DATE], LPN (licensed practical nurse) dated [DATE], from an interview with Area [NAME] President, indicated, .The nurse was as giving report to oncoming QMA at approx. [approximately] 6:20 P.M. We heard yelling. The CNA started yelling for the nurse, Nurse went immediately to the dining room. The nurse states that CNA reports to her that they observed the resident standing up with his hand on his chest and lower throat area. The nurse observed upon arrival was resident in sitting position on the floor. Resident appeared to have taken a few deep breaths every few seconds. CNA assisted Nurse with putting resident in the chair. Directive was given to staff to call 911. The crash cart was grabbed by a staff member. O2 [oxygen] was placed on the resident. O2 stat machine was showing a pulse, but the machine was not reading a number. Lips were starting to turn a light blue. Nurse suctioned resident x 2 [times two]. No particles were coming out of the resident mouth through the suction. The nurse continued with abdominal thrusts and sweep of mouth. Findings from nurse appeared to be small, diced peach-colored particles. EMT's [Emergency Medical Technicians] arrived and laid resident down on floor. EMT's initiated CPR [cardiopulmonary resuscitation] and took over from nurse A document titled, Timeline, dated [DATE], indicated the following: .1. Beginning of meal service (exact time unknown)-resident dropped plate on floor. 2. CNA 4 assisted resident from stepping in his dropped plate while another staff member cleaned up the tray on the floor. 3. Resident assisted back to his seat and provided with another tray. 4. Staff resumed their duties of assisting residents with meal service. 5. Resident appeared to still be hungry. 6. CNA 4 observed this and provided another tray to resident. 7. CNA 4 redirected this resident from taking food from a tablemate's plate. CNA 4 observed this resident take one chip from the tray he set down in front of him. 8. CNA 4 went back to cleaning the dining room. Other CNA assisting residents with finishing meal service. 9. CNA 4 states he was putting a tray in the cart and he walked back toward the tables, he observed resident Rico [sic] standing with his head down, looking unusual. 10. CNA 4 stated he rushed to the resident and called for the other CNA to get the nurse. 11. CNA 4 stated that QMA 5 arrived and abdominal thrusts were immediately started. 12. CNA 4 stated resident was starting to become weak in the legs and limp, he was sat in a chair. The nurse arrived and began abdominal thrusts. 13. 911 was called by CNA. 14. The nurse instructed CNA 4 to get O2 and crash cart. Resident was placed on floor. 15. Nurse reports she did a finger sweep and a small amount of what appeared to be sliced peaches were in resident mouth. 16. Nurse attempted to suction without observing items coming out. 17. EMT's arrived at approx. 18:39 [6:39 P.M.] and continued to suction. 18. Resident passing at approx. [approximately] 16:53 [4:53 P.M.] The folder contained the self-report incident #549, dated [DATE] at 4:16 P.M., indicated, Resident B was, .in dining room at dinner time, noted to be experiencing a change in condition. Nursing staff immediately attended to resident, as he appeared to be choking. Nurse performed abdominal thrust. 911 immediately called. Nurse triage continued until EMT arrival. Resident passed away while at facility with EMT's present Actions taken after the incident included audits and education to include checking that diet orders match the meals being served and therapeutic diet have been completed and are ongoing education completed and ongoing prior to the start of their shift During an interview, on [DATE] at 11:49 A.M., LPN 2, an agency nurse, indicated when she arrived at the dining room no one was doing anything for the resident and was found sitting on the floor. She immediately checked the resident's mouth for debris and got out a few pieces of fruit. She had staff put the resident into a chair so she could provide the Heimlich Maneuver to the resident. Once suction arrived, to the area, she suctioned the resident but did not get anything so went back to do Heimlich Maneuver ,d+[DATE] times, then back to check mouth and suction. When Emergency Personnel arrived, they asked for his DNR paperwork, but it was not on the chart, so they started CPR and continued to provide CPR until a staff member provided the DNR paperwork. The resident was pronounced dead at the scene by the Emergency Personnel. LPN 2 indicated the tray she observed, for the resident had a bun, with ground meat in it, cut up fruit and potato chips. During an interview, on [DATE] at 12:55 P.M., the Dietician indicated that potato chips were not to be provided to a resident on a mechanical soft diet. And she also indicated she did not believe cheese puffs were either. She indicated she would check to see if the resident had a speech therapy evaluation and would provide a copy. On [DATE] at 1:33 P.M., the [NAME] President of Regulatory Compliance provided the policy titled, Therapeutic Diet Orders. The policy indicated, .The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences .Mechanically Altered Diet is one in which the texture or consistency of food is altered to facilitate oral intake. Examples include soft solids, pureed foods, ground meat, and thickened liquids .3. Therapeutic diets are provided only when ordered by the attending physician or a registered or licensed dietician who has been delegated to write diet orders, to the extent allowed by state law 5. Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form The past noncompliance began on [DATE]. The tag was removed and the deficient practice corrected by [DATE] after the facility implemented a systemic plan that included the following actions: an investigation of the diet received for Resident B on [DATE], a review of all facility residents' dietary orders and recommendations with emphasis on mechanically altered diets, a review of all dietary department tray tickets for all residents, education provided to nursing staff and dietary staff that regarded appropriate diets were plated and served to residents, applicable facility policies and procedures for diet consistencies, a meal grid was placed in each dining area for easy identification of meal types, substitutions for items on the menu to be logged and approved by the Registered Dietician or clarified if needed, continued supervision for all food preparation and meals provided for three months, and nursing and dietary services to continue audits for the next four months. This Federal tag relates to complaint IN00407017. 1XXX,d+[DATE](a)(3)

Based on interview and record review, the facility failed to ensure a resident who was admitted with pressure ulcers received appropriate treatment/services to prevent deterioration, infection and additional wounds. (Resident J) The immediate jeopardy began on 1/10/23 when the facility did not follow the Nurse Practitioner treatment orders to prevent the deterioration of the of pressure ulcers, a hospitalization , additional wounds discovered in emergency room and passed away 2 days later due to complications, one being pressure ulcers. The Administrator, the Director of Nursing (DON), an Assistant Director of Nursing (ADON), a Regional Nurse and a Registered Nurse (RN) were notified of the immediate jeopardy, at 4:28 P.M. on 2/28/23. The immediate jeopardy was removed, and the deficient practice corrected, on 3/2/23. Finding includes: On 2/23/23 at 2:28 P.M., a review of the clinical record for Resident J was conducted. The record indicated the resident was admitted on [DATE], as a full code, and discharge to a local hospital on 1/27/23. The resident's diagnoses included, but were not limited to: multiple sclerosis, neuromuscular dysfunction of the bladder, history of urinary tract infections and pressure ulcer of sacral region-Stage III (pressure injury with full-thickness lose of skin). A Braden score, dated 12/30/22, indicated the resident was at high risk for developing pressure ulcers. A pressure ulcer care plan, dated 12/30/22, indicated the resident had pressure ulcers present on admission and was at risk for developing pressure ulcers related to his impaired mobility and bowel incontinence The interventions included but were not limited to: assist with repositioning, observe/report signs & symptoms of infection, provide thorough skin care after incontinent episodes and treatments as ordered. A Physician Assistant Progress Note, dated 12/30/22 indicated .Patient found to be resting comfortably in bed in no acute distress. He states he has a baclofen pump for his MS [multiple sclerosis] that has essentially left him paralyzed from the waste down. The original one that he had become infected and he became septic. He was sent to Indianapolis for surgery on the infected pump area . He spent 6 weeks until he was able to be placed in our facility for further treatment and evaluation .He is unable to voluntary move his lower extremities but does have feeling in his legs The Assessment/Plan indicated the following: .1. Pressure ulcer of sacral region: Did not visualize wound today. Most likely from being bedridden for almost 6 weeks. Wound [Nurse Practitioner] is following and we will follow their recommendations The Treatment Administration Record (TAR) for, December of 2022, had no pressure wound treatments documented. A General Note, documented by the Wound Nurse Practitioner, dated 1/15/23, with a date of service of 1/3/23, indicated .Will debride pressure ulcer with medical grade honey for autolytic debridement and softening of slough; anticipate sharp debridement in follow up. Patient is at increased risk for infection. Recommend specialty bed. Recommend offloading of bony prominence's while out of bed and heels offloaded The Note indicated to see the Tissue Analytic form in miscellaneous section of resident's chart. A Wound Nurse Practitioner Tissue Analytic form indicated, on 1/3/23 the resident had the following wounds: 1. Right buttock, Stage 3 pressure ulcer, measured 1.43 x 2.59 x 0.3 centimeters (cm) and was present on admission. The ulcer had a moderate amount of drainage and no odor. Treatment: wound cleanser then medihoney with bordered gauze TID (three times a day) 2. Left buttock, unstageable wound, measured 6.30 x 4.05 cm and had 70% slough (dead skin tissue that may have a yellow appearance) covering the wound bed. Present at admission. A moderate amount of drainage. Treatment: wound cleanser then medihoney and bordered gauze BID (twice a day). 3. MASD (Moisture-Associated Skin Damage) to the buttocks, which measured 11.6 x 13.26 x 0.20 cm and was present on admission with scant drainage. Treatment: wound cleanser and then calmoseptine daily and as need for soilage. The Admission Minimum Data Set (MDS) Assessment, dated 1/6/23, indicated the resident was cognitively intact, required extensive assistance of two people for bed mobility and transfers. The assessment indicated the resident had an impairment of lower extremities on one side, had a Foley Catheter (a thin tube inserted into the bladder to drain urine into a drainage bag) was always incontinent of bowels and was admitted with two Stage 3 pressure ulcers. A Physician Progress Note, dated 1/6/23, indicated the Medical Director had examined and reviewed the resident's history. The examination indicated the skin was very dry in the lower extremities. The Assessment portion of the Note, indicated .Pressure ulcer of sacral region, stage 3 The treatment portion of the note indicated .Pressure ulcer of sacral region, stage 3 Notes: Wound care underway A General Note, documented by the Wound Nurse Practitioner, dated 1/28/23, with a date of service of 1/10/23, indicated .Unstageable wound to the left and right buttock with surrounding MASD; sharp debridement performed today to the left buttock eschar and curette debredement to right buttock biofilm. Will optimize dressing treatment The Note indicated to see the Tissue Analytic form for full wound assessment. A Wound Nurse Practitioner Tissue Analytic form indicated, on 1/10/23 the resident had the following wounds: 1. Right buttock, Stage 3 pressure ulcer, measured 1.89 x 2.22 x 0.3 centimeters (cm) and was present on admission. The ulcer had a moderate amount of drainage and no odor. Treatment: wound cleanser then calcium alginate medihoney with bordered gauze TID (three times a day) 2. Left buttock, unstageable wound, measured 6.12 x 4.12 cm and had 70% slough (dead skin tissue that may have a yellow appearance) covering the wound bed. Present at admission. A moderate amount of drainage. Treatment: wound cleanser then calcium alginate, medical-grade honey and cover with bordered foam daily 3. MASD (Moisture-Associated Skin Damage) to the buttocks, which measured 6.86 x 7.97 x 0.10 cm and was present on admission with scant drainage. Treatment: wound cleanser and then thin layer of calmoseptine daily and as need for soilage. Treatment documentation for the left buttock wound: The TAR for January 2023, indicated an order was received, on 1/4/23, for the treatment of the left buttock, stage III, pressure ulcer, which consisted of cleansing the wound with wound cleanser, pat dry and apply Medihoney TID (6:00 A.M., 2:00 P.M. & 10:00 P.M.). This was first documented as completed, on 1/4/23 at 10:00 P.M., and continued, until 1/11/23 at 2:00 P.M. Then the TAR indicated a new order was received, on 1/11/23, which stated .Left Buttock: Pressure Ulcer Stage 3 every day shift .Cleanse with wound cleanser, pat dry, apply Medi-honey TID [three times a day] and PRN [as needed], cover with bordered gauze. Offload with pillow. This treatment documentation started, on 1/12/23 but had been documented, once a day through to 1/27/23 even though the treatment order changed on 1/10/23 (see above) Treatment documentation for the right buttock wound: The TAR, for January 2023, indicated an order was received on 1/11/23 for the treatment of a .Right Buttock: Pressure Ulcer Stage 3 every day shift .Cleanse with wound cleanser, pat dry, apply Medihoney BID [twice a day] and PRN [as needed], cover with bordered gauze. Offload with pillow The first documented right buttock treatment was on 1/12/23 and continued daily, until 1/27/23, even though the treatment order changed on 1/10/23 (see above) Treatment documentation for the MASD: The TAR, for January 2023, indicated an order was received on 1/4/23 for the treatment of .Buttocks: MASD every day shift .Cleanse with wound cleanse, pat dry, apply Calmoseptine/Calazine daily and PRN [as needed] for soilage. The first documented treatment was on 1/5/23 and continued daily until 1/11/23. Then the TAR indicated a new order was received, on 1/11/23, which stated .Buttock: MASD three times a day .Cleans with wound cleanse, pat dry, apply Calmoseptine/Calazime daily and PRN [as needed] for soilage The treatment documentation started on 1/11/23 at 10:00 P.M. and continued TID through, to 1/26/23, even though the treatment order had changed on 1/17/23 (see below) The TAR for January 2023, indicated .Staff to monitor all resident's wounds for both shifts for any changes and signs of infection. Document and report to provider for any changes This was first documented as completed on 1/6/23 at 8:00 P.M. and continued twice a day, until 1/27/23. A General Note, documented by the Wound Nurse Practitioner, dated 1/18/23, with a date of service of 1/3/23 (per DON the date of service corresponded with 1/17/23, Tissue Analytics), indicated no new information and repeated the 1/10/23 General Note. A Wound Nurse Practitioner Tissue Analytic form indicated, on 1/17/23 the resident had the following wounds: 1. Right buttock, Stage 3 pressure ulcer, measured 2.53 x 1.39 x 1.0 centimeters (cm) and was present on admission. The ulcer had a moderate amount of drainage with no odor. Treatment: cleanse wound with Dakins (antiseptic) then collagen with bordered foam daily. 2. Left buttock, unstageable wound, measured 4.46 x 3.77 cm and had 70% slough (dead skin tissue that may have a yellow appearance) covering the wound bed. Present at admission. A heavy amount of drainage with malodorous odor. Treatment: cleanse wound with Dakins (antiseptic) then Silver alginate and cover with bordered foam daily 3. MASD (Moisture-Associated Skin Damage) to the buttocks, which measured 8.17 x 6.83 cm with 30 % slough and was present on admission. Wound bed bleeding. Treatment: wound cleanser and then thin layer of Zinc HD to periwound only three times a daily and as needed. A General Note, documented by the Wound Nurse Practitioner, dated 1/24/23, with a date of service of 1/24/23, indicated skin dry/flaky.There is an unstagable wound to the left and right buttock with surrounding MASD; sharp debridement performed today. Will optimize dressing treatment. Alginate to be applied to wound base then fill wound cavity with lightly moistened fluff gauze then apply zinc HD to peri wound A Wound Nurse Practitioner Tissue Analytic form indicated, on 1/17/23 the resident had the following wounds: 1. Right buttock, Stage 3-now an unstageable pressure ulcer, measured 4.29 x 2.37 centimeters (cm) and was present on admission. The ulcer had a heavy amount of drainage with no odor. Treatment: cleanse wound with wound cleanser, apply silver alginate to wound bed then fill wound cavity with lightly-moistened fluff gauze; cover with bordered foam daily. 2. Left buttock, unstageable wound, measured 5.90 x 3.74 cm and had 50% slough (dead skin tissue that may have a yellow appearance) covering the wound bed. Present at admission. A heavy amount of drainage with no odor. Treatment: cleanse wound cleanser then Silver alginate to wound bed then fill wound cavity with lightly- moistened fluff gauze; cover with bordered foam. Change daily and as needed. 3. MASD (Moisture-Associated Skin Damage) to the buttocks, which measured 6.02 x 6.65 cm with 30 % slough and was present on admission. Wound bed bleeding. Treatment: wound cleanser and then thin layer of Zinc HD to peri wound only three times a daily and as needed. A Weekly Skin Review, dated 1/7/23 indicated pre-existing open area-pressure area noted to right buttock. No other information was documented. A Weekly Skin Review, dated 1/14/23, indicated pre-existing surgical wound to right abdomen. Wound vac in place. Coccyx-pre-existing open area. A Weekly Skin Review, dated 1/23/23, indicated pre-existing surgical wound to right abdomen. Coccyx-pre-existing open area. A General Note by LPN2, dated 1/23/23 at 7:16 P.M., indicated .Resident's wounds show no worse symptoms. Moderate drainage observed. Wounds were cleaned up and covered with bordered dressing. No s/s [signs/symptoms] infection observed. Will continue to monitor Follow by another General Note, dated 1/23/23 at the same time, indicated .Residents wounds show no unusual appearance. Copious drainage observed as usual. Wound has both eschar and slough. Skin around wounds red and peeling A General Note, dated 1/27/23 at 4:46 A.M., indicated .911 notified of need for resident to be transferred to [name of hospital] for TX [treatment] and evaluation An emergency room (ER) Physician Report, dated 1/27/23, indicated on exam the patient presented with concerns of altered mental status and fever. The patient's skin was warm and dry. There was a right lower quadrant abdominal wall wound VAC in place with what appeared to be a yellow-white material in the wound VAC. There were multiple areas of unstageable pressure ulcerations throughout bilateral lower extremities on the calves and heels., the ulceration on the right heel, measured approximately 3.0 centimeters, consistent with pressure ulceration. There was a large 2 to 3 deep pressure ulceration over the sacrum with a visible granulation tissue, tenderness surrounding it, surrounding erythema and extreme odor. Patient's skin is extremely dry on the extremities and flaking. The right lower quadrant abdominal wall incision had signs of cellulitis and tenderness with palpation. The ER Medical Decision Making indicated the resident's emergency contact was updated on the patient's condition and was explained that the patient had a .significant risk for morbidity and mortality given his septic shock, severe sepsis, dehydration, unstable a fib [atrial fibrillation], lactic acidosis [body produces to much lactic acid and is produced when oxygen levels become low in the cells], UTI [Urinary Tract Infection], sacral decubitus ulcer with cellulitis, wound VAC site with infection, lower extremity decubitus ulcers The ER Medical Decision Making indicated the physician had contacted APS [Adult Protective Services] regarding the resident's wounds. The hospital CT (Computed Toomography-diagnostic imaging exam) of the Abdomen and Pelvis with Contrast included the following: .4. Soft tissue stranding [term applied to injury of skin, the fat and layers beneath the skin] and locules of gas likely reflecting developing decubitus ulcer subcutaneous soft tissues posterior to the lower sacrum and coccyx with soft tissue stranding and edema extending to the dorsal aspect of the sacrum and coccyx . The following Wound Care Notes & Pictures, dated 1/27/23, provided by the hospital, indicated the following: .Purulent drainage from penis, erosion from Foley catheter. Negative Pressure wound therapy dressing removed. Exudate canister is full of purulent drainage with foul odor. Surrounding skin is moist erythremia, foam dressing was placed directly on skin. No date or time on dressing to indicate when it was changed last. Left medial foot, deep tissue injury, 1.0 x 1.5 cm, surrounding skin blanchable. Right posterior ankle, 4.0 x 2.0 cm, deep tissue injury, wound base purple, surrounding skin is blanchable. Right plantar medial heel, 4.5 x 6. cm, Stage 2 pressure injury intact fluid filled blister. Right plantar lateral heel 0.5 x 1 cm deep tissue injury. Surrounding skin is blanchable. Left anterior medial foot deep tissue injury 5 x 3 cm purple, surrounding skin dry, flakey blanchable. Right lateral foot deep tissue injury 1 x 0.5 cm surrounding tissue is blanchable. Left Sacrum unstageable pressure injury 5 x 4.5 x 2 cm 10% yellow/90% brown slough Left buttock stage 2 pressure injury 4 x 3 deep red to pale pink Medical Sacrum unstageable pressure injury 4 x 2 cm 30% yellow/70% brown slough Right coccyx to buttock unstageable pressure injury 7 x 3 cm 80% pale yellow/20% brown. Surrounding skin is nonblanchable red to purple in color During an interview, on 2/28/23 at 11:40 A.M., the DON indicated the General Notes were completed, by the Wound NP, and were scanned into the facility's system, at a later date. However, the date of service was in the body of the assessment and represented the day the wound care was completed. The DON indicated the Tissue Analytics form was the date the wounds were assessed, treatments were ordered and were available to the unit managers/nurses. On 2/28/23 at 12:12 P.M. an interview was conducted with the DON and LPN/Unit Manager. The Unit Manager indicated on 1/14/23 & 1/23/23 she had completed the form titled Weekly Skin Review. The Unit Manager indicated if there had been any other skin problems or ulcers she would have documented them. The DON explained the Weekly Skin Reviews were when the nurse observes all of the skin and documents on all skin issues. On 2/24/23 at 9:57 A.M., the DON provided a policy titled, Pressure Injury Prevention Guidelines, dated 2021, and indicated the policy was the one currently used by the facility. The policy indicated .Policy: to prevent the formation of avoidable pressure injuries and too promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure injury present .Policy Explanation and Compliance Guidelines: 1. Individualized interventions will address specific factors identified in the resident's risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging wound characteristics) .8. Compliance with interventions will be documented in the medical record .b. For residents who have a pressure injury present: treatment or medication administration records; weekly wound summary charting. 9. The effectiveness of interventions will be monitored through ongoing assessment of the resident and/or wound. Considerations for needed modifications include: a. Development of a new pressure ulcer. b. Lack of progression towards healing or changes in wound characteristics On 2/28/23 at 11:50 A.M., the DON provided a policy titled, Skin Assessment, dated October 2022, and indicated the policy was the one currently used by the facility. The policy indicated .Policy: It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. This policy included the following procedural guidelines in performing the full body skin assessment. Policy Explanation and Compliance Guidelines: 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury The immediate jeopardy that began on 12/30/22 was removed and the deficient practice corrected on 3/2/23 when the facility completed a facility wide skin sweep with Braden scale completed on all residents, care plans updated/revised for any residents identified to be at risk for a pressure ulcer, nursing staff in-serviced on the Pressure Injury Prevention and Management & Weekly Skin Assessment policies, with audits instituted to ensure compliance. This Federal tag relates to complaint IN00400925. 3.1-40(a)(2)

Based on interview and record review, the facility failed to ensure thorough assessments and care was provided for the use of a Foley catheter in 1 of 3 residents. And failed to identify a change in condition which resulted in sepsis and death . (Resident J) The Immediate jeopardy began on [DATE] when the resident entered the facility with a Foley catheter, and the facility did not document catheter care for 8 days and had no documentation of resident's output from the catheter. The resident was sent to a local hospital where he was diagnosed with Sepsis and an Urinary Tract Infection due to the Foley catheter. The resident deceased on [DATE]. The Administrator, the Director of Nursing (DON), Assistant Director of Nursing (ADON), a Regional Nurse and a Registered Nurse (RN) were notified of the immediate jeopardy at 4:28 P.M., on [DATE]. The immediate jeopardy was removed, and the deficient practice corrected, on [DATE]. Finding includes: On [DATE] at 2:28 P.M., a review of the clinical record for Resident J was conducted. The record indicated the resident was admitted to the facility, on [DATE], as a full code and discharged to a local hospital on [DATE]. The resident's diagnoses included, but were not limited to: multiple sclerosis, neuromuscular dysfunction of the bladder, history of urinary tract infections (UTI) and pressure ulcers of the sacral region-Stage III (pressure injury with full-thickness loss of skin). The discharging hospital form titled, Document Review Report, dated [DATE], indicated a baclofen pump replacement had occurred on [DATE], the resident had a history of UTIs, the resident performed self-catheterized on himself once a day, and an indwelling Foley catheter was inserted on [DATE]. The form indicated a CT scan was completed, on [DATE], which indicated the resident had bilateral renal staghorn calculi with a partial obstruction. The Hospital Discharge Report/orders, dated [DATE], indicated .right lower quadrant .wound vac to right lower quadrant, change every other day until wound closure .pt [patient] has neurogenic bladder. Currently with Foley in place. D/c [discontinue] on [DATE] and change to intermittent catheterization BID [twice a day] The Admission Minimum Data Set (MDS) Assessment, dated [DATE], indicated the resident was cognitively intact, required extensive assistance of two people for bed mobility and transfers. The assessment indicated the resident had an impairment of his lower extremity on one side, had an indwelling Catheter (a thin tube inserted into the bladder to drain urine into a drainage bag) was always incontinent of his bowels and was admitted with two Stage 3 pressure ulcers. A care plan, dated [DATE], for the elimination of bowel and bladder indicated the use of an indwelling urinary catheter related to diagnoses of multiple sclerosis with neurogenic bladder with frequent urinary tract infections. The interventions included, but were not limited to: encourage fluids, catheter care every shift, keep drainage bag below level of the bladder at all times, labs as ordered and monitor for signs & symptoms of UTI such as change in color, odor, consistency of urine, fever and pain. There was no documentation regarding the catheter use, discontinuing the indwelling catheter or any urine output results from [DATE] through [DATE]. A Physician's Order, dated [DATE], indicated the Foley catheter use was related to neuromuscular dysfunction of the resident's bladder and for staff to provide catheter care every shift and as needed. Catheter care included the following directions: to cleanse with soap and water, rinse and pat dry as needed and to change Foley drainage bag weekly and as needed. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) for Resident J, for [DATE], indicated the catheter type, size and diagnosis supporting the use of the catheter was to be documented every shift. The documentation was initiated on [DATE]. In addition, the Foley catheter care every shift was initiated on [DATE] The facility had documented the drainage bag changes on ,d+[DATE], ,d+[DATE] and [DATE]. During an interview, on [DATE] at 9:36 A.M., the DON indicated the drainage bag for a Foley catheter was changed once a week. She did not know if Foley was removed on the [DATE] as ordered. She provided an order for the Foley on [DATE] but did not know if it was the same Foley which was already in place at admission. During an interview, on [DATE] at 2:00 P.M., the DON indicated the facility does not document a resident's output of urine unless there was a specific order to do so. Therefore there was no documentation to indicate when the Foley catheter collection bag was emptied and how much urine was removed from the collection bag. The ER (Emergency) Physician Report, dated [DATE], indicated .the skin of the penis and scrotum is erythematous [abnormal redness] without induration. There is an extensive amount of crusting .His Foley catheter was replaced and new urine taken off of new Foley catheter was sent with with evidence of UTI [Urinary Tract Infection] . The Hospital History & Physical (H&P) , dated [DATE], indicated .Foley catheter appears to be very old, it was replaced .Foley in place with purulent urine The H&P Impression and Plan indicated the patient had a fever, septic shock, pleural effusion and had a UTI associated with chronic indwelling Foley catheter. The H&P indicated .the source of sepsis was not clear however, the UTI or pleural effusion could be causing the septic shock The resident was admitted to the ICU (intensive care unit) and passed away on [DATE]. On [DATE] at 9:26 A.M., the DON provide a policy titled, Catheter Care, dated [DATE], and indicated the policy was the one currently used by the facility. The policy indicated .1. Catheter Care will be performed every shift and as needed by nursing personal .8. Empty drainage bags when bag is half-full or every 3 to 6 hours On [DATE] at 9:30 A.M., the DON provided a policy titled, Notification of Changes, dated [DATE], and indicated the policy was the one currently used by the facility. The policy indicated .Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification .Circumstances requiring notification include: .2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial staus. This may include: a. Life-threatening conditions, or b. Clinical complications On [DATE] at 11:16 A.M., the Regional Nurse provided a policy titled, Indwelling Catheter Use and Removal, dated [DATE], and indicated the policy was the one currently used by the facility. The policy indicated .It is the policy of this facility to ensure that indwelling urinary catheters that are inserted or remain in place are justified or removed according to regulations and current standards of practice. Policy Explanation: Indwelling urinary catheters are catheters that remain in the bladder to assist with urinary elimination .Compliance Guidelines .2. Residents that admit with an indwelling catheter or subsequently receives one will be assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that the catheter is necessa [necessary]. 3. If an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures that include but are not limited to .f. Ongoing monitoring for changes in condition related too potential catheter-associated urinary tract infections, recognizing, reporting and addressing such changes .6. Additional care practices include: a. Recognition and assessment for complications and their causes, and maintaining a record of any catheter-related problems .d. Keeping the catheter anchored to prevent excessive tension on the catheter, which can lead to urethral tears or dislodgement of the catheter .7. Catheters and drainage bags should be changed based on clinical indications such as infection, obstruction, or when the closed system is compromised. Routine, fixed intervals is not recommended The immediate jeopardy that began, on [DATE], was removed and the deficient practice corrected, on [DATE], when the facility assessed all residents with indwelling catheters; to ensure no signs or symptoms of infection, nursing staff were in-serviced on the Catheter Care Policy and the Change of Condition policy, which included documentation required, and instituted on-going audits of residents with Foley catheters to ensure compliance. This Federal tag relates to complaint IN00400925. 3XXX,d+[DATE](a)(2)

Based on record review and interview, the facility failed to ensure a resident who was placed on a locked dementia unit related to an attempted elopement was removed, then returned to her normal place of residence after her behaviors subsided and the facility entrances were secured. This resulted in 10 days of repeated tearfulness and verbalizations of believing she was in a mental hospital and wanting to return to her home. This deficient practice affected 1 of 1 residents reviewed for involuntary seclusion. (Resident B) Finding includes: The clinical record for Resident B was reviewed on 10/2/18 at 11:30 A.M., [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), with an assessment reference date of 8/23/18, indicated Resident B was moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 12. A Progress Note, dated 9/22/18 at 4:16 P.M., indicated .Resident noted to be actively exit seeking. Staff attempted to redirect resident who was upset because the staff here stole my wheelchair, and my clothes. This nurse attempted to reassure resident that clothes might be in the laundry. Message left with (guardian) at (local agency) regarding behaviors. PCP (Primary Care Physician) contacted regarding room change to locked unit. Will continue to observe A Progress Note, dated 9/23/18 at 6:01 P.M., indicated .refused to get up for supper. Stated I don't like it here with the crazies, I'm not coming out. I want out of here. We will observe A Progress Note, dated 9/24/18 at 12:15 P.M., indicated .come to nurses station et (and) ask this writer why she was brought here et who made the decision. States I'm not mental, I don't belong here. The social service director is on vacation so this writer called our DNS (Director of Nurses Services) to ask who could come speak to Resident B, DNS was in a meeting et will call unit when out of meeting awaiting return call A Progress Note, dated 9/24/18 at 2:05 P.M., indicated .Spoke with DNS, she states that a social worker will be in the building tomorrow et will speak with Resident B about her questions. I relayed this to Resident B she was accepting of that. Will observe A Progress Note, dated 9/24/18 at 5:13 P.M., indicated .has not wandered et no behaviors except to ask why she is here on the mental unit with all the crazies A Progress Note, dated 9/25/18 at 4:02 P.M., indicated .Resident upset. Approached this writer asking how to get out of this place (Alzheimer's Unit). Believes she is in a mental hospital/unit and doesn't feel she belongs. States she feels like a prisoner . Successfully redirected resident by doing hair and sitting 1:1 allowing time to express feelings appropriately A Progress Note, dated 9/27/18 at 1:58 P.M., indicated .Resident noted very tearful, asking questions of when can I go to my old room, How and when can I get out of here. Spoke with resident 1:1 and notified SS (Social Service) A Progress Note, dated 9/27/18 at 2:00 P.M., indicated .Reported tearfulness and being upset to Social Services. Social Services sat 1:1 while she was eating a sandwich and drinking juice, sitting up in bed. Resident no longer tearful. Asked about getting out of this unit and back to her old room A Progress Note, dated 10/2/18 at 9:23 P.M., indicated .has not displayed any exit seeking. Continues to be cooperative with care. Continues to state that she wants to move back to her old room because she does not belong here with these kind of people During an interview, on 10/2/18 at 12:02 P.M., LPN (Licensed Practical Nurse) 1 indicated that she was the nurse working the day Resident B was exit seeking. LPN 1 indicated Resident B was her normal upset and made allegations that someone had stolen her wheelchair and attempts at redirection were made at that time and it seemed to the nurse interviewed, that Resident B had calmed down and she noted Resident B in the hallway of the unit. LPN 1 indicated she was going about her normal duties when CNA 1 told her that she had been notified by a fell ow resident that Resident B had gotten outside the egress door by the main dining room. CNA 1 then went outside and redirected Resident B back into the facility. LPN 1 indicated she notified the nurse on call of the incident and placed Resident B on 1 on 1 supervision until an appropirate intervention could be made. She was then notified of the decision to move Resident B to the locked unit for her safety and obtained an order and notified the resident's guardian of the room move. During an interview, on 10/2/18 at 12:20 P.M., the MDS Coordinator indicated that she was the nurse on call on 9/22/18 and was notified by LPN 1 that Resident B had gone outside of the egress door by the main dining room but was safely brought back into the facility and placed on 1 on 1 supervision. The MDS Coordinator indicated she then notified the Administrator of the facility and a decision was made to move Resident B to the locked unit of the facility. During an interview, on 10/2/18 at 1:30 P.M., the Administrator indicated she had conducted an investigation into the incident and contacted her superiors and a decision was made to place Resident B on the locked unit of the facility. She had a history of [REDACTED]. During an interview, on 10/2/18 at 2:45 P.M., the Maintenance Director indicated he was aware of the incident that occurred on 9/22/18 and was instructed to come to the facility to disable the egress doors for the safety of the residents. He indicated that a wanderguard system was placed on the main diningroom door and the remainder of the 17 egress doors were disabled and unable to be opened by any person without pulling a fire alarm. A tour of the building was conducted on 10/2/18 at 2:50 P.M., with the DNS and Maintenance Director of the facility. All doors were found to be locked and in good working order. During an interview, on 10/2/18 at 3:57 P.M., the SSD (Social Services Director) indicated that she had been on vacation when the incident of 9/22/18 had occurred and that she had just returned to work on 10/1/18. The SSD indicated she was notified of the incident and interventions put into place but that she had not followed up with Resident B or her guardian as of the time of the interview. The SSD indicated she believed the part-time social worker had spoken with Resident B during her abscence and was not aware of the long term plans for Resident B. During an interview, on 10/2/18 at 4:10 P.M., the social worker indicated she was notified that Resident B had experienced an emergency relocation related to getting out of the facility over the weekend. She indicated she had spoken to Resident B and kept her reassurred. She indicated Resident B was tearful and angry and not wanting to be on the secured unit as she viewed it a mental ward. She indicated she had been told that once exit seeking stopped Resident B could come off the locked unit but had not been instructed that this had taken place. She indicated she only worked one day a week at the facility. During an interview, on 10/2/18 at 4:15 P.M., the guardian for Resident B indicated she was notified on 9/24/18 of a room change for Resident B related to an incident that had occurred on the previous weekend in which she got out of the facility and had been moved to the locked unit for her safety. The guardian indicated a staff member of the agency she worked for had been notified of the room change on the day it occurred. The guardian indicated she did not give permission for the room change, she had been notified it took place but understood why it was a consideration given the history of exit seeking and elopement with regard to Resident B. Resident B's guardian indicated she had attempted to visit Resident B on 9/28/18 to see how she was adjusting but she was unable to speak with her as she was sleeping. She indicated she had wished to speak with her social worker at that time to discuss long term goals for Resident B but was notified the social worker was on vacation. During an interview, on 10/2/18 at 4:30 P.M., Resident B indicated she wanted help, she wanted to get out of the facility, it was restricted to the mentally ill and she did not consider herself mentally ill. Resident B felt the staff were kind and treated her very well but that it was wrong that they didn't ask her to move they just told her she was moving to another room in the facility.Resident B indicated she wanted assistance in returning to her room she had before. A policy titled, Investigation and Reporting of Alleged Violations of Federal and State Laws involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of Resident's Property, provided by the Administrator on 10/3/18 at 12:00 P.M., was reviewed on 10/3/18 at 3:15 P.M. The policy, with an effective date of 12/25/17 indicated .Involuntary Seclusion: Emergency or short-term monitored separation from other residents will not be considered involuntary seclusion and may be permitted if used for a limited period of time as a therapeutic intervention to reduce agitation until professional staff can develop a plan of care to meet the residents needs This Federal tag is related to Complaint IN 346. 3.1-27(a)(4)

Based on record review and interview, the facility failed to ensure an effective intervention to prevent elopements for 7 of 7 residents at risk for elopement. This deficiency resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 6/15/18 when a resident who was at risk for elopement left the building unattended. The Administrator and Director of Nurses were notified of the Immediate Jeopardy on 9/11/18 at 5:14 P.M. The Immediate Jeopardy that began on 6/15/18, but noncompliance remained at the lower scope and severity of pattern, no actual harm with potential for more than minimal harm that was not Immediate Jeopardy. Finding includes: A reportable incident, dated 6/15/18 at 7:30 P.M., indicated .Brief Description of Incident: 6/15/18 The nurse on duty was notified by a resident the (name of Resident B) went out the front door with another resident who routinely goes outside. The nurse went out to find (Resident B) at the end of the side walk sitting in her w/c (wheelchair). Resident (B) was brought back inside and put on 1:1 .Type of preventative measures added--6/15/18 investigation started. The clinical record for Resident B was reviewed on 9/11/18 at 10:30 A.M. Resident B was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) with an Assessment Reference Date of 5/3/17, indicated Resident B had a Brief Interview for Mental Status (BIMS) score of 10, moderate cognitive impairment. Section E of the MDS indicated Resident B had no episodes of wandering. A Admission assessment dated [DATE], indicated Resident B was at risk for elopement. A Care plan dated 9/19/17, indicated .Focus: At risk for elopement related to attempting to leave facility as evidenced by pushing/kicking on doors, and making statement of wanting to go home, to California, wanting to get out of this place, etc. (example)Also at risk r/t (related to) not believing she requires assistance and is safe to be in her own apartment .Goal: I will not elope through my next review. Revision on: 5/31/18 .Interventions: Encourage activity attendance .Involve the patient in decision making regarding daily choices .Redirect from doors as necessary .Update elopement book as needed .Wanderguard on person A Progress Note, dated 6/15/18 at 7:00 P.M., indicated .When the nurse returned to the cart from passing medication, another resident wheeled up to the nurse and reported, (Resident B) just followed another resident outside. The nurse immediately went out the front doors and observed (Resident B) wheeling down the sidewalk towards the parking lot. The nurse attempted to reason with (Resident B), explaining, (Resident B), you don't have anyplace else you can go. She replied, Yes I do! I have a brother who lives on the other side of town. I'll f****** hitch hike if I have to. The nurse said, That's not safe, and that's our first concern for you. She said, B*******! Nobody here gives a f*** about anyone! I f****** hate this place! As the nurse thought about what to say next, (Resident B) said, You don't need to stay out here with me. The nurse said, Yes, I do. I'm responsible for your safety, as he put his hands on her wheelchair handles. (Resident B) grounded her feet and gripped her wheels and screamed, I'm not going back to that f****** place.! The nurse called the facility to ask for extra help, Two CNA's and another nurse came out to try to talk to (Resident B) and convince her to cooperate. (Resident B) continued to be belligerent, yelling and swearing even as families with children walked past. As (Resident B) tried to work her way towards the parking lot, nursing staff came to the last resort of picking up her feet and wheeling her back in. The whole way back to the facility, (Resident B) slapped, pinched, kicked, and pulled hair. She also tried to throw herself out of her wheelchair more than once. Once staff got (Resident B) back to the unit, another nurse suggested closing the doors beside the nurse's station to help keep (Resident B) away from the doors. (Resident B) immediately demonstrated her ability to kick those doors open. A CNA came from south unit to temporarily be (Resident B's)1:1. As staff were making several phone calls to obtain orders and give notifications regarding her behaviors, even as her assigned 1:1 tried talking to her about needing to be nice, she remained verbally hostile, calling staff w*****, a*******, b******, interjecting everything staff said to one another During an interview, on 9/11/18 at 2:30 P.M., the DON (Director of Nursing) indicated that Resident B was placed on 15 minute checks after the incident on 6/15/18 and that she was sent to a psychiatric facility until she returned to the facility on [DATE]. A Progress Note, dated 7/27/18 at 10:43 A.M., indicated . At 8 P.M. resident (B) was wanting me to call her a cab. I informed her I could not do that. She was upset because she had no cigarettes. Patient stated she was tired of this place and she was leaving. I then went to my cart to get her evening medications for her and when I looked back up she was not at the desk. I then went to her room and she was not there, after looking everywhere I could a resident in the lobby told me that the patient had went out of the front door. I went out and saw patient coming on the side of (name of street - highly traveled road). I hurried back in to get help an aide and I went out to patient she was stating that she wasn't coming back in. I then promised her that I would get her a cigarette and she could go out to have it with aide if she let us bring her in and she did and then the aide took her to smoke at (sic) 2030 (8:30 P.M.). Writer notified ED (Executive Director) & ADON (Assistant Director of Nurses). Writer assessed resident for pain/discomfort and done a skin assessment on the resident 15 minute checks have been initiated and continue A Progress Note, dated 8/1/18 at 5:20 P.M., indicated .Notified around 4 P.M. that (Resident B) was by the main exit stating that she was going to leave. Staff attempted multiple interventions ( i.e. 1:1, new staff, ice cream, etc.) which were not effective .Multiple other staff members attempted to redirect (Resident B), with one being successful in getting her to go smoke for the 5 P.M. smoke time. On 9/11/18 at 1:30 P.M., Resident B was observed in the outside designated smoking area of the facility. Resident B presented with a Wanderguard attached to the back of her wheelchair. During an interview, conducted with the DON on 9/11/18 at 2:35 P.M., the DON indicated that Resident B was placed on 15 minute checks from 7/27/18 through 8/18/18 and a Wanderguard had been placed on the resident's wheelchair but no further interventions had been implemented at that time. During an interview, on 9/11/18 at 11:45 A.M., the Maintenance Director indicated that the facility had a locked door system and when questioned about the monthly checks with the Wanderguard system the Maintenance Director indicated that the facility used a pendant system, but it was obsolete because the locked door system was so old it it did not recognize when a pendant was near. The Maintenance Director indicated he had been trying to get approval for a new system that would lock when a Wanderguard was near for the past year. He did not indicate when he became aware the Wanderguard system was not working. During an interview, on 9/11/18 at 12:00 P.M., the ED indicated she began getting quotes for a new Wanderguard system as soon as she was notified the current system was not working. She was notified after the 7/27/18 incident had occurred. The ED provided quotes for a new Wanderguard and camera system but it had not been installed at the time of the interview. During a tour, conducted with the maintenance director's assistant on 9/11/18 at 12:30 P.M., the assistant indicated the facility had a pendant system in place that when a resident who was wearing one and approached an exit door it would automatically lock and prevent the resident from leaving the facility. Upon demonstration, every door that had the Wanderguard system installed remained unlocked when approached with a pendant. A Physicians Order for Resident B, dated 6/22/18 indicated .Wanderguard check placement and function every day and night shift . Although the facility reported a malfunctioning Wanderguard system for the past year, the Treatment Administration Record from 5/1/18 thru 9/11/18 indicated Resident B's Wanderguard had been checked as per physician's orders [REDACTED]. During an interview, on 9/14/18 at 10:58 A.M., RN 1 indicated wanderguards are to be checked every shift by using .a little machine that you point at the resident's wanderguard and it will tell you if it is working or not and if the wanderguard is deemed to not be working the staff are to change the battery or the wanderguard itself. During an interview, on 9/11/18 at 11:05 A.M., the Maintenance Director indicated the wanderguard system was obsolete and it was pointless to do weekly checks. During an interview, on 9/14/18 at 11:00 A.M., LPN 2 indicated that all residents who utilize a wanderguard have it checked every shift. On 9/11/18 at 10:30 A.M., the Medical Records Director provided a copy of the Elopement Guidelines, with the effective date of 1/12/2017, indicated .Prevention: Each Living Center has a system of identification of residents. The method is designed to assist law enforcement and others in identifying a resident who has left the facility without staff knowledge .Resident or responsible party is given instruction on the living center LOA or out-on-pass policy. Staff will observe that each resident's bracelet alarm/device is still in place each shift .Establish a process to check bracelet alarm/device batteries according to manufactures directions .document findings on the TAR or other form of documentation. A specific system has been developed to notify staff that an external door has been opened in an area accessible to residents .Door alarms are tested daily. The results of the tests are then recorded on designated log .Only the Executive Director/or designee may authorize disabling the alarm system and is responsible for the method of monitoring for resident safety and resetting the alarm .When door alarm batteries are required to be changed, the door alarm must be re-tested immediately after the change occurs and documented on the log .Maintain roster of bracelet battery expiration dates and replace personal alarms/devices according to manufacturer's recommendations The Immediate Jeopardy that began on 9/11/18, was removed on 9/14/18, when the facility implemented round the clock monitoring, training and a new Wanderguard system to ensure all residents were safe to move freely about the facility without the threat of elopement but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that was not Immediate Jeopardy because of the facilities need to continue monitoring, employee inservice's and completion of the installation of Wanderguard system. This Federal tag is related to Complaint IN 369. 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to provide supervision to a resident with dementia, known exit seeking behaviors and identified as an elopement risk, resulting in an elopement of 1 of 8 residents reviewed, who were at risk for elopement. (Resident D) The Immediate Jeopardy began on 6/29/17 at 7:00 A.M., when the facility failed to ensure a door frame and lock was repaired in the Activity storage area to prevent a resident from entering the area. This allowed Resident D access to an exit door, in the storage area, which didn't alert staff to the resident's departure from the facility, resulting in the resident's elopement from the facility and a minor injury. The Administrator and the Director of Nursing (DON) were notified on 7/3/17 at 3:30 P.M. The Immediate Jeopardy was removed on 7/3/17, 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. Finding includes: On 7/3/17 at 12:50 P.M., the Activity storage room door was observed with the Administrator. The old door, to the storage area, was lying inside the storage area and a new door, which locked, was observed. Inside the storage area an exit door was observed. On the exit door, at arms length, was an on/off switch located on the right side of the door. The Administrator indicated the switch, on the exit door turned the alarm on or off but it was no longer used due to a new alarm system was currently on the exit door. On 7/3/17 at 1:05 P.M., Resident D was observed on a Dementia Unit with hospitality aide #2. The aide indicated she was providing one on one care/observation for the resident due to a recent elopement. The resident was observed to have a wanderguard (a departure alert system) on his left ankle. The resident's right knee was observed to have numerous small scabs. The resident could not recall what he did to receive those scabs and thought the current month was February. During an interview, on 7/3/17 at 1:24 P.M., the Activity Aide #3 indicated when she arrived to the facility on Thursday morning, on 6/29/17 at 7:00 A.M., she noticed the door to the storage area had been kicked open and was no longer able to be locked. She contacted maintenance by 8:00 A.M. Aide #3 indicated the Maintenance Assistant #4 was looking at the door when she left for the day, around 3:00 P.M. The Activity Aide indicated she had not informed the Administrator of the door's condition. The Activity Aide indicated the exit door, in the storage area, had no sounding alarm on it and was used frequently to allow the residents access to the raised garden beds. During an interview, on 6/3/17 at 1:40 P.M., the Maintenance Assistant #4 indicated someone had pushed hard enough on the door that a piece of wood had broken off and made the door unable to lock. He recalled he had gone to the activity storage area to observe the problem. He notified the Director of Maintenance of the situation and went on to complete another concern at the time. The Maintenance Assistant #4 indicated the Director was driving the bus and didn't get back until late Thursday evening. The Director told Maintenance Assistant #4 he would fix the door the next morning. The Maintenance Assistant #4 did not inform the Administrator of the situation but had done the daily alarm check on the door. The Maintenance Assistant #4 indicated he came to the facility early Friday morning due to the elopement and he observed the on/off switch on the exit door to be in the off position. He indicated a local lock/alarm company was contacted to install a new lock and keypad on the exit door, in the storage activity area and to check all exiting doors to ensure the alarms and locks were functioning properly. An interview was conducted, on 7/3/17 at 2:00 P.M., with the local lock/alarm worker who came to the facility on [DATE] to inspect the exit door in the activity area. Upon his arrival to the facility, he indicated the exit door had a switch alarm in place. When the switch was placed in the on position an alarm would go off at a nurses station. When he checked the alarm sound he indicated the sound was weak and didn't tell the nurse where the alarm was coming from and would only alarm as long as the door was open. He suggested to the facility to replace with a door anniciator, which would alarm until someone inserted the code number into a keypad, which the facility had him install that day. On 7/3/17 at 2:15 P.M., a review of the clinical record for Resident D was conducted. The record indicated the resident was admitted on [DATE]. The resident's [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment, dated 5/29/17, indicated the resident's Brief Interview for Mental Status (BIMS) score was 3 (severe cc cognition loss), needed supervision of 1 person when walking on/off the unit and had wandering behavior which occurred 1-3 days of the assessment period. A form titled Elopement Risk Decision Tree dated 5/22/17, indicated the resident was at risk for an elopement. The form indicated one intervention was a personal safety alarm device to prevent an elopement. A care plan, dated 5/22/17, indicated the resident was at risk for an elopement related to his [DIAGNOSES REDACTED]. The interventions included but were not limited to: picture in elopement book, redirect resident from the doors and wanderguard on. The intervention to place resident on 1 to 1 care/supervision was added to the interventions on 6/30/17. A General Note, dated 6/30/17 at 1:55 A.M., indicated .At the start of this writers shift at 6pm, resident was noted on south west unit with exit seeking behaviors. He was redirected to East Unit where he lives. This nurse started medication administration and noted resident with exit seeking behaviors. One of the staff members a C.N.A. (Certified Nursing Aide) stated to this writer that he was exit seeking the day before and was caught with one of his legs through his window of his room. Windows in rooms on east are set not to completely open. Resident was seen approximately 30 minutes before this writer noted him missing around one thirty. At which time staff started a complete search of the facility, rooms and grounds Another General note indicated the Administrator, the DON, the ADON (Assistant Director of Nursing) and 911 were called and notified of the elopement. The physician and sister were also notified of the elopement. A General Note, dated 6/30/17 at 9:10 A.M., indicated .Resident returned to facility accompanied by two officers from the Elkhart Police Department. Resident ambulating per self, wearing a sweatshirt, shorts, and shoes. Speech normal for resident, speaks nonsensically about cars and buying and selling cars, answers questions with nonsensical statements but denies pain. Writer noted superficial area of abraised skin noted to Right knee. When asked the origin resident stated, I slipped although denied pain when asked. Clothing is appropriate for the weather outside and resident denies being cold or hot. Upon entering the facility, wanderguard remains in place and is active A timeline received from the Administrator, dated 6/30/17, indicated the resident was found at a car lot less than 2 miles away, sitting inside a car. The owner of the car lot contacted the police department, who transported the resident back to the facility. On 7/3/17 at 1:30 P.M., the Administrator provided a policy titled Elopement Guidelines, dated October 2015 and indicated the policy was the one currently used by the facility. The policy section titled Door Alarms and Resident Protection Alarms indicated .a specific system has been developed to notify staff that an external door has been opened in an area accessible to residents. *Door alarms are tested daily .Only the Executive Director/or designee may authorize disabling the alarm system and is responsible for the method of monitoring for resident's safety and resetting the alarm The Environmental Guidelines part of the policy indicated .The Living Center will identify such environmental hazards such as entrances, stairwells, or exits that pose a foreseeable danger to residents who wander or have an exit seeking behavior. The Living Center will implement interventions to minimize these risks and hazards as appropriate The immediate jeopardy that began on 6/29/17 was removed on 7/3/17 when the facility implemented systematic changes, such as: in-servicing all staff on elopement guidelines, door alarm/window checks and elopement drills were increased, and any repairs and/or work orders will be documented and brought to morning meeting for discussion/review/ and prioritized with the Administrator, but the non-compliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that was not immediate jeopardy because of the facility's need to continue in-services and monitoring of the resident. This Federal tag relates to complaint IN 166. 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to provide supervision to prevent resident to resident altercations on the secured Alzheimer's unit, resulting in 1 resident sustaining a fracture (Resident #C) and 2 residents being sent to the hospital (Resident #E and #F). This deficiency affected 5 of 5 residents whose behaviors were reviewed and who were involved in 3 resident to resident altercations on the secure Alzheimer's Unit, in a sample of 5. (Resident #B, #C, #D, #E, #F) Findings include: 1. On 3/9/12 at 10:00 a.m., during the orientation tour, the DON (Director of Nursing) indicated Resident #F hit Resident #E and was moved off the secure Alzheimer's unit. The DON indicated Resident #F was doing well on his new unit and had had no altercations since he moved. Resident #F was observed in his room and gave a pleasant greeting when his room was entered. The incident investigation, completed on 2/21/12, indicated on 2/18/12 at 2:40 p.m., staff on the Alzheimer unit heard yelling coming from the large dining room on the unit. The investigation indicated staff observed Resident #F standing over Resident #E swinging his fists, and Resident #E was on the floor with her hands on her head. Resident #E sustained a 5 cm bruise on her forehead and a 9 cm bruise on her right posterior head. Resident #F sustained a superficial abrasion to the left forehead and a 1 cm abrasion to the upper left forehead. The investigation further indicated Resident #F was transferred to a behavioral unit, and Resident #E was transferred to the hospital for evaluation of her head injuries. The clinical record of Resident #E was reviewed on 3/12/12 at 9:30 a.m. and indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) Assessment, dated 2/24/12, indicated Resident #E had severe cognitive impairment (scoring 3 of 15 on the Brief Interview of Mental Status) and required supervision for transfer and ambulation. Nursing notes, dated 2/18/12 at 4:34 p.m., indicated staff heard yelling coming from the large dining room and found a resident standing over Resident #E swinging his fists. The note indicated Resident #E said, "He and I got into it and he hit me." The note indicated Resident #E complained of discomfort to her head and was transferred to the hospital at 3:40 p.m. The hospital CT (Computerized Tomography) Scans, dated 2/18/12, indicated the resident had a scalp hematoma but no acute intracranial abnormality, acute intra-abdominal abnormalities and no acute fractures. Nursing notes, dated 2/18/12 at 9:30 p.m., indicated Resident #E returned from the hospital at 9:15 p.m. with no new orders. On 3/12/12 at 10:00 a.m., Resident #E was observed up walking on the Alzheimer's secure unit. The resident was carrying a Bible and wearing a straw hat. She expressed no concerns. On 3/13/12 at 12:30 p.m., the Alzheimer Unit Manager was interviewed. She indicated, on 2/18/12, at the time of the altercation between Resident #E and #F, she was at the nurses station with another staff person, two nurses were in the medication room and an aide was on the floor providing care. The Unit Manager indicated she heard yelling and was the third person to arrive in the dining room. She indicated no one actually saw who started the altercation. 2. On 3/9/12 at 10:30 a.m., during the orientation tour, accompanied by the DON (Director of Nursing) Resident #C was observed sitting on the secured Alzheimer Unit porch area with a red cast on her right arm. On 3/9/12 at 10:30 a.m., the DON was interviewed and indicated there was an altercation between Resident #B and Resident #C, which resulted in Resident #C falling and fracturing her wrist. At this time, a stop sign was observed across the entry to Resident #C's room. The incident investigation, completed on 2/28/12, indicated on 2/27/12 at 7:30 p.m., Resident #C was in her room on the Alzheimer Unit and Resident #B entered the room. Resident #C did not want the resident in her room, and she began to push Resident #B. Resident #B pushed back and Resident #C fell on the floor. The investigation indicated an x-ray was obtained which showed Resident #C had a fracture of the right distal radius, and she was sent to the hospital for treatment. The clinical record of Resident #C was reviewed on 3/9/12 at 2:30 p.m. and indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) Assessment, dated 1/27/12, indicated Resident #C had severe cognitive impairment (scoring 7 of 15 on the Brief Interview of Mental Status) and required supervision for transfer and ambulation. Nursing Notes indicated the following: On 2/27/12 at 9:58 p.m., "Pt (Patient) was in her room and another pt (patient) was in her room and trying to get him out and he pushed her to get her out of the way and she lost her balance and fell to the floor." On 2/28/12 at 12:06 a.m., an order was received to send the resident to the emergency room for treatment. On 2/28/12 at 6:34 a.m., indicated the resident returned to the facility at 4:00 a.m. On 3/9/12 at 12:30 p.m., Resident #C was asked about the cast and indicated she was "battling" the resident across the hall and slipped. She indicated she lost patience with him, because he came in her room every day. On 3/9/12 at 2:45 p.m., LPN #10, who was working on the day Resident #C fell , was interviewed. She indicated she was just coming back from lunch on 2/27/12 and she heard Resident #C yell, so she immediately went to the room and saw Resident #C falling into the hall by her doorway. She indicated she called for assistance. LPN #10 indicated no one actually saw the altercation. 3. On 3/9/10 at 10:30 a.m., during the orientation tour on the Alzheimer's secured unit, the DON (Director of Nursing) indicated, in addition to the altercation with Resident #C, Resident #B was involved in a second altercation with Resident #D. The DON indicated Resident #B wandered into Resident #D's room, and Resident #D hit Resident #B in the face with a shoe. The DON indicated a stop sign was placed across Resident #D's door. The investigation, completed on 3/4/12, indicated on 3/4/12 at 3:30 p.m., Resident # D was in his room when Resident #B wandered into his room. Resident #D became upset and was able to hit Resident #2 in the left cheek twice, with his shoe, before staff could intervene. The investigation indicated there was a quarter sized abrasion on Resident # B's left cheek. The investigation indicated Resident #B was unable to follow orders or to move out of dangerous situations and "needs constant supervision." The clinical record of Resident #B was reviewed on 3/9/12 at 11:00 a.m. and indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) Assessment indicated the resident had severe cognitive impairment (scoring 0 out of 15 on the Brief Interview of Mental Status) and required supervision for ambulation. Nursing Notes indicated the resident wandered frequently on the Alzheimer Unit, as follows: On 2/19/12 at 1:21 p.m., "...Conts (continues) to wander in and out of other pts' (patients') rooms, and will climb in any empty bed. Very difficult to redirect...." On 2/22/12 at 8:27 a.m., "...was noted to wander into other resident's room on 2/21/12..." On 2/27/12 at 10:00 p.m., "PT (Patient) wondering (Sic) into other pt's rooms on this shift...." 3/6/12 at 8:03 a.m., "noted to be wandering into other's rooms...." During interview on 3/9/12 at 2:50 p.m., CNA #11, who was working at the time of the altercation between Resident #B and #D, indicated she heard a noise and went to check. She indicated Resident #D's door was blocked, so she went through an adjoining bathroom to gain access to Resident #D's room. CNA #11 indicated when she entered the room, Resident #D was hitting Resident #B in the face with his shoe. She indicated she was able to separate the residents. On 3/9/12 at 4:00 p.m., Resident #B was observed entering another resident's room and lying in the bed. No other resident was in the room. Staff were providing activities and care at the time the resident entered the room and did not redirect the resident. This federal tag relates to Complaint IN 860. 3.1-45(a)(2)