Every finding on record at Brickyard Healthcare - Knox Care Center

Based on observation, record review, and interview, the facility failed to ensure care plans were implemented and/or updated for 1 of 15 resident care plans reviewed. (Resident 43) Finding includes: On 3/30/25 at 10:38 a.m., Resident 43 was observed lying in bed. There was a dime-sized scabbed area to his left upper cheek/temple area. The resident indicated he was unsure what happened or how long the scabbed area had been there. On 3/31/25 at 3:05 p.m., Resident 43 was observed lying in bed. The scabbed area remained to his left upper cheek/temple area. On 4/1/25 at 8:58 a.m., Resident 43 was observed lying in bed. The scabbed area remained to his left upper cheek/temple area. The record for Resident 43 was reviewed on 4/1/25 at 2:57 p.m. Diagnoses included, but were not limited to, dementia, type 2 diabetes mellitus, and hypertension. The Annual Minimum Data Set (MDS) assessment, dated 1/3/25, indicated the resident was cognitively impaired and required staff assistance with activities of daily living (ADLs). A Care Plan, dated 11/7/24, indicated the resident had a scab to the left temporal area. The interventions included to monitor the area and document weekly. There was a lack of documentation of any skin-picking behaviors by the resident or why the scabbed area remained unhealed. A Skin Check Note, dated 3/27/25, indicated the resident had a scab to the left temporal area measuring 2 cm (centimeters) by 1 cm. The wound was acquired in house and was greater than 3 months old. It was previously improving but progress had stalled. There was a lack of documentation of any skin-picking behaviors by the resident or why the scabbed area remained unhealed. During an interview on 4/2/25 at 1:47 p.m., the Director of Nursing (DON) indicated the resident had the scabbed area for a while now and would pick at the area frequently. She thought the skin-picking behaviors had been documented and care planned but was unable to provide any documentation. A treatment had been attempted to the area but was discontinued due to the resident continually picking at the area. 3.1-35(c)(1)

Based on record review and interview, the facility failed to ensure residents received necessary care and services, related to lack of monitoring of sleep patterns per the care plan for 1 of 1 resident reviewed for care planning. (Resident 22) Finding includes: On 3/30/25 at 10:48 a.m., Resident 22 indicated she had been having difficulty sleeping at night and it had been ongoing since she had her trazodone (antidepressant) discontinued. Resident 22's record was reviewed on 4/1/25 at 1:12 p.m. Diagnoses included, but were not limited to, major depressive disorder, insomnia, and seizures. The Quarterly Minimum Data Set (MDS) assessment, dated 1/6/25, indicated the resident was cognitively intact. She had received antidepressant, opioid, and anticonvulsant medications during the 7-day look back period. The Physician Order Summaries indicated the resident had an order for trazodone 150 milligram (mg) one tablet in the evening which was started on 12/4/24 and discontinued on 5/20/24. On 5/20/24, a new order was started for trazodone 100 mg one tablet in the evening, which was discontinued on 6/3/24. On 6/3/24, a new order was started for trazodone 50 mg one tablet in the evening, which was discontinued on 6/17/24. A Care Plan, updated on 12/10/24, indicated the resident was at risk for sleep pattern disturbance related to insomnia or not being able to sleep. Interventions included, but were not limited to, administer sleep medications as ordered by the physician, assess for side effects, and assess usual pattern of sleep. A Care Plan, updated on 12/10/24, indicated the resident had depression related to a major depressive disorder diagnosis. Interventions included, but were not limited to, administer medications as ordered and provide psychiatry consult if indicated. A Psychiatry Progress Note, dated 3/17/25, indicated the resident continued to report ongoing concerns with sleep and depression. The diagnoses and plan indicated the resident had sleep disorder and staff were monitoring sleep patterns due to reports of poor sleep. The record lacked documentation of any monitoring of sleep patterns. During an interview on 4/1/25 at 4:00 p.m., the Director of Nursing indicated she was not aware the resident was having complaints of trouble sleeping. There was no documentation in the record for monitoring of the resident's sleep patterns. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure indwelling Foley (urinary) catheter tubing was kept off of the floor for a resident with a history of urinary tract infections (UTIs) for 1 of 1 resident reviewed for urinary catheters. (Resident 46) Finding includes: Resident 46 was observed on 3/31/25 at 3:35 p.m., 3:44 p.m., and 4:14 p.m. sitting in a manual wheelchair in the East Hall near the nurses' station. The catheter collection bag was hanging in a dignity bag under the chair. The tubing was touching the floor. During observations of the resident, a nursing staff member was sitting at the nurses' station across from the resident and a medication pass administration observation was ongoing from 3:35 p.m. to 3:55 p.m. with QMA 1 in the same hall. Resident 46's record was reviewed on 4/1/25 at 9:14 a.m. Diagnoses included, but were not limited to, chronic kidney disease, history of urinary tract infections, and retention of urine. The Admission 5-day Minimum Data Assessment, dated 3/9/25, indicated the resident was severely cognitively impaired and had an indwelling catheter. The April 2025 Physician Order Summary indicated the resident had a urinary catheter and was currently taking macrobid (antibiotic) 100 mg, one capsule twice a day for a urinary tract infection (UTI) for 7 days. A Care Plan, dated 3/4/25, indicated the resident had an indwelling urinary catheter. Interventions included, but were not limited to, provide catheter care per orders, monitor for signs and symptoms of UTI, and monitor intake and output. On 3/31/25 at 4:25 p.m., the Director of Nursing was notified of the catheter on the floor. She indicated the catheter dignity bag needed to be adjusted so that it hung higher under the chair, she immediately took the resident to her room so that she could adjust the bag and get the tubing off of the floor. A policy related to catheters was received and was not applicable to the concern. 3.1-41(a)(2)

Based on record review and interview, the facility failed to ensure timely follow up on dietary recommendations was completed for a resident with a history of weight loss for 1 of 3 residents reviewed for nutrition. (Resident 38) Finding includes: Resident 38's record was reviewed on 3/31/25 at 1:37 p.m. Diagnoses included, but were not limited to, chronic kidney disease and heart failure. The resident admitted to the facility on [DATE], discharged on [DATE], and was readmitted on [DATE]. The Admission Minimum Data Set (MDS) assessment, dated 3/5/25, indicated the resident was severely cognitively impaired and had weight loss while not on a prescribed weight-loss regimen. A Care Plan, updated on 3/5/25, indicated the resident had a potential nutritional problem related to a diet restrictions, weight loss over the last 30 days, and the resident having a large weight loss between discharge home and readmission. Interventions included, but were not limited to, administer medications as ordered, monitor intake and record every meal, and the Registered Dietician was to evaluate and make diet change recommendations as needed. The resident weighed 244.6 pounds (lbs) on 2/7/25, 205.8 lbs on 2/28/25, and 218 lbs on 3/28/25. A Physician Order, dated 2/28/25, indicated no salt packet diet, regular texture and regular consistency. A Nutrition Assessment, dated 3/4/25, indicated a recommendation for 30 milliliters ProT gold daily (a protein supplement) due to skin impairments and ice cream at lunch to aid with weight maintenance. There were no updated dietary or physician's orders related to ProT gold daily or ice cream at lunch. During an interview on 4/1/25 at 1:35 p.m., the Director of Nursing (DON) indicated the Registered Dietician sent email updates regarding any new recommendations. The DON did not recall receiving any update around that time for the resident so the recommendations were not implemented. A policy titled, Nutritional Management, revised on 1/1/25, indicated .4. Monitoring/revision .e. Nutritional recommendations may be made by the dietitian based on the resident's preferences, goals, clinical condition or other factors and followed up with the physician/practitioner for orders as per facility policy, if indicated. Best practice to address RDN recommendations is within ~72 hours . 3.1-46(a)(1) 3.1-46(a)(2)

Based on record review and interview, the facility failed to maintain clinical records that were complete and accurately documented related to the lack of documentation prior to a urinalysis being completed on a resident for 1 of 1 resident reviewed for UTIs (urinary tract infections). (Resident 9) Finding includes: Record review for Resident 9 was completed on 4/1/25 at 2:20 p.m. Diagnoses included, but were not limited to, hypertension, diabetes mellitus, and dementia. The Quarterly Minimum Data Set assessment, dated 1/9/25, indicated the resident was moderately cognitively impaired. The resident had an indwelling urinary catheter. A Care Plan, dated 11/20/24, indicated the resident had an indwelling urinary catheter related to obstructive and reflux uropathy. An intervention included to monitor/record/report to physician any signs or symptoms of UTI which included: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse,increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, or change in eating patterns. A Progress Note, dated 3/19/25 at 2:13 p.m., indicated the urinalysis was reviewed by the physician. A new order for an antibiotic was received. There was a lack of documentation in the Progress Notes or Assessments prior to 3/19/25 to indicate why the urinalysis was completed. During an interview on 4/1/25 at 4:00 p.m., the Director of Nursing indicated the urinalysis was completed on the resident because he was not acting like himself. The urine in his catheter tube and bag was cloudy and discolored, he was pale, and he complained of back pain. They completed the urinalysis and the resident had met the criteria for an antibiotic. There was no documentation she could provide that was completed before the note about the urinalysis results on 3/19/25. 3.1-50(a)(2)

Based on observation, record review, and interview, the facility failed to ensure infection control guidelines were in place and implemented related to not changing gloves and performing hand hygiene during a wound treatment for 1 of 2 residents reviewed for pressure ulcers. (Resident 14) Finding includes: On 4/1/25 at 8:57 a.m., LPN 1 was observed completing Resident 14's wound care. She donned a gown and gloves, removed the resident's left heel protector boot and sock, removed her gloves and washed her hands. She donned new gloves and cleaned the resident's left heel wound. She then applied the treatment to the wound. After completing the treatment, she removed her gloves and washed her hands. LPN 1 had not changed her gloves or performed hand hygiene after cleaning the wound and before applying the treatment to the wound. During an interview on 4/1/25 at 9:40 a.m., the Director of Nursing (DON) indicated LPN 1 told her she thought she had changed her gloves after cleaning the wound. A facility policy, titled Clean Dressing Change, provided by the DON as current, indicated, .12. Cleanse the wound as ordered, taking care to not contaminate other skin surfaces or other surfaces of the wound .Pat dry with gauze .14. Perform hand hygiene and put on clean gloves. 15. Apply topical ointments or creams and dress the wound as ordered. Protect surrounding skin as indicated with skin protectant .17. Discard disposable items and gloves into appropriate trash receptacle and perform hand hygiene . 3.1-18(b)

Based on record review and interview, the facility failed to ensure a comprehensive care plan was developed and in place for pain for 1 of 16 resident care plans reviewed. (Residents 21 and 20) Findings include: 1. The record for Resident 21 was reviewed on 6/25/24 at 11:55 a.m. Diagnoses included, but were not limited to, hypertension, Parkinson's disease, and unspecified pain. The Quarterly MDS assessment, dated 4/9/24, indicated the resident was cognitively impaired, received opioid medication, and scheduled pain medication. The Physician Order Summary, dated 6/2024, indicated the resident was to receive tramadol (an opioid pain medication) 50 mg (milligrams) twice a day. The Medication Administration Record (MAR), dated 6/2024, indicated the resident had received the tramadol medication twice a day. During an interview on 6/26/24 at 9:38 a.m., the Director of Nursing (DON) indicated the care plan should have been in place. They had recently completed a mock survey and identified some issues with care plans. During an interview on 6/28/24 at 11:03 a.m., the [NAME] President of Regulatory Compliance (VPRC) indicated they had completed a mock survey a couple weeks ago and identified issues with care plans. They had completed an inservice and started audits. She provided the care plan audits, but the audits were for care plans related to anticoagulant medication and skin issues. 45666 2. Resident 20's record was reviewed on 6/25/24 at 1:59 p.m. Diagnoses included, but were not limited to, dementia and renal cancer. The Quarterly Minimum Data Set (MDS) assessment, dated 4/18/24, indicated the resident was severely cognitively impaired for daily decision making. She required assistance with activities of daily living including, oral hygiene, toileting hygiene, showering, and personal hygiene. While a resident, she received insulin injections, antidepressants, opioids, and hypoglycemic medications. The June 2024 Physician Order Summary indicated the resident received a scheduled Norco (opioid pain medication) 5-325 milligrams (mg) twice daily and Norco 5-325 mg every 12 hours as needed. There was no care plan related to pain or opioid medication use. During an interview on 6/26/24 at 10:33 a.m., the DON indicated the care plan should have been in place. During an interview on 6/28/24 at 9:02 a.m., the VPRC indicated they had identified a problem with their care plans and had begun auditing to correct the issue. A facility policy, titled Comprehensive Care Plans, received as current, indicated, .2. The comprehensive care plan will be developed within 7 days after completion of the comprehensive MDS assessment. All Care Assessment Areas triggered by the MDS will be considered in developing the plan of care .The facility's rationale for deciding wheter to proceed with care planning will be evicenced in the clinical record. 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 practicalbe physical, mental, and psychosocial well-being . 3.1-35(a)

Based on observation, record review and interview, the facility failed to ensure care plans were implemented and/ or updated with changes for 3 of 16 resident care plans reviewed. (Residents 44, 21, and 32) Findings include: 1. On 6/25/24 at 9:47 a.m., Resident 44 was observed in her bed. She had a tubi grip (type of compression stocking) on her left leg and she had a wound vac attached to her right leg. The resident's record was reviewed on 6/26/24 at 11:45 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, unspecified wound to right and left lower leg, cellulitis and Diabetes Mellitus. The Admission Minimum Data Set assessment, dated 5/16/24, indicated the resident was cognitively intact and received care for a surgical wound. A General Note, dated 6/10/24, indicated the resident had returned from the wound clinic with new orders for a wound vac to right lower leg at 125 mm/hg (millimeters of mercury). A Physician's Order, dated 6/10/24, indicated to ensure wound vac properly functioning at 125 mm/hg every shift. A Physician's Order, dated 6/19/24, indicated to change the wound vac three times and week. Cleanse the wound on right lower leg with wound cleanser, rinse wound with normal saline and pat dry. Apply barrier film to skin surrounding wound, apply black foam to base of wound and adhere with wound vac adhesive. A Skin Care Plan initiated, 5/21/24, indicated the resident had a surgical wound to the right shin. Interventions included, but were not limited to, weekly skin assessment by licensed nurse, encourage good nutrition, monitor for signs of infection and keep incision site clean and dry. There was no intervention related to use of a wound vac. During an interview on 6/27/24 at 10:00 a.m., the Director of Nursing indicated the care plan had not been updated. 32788 2. The record for Resident 21 was reviewed on 6/25/24 at 11:55 a.m. Diagnoses included, but were not limited to, hypertension, Parkinson's disease, and bipolar disorder with psychotic features. The Quarterly MDS assessment, dated 4/9/24, indicated the resident was cognitively impaired and received antipsychotic medication. A care plan, updated 3/1/24, indicated the resident was at risk for drug related complications associated with the use of the antipsychotic medication Nuplazid. The Physician Order Summary, dated 6/2024, indicated the resident was to receive Seroquel (an antipsychotic medication) 25 mg (milligrams) twice a day. There were no current orders for the Nuplazid medication, it was discontinued on 2/12/24. The Medication Administration Record (MAR), dated 6/2024, indicated the resident had received the Seroquel medication twice a day. During an interview on 6/26/24 at 9:38 a.m., the Director of Nursing (DON) indicated the care plan should have been updated. They had recently completed a mock survey and identified some issues with care plans. During an interview on 6/28/24 at 11:03 a.m., the [NAME] President of Regulatory Compliance (VPRC) indicated they had completed a mock survey a couple weeks ago and identified issues with care plans. They had completed an inservice and started audits. She provided the care plan audits, but the audits were for care plans related to anticoagulant medication and skin issues. 45666 3. Resident 32's record was reviewed on 6/26/24 at 10:15 a.m. Diagnoses included, but were not limited to, dementia and insomnia. The Annual Minimum Data Set (MDS) assessment, dated 6/15/24, indicated the resident was moderately impaired for daily decision making. While a resident, she received antianxiety, antidepressant, diuretic, and opioid medications. A Care Plan, dated 10/8/21, indicated the resident was at risk for sleep pattern disturbance and had an order for melatonin. Interventions included, but were not limited to, administer the sleep medications as ordered by the Physician, and observe, document, and report adverse side effects. The April Medication Regimen Review (MRR), dated 4/18/24, indicated a recommendation to discontinue melatonin tablet 5 milligrams (mg), 1 tablet at bedtime. The April 2024 Physician Order Summary indicated the melatonin 5 mg tablet at bedtime was discontinued on 4/26/24. During an interview on 6/26/24 3:01 p.m., the Director of Nursing indicated the care plan should have been updated with the medication change. During an interview on 6/28/24 at 9:02 a.m., the VPRC indicated they had identified a problem with their care plans and had begun auditing to correct the issues. A facility policy, titled Comprehensive Care Plans, received as current, indicated, .5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment . 3.1-35(b)(1)

Based on observation, record review, and interview, the facility failed to ensure activities were implemented for a cognitively impaired dependent resident for 1 of 1 residents reviewed for activities. (Resident 4) Finding includes: On 6/24/24 at 10:06 a.m., Resident 4 was lying in bed with her eyes closed. The room was dark, the television was off, and there was no music playing. There was a CD player/radio observed on her dresser, a doll and multiple stuffed animals on her shelf. On 6/24/24 at 1:50 p.m., Resident 4 was lying in bed. The room was dark, the television was off, and there was no music playing. On 6/25/24 at 1:56 p.m., Resident 4 was lying in bed. Her eyes were open, and she was yelling out. The room was dark, the television was off, and there was no music playing in her room. At this time, there was a singer performing in the main dining room. On 6/26/24 at 11:07 a.m., Resident 4 was lying in bed. Her eyes were open, she was talking, and looking around the room. The room was dark, the television was off, and there was no music playing in her room. On 6/26/24 at 2:02 p.m., Resident 4 was lying in bed. Her eyes were open, and she was looking at the ceiling. The room was dark, the television was off, and there was no music playing in her room. The record for Resident 4 was reviewed on 6/26/24 at 9:24 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, delusional disorder, circadian rhythm sleep disorder, and anxiety disorder. The Quarterly MDS assessment, dated 6/1/24, indicated the resident was cognitively impaired and required assistance with activities of daily living. The Significant Change MDS assessment, dated 9/11/23, indicated the resident was cognitively impaired and required assistance with activities of daily living. It was important for her to listen to music, be around animals/pets, participate in her favorite activities and in religious activities. A current care plan indicated the resident required one to one activity programming. Interventions included, offer 1:1 visits three or more per week as tolerated, offer activities and supplies for things she can do in her room such as Christian music, CD player, and Bible. Provide tactile stimulation such as hand massages and lotion, reading mail or reading the Bible. A current care plan indicated the resident found strength and comfort in her religious beliefs. Interventions included, offer her gospel and Christian music, have her music playing for her daily, offer reading material such as the Bible, and read the Bible to her occasionally during her 1:1 visits. The quarterly Activity Participation Review, dated 6/11/24, indicated the resident received 1:1 activities 3-4 days a week. The resident's favorite activities were marked as entertainment-television, music, movies, visiting groups. It was noted that she liked to listen to music and to her television and preferred a quiet environment. The quarterly Activity Participation Review, dated 3/11/24, indicated the resident received 1:1 activities 3-4 days a week. The resident's favorite activities were marked as entertainment-television, music, movies, visiting groups. It was noted that staff played music for her and had TV on for her. She liked to have lotion put on her arms, hands, and legs. The Activity Task documentation, dated 5/29/24 through 6/25/24, indicated 1:1 activities were completed 3 times per week and included conversation/reminiscing, sensory, music/singing, and TV. There were no other activities documented other than the 1:1 activities. During an interview on 6/26/24 at 2:26 p.m., the Director of Nursing (DON) indicated the resident went through cycles where she would be awake for three days and then sleep for three days. On the days when she was sleeping, they would respect her quiet time and let her be. When she was awake, they would put on music for her. This had not been documented in the care plan. During an interview on 6/28/24 at 9:17 a.m., the Activity Director indicated they completed 1:1 activities with the resident three times a week. They would make sure she had her music playing. If she was in a quiet time and content, then they would leave her alone and at times she would not want to be bothered. She had not documented the quiet time or any refusal in activity participation. 3.1-33(a)

Based on observation, record review, and interview, the facility failed to care for a PICC line (peripherally inserted central catheter, intravenous catheter placed into the peripheral veins of the upper arm) in accordance with professional standards of practice, related to flushing the PICC line for 1 of 1 residents reviewed for intravenous care. (Resident 148) Finding includes: On 9/6/23 at 11:03 a.m., Resident 148 was observed standing in the doorway to his room. There was a PICC line in place to his right upper arm. It was covered with a wrap and the date on the site dressing was unable to be seen. Resident 148's record was reviewed on 9/6/23 at 11:21 a.m. Diagnoses included, but were not limited to, infection and inflammatory reaction due to internal right hip prosthesis. A Physician's Order, dated 8/21/23, indicated a double lumen PICC line to the right upper extremity. A Physician's Order, dated 8/25/23, indicated ceftriaxone sodium (Rocephin, an antibiotic) 2 g (grams) IV daily at 9 a.m. A Physician's Order, dated 8/21/23, indicated normal saline flush, 10 ml (milliliters) every shift (5 a.m.-5 p.m. and 5 p.m. to 5 a.m.). There were no Physician's Orders to indicate the PICC was to be flushed with saline before and after the administration of the antibiotic medication. The Medication Administration Records (MAR), dated 8/2023 and 9/2023, indicated the ceftriaxone had been administered as ordered. The normal saline flushes were documented as given once on the 5 a.m. to 5 p.m. shift and once on the 5 p.m. to 5 a.m. shift. There was lack of documentation to indicate the PICC was flushed with saline before and after the administration of the antibiotic medication. Interview with the Director of Nursing (DON) on 9/7/23 at 11:14 a.m., indicated the PICC was to be flushed with normal saline before and after the administration of the antibiotic medication. She would clarify the flush orders to indicate that process. A facility policy, titled Intravenous Therapy, received as current, indicated, .Intermittent Medication Infusion .13. Attach 10ml syringe normal saline to flush to confirm patency of vascular access device as per protocol .19. If medication set to primary tubing, disconnect, disinfect needleless connector with appropriate antiseptic solution and flush and/or lock with 10 cc syringe of normal saline/locking solution as per protocol for vascular device used . 3.1-47(a)(2)

Based on record review and interview, the facility failed to thoroughly investigate and report an allegation of abuse to the State Agencies, related to a dependent resident grievance, which the resident indicated a staff member inappropriately spoke to the resident, for 1 of 3 residents reviewed for abuse. (Resident E) Finding includes: A facility reported incident to the Indiana Department of Health (IDOH), dated 6/14/21, indicated Resident E reported to the Social Service Director that two nurses had been abusive to him due to the wound vacuum to his pressure sore had been turned off. The facility Investigated Report, indicated a Grievance Form was written by the Social Service Director on 6/14/21, which included, Resident & his wife stated that over the weekend a CNA came into his room and told him, 'I don't know what you did to the nursing staff, but no one wants to take care of you & that's why I am here.' The staff member then told the resident .the DON (Director of Nursing) said he was being vulgar and rude .his wife was on the phone and heard everything . The Summary of Findings or Conclusions of the Grievance, indicated no other resident had concerns about the two nurses and the resident stated, they can get in and out and do what they need to do. There was no date of resolution to the Grievance due to the resident was never fully satisfied with the corrective actions and investigation steps the facility provided. Resident E's record was reviewed on 7/21/21 at 4:02 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission Minimum Data Set assessment, dated 5/17/21, indicated his cognition was intact, no behaviors, required extensive assistance of two staff for bed mobility, had not transferred out of the bed, extensive assistance on one staff for dressing, eating, and hygiene, had an indwelling urinary catheter, was always incontinent of bowel movement, and two stage 4 pressure ulcers on admission. During an interview on 7/21/21 at 3:50 p.m., the Executive Director indicated the comment voiced in the grievance was not reported to the IDOH. The resident did not feel this was abusive. The Executive Director indicated he also did not think this was abusive and he has also informed the resident it was getting difficult to find people to take care of him. During an interview on 7/21/21 at 4:01 p.m., the Executive Director indicated he was unsure who the CNA was who made the comments. The comment had not been investigated since he did not think this was abuse. An undated facility policy, titled, Abuse, Neglect and Exploitation, received as current from the Corporate RN on 7/21/21 at 4:54 p.m., indicated, Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability .'Mental Abuse' includes, but is not limited to, humiliation .threats of punishment or deprivation .An immediate investigation is warranted when suspicion of abuse .or reports of abuse .Investigations include: 1. Identifying staff responsible for the investigation .Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator .Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies .within the specified time frames: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse This Federal tag relates to Complaints IN 894 and IN 317. 3.1-28(d) 3.1-28(e)

Based on record review and interview, the facility failed to ensure necessary care and services were provided to residents who required extensive and dependent care for activities of daily living (ADL's), related to shower frequency for 2 of 3 residents reviewed for ADL's. (Residents B and C) Findings include: 1) Resident B's record was reviewed on 7/21/21 at 10:50 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission Minimum Data Set (MDS) assessment, date 5/6/21, indicated a moderately impaired cognition status, type of bathing choice was somewhat important, required extensive assistance of two for transfers and bed mobility, and was dependent on two staff for bathing. A Care Plan, dated 5/1/21, indicated a self care deficit. The interventions included, self care would be assisted by staff. The Shower Sheets and Bathing Task forms, from 4/30/21 to 6/12/21 indicated, a bathing was offered on 5/1/21 and refused. Bathing was provided on Thursday, 5/6/21 and the next bath/shower was provided eight days later on Friday, 5/14/21. Bathing was provided on Tuesday, 5/18/21 and the next bath/shower was provided 10 days later on, Friday, 5/28/21. Bathing was provided on Friday 5/28/29 and the next bath/shower was provided six days later on Sunday, 6/4/21. During an interview on 7/21/21 at 1:45 p.m., the Director of Nursing (DON), indicated she was unable to locate any further Shower Sheets. 2) Resident C's record was reviewed on 7/21/21 at 12:03 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission MDS assessment, dated 6/27/21, indicated a moderately impaired cognition status and required extensive assistance of one staff for bathing. A Care Plan, dated 7/7/21, indicated a self care impairment. The interventions included self care would be assisted by staff. The Shower Sheets and Bathing Task forms, from 6/21/21 through 7/21/21, indicated bathing was not completed until Monday, 6/28/21. Bathing was completed on Monday, 7/5/21 and the next bathing was completed six days later on 7/11/21. No further information was provided for bathing at the time of exit on 7/21/21 at 5:15 p.m. An undated facility policy, titled, Bathing a Resident, received from the Corporate RN as current on 7/21/21 at 4:54 p.m., indicated, It is the practice of this facility to assist residents with bathing to maintain proper hygiene . This Federal tag relates to Complaints IN 894 and IN 317. 3.1-38(b)(2)

Based on record review and interview, the facility failed to provide dependable transportation for a resident, related to post surgical Physician's appointments, for 1 of 3 residents reviewed for quality of care related to transportation. (Resident B) Finding includes: Resident B's record was reviewed on 7/21/21 at 10:50 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Hospital Transfer form, dated 4/30/21, indicated a right total knee arthroplasty was completed on 4/28/21. A post-operative follow up appointment was scheduled with the Orthopedic Surgeon on 5/24/21 at 3 p.m. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] There was no documentation in the Nurses' Progress Notes, dated 5/24/21, which indicated the resident had gone to the post surgical physician's appointment. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A Nurse's Note, dated 6/7/21 at 2:54 p.m., indicated the original Orthopedic Surgeon's appointment had been canceled and was to be re-scheduled. The resident's wife was made aware of the cancellation. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 7/21/21 at 1:44 p.m., the Director of Nursing (DON) indicated on 6/7/21, the Bus Driver was with another resident at an appointment, which was scheduled at 9 a.m. He thought he would be back in time. He returned to the facility at 2:14 p.m., which was not enough time to get to the appointment, due to travel distance. The appointment was canceled at the last moment. She was unsure if he had notified the facility prior to his return at 2:14 p.m. During an interview on 7/21/21 at 2:11 p.m., the DON indicated the Bus Driver attempted to get transportation on 5/21/21 for 5/24/21. He was unable to transport the resident as previously scheduled and he was unable to find other transportation. During an interview on 7/21/21 at 2:26 p.m., the DON indicated the appointment for 5/24/21 was placed on the calendar on 4/30/21. The Bus Driver had over-booked for the day of 5/24/21 and had not realized that until 5/21/21. This Federal tag relates to Complaints IN 894 & IN 317. 3.1-37

Based on record review and interview, the facility failed to ensure a resident with an identified injury was transferred to the Emergency Department in a timely manner for 1 of 3 residents reviewed for quality of care. (Resident B) Finding includes: Record review for Resident B was completed on 8/28/20 at 10:10 a.m. [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) assessment, dated 6/8/20, indicated the resident was cognitively intact. The resident required an extensive assistance for bed mobility, transfers, dressing, personal hygiene, and toilet use. A Care Plan indicated the resident was on hospice care related to end of life care. An intervention included to notify hospice of any changes in condition. A Progress Note, dated 7/23/20 at 6:27 a.m., indicated during the morning care, the CNA noted the resident's left leg was not in the right place and the resident was in increased pain. Assessment of the resident's left leg indicated it was rotated inward. When touched the resident would yell out in pain. The resident and the CNA indicated it was not like that at the beginning of the night. The CNA indicated at the beginning of the night, she was able to assist the resident with turning in bed to be changed without difficulty. The nurse notified hospice. Hospice notified the resident's son and agreed to stop Hospice services so the resident could be transferred to the hospital. The nurse attempted to call the resident's Physician with no answer. The facility Medical Director was then called and gave an order to send the resident to the hospital. Emergency Medical Transport (EMT) was called and the resident departed the facility at 5:45 a.m. Review of statements from facility staff related to the incident indicated: CNA 1 indicated on the morning of 7/23/20 at 4:00-4:15 a.m., she was providing care to the resident. The resident was alert and oriented and was able to use the quarter side rail as an enabler to help her position and roll herself during personal care. The resident used the rail and turned herself on her side so that the CNA could provide personal care. Once the care was finished, the resident released the grip on the rail and rolled back into position on her back. The CNA indicated the resident's leg did not look right and the resident indicated her leg hurt. The CNA then left the room to notify the nurse. RN 1 indicated a little after 4:00 a.m., CNA 1 reported to her that something was not right with the resident's leg. The RN went to assess the resident's leg and it appeared to be bent in an odd way. The resident indicated she was in pain. She was then administered her [MEDICATION NAME] (medicated pain patch). The nurse then notified the hospice company. Hospice then called back and indicated the son gave permission to send the resident to the emergency room (ER). The resident's Physician was then called. The resident was given her scheduled [MEDICATION NAME] (pain medication) to manage the pain. The resident's Physician did not return the call, so the facility Medical Director was paged. He returned the call at around 5:15 a.m., with an order to send the resident to the ER. Emergency Medical Services (EMS) was called at 5:48 a.m., and arrived at the facility at 5:52 a.m. An Overall General Timeline provided by the Director of Nursing (DON) related to the incident on 7/23/20 indicated the following: - 4:00 a.m.,: CNA 1 provided care to Resident B - 4:15 a.m.,: CNA 1 noticed Resident B's leg did not look right and notified RN 1 - 4:15 a.m., RN 1 observed Resident B's condition - Between 4:15 a.m., and 4:30 a.m., hospice was called and informed of resident's condition - 4:27 a.m., resident received her [MEDICATION NAME] for pain - 4:30 a.m., hospice returned a call with son's consent to send the resident to the ER. - 5:00 a.m., the resident's Physician was called for an order to send the resident to the ER. No answer from the Physician. - 5:00 a.m., resident received [MEDICATION NAME] for pain management - 5:15 a.m., Medical Director paged and called back with order to send the resident to the ER. - 5:48 a.m., EMS was called - 5:52 a.m., EMS arrived at the facility - 6:13 a.m., EMS left the facility with resident en route to the ER. Interview with the Medical Director on 8/28/20 at 1:10 p.m., indicated the nurse should have sent the resident to the ER as soon as she received the order from the hospice company. The nurse did not need to wait and get an ok from the resident's Physician. The nurse did try and manage the resident's pain until the EMT's arrived, but he had a concern that EMS was not called right away after the nurse got the order to send the resident out from the hospice provider. Interview with the DON on 8/28/20 at 1:19 p.m., indicated the nurse should have called EMS at 4:30 a.m., when she received the order from hospice. The nurse was trying to make the resident comfortable and manage her pain until the EMT's arrived to the facility. The nurse was getting all necessary paperwork together to send the resident to the hospital. She should have just sent the resident out to the hospital and then faxed all necessary paperwork to the ER after the resident left the facility. A Hospice Care Services Agreement for the resident's hospice company was received as current from the facility on 8/28/20. The agreement indicated, .5. Services Provided by Hospice. a. Hospice shall provide the following services (the Hospice Services) to each Hospice Patient, provided that such services are in accordance with the patient's Plan of Care: i. Providing medical direction and management of the patient .6. Responsibilities of Facility. d. Facility shall obtain Hospice approval prior to any relocation of a Hospice Patient This Federal Tag relates to Complaint IN 721. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure a resident was administered oxygen as ordered by the Physician, related to an empty portable oxygen machine for 1 of 3 residents reviewed for oxygen therapy. (Resident C) Finding includes: During an observation on 3/9/2020 at 8:51 a.m., Resident C was sitting in a wheelchair in her room. She had a portable oxygen machine on the back of the wheelchair set at 3 liters and oxygen was administered through a nasal cannula. Employee 1 checked the portable oxygen machine and indicated it was 1/2 full. During an observation on 3/9/2020 at 1:05 p.m., the resident was sitting in the wheelchair in the Dining Room. The Administrator was sitting next to her, and there were no other residents in the Dining Room. The nasal cannula was present in the nares and connected to the portable oxygen machine, which was set at 3 liters. Employee 2 checked the portable oxygen machine and indicated it was empty. Employee 2 indicated the portable oxygen was usually checked every two hours and she had not checked it since after breakfast (served between 7 a.m. and 7:30 a.m.). She was unaware how long the resident had been without oxygen. Normally she would have checked it before the resident was assisted to the Dining Room. She had not assisted her to the Dining Room for lunch. During observations on 3/9/2020 at 1:10 p.m., the portable oxygen machine was re-filled and brought back to the resident in the Dining Room. The Director of Nursing (DON) then connected the nasal cannula tubing to the oxygen. The oxygen administration rate was set to 3 liters. At 1:12 p.m., the DON obtained an oxygen saturation from the left ear lobe, which read 67%. The DON then used a finger oximeter and obtained oxygen saturations of 60-85%. At 1:15 p.m. the DON used another finger oximeter and the results were 63-82%. The respirations were 28. The resident was assisted to her room and the nasal cannula was attached to the oxygen concentrator in the room and set at 3 liters. At 1:20 p.m., the oxygen saturation was 92%. Resident C's record was reviewed on 3/9/2020 at 11:33 a.m. The [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set assessment, dated 12/10/19, indicated a severely impaired cognitive status and oxygen was used. A Care Plan, dated 11/4/17, indicated oxygen was used due to shortness of breath. The interventions included, oxygen was to be administered as ordered and the oxygen saturations were to be maintained at 90% or above. A physician's orders [REDACTED]. During an interview on 3/9/2020 at 2:01 p.m., the DON indicated per the (Oxygen Company Name), the portable oxygen machine at 3 liters would have lasted 5 hours. She indicated with the portable oxygen machine at 1/2 full at 8:51 a.m., the resident would have been without oxygen for a little while. The oxygen was now being administered with an oxygen concentrator and the oxygen saturations would be monitored. There was no facility policy that indicated when the portable oxygen machines were to be checked for the amount of oxygen in the machine. This Federal tag related to Complaint IN 828. 3.1-47(a)(6)

Based on observation and interview, the facility failed to ensure a wound treatment was completed using proper infection control practices for 1 of 3 pressure ulcer treatments observed. (Resident 15) Finding includes: On 2/4/2020 at 9:55 a.m., LPN 2 gathered her wound care supplies and entered Resident 15's room. She placed a paper towel down on the resident's bedside table, washed her hands and donned gloves. LPN 2 then opened the plastic bag and removed the tube of Venelex (a medicine to treat wounds) ointment and placed the bag on the paper towel. She then opened and placed sterile gauze on top of the plastic bag and placed the tube of Venelex ointment on top of the sterile gauze. CNA 2 had rolled and positioned the resident on to her left side and unfastened her brief. LPN 2 grabbed the brief and uncovered the rest of the resident's buttock, with the same gloved hand. LPN 2 cleansed the closed pressure ulcer wound with wound cleanser and gauze. After cleansing the wound, she applied a small amount of Venelex ointment on to the wound area with the same gloved hand. Interview with LPN 2 on 2/4/2020 at 10:39 a.m., indicated the gauze would be considered contaminated with placing it on the plastic bag and placing the ointment onto the gauze to be used to cleanse the closed area. She also should have changed her gloves after cleansing the wound area and before applying the ointment. Interview with the Director of Nursing on 2/4/2020 at 10:41 a.m., indicated she would have expected her Nurse to change her gloves after cleansing a wound and not place items on the gauze to be used. A policy titled, Dressing Change, Clean, was provided by the Director of Nursing on 2/4/2020 at 10:24 a.m. This current policy indicated, Procedure: .16. Cleanse wound with prescribed solution .18. Perform hand hygiene 19. Put on third pair of disposable gloves 3.1-40 (a)(2)

Based on observation, record review, and interview, the facility failed to provide treatment for [REDACTED]. (Resident 15) Finding includes: Interview with Resident 15, on 2/3/2020 at 11:13 a.m., indicated the staff did not put a splint on her left hand every day and she could not put the splint on by herself. At time, Resident 15 was observed laying in bed without a splint to her left hand. A blue splint was observed lying on the resident's room floor between two dressers. On 2/3/2020 at 3:37 p.m., Resident 15 was observed lying in her bed after she had returned from a Physician's appointment. She was in a hospital gown (per her choice) and there was no splint to her left hand. A blue splint was observed lying on the resident's floor between two dressers. Resident 15's record was reviewed on 2/3/2020 at 3:45 p.m. [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) assessment, dated 11/27/2019, indicated the resident was cognitively intact. The resident had an impairment on one side of her upper extremity. She required an extensive two person assist with bed mobility, dressing and toileting, and was totally dependent on staff for transfers. The current physician's orders [REDACTED]. The skin was to be checked prior to applying the splint to the left hand and after removing the splint every day and every evening shift. The February 2020 Medication Administration Record [REDACTED]. A Care Plan for impaired neurological status related to a stroke, dated 12/7/2018, indicated an intervention was to wear a splint to her left hand and to be removed in the evening. The record lacked an indication the resident had refused to wear the left hand splint. Interview with LPN 2 on 2/3/2020 at 3:53 p.m., indicated she refused to wear the splint and should be documented in the Nurse's Notes if she refused to wear it. Interview with CNA 3 on 2/4/2020 at 11:42 a.m., indicated if she would refuse the splint, the Charge Nurse would be notified. A policy titled, Splint Application and Removal, was provided by the Director of Nursing on 2/4/2020 at 8:30 a.m. This current policy indicated, Process: .5. All staff who work with the resident will be instructed by therapy and/or designee on the appropriate application and removal of the splint. 6. Nursing will monitor the skin integrity as the splint is removed 3.1-42(a)(2)

Based on observation, record review, and interview, the facility failed to ensure residents received proper care and treatment related to oxygen administration for 1 of 1 residents reviewed for respiratory care. (Resident 15) Finding includes: On 2/3/2020 at 11:15 a.m., Resident 15 was observed sitting up in her wheelchair in her room, with her portable oxygen tank infusing oxygen at 2 lpm (liters per minute). Interview with the resident at that time indicated the setting should be at 3 lpm. On 2/3/2020 at 3:37 p.m., Resident 15 was observed lying in her bed after she had returned from a Physician's appointment with her oxygen infusing at 2 lpm. Resident 15's record was reviewed on 2/3/2020 at 3:45 p.m. [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) assessment, dated 11/27/2019, indicated the resident was cognitively intact. The resident had an impairment on one side of her upper extremity. She required an extensive two person assist with bed mobility, dressing and toileting, and was totally dependent on staff for transfers. The resident received oxygen therapy. The current physician's orders [REDACTED]. A Care Plan for an alteration in respiratory status due to [MEDICAL CONDITION], dated 9/13/2018, indicated an intervention was to administer oxygen per the physician's orders [REDACTED]. Interview with LPN 2, on 2/3/2020 at 3:53 p.m., indicated the resident's oxygen was not set at the correct flow rate and should have been set at 2.5 lpm. A policy titled, Oxygen Administration (via Nasal Cannula), was provided by the Director of Nursing on 2/4/2020 at 8:30 a.m. This current policy indicated, .Procedure: .Connect the nasal cannula to the oxygen source and turn the flow meter to the appropriate flow as ordered by the physician 3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to ensure infection control measures were maintained related to a pulse oximeter and stethoscope not being cleaned after a nebulizer (aerolized breathing) treatment for 1 of 1 nebulizer treatments observed. (Resident 32) Finding includes: On 2/6/20 at 8:25 a.m., LPN 3 was observed administering a nebulizer treatment to Resident 32 in the resident's room. Before the treatment, the LPN listened to the resident's lungs with her stethoscope and checked her pulse and oxygen saturation with the oximeter (a device that fits onto the finger and monitors oxygen and pulse). The resident was lying in her bed and coughing during the treatment. The LPN gave her tissues to cough into. During the treatment, the resident laid the tissues on her bedside table. The treatment took fifteen minutes to complete. After the treatment, the nurse cleansed the nebulizer mask, bedside table, listened to her lungs again with the stethoscope and checked her pulse and oxygen saturation with the oximeter. She placed the stethoscope around her neck and the oximeter in her pocket, and sanitized her hands. She did not clean the stethoscope or oximeter. Interview with the LPN on 2/6/20 at 8:45 a.m., indicated she had not cleaned those items, but she usually cleaned her equipment back at the nurses station. The policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, was provided by the Director or Nursing on 2/6/20 at 10:45 a.m. The current policy indicated, c. Non-critical item are those that come in contact with skin but not mucous membranes .(2) Most non-critical reusable items can be decontaminated where they are used (as opposed to being transported to a central processing location). d. Reusable items are cleaned and disinfected or sanitized between residents (e.g., stethoscopes, durable medical equipment) 3.1-18(a)

Based on record review and interview the facility failed to ensure a CNA's certification was not expired. This had the potential to affect 41 of 41 residents who reside in the facility. Findings include: Employee licenses and certifications were reviewed on [DATE] at 2:00 p.m. The certification for CNA 4 expired on [DATE]. The CNA had worked 28 shifts since the certification expired. Interview with the Business Office Manager on [DATE] at 3:50 p.m., indicated the CNA had renewed her certification that day and should not have been working while it was expired. 3XXX,[DATE](e)