Every finding on record at Brickyard Healthcare - Laporte Care Center

Based on record review and interview, the facility failed to ensure there was an appropriate diagnosis for the use of an antipsychotic medication (Seroquel) for 1 of 6 residents reviewed for unnecessary medications. (Resident B)Finding includes:The closed record for Resident B was reviewed on 5/12/26 at 1:17 p.m. The resident was admitted to the facility on [DATE] and discharged home on 3/18/26. Diagnoses included, but were not limited to heart disease, respiratory failure, type 2 diabetes, asthma, hypertensive kidney disease, chronic kidney disease, high blood pressure, heart failure, anxiety disorder, pulmonary embolism, opioid dependence, and dependence on renal dialysis.The 3/2/26 Modification of the admission Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and received an antipsychotic medication on a routine basis.A Care Plan, dated 2/28/26, indicated the resident was on antipsychotic therapy related to anxiety disorder. A History and Physical from the hospital admission, dated 12/27/25 to 2/24/26, indicated the resident was initially started on the Seroquel medication while in the hospital. A medication list, dated 1/20/26, indicated Quetiapine 100 mg twice a day for agitation.A Physician's Order, dated 2/25/26, indicated Quetiapine Fumarate (Seroquel) 100 milligrams (mg) give one tablet by mouth two times a day related to anxiety disorder. A Physician's Order, dated 2/27/26, indicated psychiatry to evaluate.The 2/2026 and 3/2026 Medication Administration Records indicated the resident received the Seroquel as ordered from 2/25-3/18/26.A Pharmacy recommendation, dated 3/6/26, indicated please indicate FDA (Food and Drug Administration) approved diagnosis for Quetiapine 100 mg twice a day for anxiety disorder. The recommendation was signed by the Nurse Practitioner (NP) on 3/13/26 with the diagnoses of restlessness and agitation.During an interview on 5/14/26 at 11:04 a.m., the Regional Nurse Consultant indicated the resident refused psychiatry services.During an interview on 5/14/26 at 1:25 p.m., the Director of Nursing (DON) indicated the resident never saw the psychiatric NP and there was no approved diagnosis for the use of Seroquel.This citation relates to Intake 2982545.410 IAC (Indiana Administrative Code)16.2-3.1-48(b)(1)

Based on observation, record review, and interview, the facility failed to ensure a dependent resident received incontinence care and was checked and/or changed at least every two hours for 1 of 3 residents reviewed for ADLs (Activities of Daily Living). (Resident 30)Finding includes:During an interview on 5/12/26 at 9:30 a.m., Resident 30 indicated she had not been changed since 12:30 a.m. At that time, she consented for staff to check and/or change her. During an observation on 5/12/26 at 9:44 a.m., CNA 2 and CNA 3 entered the resident's room to provide incontinence care. CNA 2 indicated she had not checked or changed the resident since her shift started at 6:30 a.m. The CNA removed the bed linens and the resident was observed lying on a bed sheet and an incontinence pad and was wearing an incontinence brief. There was a large dried dark brown urine ring all the way around the incontinence pad. The bed sheets were wet all the way up the resident's back and the incontinence brief was saturated with urine. During an interview at that time, CNA 2 indicated they have a problem on the midnight shift with a CNA who did not want to change the resident. The record for Resident 30 was reviewed on 5/13/26 at 4:02 p.m. Diagnoses included but were not limited to, left leg below the knee amputation, COPD, obesity, opioid dependence, bipolar disorder, anxiety disorder, high blood pressure, and chronic pain. The 4/23/26 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and was dependent on staff for toileting. The resident was frequently incontinent of bladder. The urinary incontinence documentation in the CNA task section of the EMR (electronic medical record) indicated incontinence care was only only documented twice a day on 4/19, 4/26, 5/4, 5/8, 5/9, and 5/11/26. During an interview 5/12/26 at 11:15 a.m., the Director of Nursing (DON) indicated there was a grievance filed for the resident's complaint regarding a CNA on the midnight shift for not changing her, however, the incident on 5/12/26 involved a different CNA . During an interview on 5/14/26 at 9:30 a.m., the DON indicated the resident was to be checked and/or changed at least every two hours. 410 IAC (Indiana Administrative Code)16.2-3.1-38(a)(2)(C)

Based on observation, record review, and interview, the facility failed to ensure a resident with constipation was treated for 1 of 1 resident reviewed for constipation and bruises and skin lesions were assessed and monitored for 3 of 4 residents reviewed for non-pressure skin conditions. (Residents 30, 68 and 65)Findings include:1. During an interview on 5/12/26 at 9:30 a.m., Resident 30 indicated she was constipated all the time. During an observation on 5/12/26 at 9:44 a.m., CNA 2 and CNA 3 entered the resident's room to provide incontinence care. They removed the bed linens and rolled the resident onto her right side. The incontinent pad and bed sheets were wet with urine all the way up the resident's back. The incontinence brief was removed and saturated with urine. At that time, there was white bandage located on her upper left hip area. CNA 2 indicated the bandage was not covering the open area as it had moved and was wet with urine. The open area, which was located below the sacrum in the buttock crease, was exposed and not covered. The area was red with a small amount of drainage. The record for Resident 30 was reviewed on 5/13/26 at 4:02 p.m. Diagnoses included but were not limited to, left leg below the knee amputation, COPD, obesity, opioid dependence, bipolar disorder, anxiety disorder, high blood pressure, and chronic pain. The 4/23/26 Quarterly Minimum Data Set (MDS) assessment, indicated the resident was cognitively intact for daily decision making and was dependent on staff for toileting. The resident was frequently incontinent of bowel and bladder and received received an opioid medication. A Care Plan, revised on 2/3/26, indicated the resident had the potential for constipation related to pain. The goal was for the resident to have a normal bowel movement at least every three days. The approaches were to follow the facility bowel protocol for bowel management. The Bowel Movement documentation in the CNA task section indicated the resident had no bowel movement from 4/1-4/7/26, 4/10-4/13/26, 4/15-4/20/26, 4/22-4/29/26, and 5/5-5/9/26. Skilled Evaluation Notes, dated 4/22-4/29, 5/1-5/3, and 5/5-5/9, indicated the the resident's abdomen was nondistended and had no complaints of constipation. There was no documentation in nursing progress notes that nursing staff were aware the resident had not had a bowel movement at least one time every three days. There was no documentation indicating the resident's normal bowel pattern was longer than three days. A Physician's Order, dated 1/15/26, indicated Docusate Sodium (a stool softener) 100 milligrams (mg) one capsule two times a day. A Physician's Order, dated 1/17/26, indicated Magnesium Hydroxide (a laxative), 15 milliliters (ml) by mouth one time every other day. A Physician's Order, dated 4/2/26, indicated Glycolax Powder (a laxative) give 17 grams by mouth one time a day for constipation. A Physician's Order, dated 4/14/26, indicated Buprenorphine HCl Sublingual (a narcotic and opioid medication use to treat opioid use disorder (OUD) and manage severe, persistent pain) tablet 8 mg, give 1 tablet sublingually every 8 hours as needed for pain rated 6-10. There were no as needed orders for constipation. The Medication Administration Record for 4/2026 and 5/2026 indicated all three of the above laxatives were signed out every day as being administered to the resident. A Physician's Order, dated 4/7/26, indicated cleanse gluteal cleft with wound cleanser, pat dry, apply betadine and cover with a bordered gauze daily and prn (as needed) The Nurse Practitioner (NP) Wound Assessment, dated 5/12/26, indicated a full thickness abscess to the gluteal cleft that measured 1 centimeter (cm) in length by 0.20 cm in width. The wound had 100% of epithelial (the regeneration top layer of skin) tissue with moderate drainage. During an interview on 5/14/26 at 9:30 a.m., the Director of Nursing (DON) indicated the bandage should have been covering the open area. During an interview on 5/14/26 at 1:25 p.m., the DON indicated it looked like the resident's pattern for a bowel movement was 1 time every five to six days. She had no additional information to provide. During an interview on 5/14/26 at 2:50 p.m., the Regional Nurse Consultant indicated the computer program did not prepopulate oe flag when the resident had gone longer than three days without a bowel movement. There was no policy for constipation, they would follow whatever bowel management the resident's physician ordered. 2. During random observations on 5/12/26 at 9:19 a.m., and at 3:00 p.m., Resident 68 was observed with dark red and purple areas to the left forearm. During an interview at that time, the resident indicated she would get bruises on her arms because she was constantly bumping her arms on the wheelchair and she needed a bigger wheelchair. The record for Resident 68 was reviewed on 5/12/26 at 3:05 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, chronic kidney disease, rectal cancer, atrial fibrillation, high blood pressure, end state renal disease, and dependence on renal dialysis. The admission Minimum Data Set (MDS) assessment, dated 5/8/26, indicated the resident was cognitively intact for daily decision making. There was no care plan for bruising. A Weekly Skin Check, dated 5/2/26 and 5/5/26, indicated the resident had swelling to the left inner forearm due to fistula placement. There was no documentation the resident had any bruises to her arms. The Clinical admission Assessment, dated 5/2/26, indicated there was no documentation regarding any bruising to her arms During an interview on 5/14/26 at 1:25 p.m., the Director of Nursing was unaware the resident had any bruising. She indicated an incident report would be completed and the bruises would be monitored and assessed. Staff had also changed her out her wheelchair to a bigger one in hopes of preventing the resident from bumping her arms. 3. During a random observation on 5/11/26 at 11:22 a.m., Resident 65 had two round skin lesions on his left knee. At that time, the resident indicated the lesions resulted from scraping his knee on underside of the overbed table. The larger, nickel-sized lesion occurred about one week earlier, and the smaller, dime-sized lesion, about two weeks earlier. The record for Resident 65 was reviewed on 5/13/26 at 1:59 p.m. Diagnoses included, but were not limited to, diabetes, respiratory failure, and hemiplegia (paralysis of one side of the body) following a stroke, affecting the left side. The Significant Change Minimum Data Set (MDS) assessment, dated 3/25/26, indicated the resident was cognitively intact for daily decision making. The record lacked any documentation or prior assessment of the skin lesions. During an interview at the resident's bedside on 5/13/26 at 3:47 p.m., RN 1 indicated she knew about one of the lesions from a while ago, but had not seen the other one before. At that time, the resident again indicated the larger lesion occurred from hitting his knee under the tray table about a week ago. During an interview on 5/14/26 at 9:19 a.m., the Regional Nurse Consultant indicated they were aware the resident had lesions to his knee in the past, and they would have the wound nurse look at it again. 410 IAC (Indiana Administrative Code)16.2- 3.1-37(a)

Based on observation, record review and interview, the facility failed to ensure a resident was using a smoking apron while smoking as care planned for 1 of 1 resident reviewed for smoking. (Resident 50)Finding includes: On 5/11/26 at 1:06 p.m., Resident 50 was observed outside in the smoking area. There were several other residents, the Activity Director and two other staff members present. The resident was not wearing a smoking apron. The Activity Director indicated the resident did not need a smoking apron. On 5/11/26 at 2:49 p.m., the resident was observed in his room seated in his chair. His wheelchair was in front of him and there were two burn holes in the cushion. The resident's record was reviewed on 5/13/26 at 10:15 a.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease. The Quarterly Minimum Data Set assessment, dated 3/16/26, indicated the resident was cognitively intact.A Smoking and Safety assessment, dated 5/6/26, indicated the resident was lethargic and falls asleep easily during tasks or activities. He also had burned clothing, skin, furniture or other. The recommendation was to use a smoking apron and staff to light and extinguish smoking material. The Tobacco Use Care Plan, dated 5/7/26, indicated to utilize a smoking apron. During an interview on 5/11/26 at 1:25 p.m., the Regional Nurse Consultant indicated she had been made aware the resident was not using a smoking apron. They were in the process of updating the list of residents who required a smoking apron and educating the staff. 410 IAC (Indiana Administrative Code)16.2-3.1-45(a)

Based on observation, record review, and interview, the facility failed to ensure oxygen was on at the correct flow rate for 3 of 3 residents reviewed for oxygen. (Residents 5, 30, and 17)Findings include:1. During random observations on 5/11/26 at 12:06 p.m. and 2:25 p.m., on 5/12/26 at 9:43 a.m. and 2:59 p.m., and on 5/13/26 at 9:25 a.m., Resident 5 was observed in bed with a tracheostomy and was receiving oxygen by the way of a mask over the trach. He was connected to the oxygen concentrator in the room and the rate was set at four liters per minute. During an interview on 5/13/26 at 9:35 a.m., LPN 1 indicated the Respiratory Therapist (RT) told her it did not matter what the oxygen rate was set at as long as the humidity was at least at 28%. The record for Resident 5 was reviewed on 5/13/26 at 11:18 a.m. Diagnoses included, but were not limited to, traumatic subdural hemorrhage, traumatic brain injury, compression of the brain, tracheostomy, and high blood pressure. The Quarterly Minimum Data Set (MDS) assessment, dated 4/8/26, indicated the resident was rarely understood/rarely understands, had a tracheostomy, and received oxygen while a resident. A Physician's Order, dated 4/1/26, indicated oxygen at two liters per minute with 28% humidification via trach mask while laying in bed. A Care Plan, revised on 4/28/26, indicated the resident had a tracheostomy and was dependent on oxygen. The approaches were to provide oxygen per physician orders. A Care Plan, revised on 4/28/26, indicated the resident had an altered respiratory status/difficulty breathing. The approaches were to provide oxygen at two liters per minute and 28% humidification via trach mask. During an interview on 5/13/26 at 11:00 a.m., the Regional Nurse Consultant indicated they were going to have the Nurse Practitioner look at the oxygen settings. She had no further information to provide. 2. During random observations on 5/11/26 at 10:01 a.m., on 5/12/26 at 9:30 a.m. and at 1:00 p.m., and on 5/13/26 at 3:00 p.m., Resident 30 was observed in bed and wearing oxygen via nasal cannula at 2.5 liters per minute. The record for Resident 30 was reviewed on 5/13/26 at 4:02 p.m. Diagnoses included but were not limited to, COPD, obesity, bipolar disorder, anxiety disorder, high blood pressure, and chronic pain. The 4/23/26 Quarterly Minimum Data Set (MDS) assessment, indicated the resident was cognitively intact for daily decision making and received oxygen while a resident.A Physician's Order, dated 2/3/26, indicated continuous oxygen at two liters per minute at bedtime and prn (as needed) shortness of breath. During an interview on 5/13/26 at 11:00 a.m., the Regional Nurse Consultant indicated the oxygen was to be set as ordered by the physician. During an interview on 5/14/26 at 9:30 a.m., the Director of Nursing had no additional information to provide. 3. During random observations on 5/11/26 at 12:06 p.m. and 2:25 p.m., and on 5/12/26 at 9:43 a.m., Resident 17 was observed in bed and wearing oxygen per nasal cannula at 4.5 liters per minute. The record for Resident 17 was reviewed on 5/13/26 at 2:45 p.m. Diagnoses included but were not limited to, COPD, heart failure, heart disease, anxiety, and vascular dementia. A Care Plan, revised on 10/24/25, indicated the resident had an altered respiratory status/difficulty breathing. The approaches were to provide oxygen at four liters per physician orders. A Physician's Order, dated 2/2/26, indicated continuous oxygen at four liters per minute. The 2/20/26 Quarterly Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making, and received hospice and oxygen while a resident. During an interview on 5/13/26 at 9:35 a.m., LPN 1 indicated the resident's oxygen was to be set at four liters per minute. During an interview on 5/13/26 at 11:00 a.m., the Regional Nurse Consultant indicated she changed the oxygen from 4.5 to four liters on Tuesday 5/12/26. 410 IAC (Indiana Administrative Code)16.2-3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure a resident's fluid restriction was accurately documented for 1 of 1 resident reviewed for dialysis. (Resident 68)Finding includes:During an interview on 5/12/26 at 9:21 a.m., Resident 68 indicated she was not on a fluid restriction and could drink whatever she wanted. She liked apple juice and received it for all three meals. She usually drank about 1.5 of the large white styrofoam cups of water every day. The record for Resident 68 was reviewed on 5/12/26 at 3:05 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, chronic kidney disease, end state renal disease, and dependence on renal dialysis. The admission Minimum Data Set (MDS) assessment, dated 5/8/26, indicated the resident was cognitively intact for daily decision making and received dialysis while a resident.Nurse's Notes, dated 5/6/26 at 4:31 p.m., indicated the residenr received new orders from the dialysis physician to start LiquaCel 1 ounce twice a day or an equivalent protein supplement and implement a 1200 milliliters (ml) fluid restriction. Physician's Orders, dated 5/6/26, indicated 1200 ml fluid restriction every shift and Nepro with Carb Steady three times a day for nutritional support, 237 ml. Dialysis treatment on Monday, Wednesday, and Friday at the dialysis center. ProT Gold supplement two times a day. A Care Plan, dated 5/7/26, indicated the resident had the potential for fluid volume overload related to kidney failure. The goal was for the resident to comply with diet and/or fluid restrictions daily. The approaches were to restrict and give fluids per physician's order.The Medication Administration Record (MAR) for 5/2026 indicated there was no amount consumed documented for the ProT Gold protein supplement, nor was there a specific amount ordered for the resident. The 5/2026 MAR indicated the fluid restriction was documented every shift, however on most shifts the amount of 240 cubic centimeters (cc) was documented. The amount was not reflective of the intake of the Nepro, ProT Gold supplement, what the resident drank during meals and/or the water intake from the styrofoam cup at the bedside. During an interview on 5/14/26 at 1:25 p.m., the Director of Nursing indicated she was unaware the resident was receiving the Nepro supplement three times a day, she thought it was only one time. She indicated with the amounts documented, nursing staff were not taking in consideration of what dietary served her and the Nepro supplement. There was no documentation of the amount of the ProT Gold supplement to be administered or the amount consumed. 410 IAC (Indiana Administrative Code)16.2-3.1-37(a)

Based on record review and interview, the facility failed to ensure an opioid medication was administered and had an indication for use for 1 of 1 resident reviewed for hospice. The facility also failed to ensure a heart rate was monitored prior to the administration of blood pressure medication for 1 of 4 residents reviewed for non-pressure skin conditions. (Residents 17 and 65)Findings include: 1. The record for Resident 17 was reviewed on 5/13/26 at 2:45 p.m. Diagnoses included but were not limited to, COPD, heart failure, heart disease, anxiety, and vascular dementia. The 2/20/26 Quarterly Minimum Data Set (MDS) assessment, indicated the resident was not cognitively intact for daily decision making and received hospice while a resident. A Physician's Order, dated 1/28/26, indicated Morphine Sulfate Oral Solution 20 milligrams (mg)/5 milliliters (ml), give 0.25 ml by mouth every 1 hour as needed for pain rated 5-10 or shortness of breath. The 1/2026, 3/3026, and 4/2026 Medication Administration Records (MAR) indicated the Morphine was administered to the resident when his pain rating was a 0 on the following days and times: 1/15 at 3:19 p.m., 1/25 at 4:01 p.m., 3/17 at 3:54 p.m., 3/21 at 9:40 p.m., 4/19 at 8:00 p.m.,and 4/21/26 at 3:20 a.m. During an interview on 5/14/26 at 1:25 p.m., the Director of Nursing indicated there was a different pain scale for residents who could not communicate their level of pain. She had no additional information to provide. 2. The record for Resident 65 was reviewed on 5/13/26 at 1:59 p.m. Diagnoses included, but were not limited to, diabetes and hypertension. The Significant Change Minimum Data Set (MDS) assessment, dated 3/25/26, indicated the resident was cognitively intact for daily decision making. A Physician's Order, dated 5/1/25, indicated Metoprolol Tartrate (a blood pressure medication) two times a day, hold for pulse rate less than 60. The resident received the medication without a documented pulse rate on each day from 4/1/26 through 5/12/26. During an interview on 5/14/26 at 9:46 AM, the Regional Nurse Consultant indicated the pulse should be documented with each dose of the medication administered, and should have been added to the MAR (medication administration record). 410 IAC (Indiana Administrative Code)16.2-3.1-48(a)(3) 410 IAC (Indiana Administrative Code)16.2-3.1-48(a)(4)

Based on observation, record review and interview, the facility failed to ensure infection control practices were in place and implemented related to staff failing to perform hand hygiene after glove removal during a pressure ulcer treatment for 1 of 2 pressure ulcer treatments observed. (Resident 1)Finding includes: During a pressure ulcer treatment observation on 5/15/26 at 8:00 a.m., the Unit Manger gathered supplies for Resident 1's pressure ulcer treatment. She performed hand hygiene, donned the appropriate personal protective equipment and placed the supplies on a clean towel on the over bed table. She had clean gloves to both hands and removed the resident's sock and old bandage. With the same gloves, she cleaned the pressure ulcer with wound cleaner and patted it dry. She removed her gloves and donned a clean pair of gloves to both hands. She did not perform hand hygiene after glove removal. She opened the package of collagen particles and with her gloved hands placed the particles on the open area. She then opened a tube of zinc oxide and squeezed an amount onto her gloved finger and placed the ointment all over the wound including the surrounding skin. She removed her gloves and donned a clean pair of gloves to both hands without performing hand hygiene. She opened a bordered gauze bandage, placed it on top of the ulcer, removed her gloves and washed her hands with soap and water. During an interview on 5/15/26 at 8:13 a.m., the Unit Manager indicated she was aware she should have performed hand hygiene after glove removal. During an interview on 5/15/26 at 8:30 a.m., the Regional Nurse Consultant indicated the nurse should have performed hand hygiene after glove removal. The current 2025 Clean Dressing Change policy, provided by the Director of Nursing on 5/15/26 at 8:52 a.m., indicated loosen the tape and remove the existing dressing. If needed to minimize skin stripping or pain, moisten with prescribed cleansing solution or use adhesive remover to remove tape. Remove gloves, pulling inside out over the dressing and discard into appropriate receptacle. Wash hands and put on clean gloves. Cleanse the wound as ordered, taking care to not contaminate other skin surfaces or other surfaces of the wound, pat dry with gauze, and wash hands and put on clean gloves.410 IAC (Indiana Administrative Code) 16.2-3.1-18(b)

Based on observation, record review, and interview, the facility failed to ensure all essential equipment was in safe operating condition for 1 of 1 kitchen. (Main Kitchen)Finding includes:During a tour of the Main Kitchen on 5/11/26 at 9:22 a.m., a large buildup of ice was observed in the walk-in freezer. There was ice on the fans, shelves, floor, and door frame. The food on the shelves had a thick layer of frost on it. At that time, the Kitchen Manager indicated the freezer had been building up with ice for a long time, and once a week, she would go in and try to scrape out all of the ice. She believed they were waiting to get a new freezer next year. During an interview on 5/12/26 at 1:58 p.m., the Maintenance Director indicated the freezer had been building up with ice for a long time. It had been looked at, but could not be repaired. It would probably be replaced next year. During an interview on 5/12/26 at 3:30 p.m., the Regional Nurse Consultant indicated she was aware of issues with freezer for months. They had been trying to figure it into the budget to replace it. On 5/13/26 at 3:10 p.m., the Regional Head of Maintenance provided a service call report, dated 5/13/26, from a repair company. The report indicated, . Inspected the walk in freezer condenser located near the northeast [NAME] of the facility . noted the customer manually defrosted the box due to ice buildup on the ceiling . Identified the box is in poor condition with saturated and taped insulation. Observed moisture dropping from the suction elbow. Recommended reinsulating the refrigeration piping and exposed line outside. Determined a new closer is needed for the walk in freezer condenser . Will order the closer and insulation and schedule a follow up when parts arrive.A policy titled, Food Safety Requirements, received from the Director of Nursing (DON) as current on 5/14/26 at 1:55 p.m., indicated, . Food safely practices should be followed throughout the facility's entire food handling process . Elements of the process include the following: . Equipment used in the handling of food .A policy titled, Maintenance Inspection, received from the DON as current on 5/15/26 at 10:37 a.m. indicated, . It is the policy of this facility . to assure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public . The Administrator, or designee, will perform random inspections of the physical plant using the checklist . All opportunities will be corrected immediately by maintenance personnel .410 IAC (Indiana Administrative Code)16.2-3.1-19(bb)

Based on observation and interview, the facility failed to serve food under sanitary conditions related to dirty food equipment, dirty floors and dirty PVC pipes under the dish machine for 1 of 1 kitchen observed. (The Main Kitchen) Findings include: During the brief Kitchen Sanitation Tour with the Dietary Food Manager on 3/31/25 at 9:38 a.m., the following was observed: a. There was a large amount of dried grease spillage on top of and on the sides of the deep fryer. The side of the stove next to the deep fryer was also dirty with dried grease. The side of the steamer was observed with dried grease as well as a large amount of food crumbs and dust under the steamer. b. The oven hood vents were dirty and greasy. c. The white PVC pipes under the dish machine were very dirty with a large accumulation of dried food spillage. The floor under the dish machine was dirty with adhered dirt against the wall. d. There were two rusted ceiling vents in the dish room. During an interview on 4/3/25 at 10:45 a.m., the Dietary Food Manager indicated all of the above was in need of cleaning. 3.1-21(i)(3)

Based on observation, record review, and interview, the facility failed to ensure a resident was assessed to self-administer medications and had physician's orders to self-administer for 4 of 4 residents reviewed for self-administration of medication. (Residents 44, 52, 20 and 8) Findings include: 1. On 4/1/25 at 9:44 a.m., 1:09 p.m. and 3:50 p.m., a bag of Mucinex throat lozenges was observed in a plastic bin on Resident 44's overbed table. On 4/2/25 at 1:50 p.m., the bag of throat lozenges remained on the resident's overbed table. The record for Resident 44 was reviewed on 4/3/25 at 2:05 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD) and chronic respiratory failure. The 3/12/25 Significant Change Minimum Data Set (MDS) assessment, indicated the resident was cognitively intact. The April 2025 Physician's Order Summary (POS) indicated the resident may self-administer her nebulizer treatment and oral medications once prepared by the licensed nurse/QMA. Medications may be left with me to self-administer as long as I am in the room. There was no physician's order for the throat lozenges. The last self-administration of medication assessment was dated 2/9/24. During an interview on 4/3/25 at 2:00 p.m., the Director of Nursing indicated the resident was no longer capable of self-administering her medications and the cough drops were removed from the resident's room. 2. On 4/1/25 at 1:05 p.m., 2:12 p.m. and 3:50 p.m., Resident 52 was observed in her room sleeping. A bottle of Thera Tears was observed on the resident's overbed table. The record for Resident 52 was reviewed on 4/1/25 at 3:22 p.m. Diagnoses included, but were not limited to, neurocognitive disorder with behavior disturbance and cerebral aneurysm. The Quarterly Minimum Data Set (MDS) assessment, dated 2/28/25, indicated the resident was cognitively impaired for daily decision making. The April 2025 Physician's Order Summary (POS), indicated the resident was to receive Refresh Plus Ophthalmic Solution, instill 2 drops in both eyes one time a day for chronic dry eyes. There was no physician's order to self-administer the eye drops. There was no self-administration of medication assessment available for review. During an interview on 4/3/25 at 11:45 a.m., the Director of Nursing indicated the resident did not have an order to self-administer the eye drops and they should not have been in the resident's room. 43293 3. During a random observation on 3/31/25 at 10:36 a.m., a nebulizer machine, a bottle of Biofreeze (a topical pain medication), and a bottle of Fluticasone (an allergy nasal spray) were observed in Resident 20's room. At that time, the resident indicated the staff let him do nebulizer treatments on his own and there was a bag in his closet with the medication for the nebulizer that he got from his own pharmacy. During an observation on 4/1/25 at 9:20 a.m., the Biofreeze, Albuterol, and Fluticasone remained in the resident's room. The resident indicated he used them when he felt like he needed them. The resident's record was reviewed on 4/1/25 at 3:30 p.m. Diagnoses included but were not limited to, amputation of the left leg, COPD (chronic obstructive pulmonary disease), and acute respiratory failure with hypoxia (low oxygen levels). The 2/5/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily incision making, required partial assistance with ADLs (activities of daily living) and was independent with transfers. A Physician's Order, dated 10/6/24, indicated Albuterol Inhaled Solution three times a day. A Physician's Order, dated 12/22/24, indicated Biofreeze Gel to the left hip topically every 3 hours as needed for hip pain. There were no orders for self-administration of Albuterol and Biofreeze or to keep the medications at the bedside. There was no order for Fluticasone. The most recent Self-Administration of Medication Assessment was dated 4/23/24. There was no documentation the resident was capable of administering topical medication. During an interview on 4/3/25 at 11:37 a.m., the Director of Nursing indicated medication self-administration assessments should be performed quarterly and as needed. If a medication was to be self-administered and/or kept at the bedside, it should be written in the medication order. She indicated she was not aware of the bag of medications in the resident's closet, but would look into it. 4. During a random observation on 3/31/25 at 10:49 a.m., a bottle of Astepro (an allergy nasal spray) and Mometasone Furoate (a topical steroid) were observed on Resident 8's bedside table. During an observation on 4/1/25 at 2:33 p.m., both medications remained on the bedside table. At that time, the resident indicated he used both of the medications when he needed them. The resident's record was reviewed on 4/1/25 at 3:35 p.m. Diagnoses included but were not limited to, dependence on renal dialysis, COPD, diabetes and seizures. The 12/24/24 Quarterly MDS assessment indicated the resident was cognitively intact for daily decision making, and required substantial assistance with ADLs and transfers. The most recent Self-Administration of Medication Assessment in the record was dated 5/11/23. During an interview on 4/3/25 at 11:37 a.m., the Director of Nursing indicated medication self-administration assessments should be performed quarterly and as needed. She indicated it was something they were working on correcting. A policy titled, Resident Self-Administration of Medication, received as current from the Director of Nursing on 4/4/25 at 8:30 a.m. indicated, . A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely . Each resident is offered the opportunity to self-administer medications during the routine assessment by the facility's interdisciplinary team . 3.1-11

Based on observation, record review, and interview, the facility failed to ensure the head of the bed was elevated to at least 45 degrees while a resident's enteral feeding was infusing into the peg tube (a tube inserted directly into the stomach for nutrition) for 1 of 1 resident reviewed for tube feeding. (Resident 17) Finding includes: During a random observation on 4/2/25 at 5:14 p.m., Resident 17 was observed lying completely flat in bed. The head of the bed was flat and not elevated to at least 45 degrees. At that time, the resident had an enteral tube feeding infusing at 55 cubic centimeters (cc) per hour. CNA 2 and RN 1 were immediately notified and asked to reposition the resident in bed. During an interview at that time, CNA 2 and RN 2 both indicated the resident played with the remote control and would lower the head of the bed all the time by herself. RN 1 indicated she had administered her medication at 4:10 p.m., and the head of the bed was elevated at that time. The record for Resident 17 was reviewed on 4/2/25 at 10:45 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, stroke, hemiplegia, dysphagia (difficulty swallowing), chronic kidney disease, heart failure, peg tube, high blood pressure, and a cardiac pacemaker. The Significant Change Minimum Data Set (MDS) assessment, dated 1/22/25, indicated the resident was not cognitively intact for daily decision making, had no oral problems and had a feeding tube through which she received 51% or more of nutrition. A Care Plan, dated 11/24/24, indicated the resident required a tube feeding related to dysphagia. The approaches were to ensure the head of the bed was at least 45 degrees. A Physician's Orders, dated 3/5/25, indicated Enteral Feed every shift of Jevity 1.2 Cal at 55 cc per hour times 24 hours a day. During an interview on 4/3/25 at 11:00 a.m., the Director of Nursing indicated the head of the resident's bed was to be elevated to at least 45 degrees. She was aware of the incident that happened on 4/2/25. The current 2024 Care and Treatment of Feeding Tubes policy provided by the DON on 4/4/25 at 8:30 a.m., indicated the resident's care plan will direct staff regarding proper positioning of the resident consistent with the resident's individual needs. 3.1-44(a)(2)

Based on observation, record review and interview, the facility failed to maintain a resident's dignity related to wearing a hospital gown during the day and not consistently offering pleasure food for 1 of 1 resident reviewed for dignity. (Resident 17) Finding includes: During a random observation on 3/31/25 at 11:21 a.m., Resident 17 was observed in bed wearing a hospital gown. At that time, an enteral tube feeding was infusing into the peg tube (a tube inserted directly into the stomach for nutrition). The resident's roommate was seated in a chair in the room as well. At 11:25 a.m., the roommate received her lunch meal and proceeded to eat in the room. Resident 17 did not receive a tray and was not offered anything to eat. On 3/31/23 at 3:22 p.m., the resident was observed in bed still wearing a hospital gown. During an interview at that time, the resident indicated she did not receive anything to eat for lunch, and sometimes they would bring a pudding for me to eat. During random observations on 4/1/25 at 8:58 a.m., 1:10 p.m. and 2:30 p.m., the resident was observed in bed wearing a hospital gown. During random observations on 4/2/25 at 10:20 a.m. and 11:26 a.m., the resident was observed in bed wearing a hospital gown. During lunch, the resident's roommate received her tray in the room, however, Resident 17 was not offered anything to eat. At 1:30 p.m., the resident remained dressed in her hospital gown. At 5:14 p.m., the resident's roommate received her dinner tray and again Resident 17 was not asked if she wanted anything to eat or served a dinner tray. The record for Resident 17 was reviewed on 4/2/25 at 10:45 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, stroke, hemiplegia (weakness or paralysis on one side of the body), dysphagia (difficulty swallowing), chronic kidney disease, heart failure, peg tube, high blood pressure, and a cardiac pacemaker. The Significant Change Minimum Data Set (MDS) assessment, dated 1/22/25, indicated the resident was not cognitively intact for daily decision making and was dependent on staff for dressing and personal hygiene. There was no care plan that indicated the resident preferred to wear a hospital gown during the day. A Physician's Order, dated 3/5/25, indicated enteral feed of Jevity 1.2 Cal at 55 cubic centimeters (cc) per hour for 24 hours. There was no order indicating nothing by mouth. During an interview on 3/31/25 at 12:07 p.m. CNA 1 indicated they would serve the resident pleasure foods only if she requested something. During an interview on 4/3/25 at 10:49 a.m., the Dietary Food Manager indicated they do not normally send the resident any food, they wait to see if the resident requested a pudding or yogurt and then they would send one up. During an interview on 4/3/25 at 11:00 a.m., the Director of Nursing indicated the resident should be offered pleasure foods at every meal and there was no care plan indicating the resident preferred to be dressed in a hospital gown. During an interview on 4/3/25 at 2:00 p.m., CNA 1 indicated they had always dressed the resident in the hospital gown. 3.1-3(t)

Based on record review and interview, the facility failed to file a grievance form, thoroughly investigate, and resolve grievances related to a resident representative's complaints for 1 of 1 resident reviewed for grievances. (Resident B) Finding includes: The closed record for Resident B was reviewed on 4/3/25 at 10:43 a.m. Diagnoses included but were not limited to, diabetes, sacral (tailbone area) pressure ulcer, cancer of the large intestine, and dementia. The 1/29/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making, and required maximum assistance with ADLs (activities of daily living) and transfers. A Social Services Note, dated 3/3/25, indicated during a meeting with the SSD (Social Services Director), nursing, wound care, and the Administrator, the resident's representative had concerns about the resident's care and made multiple accusations. There was no documentation of the specific concerns, investigation or resolution. A grievance form was not initiated. A Social Services Note, dated 3/6/25, indicated the resident's representative made accusations that a bug was found on the resident when he was at the wound clinic, and that he had bite marks on his skin. The nurse and aide assessed the resident and his room, and found no bugs or bite marks. The note from the wound clinic did not indicate finding a bug or bite marks. The Social Service Note did not indicate a resolution of the complaint. A grievance form was not initiated. During an interview on 4/3/25 at 3:15 p.m., the SSD indicated no grievances had been filled out regarding the representative's concerns because they wanted everything done immediately. She met with the representative regularly and documented this in her notes. The SSD indicated they should have filled out a grievance for each of the resident representative's concerns. A policy titled, Resident and Family Grievances, received as current on 4/4/25 at 12:00 p.m. from the SSD indicated, . The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form . The Grievance Official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form . The Grievance Official, or designee, will keep the resident appropriately apprised of progress towards resolution of the grievances . This citation relates to complaint IN00455286. 3.1-7(a)(2)

Based on observation, record review, and interview, the facility failed to ensure activities of daily living (ADLs) were completed for dependent residents related to shaving and washing hair for 3 of 8 residents reviewed for ADLs. (Residents 17, 37, and 63) Findings include: 1. During random observations on 3/31/25 at 11:21 a.m. and 3:22 p.m., Resident 17 was observed in bed wearing a hospital gown. At that time, she had a moderate amount of facial hair on her chin. During random observations on 4/1/25 at 8:58 a.m., 1:10 p.m. and 2:30 p.m., the resident was observed in bed wearing a hospital gown and had a moderate amount of facial hair on her chin. During random observations on 4/2/25 at 10:20 a.m., 11:26 a.m., 1:30 p.m. and 5:14 p.m., the resident was observed in bed wearing a hospital gown and had a moderate amount of facial hair on her chin. The record for Resident 17 was reviewed on 4/2/25 at 10:45 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, stroke, hemiplegia, dysphagia (difficulty swallowing), chronic kidney disease, heart failure, peg tube, high blood pressure, and a cardiac pacemaker. The Significant Change Minimum Data Set (MDS) assessment, dated 1/22/25, indicated the resident was not cognitively intact for daily decision making and was dependent on staff for dressing and personal hygiene. A Care Plan, dated 11/25/24, indicated the resident had an ADL self-care performance deficit related to a stroke. The resident required assistance of one person with personal hygiene. The CNA task section indicated the resident received a shower on Tuesday and Fridays. There was no documentation the resident had been assisted with the removal of the facial hair on her chin. During an interview on 4/3/25 at 11:00 a.m., the Director of Nursing indicated the resident should be shaved as needed. 2. During a random observation on 3/31/25 at 11:35 a.m., , Resident 37 was observed sitting up in a Broda chair. At that time, he had a large amount of facial hair observed on his face and chin. During random observations on 4/1/25 at 9:00 a.m., 1:14 p.m., and 2:30 p.m., the resident remained with a large amount of facial hair on his face and chin. The record for Resident 37 was reviewed on 4/1/25 at 2:50 p.m. Diagnoses included, but were not limited to, Parkinson's disease, Alzheimer's disease, high blood pressure, delusions, osteoarthritis, depression, and acute kidney failure. The 3/3/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was not alert and oriented and was dependent on staff for personal hygiene. A Care Plan, revised on 12/9/23, indicated the resident had an ADL self-care performance deficit related to Parkinson's and Alzheimer's disease. The resident required assistance of one person with personal hygiene. The CNA task section indicated the resident had completed showers on 3/6, 3/10, 3/17, and 3/20/25, however, there was no documentation the resident was shaved. During an interview on 4/3/25 at 11:00 a.m., the Director of Nursing indicated the resident should be shaved as needed. She has contacted hospice to ensure this was done during his bath days. 3. During random observation on 3/31/25 at 11:25 a.m., 2:20 p.m., and 3:15 p.m., on 4/1/25 at 8:59 a.m., 1:10 p.m., and 2:32 p.m., and on 4/2/25 at 10:20 a.m., 11:30 a.m., and 5:20 p.m., Resident 63 was observed with a large amount of facial hair on his face and chin area. The resident's hair was also observed to be matted and knotted on the back of his head. On 4/3/25 at 9:30 a.m., QMA 1 and the Wound Nurse were observed in the room and were shown the resident's hair and that he was unshaven. During an interview on 4/3/25 at 9:50 a.m., QMA 1 indicated the hospice CNA came at least two times a week to bathe the resident. She indicated he was in need of a shave. During an interview on 4/3/25 at 9:55 a.m., the Wound Nurse indicated the resident's hair was matted and his scalp was dry. The record for Resident 63 was reviewed on 4/2/25 at 11:45 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, acute respiratory failure, anxiety, heart disease, osteoarthritis, and heart failure. The 12/24/24 Significant Change Minimum Data Set (MDS) assessment indicated the resident was never/rarely understood and was severely impaired for decision making. The resident was dependent on staff for personal hygiene. A Care Plan, revised on 3/4/25, indicated the resident had an ADL self-care performance deficit related to impaired balance and limited mobility. The resident required assistance of one staff with personal hygiene. The CNA task section indicated the resident received a shower or bed bath on Wednesdays and Saturdays. A complete bed bath was last given on 3/29/25. There was no documentation the resident was shaved or had his hair washed. During an interview on 4/3/25 at 11:09 a.m., the Director of Nursing indicated the resident should have been shaved and had his hair washed as needed. 3.1-38(a)(3)(B) 3.1-38(a)(3)(D)

Based on observation, record review, and interview, the facility failed to ensure a resident with signs and symptoms of constipation was treated for 1 of 1 resident reviewed for constipation, and areas of discoloration, and edema were assessed and monitored for 1 of 2 residents reviewed for skin conditions non-pressure related and for 1 of 1 resident reviewed for edema. (Residents 63, 57, and 122) Findings include: 1. The record for Resident 63 was reviewed on 4/2/25 at 11:45 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, acute respiratory failure, anxiety, heart disease, osteoarthritis, and heart failure. The 12/24/24 Significant Change Minimum Data Set (MDS) assessment indicated the resident was never/rarely understood and was severely impaired for decision making. The resident was dependent on staff for ADL care and was always incontinent of bowel. A Care Plan, revised on 1/19/25, indicated the resident was at risk for constipation related to decreased mobility. The approaches were to follow facility bowel protocol for bowel management and record bowel movements each day. A Physician's Order, dated 12/18/24, indicated Bisacodyl Rectal Suppository, insert 1 suppository rectally every 24 hours as needed for constipation. A Physician's Order, dated 12/20/24, indicated hospice care. A Physician's Order, dated 1/31/25, Morphine Sulfate (Concentrate) Solution 20 milligrams (mg) give 0.25 milliliter (ml) by mouth every 1 hour as needed (prn) for pain. A Physician's Order, dated 2/3/25 indicated Morphine Sulfate (Concentrate) Solution 20 mg give 0.25 milliliter (ml) by mouth every six hours for pain. A Physician's Order, dated 3/14/25, indicated Docusate Sodium Liquid 50 mg, give 10 ml by mouth one time a day for constipation. The resident had no bowel movement on the following days: 1/1/25-1/5/25, 2/16/25-2/21/25, 3/3/25-3/8/25, and 3/22/25-3/25/25. The Medication Administration Record (MAR) for the month of 3/2025 indicated the prn suppository was not signed out as being administered for constipation. During an interview on 4/3/25 at 3:00 p.m., the Director of Nursing indicated they had no policy for constipation. If the resident had no bowel movement after three days, they would give the as needed (prn) medications and if there were no as needed medications, the nurses should be calling the doctor. 43293 2. During a random observation on 3/31/25 at 11:10 a.m., bruising was observed to Resident 57's shins and right knee. During subsequent observations on 4/1/25 at 1:33 p.m. and 4/2/25 at 10:05 a.m., the bruising remained present to the resident's shins and right knee. Resident 57's record was reviewed on 4/2/25 at 11:33 a.m. Diagnoses included, but were not limited to, hypertensive heart disease with heart failure and diabetes. The 1/27/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making, required substantial assistance with ADLs, and partial/moderate assistance with transfers. A Care Plan, dated 12/14/24, indicated the resident was on anticoagulant therapy (blood thinners). Interventions included monitoring and documenting bruising. A Physician's Order, dated 1/28/25, indicated to observe for signs and symptoms of bleeding including tarry stools, blood in urine, and bruising every shift. The record lacked documentation of assessments of the resident's bruised shins and right knee. During an interview on 4/3/25 at 11:36 a.m., the Director of Nursing indicated bruises should be assessed and documented in the resident's record. During an interview on 4/3/25 on 3:05 p.m., the DON indicated the resident was up and about all of the time, bruised easily and was on blood thinners. 3. During a random observation on 4/1/25 at 9:02 a.m., Resident 122's hands were observed to be swollen. The ring on his left hand was digging into his finger. At that time, the resident indicated his hands were swollen, but he did not know why. During an observation on 4/02/25 at 9:33 a.m., the resident was resting in bed. The swelling to his hands appeared unchanged. The resident's record was reviewed on 4/2/25 at 9:00 a.m. Diagnoses included, but were not limited to, gastrointestinal bleed, heart disease, and chronic kidney disease. The 3/28/25 Skilled Nurse Admission Assessment indicated the resident was cognitively intact for daily decision making, required one person physical assist with ADLs (activities of daily living) and transfers, and had new,1+ pitting edema (1 out of 4 on a scale of severity of swelling that stays indented when pressed with a finger) to his left hand/fingers. A Nurse's Note, dated 3/9/25, indicated the resident had edema (swelling) to both arms/hands. The record lacked any other assessments of the resident's edema. The care plan lacked interventions related to monitoring or treatment of the edema. During an interview on 4/3/25 at 9:38 a.m., RN 2 indicated she did not notice the resident's swelling, she only checked his vital signs. During an interview on 4/03/25 at 3:06 p.m., the Director of Nursing indicated edema should be assessed and documented regularly. She was not sure why the resident had edema and would ask the nurse practitioner to see the resident. 3.1-37

Based on observation, record review, and interview, the facility failed to ensure a resident's toenails were cut, kept trimmed and podiatry care was provided for 1 of 1 resident reviewed for foot care. (Resident 63) Finding includes: During random observations on 3/31/25 at 11:25 a.m. and 4/1/25 at 8:59 a.m., Resident 63 was sitting up in a Broda chair. On 4/2/25 at 10:20 a.m., 11:30 a.m., and 5:20 p.m., the resident was observed reclined in a Broda chair. At those times, the resident was observed with very long toenails. On 4/3/25 at 9:32 a.m., QMA 1 and the Wound Nurse were in the room. At that time, they were both shown the resident's long toenails. During an interview on 4/3/25 at 9:55 a.m., the Wound Nurse indicated the resident received hospice care, so they would have to let hospice know the toenails needed to be trimmed. The record for Resident 63 was reviewed on 4/2/25 at 11:45 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, acute respiratory failure, anxiety, heart disease, osteoarthritis, and heart failure. The 12/24/24 Significant Change Minimum Data Set (MDS) assessment, indicated the resident was never/rarely understood and was severely impaired for decision making. The resident was dependent on staff for personal hygiene. There were no visits by the podiatrist. During an interview on 4/3/25 at 11:08 a.m., the Social Service Director indicated on 2/10/25 hospice deemed podiatry services were not necessary for the resident, therefore he had not seen the podiatrist since admission. During an interview on 4/3/25 at 11:09 a.m., the Director of Nursing indicated the hospice CNA and hospice nurse were in the facility at least three times during the week and provided his baths, so his toenails should have been observed. 3.1-47(a)(7)

Based on observation, record review, and interview, the facility failed to ensure assistive devices were in place for a resident with a limited range of motion for 1 of 1 resident reviewed for positioning. (Resident 50) Finding includes: During random observations on 3/31/25 at 11:34 a.m. and 12:15 p.m., and on 4/1/125 at 11:32 a.m. and 1:12 p.m., Resident 50 was observed sitting in her wheelchair. At that time, her right arm was elevated on a small bed pillow. There was no arm tray observed on the wheelchair. The record for Resident 50 was reviewed on 4/1/125 at 2:10 p.m. Diagnoses included, but were not limited to, Alzheimer's disease, stroke, right side hemiplegia (weakness or paralysis of one side of the body), vascular dementia, anxiety, high blood pressure, and osteoarthritis. The 2/10/25 Annual Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making and had a limited range of motion impairment to one side for the upper extremity. A Care Plan, dated 12/13/24, indicated the resident had an ADL self-care performance deficit related to a stroke and hemiplegia. The approaches were for the resident to use the right shoulder arm tray to support the right upper extremity while upright in wheelchair for joint protection and proximal support. A Physician's Order, dated 3/29/24, indicated the resident was to use a right shoulder arm tray to support the right upper extremity while upright in wheelchair for joint protection and proximal support. every shift. The 1/2025, 2/2025 and 3/2025 Medication Administration Records (MAR) indicated the right shoulder tray was signed out as being on the wheelchair every day shift. There were no documented refusals of the right shoulder arm tray. During an interview on 4/3/25 at 2:00 p.m., CNA 1 indicated the tray was located in between the dresser and night stand and was to be attached to her wheelchair when she was up. She indicated the resident's daughter may ask for it to be removed sometimes. During an interview on 4/3/25 at 3:00 p.m., the Director of Nursing indicated the tray was to be on the resident's wheelchair. 3.1-42(a)(2)

Based on observation, record review, and interview, the facility failed to ensure residents with a history of falls had preventions in place to prevent more falls/injuries related to a floor mat beside the bed and keeping the bed in the lowest position for 2 of 3 residents reviewed for falls. (Residents 37 and 63) Findings include: 1. During random observations on 4/1/25 at 9:00 a.m. and 2:30 p.m., and on 4/2/25 at 3:00 p.m., Resident 37 was observed in bed. At those times, the resident's bed was not in the lowest position. The record for Resident 37 was reviewed on 4/1/25 at 2:50 p.m. Diagnoses included, but were not limited to, Parkinson's disease, Alzheimer's disease, high blood pressure, delusions, osteoarthritis, depression, and acute kidney failure. The 3/3/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was not alert and oriented and was dependent on staff transfers and bed mobility. The resident had no falls since the last assessment. A Care Plan, revised on 9/20/24, indicated the resident was at risk for falls. The approaches were to keep the bed in the lowest position. A Nurses' Note, dated 12/28/24 at 9:28 p.m., indicated the resident was found on the floor on the floor mat next to the bed. During an interview on 4/3/25 at 3:00 p.m., the Director of Nursing indicated the bed should be in the lowest position. 2. During random observations on 3/21/25 at 2:20 p.m. and 3:15 p.m., Resident 63 was observed in bed. There was no floor mat on the floor next to the bed. The record for Resident 63 was reviewed on 4/2/25 at 11:45 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, acute respiratory failure, anxiety, heart disease, osteoarthritis, and heart failure. The 12/24/24 Significant Change Minimum Data Set (MDS) assessment, indicated the resident was never/rarely understood and was severely impaired for decision making. The resident was dependent on staff for bed mobility and transfers. There was no history of falls since the last assessment. A Care Plan, dated 11/25/24, indicated the resident was at risk for falls. The approaches were to place a floor mat next to the bed at all times while the resident was in the bed. The record indicated the resident was found on the floor next to the bed on 11/22/24 and 11/25/24. A Physician's Order, dated 11/26/24, indicated to place a floor mat at the bedside at all times while the resident was in the bed, every shift. During an interview on 4/3/25 at 11:00 a.m., the Director of Nursing indicated the mat should have been on the floor next to the bed. 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure food consumption logs were completed for residents with a history of weight loss for 3 of 4 residents reviewed for nutrition. (Residents 14, 39, and 52) Findings include: 1. On 3/31/25 at 11:54 a.m., Resident 14 was seated in her room in her wheelchair. The resident was served noodles, meatballs, peas, and a fruit cup. The resident indicated she wanted nothing to eat. On 4/2/25 at 11:38 a.m., the resident was served grilled cheese and soup for lunch. She was not eating any of her meal. At 11:55 a.m., the resident was observed drinking her milk but not eating any food. The record for Resident 14 was reviewed on 4/1/25 at 1:12 p.m. Diagnoses included, but were not limited to, mild cognitive impairment, adult failure to thrive, and dysphagia (difficulty swallowing). The Significant Change Minimum Data Set (MDS) assessment, dated 1/13/25, indicated the resident had moderate cognitive impairment. The resident had sustained a weight loss during the assessment reference period. A Care Plan, dated 9/30/24 and reviewed on 3/31/25, indicated the resident had a nutritional problem or potential nutritional problem related to hemiplegia and hemiparesis (muscle weakness and/or paralysis), chronic obstructive pulmonary disease (COPD), anxiety disorder, hypertension, recurrent depressive disorder, and adult failure to thrive. The goal was for the resident to maintain adequate nutritional status. A Physician's Order, dated 3/6/25, indicated the resident received a regular diet. A Physician's Order, dated 3/11/25, indicated the resident was also receiving an enteral feeding (a method of providing nutrition directly into the gastrointestinal tract through a tube) of Jevity 1.2, 100 milliliter (ml) bolus five times a day. The resident had sustained a 27% weight loss in the past six months. The March 2025 Food Consumption Log indicated there was no intake documented for all three meals on 3/4/25. No breakfast was documented on 3/25/25 and no dinner was documented on 3/10/25, 3/20/25, and 3/26/25. During an interview on 4/4/25 at 8:45 a.m., the Director of Nursing indicated the resident's food consumption should have been documented for each meal. 2. On 4/2/25 at 11:55 a.m., Resident 39 was observed in his room eating lunch. He was served soup and a grilled cheese sandwich. The record for Resident 39 was reviewed on 4/2/25 at 9:57 a.m. Diagnoses included, but were not limited to, stroke, congestive heart failure, and dependence on renal dialysis. The Quarterly Minimum Data Set (MDS) assessment, dated 3/4/25, indicated the resident was moderately impaired for daily decision making and he required set up or clean up assistance with eating. No weight issues were identified during the assessment reference period. A Care Plan, dated 10/18/24 and reviewed on 2/14/25, indicated the resident had a nutritional problem or potential nutritional problem related to being on a therapeutic diet due to end stage renal disease (ESRD) with hemodialysis. The resident would request foods that were restricted on his dialysis diet; weight may fluctuate due to dialysis; meal intakes vary; potential for chewing/swallowing difficulty due to dysphagia (difficulty swallowing). The goal was for the resident to maintain adequate nutritional status as evidenced by maintaining weight with no significant weight changes, no signs and symptoms of malnutrition, and meeting estimated nutrition needs. The resident was hospitalized [DATE]-[DATE] and had a 12% weight loss in one month. A Physician's Order, dated 3/18/25, indicated the resident was to receive a regular diet with no salt packet; no bananas, dried fruit, potatoes, tomatoes, or oranges. Limit to four ounces of milk daily and double protein at meals. The March 2025 Food Consumption Log indicated the resident's dinner intake was not documented on 3/4/25, 3/20/25, and 3/27/25. During an interview on 4/4/25 at 8:45 a.m., the Director of Nursing indicated the resident's food consumption should have been documented. 3. On 3/31/25 at 11:52 a.m. and 12:03 p.m., Resident 52 was observed in her room in bed sleeping. The resident's lunch tray was covered and on the overbed table. On 4/2/25 at 12:02 p.m., the resident was seated in the main dining room. She was served grilled cheese, soup, and jello for lunch. The resident was encouraged to eat by staff and was asked if she would like something else. The resident indicated she didn't want anything else and she would just drink her coffee. The record for Resident 52 was reviewed on 4/1/25 at 3:22 p.m. Diagnoses included, but were not limited to, neurocognitive disorder with behavior disturbance, protein-calorie malnutrition, and dysphagia (difficulty swallowing). The Quarterly Minimum Data Set (MDS) assessment, dated 2/28/25, indicated the resident was cognitively impaired for daily decision making and she required set up or clean up assistance with eating. No weight issues were noted during the assessment reference period. A Care Plan, dated 10/18/24 and reviewed on 1/19/25, indicated the resident had a nutritional problem or potential nutritional problem related to being at nutritional risk related to low body weight (LBW), a body mass index (BMI) less than 19; meal intake varied, would decline breakfast but would drink coffee; history of receiving a mechanically altered diet due to Barrett's esophagus, dysphagia; abnormal labs due to anemia, LBW; weight may fluctuate due to edema, diuretic; weight gain was desired; diagnoses include depression, protein calorie malnutrition; need for supplements to meet estimated needs. Interventions included, but were not limited to, monitor intake and record every meal. The April 2025 Physician's Order Summary (POS) indicated the resident was to receive a regular diet, mechanical soft/easy to chew texture and nectar thick liquids. The resident was also to be weighed weekly and was receiving an appetite stimulant. The March 2025 Food Consumption Log indicated there was no intake documented for lunch and dinner on 3/4/25. There was no intake documented for dinner on 3/7/25, 3/10/25, and 3/21/25. During an interview on 4/4/25 at 8:45 a.m., the Director of Nursing indicated the resident's food consumption should be monitored for each meal. 3.1-46(a)(1)

A. Based on observation, record review and interview, the facility failed to ensure infection control practices for COVID-19 were followed during the pandemic and during an outbreak at the facility. Staff were self-monitoring for symptoms of COVID-19 prior to their shift and were not monitored or screened by anyone else. Multiple staff worked with symptoms including fever, body aches, cough and runny nose, some providing resident care in the green zone (the area where residents have no symptoms, and have not been exposed to COVID-19). As of 10/29/2020, the facility had 25 residents and 19 staff members who were COVID-19 positive. The facility also failed to complete contact tracing for the staff members who worked with symptoms and tested positive for COVID-19. This deficient practice increased the likelihood of [MEDICAL CONDITION] spreading to the remaining 22 residents in the facility who currently were not COVID-19 positive. The Immediate Jeopardy began on 10/10/20 when multiple staff members were working, or had worked, with symptoms of COVID-19. The staff self-screening forms were not reviewed by the Infection Preventionist (IP) or any other clinical staff member, and despite having signs and symptoms answered positively on the questionnaire, the staff members were permitted to work. Employees 3, 5, 16 and 17, who worked with symptoms, also tested positive for COVID-19. The Nurse Consultant and Area Vice President were notified of the immediate jeopardy at 11:30 a.m. on 10/29/20. The immediate jeopardy was removed on 10/30/20, but noncompliance remained at the lower scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy. B. Based on observation, record review and interview, the facility failed to ensure infection control guidelines were followed related to staff wearing isolation gowns in the hall of isolation units and not wearing appropriate face shields with KN95 face masks. This had the potential to effect the remaining 22 residents who were not currently COVID-19 positive. Findings include: A. On 10/28/20 at 1:50 p.m., Employee 15, Therapy Coordinator, was observed entering the employee entrance and approached the screening table. She filled out the questionnaire, took her own temperature, and proceeded into the building. The employee had indicated on the questionnaire she had a runny nose and had been exposed to someone with COVID-19. There was no staff member reviewing the questionnaires. The Coronavirus Screening Forms were reviewed on 10/28/20 at 3:30 p.m. The form had four sections. The first requested information about symptoms, the second requested additional information such as travel history, the third section asked if the staff member would like to speak to the Infection Preventionist (IP) and if they were allowed to work, and the final section was for the Infection Preventionist's signature. Interview with the Area Vice President at this time indicated these were new forms that that had been initiated on 10/26/20. Prior to that date, the facility had used a different form, which was a line listing that included date, name, temperature, and asked to check box if temperature over 100.0, sore throat, cough, runny nose, shortness of breath, diarrhea, exposure last 14 days, traveled and where to. The form had no designated area for the screener or Infection Preventionist to sign. The following employees checked off one or more symptoms of COVID-19 on the screening questionnaires: -Employee 1, Activity Aide, indicated a cough on 10/12, 10/13, 10/15, 10/16, 10/17, 10/20, 10/21, 10/22, 10/27 and 10/28/20. -Employee 2, Nurse, indicated a sore throat, runny nose, exposure in past 14 days, traveled on 10/09; runny nose, diarrhea, traveled on 10/12; sore throat, runny nose, cough, diarrhea on 10/13; sore throat, cough, runny nose on 10/19/20. -Employee 3, Central Supply, indicated a cough and runny nose on 10/9; and cough on 10/19/20. Employee was tested on [DATE] and was positive on 10/19/20 for COVID-19. The time card was reviewed on 10/30/20 at 1:55 p.m., and indicated the employee worked 8:01 a.m. to 4:53 p.m. on 10/9 and 7:55 a.m. to 2:10 p.m. on 10/19/20. -Employee 4, Nurse, indicated a sore throat and runny nose on 10/09; cough and runny nose on 10/11, 10/13 and 10/14/20. -Employee 5, CNA, indicated a sore throat on 10/10 and 10/11/20; sore throat, cough, runny nose and exposure in past 14 days on 10/13/20. Employee was tested on the 10/12/20, and results positive on 10/15/20 for COVID-19. The time card was reviewed on 10/30/20 at 1:55 p.m. and indicated she worked, 6:30 a.m. to 11:21 a.m. on 10/10; 2:59 a.m. to 6:39 a.m. on 10/11; 2:59 a.m. to 6:37 a.m. on 10/13/20. -Employee 6, Nurse, indicated a cough, runny nose on 10/10; sore throat, cough and runny nose on 10/11, 10/23 and 10/25/20. -Employee 7, Nurse, indicated a runny nose on 10/12/20. -Employee 8, CNA, indicated a cough on 10/12/20. -Employee 9, Nurse, indicated a cough, runny nose and exposure in past 14 days on 10/12/20. -Employee 10, Nurse, indicated sore throat, cough and runny nose on 10/15/20. -Employee 11, Nurse, indicated sore throat, runny nose, cough, shortness of breath and exposure in past 14 days on 10/18; sore throat, runny nose, cough and shortness of breath on 10/20, 10/21, 10/25 and 10/26; cough, sore throat, shortness of breath, body aches, headache, runny nose and exposure to someone on 10/29/20. -Employee 12, CNA, indicated cough and shortness of breath on 10/19/20; cough and shortness of breath, undated. -Employee 13, Laundry, indicated cough, runny nose and diarrhea on 10/19; runny nose on 10/20; cough and runny nose on 10/21; headache on 10/27/20. -Employee 14, CNA, indicated cough, runny nose, diarrhea and exposure in past 14 days on 10/20; sore throat, cough, runny nose, diarrhea and exposure in past 14 days on 10/21, 10/23 and 10/24; cough and runny nose on 10/27/20. -Employee 15, Therapy, indicated runny nose on 10/20; cough on 10/24; runny nose and exposure to someone on 10/27 and 10/28/20. -Employee 16, CNA, indicated cough on 10/21; cough and exposure in past 14 days on 10/23; cough and nausea, vomiting or diarrhea on 10/26, and 10/27/20. Employee 16 was tested on [DATE] and positive results on 10/12/20 for COVID-19. The time card was reviewed on 10/30/20 at 1:55 p.m. and indicated Employee 16 worked on the following dates and times: on 10/21 from 2:31 p.m. to 10:46 p.m.; on 10/23 from 2:30 p.m. to 9:00 p.m.; 10/26 from 2:27 p.m. to 10:51 p.m.; 10/27 from 2:30 to 10:00 p.m. -Employee 17, CNA, indicated a runny nose 10/15 and 10/18; sore throat and runny nose 10/16, 10/17, 10/20; sore throat, body aches, runny nose on 10/27; sore throat, cough and exposed to someone 10/22, 10/23 and 10/26/20. Employee 17 was tested on ,[DATE], with positive results on 10/28/20 for COVID-19. The time card was reviewed on 10/30/20 at 1:55 p.m. and indicated Employee 17 worked the following dates and times: 10/15 from 4:11 a.m. to 2:32 p.m.; 10/16 from 3:51 a.m. to 2:02 p.m.; 10/17 from 2:50 a.m. to 10:06 a.m. and 10:26 a.m. to 2:31 p.m.; 10/18 from 2:45 a.m. to 2:30 p.m.; 10/20 from 4:25 a.m. to 12:33 p.m.; 10/22 from 2:47 a.m. to 2:45 p.m.; 10/23 from 4:02 a.m. to 12:26 p.m.; 10/26 5:22 a.m. to 2:43 p.m.; 10/27 3:58 a.m. to 11:30 a.m. -Employee 18, CNA, indicated a headache on 10/26/20. Employee was sent home later for a temperature of 100.2. -Employee 19, Business Office Manager, indicated runny nose on 10/27/20. -Employee 20, Speech Therapist, indicated exposure to someone on 10/27/20. -Employee 21, Housekeeping, indicated was at a public event where unable to social distance and not able to wear face covering and had a cough on 10/26; at a public event where unable to social distance and not able to wear face covering, cough, sore throat and runny nose on 10/27; at a public event where unable to social distance and not able to wear face covering, cough, sore throat, runny nose and nausea, vomiting or diarrhea on 10/28/20. -Employee 22, Maintenance Manager, indicated cough, body aches and runny nose on 10/27; cough, body aches, runny nose and exposure to person on 10/28/20. -Employee 23, Nurse, indicated a headache on 10/26/20. There was no indication the above employees' screening questionnaires were reviewed prior to them proceeding to work. A Coronavirus Screening Form was reviewed on 10/29/20 at 9:15 a.m. for Employee 5, an aide. It indicated she had a temperature of 100.0, a cough, body aches, runny nose and sore throat. When questioned if the employee was in the facility, a staff member indicated she was giving a resident a bed bath. The Nurse Consultant was notified and she removed the employee from the resident's room on the green zone. Employee 5 indicated she had tested positive for COVID-19 on 10/12/20, but today was the first time she had a fever. She indicated she felt fine. The Nurse Consultant sent the aide home at 9:30 a.m., and instructed her to follow up with her physician prior to returning to work. Employee 5 had clocked in for work at 4:29 a.m. on 10/29/20. During interview with the IP nurse at 2:45 p.m. on 10/28/20, she indicated the screening sheets were reviewed in the morning by the management team from the previous day. She indicated they needed a screener, they had someone starting Monday during the day, and the National Guard were going to start to help screen on 3-11 shift Monday. A document titled, COVID-19 LTC Facility Infection Control Guidance Standard Operating Procedure, updated 10/20/20, was received from the Nurse Consultant on 10/28/20 at 3:45 p.m. The document indicated, .Long-term care centers should take every day preventive measures to help contain the spread of COVID-19. Actively screen all healthcare personnel (HCP), visitors, vendors entering the facility for symptoms of COVID-19 and any history of being in close contact or exposed to COVID-19 positive or symptomatic person During an interview with the Nurse Consultant on 10/29/20 at 9:28 a.m., she indicated staff should not be caring for residents while sick. On 10/30/20 at 11:10 a.m., the Nurse Consultant indicated there had been no contact tracing completed on the positive staff members. They were currently testing all residents and staff on Mondays for outbreak testing. At 1:55 p.m. she indicated the above staff worked half shift, full shifts or over their shifts to meet the residents' needs. They were not sent home due to symptoms. During an interview with Employee 1 on 10/30/20 at 1:50 p.m., she indicated she has had a chronic cough; however, no one had ever questioned her until recently. The Administrator and Director of Nursing were unavailable for interview due to testing positive for COVID-19. Review of CDC guidance, Preparing for COVID-19 in Nursing Homes, dated as updated on 6/25/2020, indicated the following: As part of routine practice, ask HCP (including consultant personnel and ancillary staff such as environmental and dietary services) to regularly monitor themselves for fever and symptoms consistent with COVID-19. Remind HCP to stay home when they are ill. If HCP develop fever (T100.0oF) or symptoms consistent with COVID-19 while at work they should inform their supervisor and leave the workplace. Have a plan for how to respond to HCP with COVID-19 who worked while ill (e.g., identifying and performing a risk assessment for exposed residents and co-workers). HCP with suspected COVID-19 should be prioritized for testing. Screen all HCP at the beginning of their shift for fever and symptoms of COVID-19. Actively take their temperature* and document absence of symptoms consistent with COVID-19. If they are ill, have them keep their cloth face covering or facemask on and leave the workplace. Review of CDC guidance, 'Responding to Coronavirus (COVID-19) in Nursing Homes', dated as updated 4/30/2020, indicated the following: HCP who worked with symptoms consistent with COVID-19 or in the 48 hours prior to symptom onset - Prioritize these HCP for [DIAGNOSES REDACTED]-CoV-2 testing. Exclude HCP with COVID-19 from work until they have met all return to work criteria . Determine which residents received direct care from and which HCP had unprotected exposure to HCP who worked with symptoms consistent with COVID-19 or in the 48 hours prior to symptom onset. Residents who were cared for by these HCP should be restricted to their room and be cared for using all recommended COVID-19 PPE until results of HCP COVID-19 testing are known. If the HCP is diagnosed with [REDACTED]. Exposed HCP should be assessed for risk and need for work exclusion. If testing is available, asymptomatic residents and HCP who were exposed to HCP with COVID-19 should be considered for testing. Review of CDC guidance, Criteria for Return to Work for Healthcare Personnel with [DIAGNOSES REDACTED]-CoV-2 Infection (interim guidance), dated 8/10/2020, indicated the following: After returning to work HCP should .Self-monitor for symptoms, and seek re-evaluation from occupational health if symptoms recur or worsen. The Immediate Jeopardy that began on 10/10/20 was removed on 10/30/20 when the facility inserviced staff on check in process, screening for all units and consulting with Infection Preventionist. The facility also condensed entrance areas to one door with a dedicated screener during day hours and a designated staff member during off hours and weekends, all employees with symptoms of COVID-19 were immediately sent home and tested . The noncompliance remained at a lower scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy, due to pending staff test results and subsequent contact tracing to identify at risk residents as well as the need for monitoring of the screening process. B. On 10/29/20, at 11:20 a.m., Employee 26, an LPN, was observed on the COVID-19 unit. She was wearing a KN95 mask and goggles. She indicated that is what she wore when she went into the resident rooms. On 10/30/20, at 5:40 a.m., Employee 24, an LPN, was observed exiting a resident room in the yellow zone (area where resident's COVID-19 status is unknown) wearing a yellow isolation gown. On 10/30/20, at 6:05 a.m., Employee 24, a nurse, was observed on the COVID-19 unit. She was standing by the nurse's station wearing a yellow isolation gown and gloves on both hands. Review of Infection Prevention Updates, dated 10/8/20, indicated, Many KN95 mask are not considered N95 level-if they are used the HCP (health care provider) must wear face shield/ not goggles when in use with COVID + and Symptomatic Review of CDC guidance COVID-19 LTC Facility Infection Control Guidance Standard Operating Procedure, updated on 10/20/20, indicated the following on COVID-19 positive units, .Gowns and gloves should be changed after every resident encounter and, .Gowns should always be doffed (removed) prior to leaving unit/ or resident room (hot zone), when working in the nurses station and break rooms During an interview with Employee 26 on 10/29/20 at 11:20 a.m., she indicated she was not aware she had to wear a face shield with the KN95 masks. During an interview with Employee 24 on 10/30/20 at 5:40 a.m., she indicated all residents in the yellow zone were on transmission based precautions. She was not aware she could not wear the isolation gown in the hallway. 3.1-18(a)

Based on record review and interview, the facility failed to ensure residents identified as being at risk for dehydration were monitored to ensure sufficient fluid intake was maintained which resulted in the resident being hospitalized for [REDACTED]. (Resident #E) Finding includes: The closed record for Resident #E was reviewed on 10/27/16 at 9:00 a.m. The resident's [DIAGNOSES REDACTED]. The 10/5/16 Quarterly Minimum Data Set (MDS) assessment indicated the resident was on a mechanically altered diet. The resident required extensive assistance of one staff member for eating and personal hygiene and was always incontinent of urine. A Care Plan initiated on 7/14/16 indicated the resident was a Nutritional risk as she received a mechanically altered diet with nectar thickened liquids related to a [DIAGNOSES REDACTED]. A Care Plan initiated on 7/14/16 indicated the resident had a potential for dehydration related to [MEDICAL CONDITION] (swelling) and the use of a Diuretic medication. Interventions included, but were not limited to, administer diuretics as ordered, observe for side effects, and observe for mental status changes. The resident's weights were recorded as follows: 10/13/16 - 159 pounds (re-weight) 10/11/16 - 149 pounds 09/12/16 - 164 pounds 08/10/16 - 166 pounds 07/24/16 - 165 pounds A 10/5/16 Nutrition Data quarterly note indicated the resident received a regular pureed diet with liquids thickened to nectar consistency. The resident's average meal intake per day was 76%. The resident's Hydration Risk Factors included, the use of daily diuretics and laxative use. The 10/2016 Medication Administration Record [REDACTED] Recent laboratory test results were reviewed. A Comprehensive Metabolic Panel (CMP) was completed on 9/15/16. The results were noted as follows: Sodium level: 146 (normal level 136- 145) BUN (Blood urea nitrogen) 20.7 (normal level 6-20) October 2016 Meal Consumption Logs were reviewed. 10/11/16 - Consumed 100 % of all three meals and evening snack 10/12/16 - Consumed 25%, 25%, 50% of meals and 50% of evening snack 10/13/16- Consumed 75%, 75%, 75% of meals and 0% of evening snack 10/14/16 - Consumed 25%, 25%, 50% of meal and 100% of evening snack 10/15/16 - Consumed 75%, 25%, 50% of meals and 50% of evening snack 10/16/16 - Consumed little to none of all three meals and evening snack 10/17/16 - Consumed 50% of all three meals and 100% of evening snack 10/18/16 and 10/19/16- Consumed little to none off all three meals and evening snacks. 10/201/6 - Consumed little to none of Breakfast meal; The 10/2016 Progress Notes were reviewed as follows: Nursing Progress Note for 10/12/16 at 3:50 p.m. indicated the resident's skin was warm and dry. Resident was incontinent of bowel and bladder and had her meals in the assisted dining room. Resident consumed average of 86% of her meals. Registered Dietitian Note for 10/13/16 at 1:06 p.m. indicated the resident's current weight of 149 pounds was a weight loss of 15 pounds in one month. A re-weight was requested. The resident's oral intakes averaged 54% in the past (7) days which were down from the usual. No further Progress Notes were entered until 10/18/16. An entry on 10/18/16 at 9:09 a.m. indicated the resident was lethargic and did not want to eat or drink. Staff will continue to monitor the resident. The next entry was on 10/18/16 at 10:58 p.m. This was a Medication Administration note which indicated the resident had wheezes. 10/18/16 at 9:09 a.m. Increased lethargy noted. The resident did not eat anything for dinner. She was able to hold her own cup and drink thickened liquids, looking around but not talking or answering questions. The Nurse Practitioner was notified and orders noted to hold the resident's [MEDICATION NAME] (an anti anxiety medication) tonight. An non- emergency message was left for the family. 10/19/16 at 4:01 a.m. The resident's condition declined. Resident will wake easily and look staff in the eyes, does not hold focus long, will continue to monitor. 10/19/16 at 2:33 p.m. The resident's condition remains the same. Writer gave the resident medications and drinks with out any issue. 10/19/16 at 7:04 p.m. The resident's condition remains in decline. The resident was in bed all shift. 10/20/16 at 4:56 a.m. The resident's condition remains declined. 10/20/16 at 10:30 a.m. Resident noted to be having difficulty breathing, 02 saturation 82% Oxygen applied via rebreather mask. The resident is lethargic and not responding to verbal stimuli as normal. Order received to send the resident to the hospital via 911. The resident's Hospital Records were reviewed. A Physician note completed on 10/23/16 indicated the resident was brought to the hospital emergency room due to a decrease in oral intake and responsiveness with an alteration in mental status. Upon an examination the resident was obtunded and not communicating. Laboratory test results showed severe [MEDICAL CONDITION] (high sodium level), elevated creatinine, [MEDICATION NAME], and white blood cell count levels. The symptoms and laboratory test results were attributed to severe dehydration. Laboratory tests completed on 10/20/16 were noted as follows: BUN (76) High Creatinine: 2.67 High Sodium 173 Critical Level A Physician Note completed on 10/22/16 at 2:20 p.m. indicated the resident had been a resident at a nursing home and was said to not have been eating for several days. Markedly elevated serum sodium level of 173 and marked elevated BUN and Creatinine levels were noted. The patient was being monitored for acute metabolic [MEDICAL CONDITION] from severe [MEDICAL CONDITION] (elevated sodium level). The current Hydration Policy was received from the Director of Nursing on 10/27/16 at 1:15 p.m. The policy indicated Risk Factors for dehydration included, but were not limited to, refusal of fluids, dementia, and functional impairments making it hard to drink such as [MEDICAL CONDITION] and use of thickened liquids. Increased fluid needs could occur from infections, dehydration, and diuretic use. When interviewed on 10/27/16 at 12:30 p.m., the Director of Nursing indicated the resident had episodes in the past where she would not eat for a few days and then start eating again. The Nurse Practitioner had been notified as in the Nursing Progress note. This Federal tag relates to Complaint IN 499. 3.1-46(B)

Based on record review and interview, the facility failed to ensure each resident was free from accidents related to ensuring the safety belt was securely strapped across the resident's waist while using a mechanical lift for a transfer from the toilet to a wheelchair which resulted in a fall with a laceration to the back of the head that required five staples for 1 of 3 residents reviewed for accidents. (Resident #E) Finding includes: The closed record for Resident #E was reviewed on 12/9/15 at 10:15 a.m. The resident's [DIAGNOSES REDACTED]. The 9/3/15 Quarterly Minimum Data Set (MDS) assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 9, indicating the resident was moderately impaired for decision making and had some cognitive impairment. The resident was an extensive assist with a physical assist of one person for transfers and toilet use. The resident had no history of falls since the last assessment. The current and updated plan of care dated 9/2015 indicated the resident was at risk for falls. The Nursing approaches were to transfer with the Sara lift (a mechanical sit to stand lift). Nursing Progress Notes dated 11/4/15 at 9:20 a.m., indicated the Nurse was called to the resident's room by the CNA. The CNA indicated she was lifting the resident up on the Sara lift, the resident slipped out of the lift and fell to the ground and hit her head. The resident sustained [REDACTED]. The resident's Physician was notified and new orders were obtained to send her to the emergency room . Nursing Progress Notes dated 11/4/15 at 1:30 p.m., indicated the resident returned from the hospital with five staples to the back of her head. The verification of investigation form provided by the Director of Nursing on 12/9/15 at 12:15 p.m., was reviewed. The description of the event indicated Upon entering the room, resident was laying on her back with her head against the bathroom doorway frame. Her legs were out straight with them still on the base of the Sara lift. The arms of the Sara lift were in an upright position with the sling still attached. The Assessment of Resident/Injury indicated a laceration to the back of her head which was bleeding. The resident was slow to respond with answering questions. The resident wanted to go to sleep and complained of a headache. Resident also indicated she had tingling to her right fingers. The summary of the staff interview indicated CNA #1 was transferring the resident from the toilet to her wheelchair with the Sara lift. The CNA indicated she had the sling on the resident but did not have the belt strapped and tightened. She lifted the resident up to transfer her and had seen the resident was sliding and going to fall. She indicated she tried to prevent her from falling but was unable to get around to catch her. The CNA indicated the resident slipped out of the sling and fell to the floor hitting her head. The current and undated GLC Lift Program-Mechanical Skills Check-off provided by the Director of Nursing on 12/9/15 at 12:15 p.m., indicated the Sara lift was used for pivot transfers, toileting, changing clothes, incontinence pads and repositioning in chair. The procedure was to position the Sara sling around the resident's back at the waist, position resident's arms outside of the sling and fasten the safety belt around the resident's waist Interview with the Director of Nursing on 12/9/15 at 12:20 p.m., indicated CNA #1 did not have the safety belt securely fastened around the resident's waist. She further indicated the safety belt needed to be tightened and fastened to prevent the resident from falling. This Federal Tag relates to Complaint IN 050. 3.1-45(a)(2)