Every finding on record at Brickyard Healthcare - Portage Care Center

Based on record review and interview, the facility failed to ensure assessments of a resident's vascular wound were timely and accurate for 1 of 3 residents reviewed for wounds. (Resident H) The facility also failed to ensure Physician's Orders were followed related to insulin administration and blood sugar monitoring, for 3 of 3 residents reviewed for insulin administration and blood sugars. (Residents H, F, and J)Findings include:1. Resident H's closed record was reviewed on 6/25/26 at 11:13 a.m. The diagnoses included, but were not limited to, severe peripheral arterial occlusive disease with right common iliac artery and right common femoral artery occlusions (major blood vessels supplying the right leg), diabetes mellitus, and dementia.A Care Plan, dated 5/22/26, indicated a diagnosis of diabetes mellitus. The interventions included, the body would be assessed for breaks in the skin and treated promptly as ordered by a Physician, diabetes medication would be administered and blood sugars would be obtained as ordered by the Physician.A Care Plan, dated 5/22/26, indicated a risk for impairment of the skin. The interventions included, the facility protocols would be followed for the treatment of injuries.An admission Minimum Data Set (MDS) assessment, dated 5/28/26, indicated a moderately impaired cognitive status, required maximum assistance with bathing and hygiene, no venous/arterial ulcers present, and received and anticoagulant and insulin.A Care Plan, dated 6/11/26, indicated a scab was observed on the right foot. The interventions indicated the causative factors would be identified and eliminated/resolved if possible, the location, size and treatment would be monitored and the Physician notified if changes.a) The Nurse's Skin Check Progress Note, dated 5/21/26 at 5:36 p.m., indicated the skin was warm, dry and color was within normal limits. There was dry skin to the bilateral legs and feet and no skin issues were identified.A Change of Condition Progress Note, dated 6/6/26 at 12:00 p.m., indicated an open area was observed on the side of the right foot. The Physician was notified and a monitoring order was received. The Responsible Party was notified.A Skin Assessment Progress Note, dated 6/6/26 at 8:41 p.m., indicated a new skin issue of the right lateral foot had been observed. There was a new open area of the right lateral foot. The measurements were one centimeter (cm) in length by one cm in width. There was no further assessment of the description or the depth of the open area.The Skilled Evaluation Nurses' Progress Notes, dated 6/7/26 at 7:21 p.m., 6/8/26 at 8:33 a.m., 6/10/26 at 1:20 p.m., and 6/11/26 at 11:56 a.m., indicated the skin issue on the right lateral foot had not been evaluated and was an open wound acquired in-house.A Wound Nurse Progress Note/Assessment, dated 6/11/26 (five days after the area was first observed), indicated the wound on the right lateral foot had been resolved (healed) and a new area described as a scab was observed on the right dorsum of the foot (top of the foot), that measured 1 cm by 1.4 cm with no depth. The family had been notified.The Skilled Evaluation Nurses' Progress Notes, dated 6/13/26 at 7:51 p.m., 6/14/26 at 9:47 p.m., 6/15/26 at 8:22 p.m., 6/16/26 at 3:39 p.m., 6/17/26 at 9:00 p.m., 6/18/26 at 11:59 a.m., 6/19/26 at 12:22 a.m., 6/20/26 at 12:36 a.m., and 6/21/26 at 2:26 a.m., indicated there were now two areas on the resident's right foot, .Skin Issue: #001: Skin issue has not been evaluated. Location: Right Dorsum foot. Additional location information: right foot Issue type: Other skin issue. Other skin issue description: scab Wound acquired in-house. #002: Skin issue has not been evaluated. Location: Right Dorsum foot. Issue type: Other skin issue. Other skin issue description: Scab Wound acquired in-house .There was no Weekly Skin Assessment completed by the Wound Nurse. A Change of Condition Nurse's Progress Note, dated 6/22/26 at 10:05 a.m., indicated the right foot was cold to touch and the toes were discolored. There were no complaints of pain. The Physician was notified and the resident was transferred to the Hospital emergency room (ER).The Hospital ER physical exam, Dated 6/22/26, indicated the right foot had ischemic ulcers, extensive with multiple digit discoloration. The resident had severe peripheral artery disease with occlusion of the right leg blood vessels. The Abdominal Angiogram indicated the right iliac artery was 100% occluded with no reconstitution in the right lower extremity seen. Due to the location of the occlusion they were unable to open the artery.During an interview on 6/24/26 at 8:45 a.m., the Wound Nurse indicated the Wound Nurse Practitioner (NP) visited weekly to assess/treat all pressure and vascular open areas. The NP also assessed all new admissions. During an interview on 6/24/26 at 9:40 a.m., the Wound Nurse indicated the nurses complete the weekly skin assessments and if an area is found, they fill out a Risk Management Form, then she looks at the forms every morning and follows up with an assessment of the area.A Wound Nurse Practitioner's Progress Note, dated 6/24/26 at 12:28 p.m. with the date of service on 6/11/26, indicated a dark reddish brown healing crusted area was observed on the the right foot, consistent with a resolved previous injury. The periwound was clean and dry and free from infection and inflammation. No treatment or dressing was necessary. Preventative skin care and injury avoidance were recommended. Risk factors included diabetes mellitus and peripheral vascular disease. There was no open wounds observed.During interviews on 6/25/26 at 1:04 p.m., the Wound Nurse indicated the open area on the lateral right foot was observed on Saturday 6/6/26. The Director of Nursing (DON) indicated the Risk Management Form had been completed by the nurse on 6/6/26. The Wound Nurse indicated she had not seen the Risk Management Form completed on 6/6/26. She and the Wound NP assessed the area on 6/11/26 and there was no open area on the right lateral foot. The area was marked as healed. There was a scab observed on the right dorsum foot and this would have been labeled as wound two. She was unsure if the scab was the same area as the open wound. The nurses had not been questioned on this. She acknowledged the Nurses' Progress Notes indicated there were two wounds and she only assessed the open wounds weekly and the floor nurses complete the assessments on non-opened areas. The DON indicated the resident had diabetes mellitus, peripheral vascular disease, and smoked. The wound should have been assessed by the Wound Nurse.During an interview on 6/25/26 at 2:26 p.m., the DON indicated the protocol at the facility for wounds was the nurse filled out the Risk Management Form, the Wound Nurse read the Risk Management Form the next working day and was to assess the wound as soon as possible. During an interview on 6/29/26 at 8:40 a.m., LPN 1 indicated she was the nurse who transferred the resident to the ER. She indicated there were thick scabs on the side of the foot though unsure how many. She had not taken care of the resident prior to 6/22/26.During an interview on 6/29/26 at 8:45 a.m., LPN 2 indicated there was one area on the foot and was not sure why she had documented there were two areas.During an interview on 6/29/26 at 8:50 a.m., LPN 3 indicated the resident had scabs on his right foot. She was unsure how many areas there were. He would refuse to let them assess the areas frequently.During an interview on 6/29/26 at 9:15 a.m., CNA 4 indicated she gave him a bed bath on 6/18/26 because he refused his shower. There was one small scabbed area in the shape of a circle on the top of the right foot. He would refuse to have his socks removed frequently.A Skin Assessment Policy, dated 2/2023, and received as current from the Corporate Staff Development Coordinator (SDC) as current, indicated a full body skin assessment would be conducted by a licensed or registered nurse upon admission/re-admission and weekly there after. Documentation of the skin assessment was to include the date and time, the observation, the type of wound, and the description of the wound.b) A Physician's Order, dated 5/21/26, indicated Glargine-yfgn insulin 30 units was to be administered every morning after the blood sugar level was checked.The Medication Administration Record (MAR), dated 5/2026, indicated the insulin had not been administered as ordered on 5/26/26. The MAR was coded with a seven (see Nurse's Notes). There was no documentation in the Nurse's Notes that indicated why the insulin had not been administered.The MAR, dated 6/2026, indicated the insulin had not been administered on the following mornings:On 6/1/26 due to a blood sugar of 106. There were no ordered parameters for the insulin.On 6/3/26 there was no blood sugar result and it was coded with a three/see Nurse's Notes. There was no documentation in the Nurses' Notes that indicated why the insulin had not been given.On 6/7/26 due to blood sugar of 94.On 6/12/26 there was no blood sugar recorded or reason given for not administering the insulin.During an interview on 6/25/26 at 1 p.m., the DON acknowledged there were no parameters to hold the insulin and the insulin administrarion and blood sugar testing were not completed as ordered. 2) Resident F's record was reviewed on 6/25/26 at 6:50 a.m. The diagnoses included, but were not limited to, diabetes mellitus.A Care Plan, dated 12/13/24 and revised 4/16/26, indicated a diagnoses of diabetes mellitus. The interventions included the blood sugars would be checked and medications would be administered as ordered by the physician.a) A Physician's Order, dated 10/23/25, indicated Fiasp insulin, 15 units was to be administered before meals. The MAR, dated 4/2026, indicated the insulin had not been given before dinner on 4/7/26, 4/29/26, and 4/23/26.The MAR, dated 5/2026, indicated the insulin had not been given before dinner on 5/3/26 and before breakfast on 5/8/26.b) A Physician's Order, dated 3/20/26, indicated Lantus insulin, 45 units was to be given twice a day in the morning and evening. The insulin was to be held if the blood sugar was less than 110.The MAR, dated 4/2026, indicated on 4/27/26 the morning blood sugar was 96 and the insulin was administered. The blood sugar in the evening on 4/7/26 was 108, on 4/10/26 was 100, and 4/23/26 was 109 and the insulin had been administered. On 4/8/26 the evening blood sugar was 163 and the insulin was not given.The MAR, dated 5/2026, indicated the morning blood sugar on 5/7/26 was 205 and the insulin had not been given. On 5/30 26, the blood sugar was 81 and the insulin had been administered. The evenings of 5/5/26 the blood sugar was 104, 5/21/26 the blood sugar was 87, and 5/29/26 the blood sugar was 81 and the insulin had been administered.The MAR, dated 6/2026, indicated the morning blood sugar on 6/5/26 was 94 and the insulin had been administered. The evening blood sugar on 6/15/26 was 82 and on 6/18/26 was 84 and the insulin had been administered.c) A Physician's Order, dated 4/5/26, indicated Aspart insulin was to be given on a sliding scale (amount given was based on blood sugar result) in the morning, mid-day and evening. The sliding scale indicated a blood sugar result of 150 -200 was to receive four units of insulin.The MAR, dated 4/2026, indicated the evening blood sugar on 4/8/26 was 163 and no insulin was administered. The MAR, dated 5/2025, indicated the mid-day blood sugar on 5/2/26 was 150 and the insulin had not been administered. The morning blood sugar on 5/8/26 was not checked and no insulin was documented as received.During an interview on 6/25/26 at 10:05 a.m., the DON acknowledged the insulin and blood sugar orders were not followed. 3) Resident J's record was reviewed on 6/25/26 at 1:42 p.m. The diagnoses included, but were not limited to, diabetes mellitus. A Care Plan, dated 10/30/24 and revised on 3/5/26, indicated a diagnosis of diabetes mellitus. The interventions included the medication and blood sugars would be administered as ordered by the physician.A Physician's Order, dated 4/15/26, indicated Glargine insulin, 55 units was to be administered every morning and bedtime. The insulin was not to be administered if the blood sugar was less than 100.The MAR, dated 4/2026, indicated there was no blood sugar checked and insulin had not been administered on the morning of 4/24/26.The MAR, dated 6/2026, indicated on 6/11/26, the morning blood sugar was 94 and the insulin had been administered.The medication administration policy, dated 2026 and received as current from the Corporate EDC, indicated medications were to be administered as ordered by the physician.This citation relates to Intakes 3002892 and 3045641.410 IAC (Indiana Administrative Code) 16.2-3.1-48(a)(6)

Based on observation, interview, and record review, the facility failed to ensure a sanitary kitchen related to the dishwasher not reaching the required temperature for a high temperature dish machine. This had the potential to affect 149 residents who received meals from the Main Kitchen. Finding includes: The initial kitchen tour was completed on 1/5/26 at 9:09 a.m. with the Dietary Manager (DM). The DM indicated the dishwasher was a high temperature dish machine. Dietary Server 1 was observed putting trays of dishes through the dishwasher. A wash cycle was observed with Dietary Server 1. There were three gauges on top of the dishwasher. During the wash cycle, the wash temperature gauge and the rinse temperature gauge did not move from 150 degrees F (Fahrenheit). The final rinse sanitation gauge did not move from 130 degrees F. The DM asked the Dietary Server to run a few more cycles. Each time the gauges did not move. The DM then put a digital thermometer on a tray and ran it through a cycle. The reading on the thermometer was 153.6 F.During an interview at the time of the observation, Dietary Server 1 indicated she had not checked the dishwasher temperatures before she started using the dishwasher that day. She indicated she was unaware to check the gauges for the temperatures and what the appropriate temperatures should have been.During an interview at the time of the observation, the DM indicated the Dietary Staff should have checked the dishwasher temperature prior to using it. The final rinse cycle should have been 180 degrees; she was unsure why the gauges were not working and she would have to get it serviced. A policy titled, Dishwasher Temperature and received as current from the facility on 1/12/26, indicated, .3. For high temperature dishwashers (heat sanitization).b. The final rinse temperature shall be 180 F or above but not to exceed 194 F.6. Water temperatures shall be measured and recorded prior to each meal and/or after the dishwasher has been emptied or re-filled for cleaning purposes.3.1-21(i)(3)

Based on observation, record review, and interview, the facility failed to maintain clinical records that were complete and accurately documented related to clarification of oxygen orders and incorrect documentation of obtaining blood pressure readings on a restricted arm for 4 of 34 records reviewed. (Residents 112, 161, 92, and 2)Findings include:1. On 1/6/26 at 11:00 a.m., Resident 112 was seated in her wheelchair in her room. She had no oxygen in use. On 1/7/26 at 9:33 a.m. and 2:00 p.m., the resident was observed in her room. She was not wearing oxygen per a nasal cannula at the time. On 1/8/26 at 2:05 p.m., the resident was seated in her wheelchair and being transported back to her room. A portable oxygen tank was hanging from the back of the wheelchair. The resident was not wearing oxygen at the time. The record for Resident 112 was reviewed on 1/7/26 at 2:38 p.m. Diagnoses included, but were not limited to, congestive heart failure and chronic obstructive pulmonary disease (COPD). The admission Minimum Data Set (MDS) assessment, dated 12/13/25, indicated the resident was cognitively intact for daily decision making. A Physician's Order, dated 12/7/25, indicated the resident was to receive continuous oxygen at 2 liters per minute via nasal cannula. The physician was to be notified if the resident's oxygen saturation was below 90% every shift. The January 2026 Treatment Administration Record (TAR) indicated the resident's oxygen had been signed out as being applied for all three shifts 1/6/2026 through 1/8/2026. During an interview on 1/9/26 at 2:30 p.m., the Director of Nursing indicated a clarification order would be obtained since the resident wasn't wearing her oxygen as ordered. 2. During a random observation on 1/5/26 at 11:00 a.m., a PICC line (long-term use IV line) was observed in resident 161's left arm. The resident's record was reviewed on 1/7/26 at 10:47 a.m. Diagnoses included, but were not limited to, unspecified severe protein-calorie malnutrition, colostomy, and intestinal obstruction. The admission Skilled Evaluation, dated 12/22/25, indicated the resident was alert and oriented and had a PICC line in his left arm. A review of the Vital Signs Record indicated the resident's blood pressure was checked on his left arm on 12/22/25 at 6:23 p.m., 12/24/25 at 7:09 a.m., 12/24/25 at 8:45 a.m., 12/30/25 at 2:57 p.m., 12/31/25 at 4:12 p.m., 1/4/26 at 12:41 p.m., 1/5/26 at 1:12 p.m., and 1/6/26 at 11:47 a.m. A Care Plan, dated 12/23/25, indicated the resident was at risk for infection related to the PICC Line. Interventions included to not take blood pressure in the arm with the access site (PICC line). During an interview on 1/9/26 at 9:08 a.m., the resident indicated the staff did not check his blood pressure on his left arm. During an interview on 1/12/26 at 10:16 a.m., the Nurse Consultant indicated staff must have documented the arm used for the blood pressure incorrectly, and they needed to work with staff on documentation. 3. During a random observation on 1/5/26 at 2:16 p.m., a PICC line (long-term use IV inserted through the arm) was observed in Resident 92's right arm. At that time, the resident indicated the staff did not use his right arm to check his blood pressure. The resident's record was reviewed on 1/8/26 at 2:03 p.m Diagnoses included, but were not limited to, chronic osteomyelitis (bone infection)of the left thigh, and paraplegia. The admission Minimum Data Set (MDS) assessment, dated 12/19/25, indicated the resident was cognitively intact for daily decision making, and required maximal assist in ADLs. and transfers. A Physician's Order, dated 12/13/25, indicated no blood pressure checks in the right arm. A review of the Vital Signs Record indicated the resident's blood pressure was checked on his right arm on 12/13/25 at 11:50 p.m., 12/14/25 at 10:13 p.m., 12/17/25 at 2:37 p.m., and 12/21/25 at 3:44 p.m. A Care Plan, dated 12/15/25, indicated the resident was at risk for infection related to the PICC Line. Interventions included to not take blood pressure in the arm with the access site (PICC line). During an interview on 1/12/26 at 10:16 a.m., the Nurse Consultant indicated staff must have documented the arm used for the blood pressure incorrectly, and they needed to work with staff on documentation. 4. During a random observation on 1/6/26 at 10:54 a.m., Resident 2 had two bandages intact to his right forearm. At that time, he indicated that was where he had a graft (access device) for hemodialysis. The resident's record was reviewed on 1/8/26 at 8:01 a.m Diagnoses included, but were not limited to, end stage renal disease. The Quarterly Minimum Data Set (MDS) assessment, dated 12/23/25, indicated the resident was cognitively intact for daily decision making, and was on dialysis. A Physician's Order, dated 1/3/26, indicated no blood pressures were to be taken on the resident's right arm. A review of the Vital Signs Record indicated the resident's blood pressure was checked on his right arm at the following times: 11/20/25 at 8:25 p.m., 11/25/25 at 8:02 p.m., 11/25/25 at 8:12 p.m., 11/28/25 at 4:46 p.m., 11/28/25 at 4:36 p.m., 12/11/25 at 10:05a.m., 12/21/25 at 3:17 p.m., 12/21 at 10:28 a.m., 1/3/26 at 10:46 p.m. 1/4/26 at 5:11 a.m., and 1/6/26 at 10:44 a.m. A Care Plan, dated 10/4/24, indicated the resident needed dialysis due to end stage renal disease. Interventions included to not draw blood or take blood pressure in the arm with the graft. During an interview on 1/9/26 at 9:16 a.m., the resident indicated the staff did not check his blood pressure on his right arm. During an interview on 1/12/26 at 10:16 a.m., the Nurse Consultant indicated staff must have documented the arm used for the blood pressure incorrectly, and they needed to work with staff on documentation. 3.1-50(a)(1)3.1-50(a)(2)

Based on observation, record review, and interview, the facility failed to ensure blood pressure medications and insulin were held according to parameters for 3 of 7 residents reviewed for unnecessary medications. The facility also failed to ensure TED hose (compression stockings) were applied as ordered for 1 of 1 resident reviewed for TED hose and areas of bruising were assessed and monitored for 3 of 4 residents reviewed for non-pressure related skin conditions. (Residents 10, 64, 75, 126, 17, 4, and 114)Findings include: 1. The record for Resident 10 was reviewed on 1/8/26 at 11:32 a.m. Diagnoses included, but were not limited to, hypertension and congestive heart failure The Quarterly Minimum Date Set (MDS) assessment, dated 12/2/25, indicated the resident was moderately impaired for daily decision making. A Physician's Order, dated 11/26/25, indicated the resident was to receive Norvasc (a blood pressure medication) 5 milligrams (mg) in the morning. Hold if the resident's systolic (top number) blood pressure was less than 120 or pulse less than 60. The November 2025 Medication Administration Record (MAR) indicated the resident's blood pressure on 11/29/25 was 116/64 and on 11/30/25 was 116/63. The resident received the medication on both dates. The December 2025 MAR indicated the resident's blood pressure was 108/44 on 12/1/25 and 117/81 on 12/25/25. Again, the resident received the Norvasc on both dates. The January 2026 MAR indicated the resident's blood pressure was 119/60 on 1/1/26. The resident received her Norvasc on that date. A Physician's Order, dated 12/4/25, indicated the resident was to receive Lisinopril (a blood pressure medication) 10 milligrams (mg) daily. Hold the medication if the resident's systolic (top number) was less than 110. The December 2025 Medication Administration Record (MAR) indicated the resident's blood pressure was 119/55. The resident's Lisinopril was held rather than being administered. During an interview on 1/9/26 at 2:30 p.m., the Director of Nursing indicated the Norvasc should have been held based on the parameters and the Lisinopril should have been given. 2. On 1/7/28 at 2:48 p.m., Resident 64 was seated in her room in her wheelchair. An area of reddish/purple discoloration was observed on her right forearm. On 1/9/26 at 9:30 a.m., the reddish/purple discoloration remained to the resident's right forearm. The record for Resident 64 was reviewed on 1/9/26 at 9:31 a.m. Diagnoses included, but were not limited to, atrial fibrillation (irregular heartbeat), atherosclerotic heart disease, and neurocognitive disorder with Lewy bodies. The 11/20/25 admission Minimum Data Set (MDS) assessment indicated the resident was cognitively intact and had received an anticoagulant (blood thinner) during the assessment reference period. A Care Plan, dated 11/26/25, indicated the resident was on anticoagulant therapy related to atrial fibrillation. Interventions included, but were not limited to, administer anticoagulant medications as ordered by the physician and observe for side effects and effectiveness every shift. Monitor, document, and report PRN (as needed) adverse reactions of anticoagulant therapy such as bruising. A Physician's Order, dated 11/15/25, indicated the resident received Eliquis (a blood thinner) 5 milligrams (mg) twice a day. A Skilled Evaluation note, dated 1/8/26 at 8:30 p.m., indicated no skin issues had been identified. There was no documentation indicating when the bruising appeared and an assessment of the area. During an interview on 1/9/26 at 2:30 p.m., the Director of Nursing indicated the bruise should have been assessed and monitored. 3. On 1/7/26 at 1:40 p.m., Resident 75 was observed in her room in bed. The resident was not wearing any TED hose (compression stockings) at that time. On 1/8/26 at 10:42 a.m. and 1:55 p.m., the resident was again observed in her room sleeping with no TED hose in use. On 1/9/26 at 9:22 a.m., the resident was observed in bed with no TED hose in use. The record for Resident 75 was reviewed on 1/7/25 at 10:35 a.m. Diagnoses included, but were not limited to, stroke, dementia without behavior disturbance, and heart failure. The Annual Minimum Data Set (MDS) assessment, dated 11/26/25, indicated the resident had short and long term memory problems and was severely impaired for daily decision making. The resident was also dependent on staff for upper and lower body dressing. A Care Plan, reviewed on 12/9/25, indicated the resident had an ADL (activities of daily living) self-care performance deficit related to the diagnoses of stroke with left hemiplegia (muscle weakness), dementia, and chronic obstructive pulmonary disease (COPD). Interventions included, but were not limited to, apply TED hose as ordered. A Physician's Order, dated 10/13/25 and listed as current on the January 2026 Physician's Order Summary (POS), indicated the resident was to wear knee high TED hose daily for edema and remove per schedule. The January 2026 Medication Administration Record (MAR) indicated the TED hose were to be applied at 9:00 a.m. and removed at 9:00 p.m. The TED hose were signed out as being applied at 9:00 a.m. on 1/7/26. A Physician's Order, dated 10/14/25 and listed as current on the January 2026 POS, indicated the resident was to receive Coreg (a medication to treat heart failure and high blood pressure) 6.25 milligrams (mg) twice a day. The medication was to be held if the resident's systolic blood pressure (top number) was less than 110 and her heart rate was less than 60. The October 2025 MAR indicated the resident's morning blood pressure on 10/28/25 was 108/64 and the medication was administered. The November 2025 MAR indicated the resident's evening blood pressure on 11/23/25 was 92/61 and her morning blood pressure on 11/25/25 was 104/66. The resident received the Coreg on both dates. The January 2026 MAR indicated the resident's morning blood pressure on 1/2/26 was 106/62 and the medication was administered. During an interview on 1/9/26 at 2:30 p.m., the Director of Nursing indicated the resident's TED hose should have been applied as ordered and the Coreg should have been held as ordered. 4. During random observations on 1/5/26 at 10:15 a.m., on 1/6/25 at 10:40 a.m. and 2:50 p.m., and 1/7/25 at 9:15 a.m. and 1:30 p.m., Resident 126 was observed in bed. At those times, a large red and purple bruise was observed to his left forearm and the back of his left hand. During a random observation on 1/9/26 at 9:00 a.m., the resident was observed in bed. There was a bruise to his left forearm and a bandage over his left hand. At 9:15 a.m., the B-Wing Unit Manager was asked to perform a skin assessment. She indicated she was unaware of the bruise to his left forearm, but thought it was from a recent fall on 1/3/25 and he had just sustained a skin tear to his left hand from a fall on 1/9/26. The record for Resident 126 was reviewed on 1/7/26 at 9:38 a.m. Diagnoses included, but were not limited to, osteoarthritis, dizziness, repeated falls, dementia with behaviors, major depressive disorder, and, late onset Alzheimer's disease. The 12/8/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making and had a history of falls. The Care Plan, revised on 11/13/25, indicated the resident had potential impairment to skin integrity related to fragile skin and incontinence. The approaches were to monitor/document location, size and treatment of any skin injury and report abnormalities, failure to heal, signs and symptoms of infection, and maceration to the physician. A Change of Condition form, dated 1/3/26 at 10:10 p.m., indicated the resident was sitting on the side of his roommate's bed. He could not explain how he got there and sustained a skin tear to his left elbow area. There was no documentation regarding any bruises to the left arm. A Weekly Skin Review, dated 1/1/26, indicated there were no pre-existing conditions and the resident's skin was intact. A Weekly Skin Review, dated 1/8/26, indicated the resident had no new skin issues and had pre-existing skin tears. There was no documentation regarding any bruising. During an interview on 1/9/26 at 9:15 a.m., the B-wing Unit Manager indicated the bruise should have been assessed, the wound nurse and NP notified, and the findings documented in the clinical record. The current and undated Skin Assessment policy, provided by the Nurse Consultant on 1/9/26 at 11:20 a.m., indicated a full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/readmission, daily for three days, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. Document observations, type and description of wound. 5. The record for Resident 17 was reviewed on 1/7/26 at 1:53 p.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus. The 12/22/25 Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making and received insulin and an oral hypoglycemic medication. The Care Plan, revised on 11/12/25, indicated the resident had diabetes mellitus. The approaches were to check the blood sugar as ordered by the physician. A Physician's Order, dated 10/16/25, indicated Humalog Insulin (a short acting insulin) inject 5 units subcutaneously (sq) with meals and hold if the blood sugar level was less than 110. The 10/2025 Medication Administration Record (MAR) indicated the Humalog Insulin was administered on the following days when the resident's blood sugar level was less than 110: breakfast: 10/12 and 10/13/25 lunch: 10/8/25 dinner: 10/1 and 10/11/25 A Physician's Order, dated 9/16/25, indicated Nateglinide (oral prescription medication used to manage blood sugar levels in adults with type 2 diabetes) 120 milligrams (mg), give 1 tablet by mouth two times a day and hold if the blood sugar level was less than 110. The 10/2025 MAR indicated the Nateglinide was signed out as being administered on the following days and the resident's blood sugar level was less than 110: 8:00 a.m.: 10/7, 10/8, 10/12, 10/13, 10/20, 10/26, 10/28. and 10/30/25 5:00 p.m.: 10/1, 10/2, 10/7, 10/8, 10/9, 10/11, 10/15, 10/16, and 10/30/25 The 11/2025 MAR indicated the Nateglinide was signed out as being administered on the following days and the resident's blood sugar level was less than 110: 8:00 a.m.: 11/3, 11/6, 11/8, 11/11, 11/14, 11/19, 11/23, 11/24, and, 11/26/25 5:00 p.m.: 11/8, 11/15, 11/17, 11/19, 11/22, 11/23, 11/25, 11/26/25 The 12/2025 MAR indicated the Nateglinide was signed out as being administered on the following days and the resident's blood sugar level was less than 110: 8:00 a.m.: 12/2/25 5:00 p.m.: 12/19/25 During an interview on 1/12/26 at 9:40 a.m., the Nurse Consultant indicated the medication should have been administered according to the physician's orders. 6. The record for Resident 4 was reviewed on 1/8/26 at 11:02 a.m. Diagnoses included, but were not limited to type 2 diabetes. The 11/12/25 Quarterly Minimum Data Set (MDS) assessment, indicated the resident was not cognitively intact for daily decision making and received insulin. The Care Plan, revised on 11/3/25, indicated the resident had diabetes mellitus. The approaches were to check the resident's blood sugar level as ordered by the physician. A Physician's Order, dated 10/16/25, indicated Insulin Lispro (a short acting insulin) inject 10 units subcutaneously (sq) before meal and hold if blood sugar level was less than 100. The Medication Administration Record (MAR) for the months of 11/2025 and 12/2025, indicated the Lispro Insulin was administered on the following days and blood sugar level was less than 100: breakfast: 11/24/25 the blood sugar was 90, 11/27/25 the blood sugar was 99, 12/1/25 the blood sugar was 82, and on 12/13/25 the blood sugar was 90. Lunch: 12/13/25 the blood sugar was 90. Dinner: 11/2/25 the blood sugar was 99, 11/13/25 the blood sugar was 92, 11/16/25 the blood sugar was 86, 11/20/25 the blood sugar was 67, 11/30/25 the blood sugar was 78, 12/3/25 the blood sugar was 78, 12/7/25 the blood sugar was 98, and on 12/10/25 the blood sugar was 92. During an interview on 1/12/26 at 9:40 a.m., the Nurse Consultant indicated the insulin should have been administered as ordered by the physician. 7. On 1/6/26 at 1:37 p.m., Resident 114 was observed lying in bed with his eyes closed. The resident had a large dark purple discoloration observed to the outer side of his left hand. On 1/9/26 at 10:52 a.m., Resident 114 was observed sitting in a wheelchair in the hallway. The dark purple discoloration was still observed to his left hand. Record review for Resident 114 was completed on 1/9/26 at 10:53 a.m. Diagnoses included, but were not limited to, anemia, atrial fibrillation, hypertension, end stage renal disease, diabetes mellitus, and dementia. The Annual Minimum Data Set (MDS) assessment, dated 11/10/25, indicated the resident was cognitively impaired. The resident required substantial maximal assistance with dressing. The resident received an anticoagulant (blood thinning) medication. A Care Plan, dated 12/8/24 and revised 6/16/25, indicated the resident was on anticoagulant therapy related to atrial fibrillation. An intervention included to monitor, document, and report adverse reactions which included bruising. The January 2026 Physician's Order Summary (POS) indicated an order for Eliquis (blood thinner) 2.5 mg (milligrams) two times a day. The Weekly Skin Assessments, dated 12/31/25 and 1/7/26, indicated no issues. The record lacked any documentation the resident's discoloration had been assessed or was being monitored. During an interview on 1/9/26 at 11:02 a.m., RN 1 indicated she was unaware the resident had the discoloration to his hand. Staff should have observed the discoloration and assessed it. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure each resident's dignity was maintained related to wearing a hospital gown while in bed during the day for 1 of 1 resident reviewed for dignity. (Resident 75)Finding includes:On 1/5/26 at 11:21 a.m., Resident 75 was observed in her room in bed. The resident was wearing a hospital gown. On 1/6/26 at 9:35 a.m. and 11:38 a.m., the resident was observed in her room in bed and wearing a hospital gown. On 1/7/26 at 9:15 a.m., 11:37 a.m., and 1:40 p.m., the resident was observed in her room in bed wearing a hospital gown. On 1/8/26 at 10:42 a.m. and 1:55 p.m., the resident was observed in her room in bed wearing a hospital gown. The record for Resident 75 was reviewed on 1/7/25 at 10:35 a.m. Diagnoses included, but were not limited to, stroke and dementia without behavior disturbance. The Annual Minimum Data Set (MDS) assessment, dated 11/26/25, indicated the resident had short and long term memory problems and was severely impaired for daily decision making. It was important for the resident to choose what clothes to wear. The resident was dependent on staff for upper and lower body dressing. The resident's last care plan review was on 12/9/25. There was no care plan related to wearing a hospital gown while in bed. During an interview on 1/9/26 at 2:30 p.m., the Director of Nursing (DON) indicated the resident's care plan would be updated. During an interview on 1/12/26 at 11:30 a.m., the DON indicated the resident's family was contacted and they would like the resident to wear a gown when in bed for comfort and her care plan was updated. 3.1-3(t)

Based on record review and interview, the facility failed to ensure referrals from the optometrist were carried out and appointments were made for 1 of 1 resident reviewed for hearing and vision. (Resident 9)Finding includes:During an interview on 1/5/26 at 2:28 p.m., Resident 9 indicated he had seen the eye doctor a couple of times this year and was still waiting for his glasses and possibly eye surgery. The record for Resident 9 was reviewed on 1/9/26 at 10:32 a.m. Diagnoses included, but not limited to, end stage renal disease, heart failure, stroke, major depressive disorder, vascular dementia, anxiety, and renal dialysis. The 11/4/25 Annual Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and his vision was adequate with no corrective lens. There was no care plan for vision. An Eye Exam Visit Note by the optometrist, dated 7/12/25, indicated the resident had a mild cataract in his left eye and it was recommended to have YAG laser posterior capsulotomy (an outpatient procedure to address scar tissue that forms behind an artificial lens after cataract surgery). The patient wanted to proceed with the surgery and a referral was written and given to social service. An Eye Exam Visit Note by the optometrist, dated 11/11/25, indicated the resident had a opacification of posterior capsule (a clouding of the lens capsule after cataract surgery, causing blurry vision, glare, and halos) of the left eye and a moderate cataract in the right eye. The plan was to recommend YAG laser posterior capsulotomy and cataract surgery. Both referrals were written and given to social service as the patient wanted to proceed with the surgery. During an interview on 1/9/26 at 11:15 a.m., the Social Service Director (SSD) indicated the Medical Records Supervisor (MRS) was helping with ancillary appointments now, so Social Service was not receiving the referrals, as the MRS was getting them. The SSD was unaware of both referrals. During an interview on 1/9/26 at 11:50 a.m., the B-Wing Unit Manager indicated she tried calling the facility where they had sent Medicaid residents before and that facility was closed indefinitely. She then googled other eye surgeons in the area and called them and none of them took the resident's insurance. During an interview on 1/9/26 at 11:50 a.m., the SS Assistant indicated she had not tried calling the ombudsman to get any kind of resources for local eye surgeons who could take care of the laser surgery and the cataract surgery, nor had she reached out to the Corporate Social Service Director. 3.1-39(a)(1)

Based on observation, record review, and interview, the facility failed to ensure a resident was transferred properly in a mechanical lift and a floor mat was in place for a resident with a history of falls for 2 of 8 residents reviewed for accidents. (Residents B and C)Findings include:1. The record for Resident B was reviewed on 1/7/26 at 10:12 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, dementia without behaviors, high blood pressure, major depressive disorder, anxiety, and osteoarthritis. The 12/18/25 Minimum Data Set (MDS) assessment indicated the resident was severely impaired for daily decision making and was dependent on staff for transfers from the bed to the chair. A Care Plan, revised on 6/16/25, indicated the resident had an activities of daily living (ADL) deficit. The approaches were to provide assistance with transfers and the resident required a mechanical lift. The 12/2025 Physician Order Summary indicated the resident received Hospice Services. A Change of Condition form, dated 12/8/25 at 6:57 a.m., indicated while staff was passing morning medications, a scream was heard and then one of the CNA's came out of the room yelling for help. The CNA indicated the resident slipped out of the Hoyer (mechanical lift) pad when she was getting him up. The resident was observed lying on his right side. The CNA indicated the resident did not hit his head. The resident was put back to bed using the Hoyer lift and three staff members. The resident had tenderness on the right side near the rib area. The hospice nurse was called and informed of the fall and indicated they would be out later in the morning to visit the resident. The IDT Fall Review Note, dated 12/8/25 at 9:28 a.m., indicated date and time of fall was 12/8/25 at 5:45 a.m. Writer was passing morning medications when she heard a scream and then one of the CNA's came out the room yelling for help. CNA said resident slipped out of the Hoyer pad when she was getting him up. Writer then rushed to the room and observed resident laying on his right side rib area on the right Hoyer leg. When asked the CNA, she said he did not hit his head. Resident was put back to bed using Hoyer lift with 3 attendees . Interventions were to re-evaluate the size of the Hoyer pad. During a phone interview on 1/6/26 at 1:41 p.m., CNA 2 indicated she was working on 12/8/25 during the midnight shift. At 5:40 a.m., she and another CNA were in Resident B's room and were transferring him to the chair using the Hoyer lift. At that time, the other CNA got called away from the resident across the hall, and she left the room to attend to her. CNA 2 indicated within 30 seconds the resident slipped out of the Hoyer pad and fell to the floor. She screamed for help and the nurse, QMA, and another CNA came into the room and assisted the resident back into bed. The resident had some pain to his rib area. The nurse asked her to write a statement and indicate exactly what happened but not to include the other CNA's name. CNA 2 was terminated after the incident. CNA 2 indicated there were three CNA's working that night and sometimes there was no staff to help transfer the residents with the Hoyer lift and she had to do it by herself. On 1/7/26 at 3:00 p.m., the Director of Nursing (DON) provided a typed statement regarding the fall and indicated it was from the Assistant Director of Nursing (ADON). The statement read, On 12/8/25, I was in the building doing my rounds and the CNA asked me to help with a lift. [resident name] was moving about and began to slide form the Hoyer pad. We lowered [resident name] to the floor. After assessing the resident, he was transferred with 3 staff members back into bed. During an interview on 1/7/26 at 3:10 p.m., the DON indicated she was not sure if there was a statement from CNA 2 during the time of the fall, but would check. On 1/7/26 at 3:30 p.m., the DON provided a typed statement regarding the fall, indicating it was from CNA 2. The statement read, On 12/8/25, I was transferring Resident B with another staff member, when he began to slide out of the hoyer pad and we lowered him to the floor. I let the nurse know and she came and assessed the resident. We put him back into bed with the hoyer. During an interview on 1/7/26 at 3:30 p.m., the DON indicated CNA 2 was terminated after the incident for taking long breaks and wearing her air pods during work. The DON indicated the ADON does come in early at times and had helped CNA 2 lower the resident to the floor. She was not sure if there were any other statements from other staff working that shift and verified this was exactly what happened during the fall. On 1/7/26 at 3:45 p.m., the Human Resource (HR) Director was asked to see CNA 2's employee file. She opened the cabinet drawer and there were 2 visible folders in the cabinet with CNA 2's name on them. The HR Director only removed a purple folder, and left another manilla folder with CNA 2's name in the cabinet. When queried as to what was in the manilla folder, her response was Personal file. She did not remove that file, and was informed the personal file also needed to be reviewed. CNA 2's personal employee file was reviewed on 1/7/26 at 3:50 p.m. in the HR office. An Employee Memorandum, dated 12/8/25, indicated, On 12/7/25, CNA transferred a resident improperly leading to a fall. CNA was educated during orientation on proper transfer techniques and operated a hoyer improperly. The CNA was terminated. The form was signed by the DON and ADON. A typed statement from the DON and ADON indicated, I spoke with CNA 2 on 12/9/25 with the ADON present, and CNA 2 did admit to improperly using the hoyer when transferring a resident resulting in a fall. A hand written statement from CNA 1, who was also working on 12/8/25, was in the employee's file. The hand written statement indicated, On 12/8/25 around 6:00 a.m., I was in room [ROOM NUMBER] doing patient care. While I was doing patient care I heard a loud noise. Once I heard the noise I looked in the hallway and saw the aid [name] asking for help. Me, [nurse's name] and [QMA name], ran to room [ROOM NUMBER] and saw [Resident B] on the floor and the hoyer pad still in the air. The nurse began to assess the patient then we hoyered him into the bed. Once he was in the bed I left and continued to do my work. (sic) During an interview on 1/7/26 at 4:00 p.m., the Administrator and the Nurse Consultant indicated they were unaware of information that was in CNA 2's employee file. During an interview on 1/8/26 at 10:00 a.m., the Administrator indicated she was unaware there was a written statement from CNA 1, she was also unaware CNA 2 had transferred the resident by herself. During an interview on 1/8/26 at 2:50 p.m., the Nurse Consultant indicated she was unaware of the written statement from the CNA 1 and that CNA 2 was terminated due to the improper transfer. She indicated two nursing staff members were to transfer residents while using the Hoyer lift. During an interview on 1/9/26 at 9:20 a.m., CNA 1 indicated she was working that night with CNA 2. She was in a resident's room right across the hall from Resident B's room providing patient care. The CNA indicated she heard a large thump and a scream, and CNA 2 opened the door and yelled for help. She indicated she was not in Resident B's room prior to the fall. There were times when they have to transfer a resident by themselves using the Hoyer lift because it all depended on who was working that night and if they were willing to help. Some CNA's and nurses would not help. The current and undated Safe Resident Handling/Transfers policy, provided by the Nurse Consultant on 1/9/26 at 8:20 a.m., indicated two staff members must be utilized when transferring residents with a mechanical lift. Staff will be educated on the use of safe handling/transfer practices to include use of mechanical lift devices upon hire, annually, and as the need arises or changes in equipment occurred. 2. During random observations on 1/6/26 at 10:20 a.m., on 1/7/26 at 9:17 a.m., 11:00 a.m. and 1:32 p.m., and on 1/8/26 at 7:55 a.m. and 11:00 a.m., Resident C was observed in bed. The bed was in a very high position and at those times and there was no floor mat beside the bed. On 1/8/26 at 11:09 a.m., QMA 1 was asked if she was aware if the resident was supposed to have a floor mat beside the bed. She observed the resident in bed. There was no floor mat beside the bed and she indicated she did not recall if the resident was to have a floor mat beside the bed. The record for Resident C was reviewed on 1/7/26 at 11:35 a.m. Diagnoses included, but were not limited to, fracture of right femur, dementia, anxiety, repeated falls, major depressive disorder, Alzheimer's disease, and osteoarthritis. The 1/1/26 Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making and has had no falls since the previous assessment. The resident had a fracture that required surgery and needed substantial to max assist for bed mobility and was dependent on staff for transfers from the bed to the chair. The Care Plan, revised on 11/10/25, indicated the resident was at risk for falls. The approaches were to place a mat on the floor beside the bed. A Care Plan, revised on 11/10/25, indicated the resident preferred to keep her bed in a high position. A Change of Condition Note, dated 11/14/25 at 2:35 a.m., indicated the resident was found on the floor sitting next to the bed. The resident was complaining of hip and shoulder pain. The NP was notified and ordered X-rays of both hips and shoulders and something for the pain. A Change of Condition Note, dated 11/14/25 at 5:15 p.m., indicated the resident had difficulty waking up and was unresponsive. The physician was notified and orders were obtained to send the resident to the hospital. An IDT Fall Note, dated 11/14/25 at 9:12 a.m., indicated the resident was found on the floor next to the bed. Additional fall interventions put in place included to provide a floor mat beside the bed. Hospital notes, dated 11/14/25, indicated the resident had right neck femur fracture. During an interview on 1/8/26 at 11:12 a.m., the B-Wing Unit Manager indicated the resident was care-planned for having her bed in a high position. She was unaware the resident was to have a floor mat beside her bed. She reviewed the chart and indicated the care plan did indicate for a floor mat to be beside the bed. This citation relates to Intake 2688435. 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure bolus tube feeding administration as well as gastrostomy tube (a tube inserted directly into the stomach for nutrition) site care was completed as ordered for 2 of 2 residents reviewed for tube feeding. (Residents 75 and 13)Findings include:1. The record for Resident 75 was reviewed on 1/7/25 at 10:35 a.m. Diagnoses included, but were not limited to, stroke, dysphagia (difficulty swallowing) and dementia without behavior disturbance. The Annual Minimum Data Set (MDS) assessment, dated 11/26/25, indicated the resident had short and long term memory problems and was severely impaired for daily decision making. The resident was also receiving a tube feeding (a tube inserted directly into the stomach for nutrition). A Care Plan, reviewed on 12/9/25, indicated the resident required a tube feeding related to the diagnosis of dysphagia. The resident was NPO (nothing by mouth) status. A Physician's Order, dated 7/31/25, indicated bolus feedings (a method of delivering liquid nutrition through a feeding tube as a single meal) were permissible per the physician if [brand name] feeding bags were unavailable. A Nurse's Note, dated 12/31/25 at 3:36 p.m., indicted bolus feed continued related to peg (percutaneous endoscopic gastrostomy tube) tube issues. A Nurse's Note, dated 1/2/26 at 3:22 a.m., indicated the resident was recently receiving bolus tube feeding and flushes due to peg port issues. The December 2025 and January 2026 Medication and Treatment Administration Records indicated there was no documentation of the bolus tube feeding administration being completed. During an interview on 1/9/26 at 2:30 p.m., the Director of Nursing indicated documentation of the resident's bolus feeding and how much was instilled should have been completed. 2. On 1/6/26 at 1:53 p.m., Resident 13's PEG tube (a feeding tube inserted through the abdomen) was observed. There was a soiled, undated dressing around the tube insertion site. The skin around the tube was red with tan/yellow drainage and there was thicker, brown drainage noted on the dressing and on the resident's abdomen. At that time, the resident indicated the nurse last changed the dressing on 1/5/26. On 1/7/26 at 9:58 a.m., the resident was observed resting in bed. She indicated she had just gotten cleaned up and changed, but the nurse still had not changed the PEG tube dressing or cleaned the site since 1/5/26. The dressing / site were observed, and appeared the same as when observed on 1/6/26 at 1:53 p.m. On 1/7/26 at 3:19 p.m., the PEG tube dressing was observed to have thick brown drainage. The site was unchanged from the prior aobservation. At that time, the resident's family member was at the bedside. Both the family member and resident indicated the dressing had not been changed on the PEG site and it had not been cleaned. On 1/8/26 at 7:44 a.m., there was no dressing on the PEG tube site. Scant dried drainage was observed around the tube and there was no visible ointment on the surrounding skin. At that time, the resident indicated the dressing came off around 4:00 a.m. and the nurse threw it away. The nurse did not clean the site or apply topical medication or a dressing. On 1/8/26 at 9:28 a.m., the resident indicated LPN 1 already brought in her morning medications but did not look at, clean, or apply ointment to the PEG tube site. There was no dressing in place. The resident's record was reviewed on 1/7/26 at 2:18 p.m Diagnoses included, but were not limited to having a feeding tube, diabetes, and lupus. The admission Minimum Data Set (MDS) assessment, dated 12/12/25, indicated the resident was cognitively intact for daily decision making, and required maximal assist with ADLs, A Physician's Order, dated 1/5/26, indicated mupirocin-lidocaine external ointment (a topical antibiotic and numbing agent), apply to G-tube site topically three times a day for G-tube site infection. Cleanse site and apply three times a day for 14 days. The order was signed out as completed three times a day on the Medication Administration Record (MAR) on 1/6/26 and 1/7/26 and for the morning of 1/8/26. During an interview on 1/8/26 at 9:38 a.m., LPN 1 indicated he did not perform PEG tube care for the resident that morning, even though he signed it off on the MAR. He indicated he planned to go back and do the care later, but he should not have signed it out. During an interview on 1/8/26 at 10:30 a.m., the Director of Nursing (DON) was informed of the findings and indicated she would follow up with LPN 1. A policy, titled, Care and Treatment of Feeding Tubes was received as current from the Nurse Consultant on 1/9/26 at 11:42 a.m. and indicated, It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible . Direction for the staff on how to provide the following care will be provided: . Examination and cleaning of the insertion site in order to identify, lessen, or resolve possible skin irritation and local infection. 3.1-44(a)(2)

Based on record review and interview, the facility failed to document PICC line (a long-term use IV line) measurements as ordered for 1 of 2 residents reviewed with a PICC line. (Resident 161)Finding includes:The record for Resident 161 was reviewed on 1/7/26 at 10:47 a.m Diagnoses included, but were not limited to, unspecified severe protein-calorie malnutrition, colostomy, and intestinal obstruction.The admission Skilled Evaluation, dated 12/22/25, indicated the resident was alert and oriented and had a PICC line (a long-term use IV line).A Physician's Order, dated 12/23/25, indicated to measure the PICC catheter length on admission and with each dressing change thereafter, every Sunday night. The Medication Administration Record (MAR) indicated the PICC line dressing was changed on 12/24/25, 12/28/24, 12/31/24, and 1/4/26. The record lacked measurements of the PICC catheter length.A Care Plan, dated 12/23/25, indicated the resident was at risk for infection related to having a PICC line. Interventions included dressing change as ordered with measurements of the length of the external catheter and the circumference of the arm 10cm (centimeters) above the insertion site.During an interview on 1/12/26 at 8:16 a.m., the Nurse Consultant indicated she reviewed the record, and did not find any documentation of PICC length measurements. 3.1-47(a)(2)

Based on observation, record review, and interview, the facility failed to ensure oxygen was flowing at the correct rate per minute for 1 of 1 resident reviewed for oxygen. (Resident 14)Finding includes:During random observations on 1/5 at 10:46 a.m., 11:36 a.m., and 2:13 p.m., on 1/6 at 9:50 a.m., on 1/7 at 9:14 a.m. and 11:00 a.m., and on 1/8/26 at 7:56 a.m., Resident 14 was observed in bed. At those times he was wearing oxygen at 1.5 liters per nasal cannula on the room concentrator. On 1/8/26 at 2:25 p.m. RN 1 entered the resident's room and observed the oxygen at 1.5 liters. The RN indicated, she was unaware what his oxygen was to be set at. The record for Resident 14 was reviewed on 1/6/26 at 4:03 p.m. Diagnoses included, but were not limited to, COPD, paranoid schizophrenia, intellectual disabilities, asthma, psychotic disorder, and high blood pressure. The 12/5/26 Quarterly Minimum Data Set (MDS) assessment, indicated the resident was cognitively intact for daily decision making and wore oxygen while at the facility. The Care Plan, revised on 10/23/25, indicated the resident had oxygen therapy related to COPD. The approaches included to set the oxygen per physician's order. A Physician's Order, dated 10/16/25, indicated oxygen at one liter per nasal cannula and keep oxygen saturation about 90%. During an interview on 1/8/26 at 2:27 p.m., the B-Wing Unit Manager indicated the oxygen should be on the current liters per minute as ordered. 3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure residents were provided with medically related social services, related to the lack of documentation and follow up of an abuse allegation, missing cell phone, and a referral sent to another facility for 2 of 2 residents reviewed for Social Services. (Residents E and D)Findings include: 1. Closed record review for Resident E was completed on [DATE] at 9:38 a.m. Diagnoses included, but were not limited to, cancer, heart failure, hypertension, end stage renal disease, diabetes mellitus, thyroid disorder, anxiety, depression, chronic obstructive pulmonary disease, and metabolic encephalopathy. The admission Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident was cognitively intact.A Behavior Charting Progress Note, dated [DATE] at 8:42 p.m., indicated the resident contacted 911 multiple times stating, we are breaking into her house. Prior to the behavior the resident was lying in bed. Interventions attempted were redirection and offered a beverage or snack. The resident was placed in a wheelchair and taken to the nurse's station after the second call to 911. The interventions were ineffective until taken to the nurse's station. The record lacked any documentation Social Services followed up on the behavior charting related to the resident calling 911.An Indiana Department Of Health Facility Reported Incident, dated [DATE], indicated the following:Description added - [DATE]-While Resident E was at a doctor's appointment, the resident reported to their staff that she was hit by a staff member at the facility, and her cell phone was stolen.Action Taken added - [DATE]-Investigation initiated. Staff and resident interviews initiated. Physician and family were notified.Type of injury added - [DATE]-Resident was still out of the facility for the appointment and an assessment would be completed immediately upon return to the facility.Type of preventative measures added - [DATE]-Investigation initiated. Staff and resident interviews initiated. Staff education ongoing. Physician and family were notified.-Follow up added - [DATE] -Upon investigation and interviews with staff and residents, the allegation was unsubstantiated. Upon skin assessment the resident showed no evidence of bruising or harm indicating abuse. The resident's inventory did not indicate a cell phone, and family could not confirm having a cell phone. The record lacked any documentation related to the facility reported incident. There was no documentation Social Services had interviewed the resident or completed any follow up with the resident related to the abuse allegation and the missing cell phone. A Change of Condition Progress Note, dated [DATE] at 11:56 p.m., indicated the resident had died. The resident's emergency contact indicated she would pick up the resident's belongings.The Personal Belongings Inventory had a handwritten note on it that indicated, all items were to be donated except the cell phone, charger, and glasses. The inventory was signed by the emergency contact on [DATE].During an interview on [DATE] at 3:06 p.m., the Administrator indicated the resident was confused. Social Services should have documented her interview with the resident and follow up information related to the resident calling 911, the abuse allegation, and the missing cell phone since the resident was showing confusion. During an interview on [DATE] at 11:01 a.m., the Social Services Director (SSD) indicated the resident was confused. She was made aware the resident had called 911. She did not complete any follow up with the resident after the incident as to why she had called 911. She was unsure how the resident called 911. She interviewed the resident after the abuse allegation and the resident indicated it did not happen, and the resident did not know what she was talking about related to a cell phone. She looked at the resident's inventory sheet, and a cell phone was not marked on the sheet, so she did not think the resident had a cell phone. She did not document the interview she completed with the resident related to the abuse allegation or the missing cell phone. She did not do any follow up with the resident since the resident said the abuse did not happen and she did not believe the resident had a cell phone. 2. Record review for Resident D was completed on [DATE] at 9:16 a.m. Diagnoses included, but were not limited to, dementia, anemia, hypertension, neurogenic bladder, hyperlipidemia, and adult failure to thrive.The Quarterly MDS assessment, dated [DATE], indicated the resident was cognitively impaired. A Progress Note, dated [DATE] at 12:05 p.m., indicated a referral was faxed to another nursing home after a family request to do so.A Progress Note, dated [DATE] at 2:06 p.m., indicated the referred nursing home was called and they indicated the referral was passed on to management and they would return a call with an update.There was a lack of documentation of any more correspondence with the referred nursing home. There was no documentation related to the resident being accepted at the referred nursing home or not or if any more documentation was needed from the referred nursing home.During an interview on [DATE] at 11:10 a.m., the SSD indicated the above notes were written by a Social Services employee who no longer worked at the facility. She was unaware a referral had been sent to another facility for the resident, and the referral should have been followed up on and documented.The facility did not provide any Social Service policies.This citation relates to Intake 2578531.3.1-34(a)

Based on record review and interview, the facility failed to ensure insulin was administered as ordered and blood sugars were monitored for 1 of 5 residents reviewed for unnecessary medications. (Resident 4)Finding incudes:The record for Resident 4 was reviewed on 1/8/26 at 11:02 a.m. Diagnoses included, but were not limited to type 2 diabetes. The 11/12/25 Quarterly Minimum Data Set (MDS) assessment, indicated the resident was not cognitively intact for daily decision making and received insulin. The Care Plan, revised on 11/3/25, indicated the resident had diabetes mellitus. The approaches were to check the resident's blood sugar as ordered by the physician. A Physician's Order, dated 11/5/25, indicated Insulin Glargine (a long acting insulin) inject 15 units subcutaneously (sq) every morning and at bedtime and to hold if the blood sugar was less than 100. The Medication Administration Record (MAR) for the months of 11/2025 and 12/2025, indicated the Glargine Insulin was administered at bedtime and there was no documentation the resident's blood sugar was checked on the following days: -11/13/25-11/15/25-11/17/25-12/4/25 During an interview on 1/12/26 at 9:40 a.m., the Nurse Consultant indicated there were no blood sugars available for review for the above mentioned dates. 3.1-48(a)(3)

Based on record review and interview, the facility failed to ensure anti-seizure medications were available and dispensed according to physician's orders for 1 of 3 residents reviewed for seizure medication administration. (Resident B)Finding includes:The record for Resident B was reviewed on 10/30/25 at 9:40 a.m. Diagnoses included, but were not limited to, seizures.A Physician's Order, dated 8/15/25 indicated lacosamide (an anti-seizure medication) oral tablet, 50 mg (milligrams) every morning and bedtime.The October 2025 medication administration record (MAR) lacked documentation that the 10/24/25 bedtime and 10/25/25 morning doses were administered. A Progress Note, dated 10/25/25 at 9:08 a.m., indicated the lacosamide medication was unavailable, and the pharmacy indicated a new prescription was needed. During an interview on 10/30/25 at 2:21 p.m., the Corporate Nurse Consultant indicated the medication came from the pharmacy on a card, and the nurse could visualize when a refill would be needed. She indicated the pharmacy had a prescription with refills available for the medication, and they received the medication after the resident transferred out of the facility on 10/25/25. This Federal tag relates to Intake 2654366.3.1-25(a)

Based on record review and interview, the facility failed to ensure medical appointments were completed in a timely manner for 1 of 1 resident reviewed for a medical referral. (Resident B) Finding includes: The record for Resident B was reviewed on 8/20/24 at 3:40 p.m. Diagnoses included, but were not limited to, stroke, aphasia (a language disorder) following a stroke, hemiplegia and hemiparesis (muscle weakness and paralysis) following a stroke affecting the left non-dominant side, seizures, and altered mental status. The resident was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) assessment, dated 7/26/24, indicated the resident was cognitively impaired for daily decision making. A Physician's Order, dated 3/8/24, indicated an appointment with the resident's Neurologist was to be scheduled in one month. An appointment was scheduled for 4/16/24 at 9:30 a.m. Nurses' Notes, dated 4/16/24 at 10:41 a.m., indicated the resident's appointment was rescheduled for 5/8/24 at 10:45 a.m. due to transportation did not show up for the appointment. The transportation company indicated the pick up time was entered in the portal at 5:00 p.m. on 4/15/24 and that did not give them enough time to see it. Nurses' Notes, dated 5/8/24 at 11:53 a.m., indicated the resident's daughter was contacted concerning the appointment with the Neurologist had been rescheduled. A transportation request was submitted. A Physician's Order, dated 5/8/24, indicated the resident was to see the Neurologist on 5/14/24 at 12:45 p.m. There was no documentation in the nursing progress notes on 5/14/24 to indicate the resident was seen by the neurologist. A Physician's Order, dated 6/7/24, indicated the resident was to see the Neurologist on 6/11/24 at 1:00 p.m. There was no documentation in the nursing progress notes on 6/11/24 to indicate the resident was seen by the neurologist. A Physician's Order, dated 8/15/24, indicated the resident was to be seen by the Neurologist on 8/19/24 at 9:30 a.m. There was no documentation in the nursing progress notes on 8/19/24 to indicate the resident was seen by the neurologist. Nurses' Notes, dated 8/20/24 at 8:49 a.m., indicated the resident's daughter was contacted to discuss the neurology appointment. An appointment was scheduled for 9/19/24. During an interview on 8/23/24 at 10:19 a.m., the C Wing Unit Manager indicated there had been issues getting the resident seen by the neurologist. For his first scheduled appointment, transportation did not show up. For the next appointment, his wheelchair did not fit through the door at the office, then they changed neurologists. Another time, he couldn't get off the transportation van, and his last appointment on 8/19/24 was supposed to be on 9/19/24. The Unit Manager indicated the resident had not been seen by a neurologist since admission. Facility Calendar Notes, provided by the C Wing Unit Manger, indicated on 4/16/24 transportation was unavailable and the appointment was rescheduled, on 5/14/24 the resident's wheelchair was not able to fit through the office doors and the resident would need to see a different neurologist, on 6/14/24 transport staff were unable to get the resident off of the van and the appointment was rescheduled, and on 8/19/24 there was an error with the appointment date. The resident's appointment was scheduled for 9/19 rather than 8/19/24. During an interview on 8/23/24 at 1:45 p.m., the Executive Director indicated alternative measures should have been attempted to get the resident seen by the neurologist. This citation relates to Complaint IN00441573. 3.1-37(a)

Based on record review and interview, the facility failed to ensure residents with pressure ulcers received the necessary treatment and services to promote healing related to offloading heels when in bed for 1 of 5 residents reviewed for pressure ulcers. (Resident D) Finding includes: During random observations on 8/19/24 at 3:00 p.m. and 3:45 p.m., on 8/20/24 at 10:10 a.m., 3:07 p.m., and 3:55 p.m., and on 8/21/24 at 1:39 p.m. and 2:45 p.m., Resident D was observed lying in bed. At those times, the resident's heels were not offloaded while in the bed. The heels were lying directly on the mattress. On 8/22/24 at 2:55 p.m., the Wound Nurse removed the resident's sock so his pressure ulcer could be observed. The wound was located on the left heel and had black and dark maroon intact tissue to the wound bed. The surrounding skin was starting to flake off. There was no drainage noted. The record for Resident D was reviewed on 8/20/24 at 3:15 p.m. Diagnoses included, but were not limited to, urine retention, anemia, high blood pressure, obstructive uropathy (a disorder of the urinary tract that occurred due to obstructed urinary flow), anxiety, schizophrenia, mood disturbance, dementia, and depression. The 8/4/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making. The resident had no pressure ulcers during the assessment reference period. A Care Plan, dated 8/12/24, indicated the resident had a pressure ulcer to the left heel. The approaches were to float the heels. A Change of Condition Note, dated 8/11/24 at 2:11 p.m., indicated the resident was noted to have a pressure related area to the right heel measuring 4 centimeters (cm) by 4 cm. The wound nurse was notified. A Wound Nurse Practitioner (NP) Note, dated 8/14/24 at 1:07 p.m., indicated the resident had a deep tissue injury (a form of pressure ulcer) to the left heel that measured 4 cm by 3.5 cm. The wound base had 100% of epithelial tissue (a layer of skin cells) and the wound edges were intact. The treatment recommendations were to apply skin prep to the base of the wound twice daily, leave open to air, and float the heels while in bed with the use of heel boots. Physician's Orders, dated 8/11/24, indicated to off load heels at bedtime for skin integrity. During an interview on 8/22/24 at 11:30 a.m., the Wound Nurse indicated the resident's heels should be offloaded all the time while in bed. During an interview on 8/22/24 at 2:00 p.m., the Executive Director had no additional information to provide. 3.1-40(a)(2)

Based on observation, record review, and interview, the facility failed to ensure a call light was in reach and preventative fall measures were in use for residents who were identified as a fall risk for 2 of 5 residents reviewed for falls. (Residents C and D) Findings include: 1. During a random observation on 8/20/24 at 11:40 a.m., Resident C was in her room in bed. The resident's eyes were closed and her call light was observed on the floor underneath her bed. On 8/20/24 at 3:05 p.m., the resident remained in her bed and was watching television. The call light remained on the floor underneath the bed. At 3:12 p.m., a CNA entered the resident's room. The CNA exited the room after providing care. At 3:25 p.m., the resident was observed in bed and the call light was in reach. The record for Resident C was reviewed on 8/21/24 at 3:32 p.m. Diagnoses included, but were not limited to, repeated falls, anxiety, and dementia without behavior disturbance. The Quarterly Minimum Data Set (MDS) assessment, dated 5/17/24, indicated the resident was cognitively intact. The resident required substantial to maximum assistance with bed mobility and transfers. The resident had not had any falls since the prior assessment. A Care Plan, dated 1/3/23 and reviewed on 6/18/24, indicated the resident was at risk for falls related to a history of falls and weakness. Interventions included, but were not limited to, keep call light or personal items available and in easy reach. The Fall Risk Assessment, dated 8/13/24, indicated the resident was a fall risk. During an interview on 8/23/24 at 2:54 p.m., the Executive Director indicated the resident's call light should have been in reach. 10770 2. During random observations on 8/19/24 at 3:00 p.m. and 3:45 p.m., and on 8/20/24 at 10:10 a.m., 3:07 p.m., and 3:55 p.m., Resident D was observed lying in bed. At those times, the resident's bed was in a high position and there was no floor mat on the ground. The record for Resident D was reviewed on 8/20/24 at 3:15 p.m. Diagnoses included, but were not limited to, urine retention, anemia, high blood pressure, obstructive uropathy (a disorder of the urinary tract that occurred due to obstructed urinary flow), anxiety, schizophrenia, mood disturbance, dementia, and depression. The 8/4/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making. The resident had no falls since the last assessment and had a urinary catheter. A Care Plan, initiated on 7/25/24, indicated the resident was at risk for falls related to confusion and poor safety awareness. The approaches were to have a mat beside the bed and keep the bed in a low position. Physician's Orders, dated 11/26/24, indicated a floor mat every shift for fall prevention. The Treatment Administration Record for the month of 8/2024, indicated the floor mat was signed out as being down and in place for the day shift on 8/19-8/20/24. During an interview on 8/22/24 at 9:55 a.m., CNA 1 indicated she was aware the resident was to have a floor mat beside the bed, and it was in the closet. During an interview on 8/22/24 at 10:05 a.m., the ACU Unit Manager indicated she was aware the resident needed a floor mat beside the bed and it was kept in the closet because his roommate was ambulatory and they did not want him to trip over it. During an interview on 8/22/24 at 2:00 p.m., the Executive Director indicated she had no additional information to provide. The current 2023 Accidents and Supervision policy, provided by the Executive Director on 8/22/24 at 11:42 a.m., indicated Implementation of Interventions-using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes: e. Ensuring that the interventions are put into action. Monitoring and Modifications - Monitoring is the process of evaluation the effectiveness of care plan interventions. - Modification is the process of adjusting interventions as needed to make them more effective in addressing hazards and risks. Monitoring and modification processes include: Ensuring that interventions are implemented correctly and consistently This citation relates to Complaint IN00438937. 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure Foley catheter bags and tubing were kept off of the floor for 1 of 1 resident reviewed for catheters. (Resident D) Finding includes: During random observations on 8/19/24 at 9:56 a.m. and 11:40 a.m., Resident D was observed sitting in a high back wheelchair. The bottom of the catheter bag was observed on the floor under the wheelchair. During a random observation on 8/21/24 at 1:39 p.m., the resident was observed in bed. The bed was very low to the ground and the catheter bag and tubing was observed laying on the floor mat. On 8/22/24 at 10:00 a.m., the resident was observed sitting in the high back wheelchair. At that time, the catheter bag was hanging right below the arm rest of the wheelchair and not below his waist. The record for Resident D was reviewed on 8/20/24 at 3:15 p.m. Diagnoses included, but were not limited to, urine retention, anemia, high blood pressure, obstructive uropathy (a disorder of the urinary tract that occurred due to obstructed urinary flow), anxiety, schizophrenia, mood disturbance, dementia, and depression. The 8/4/24 Quarterly Minimum Data Set (MDS) assessment, indicated the resident was not cognitively intact for daily decision making. The resident had a urinary catheter. A Care Plan, revised on 7/19/24, indicated the resident had a history of chronic/recurring urinary tract infections. The approaches were to keep the drainage bag of the catheter below the level of the bladder at all times and off the floor. A Care Plan, revised on 7/19/24, indicated the resident had an indwelling catheter related to urine retention and obstructive uropathy. The approaches were to keep the drainage bag of the catheter below the level of the bladder at all times and off the floor. A Physician's Order, dated 5/26/24, indicated Foley catheter, size 14 French and 10 cubic centimeter (cc)balloon. Physician's Orders, dated 8/6/24 and discontinued on 8/14/24, indicated Augmentin (an antibiotic medication) 500-125 milligrams (mg), give 1 tablet by mouth three times a day for ESBL (Extended-Spectrum Beta-Lactamase infection caused by bacteria that produce an enzyme that was resistant to many commonly used antibiotics) for 7 days. During an interview on 8/22/24 at 9:55 a.m., CNA 1 indicated she was aware the catheter bag and tubing were on the floor because the bed had to be in a low position. She was told by the Unit Manager to put the bag and tubing in a basin. During an interview on 8/22/24 at 10:05 a.m., the ACU Unit Manager indicated she observed the catheter bag and tubing on the floor mat and instructed the CNA to put it in a basin. The catheter bag was to be below the resident's waist. The current 2023 Indwelling Catheter Use and Removal policy, provided by the Executive Director on 8/22/24 at 3:00 p.m., indicated If an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care polices and procedures that include but are not limited to: . d. Insertion, ongoing care and catheter removal protocols that adhere to professional standards of practice and infection prevention and control procedures. Additional care practices include: e. Securement of the catheter to facilitate flow of urine, prevention of kinks in the tubing and positioning below the level of the waist . 3.1-41(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 sanitizing and disinfecting multiple resident use equipment for a random observation during medication pass. (Residents 71 and 53) Finding includes: During medication administration pass on 8/22/24 at 8:10 a.m., LPN 1 was observed checking Resident 71's blood pressure, pulse, and temperature with reusable instruments. After she had finished, she brought all of the items back to the medication cart and placed them to the side. The LPN did not sanitize the blood pressure machine and cuff, thermometer, or the pulse oximetry device. LPN 1 prepared, poured, and administered the resident's medication and left the room. She moved the medication cart across the hall to Resident 53's room. At 8:27 a.m., she took the blood pressure machine, thermometer, and pulse oximetry device into his room and checked his vital signs. The items had not been sanitized after they were previously used. After checking his vital signs, she brought all of the devices to the medication cart and cleaned them with a germicide wipe. During an interview at that time, LPN 1 was aware the reusable equipment was to be cleaned and sanitized after each use. During an interview on 8/22/24 at 2:00 p.m., the Executive Director had no additional information to provide. The current 2024 Cleaning and Disinfection of Resident-Care Equipment policy, provided by the Executive Director on 8/22/24 at 3:00 p.m., indicated Staff shall follow established infection control principles for cleaning and disinfecting reusable, non critical equipment. General guidelines include: . b. Each user is responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use for another resident. d. Multiple resident use equipment shall be cleaned and disinfected after each use . 3.1-18(b)

Based on observation, record review, and interview, the facility failed to ensure oxygen was set at the correct flow rate for 1 of 2 residents reviewed for respiratory care. (Resident 90) Finding includes: During random observations on 8/19/24 at 10:36 a.m. and 3:35 p.m., Resident 90 was observed wearing oxygen per nasal cannula at just under 3 liters per minute. During random observations on 8/22/24 at 9:56 a.m. and 11:12 a.m., the resident was observed wearing oxygen per nasal cannula. The oxygen flow rate was set right under 3 liters. During a random observation on 8/23/24 at 8:46 a.m., the resident was observed awake in bed. The resident was wearing oxygen per nasal cannula. The oxygen flow rate was set directly below 3 liters. The record for Resident 90 was reviewed on 8/19/24 at 10:45 a.m. Diagnoses included, but were not limited to, insomnia (difficulty sleeping), chronic obstructive pulmonary disease (COPD), and high blood pressure. The Quarterly Minimum Data Set (MDS) assessment, dated 7/22/24, indicated the resident was cognitively intact for daily decision making and she wore oxygen. Physician's Orders, dated 4/30/24, indicated the resident was to have continuous oxygen at 2 liters per minute per nasal cannula. The Medication Administration Record (MAR), dated August 2024, indicated the oxygen was signed out as being given at 2 liters on the following dates: 8/19/24, 8/20/24, 8/21/24 and 8/22/24. During an interview on 8/22/24 at 9:35 a.m., the Executive Director (ED) indicated the resident's oxygen should have been on at the correct flow rate. During an interview on 8/22/24 at 10:22 a.m., QMA 1 indicated the oxygen ball should be directly in the middle of the 2 liter line if the resident was on 2 liters of oxygen. She had signed off in Resident 90's MAR that the oxygen was given at 2 liters per nasal cannula on 8/22/24 for the AM shift. 3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure resident records were complete and accurate related to a lack of documentation regarding edema and laboratory testing for 1 of 3 residents reviewed for edema. (Resident D) Findings include: Resident D's record was reviewed on 1/17/24 at 10:00 a.m. Diagnoses included, but were not limited to, muscle wasting and atrophy, schizophrenia, bipolar disorder, autistic disorder and deaf non speaking. The Admission Minimum Data Set assessment, dated 9/6/23, indicated the resident required substantial/ maximum assistance for bed mobility and transfers, and was dependent on staff for toileting. A General Note, dated 10/4/23, indicated the resident had completed the Brief Interview for Mental Screening and was cognitively intact. A General Note, dated 10/4/23, indicated a verbal order had been received from the Physician's nurse for Lasix (a diuretic) 40 milligrams daily for 5 days for lower extremity swelling and to obtain a uric acid lab test to rule out the medical diagnosis of gout. The record lacked results of the uric acid lab test. There was no documentation the lab test had been completed or was refused. There were no orders for the uric acid test in Physician Orders in the electronic record. The Skilled Nursing Assessments, dated 10/4, 10/5, 10/6 and 10/7/23, indicated there was no edema and no labs ordered. Progress notes after 10/4/23, lacked any documentation related to lower extremity edema, labs completed or refused, or family or Physician notification. The AIT (Administrator in Training) provided a lab requisition dated 10/4/23 for a uric acid test. A refusal had been circled, it was signed by a nurse and undated. During a telephone interview with a laboratory employee on 1/18/24 at 8:55 a.m., she indicated if a resident refused to have a lab obtained, they would have a record in their system. She indicated there was no order received for Resident D for a uric acid test around 10/4/23 or a refusal of the test. During an interview with RN 1 on 1/18/24 at 8:50 a.m., she indicated when a lab order was received the procedure was to enter the order into the computer, fill out a lab requisition, and call the lab to let them know if it was something unusual. The lab came to the facility 5 days a week. If the resident refused, they would notify the Physician and family and document in a progress note. During an interview with the Physician on 1/18/24, he indicated he was aware the resident had refused the lab test three months ago, but had not documented in the record. This citation relates to Complaint IN00421983. 3.1-50(a)(1)

Based on observation, record review and interview failed to ensure a resident was free from neglect related to not being assessed and transferred to the hospital in a timely manner after a change in condition, which resulted in a delay of treatment for a resident who later expired, for 1 of 3 residents reviewed for change in condition. (Resident B) The deficient practice involving Resident B was corrected on [DATE], prior to the start of the survey, and was therefore past noncompliance. The facility investigated the resident's change of condition and then assessed all residents for change of condition, provided inservice education to all staff and audited assessment skills for licensed nurses. The nurse who did not address the change of condition was disciplined. Finding includes: The closed record for Resident B was reviewed on [DATE] at 9:40 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, myopathy, spinal stenosis cervical region, polyneuropathy and dysphagia. The resident expired at the hospital on [DATE]. The Quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident was cognitively intact and required supervision for eating and extensive assist of one for transfers and bed mobility. A General Note, dated [DATE] at 5:23 p.m., indicated the resident was assisted to the restroom and had two large bowel movements (BM). There were no notes documented on the midnight shift ,d+[DATE] to [DATE]. A General Note, dated [DATE] at 6:45 a.m., documented as a late entry on [DATE] at 5:19 p.m. by RN 1, indicated upon rounds with night nurse resident was resting in bed in no distress. Per report resident had emesis previous night around dinner, also had a large BM. A General Note, dated [DATE] at 10:19 a.m., documented as a late entry on [DATE] at 5:27 p.m. by RN 1, indicated the resident was sitting in his room in a chair with a basin on the bed. Alert and oriented x ,d+[DATE] (person, place, time), stated he had an upset stomach yesterday, stated he did not have a BM for several days until yesterday and felt somewhat relieved after BM and throwing up that food they gave me. Vitals noted blood pressure ,d+[DATE], temperature 98.5 degree Fahrenheit, respirations 18 per minute and oxygen saturation 92% on room air and heart rate was 108 beats per minute. Resident did not complain of acute pain. A Change of Condition, dated [DATE] at 3:44 p.m. by LPN 1, indicated the resident was complaining of abdominal pain with nausea and vomiting since last night. The assessment indicated there was abdominal pain on palpation, nausea and vomiting, oxygen saturation was 77% on room air, unable to get a blood pressure and temperature was 101 degrees Fahrenheit. The Physician was notified and an order received to send to the emergency room . Hospital Emergency Department (ED) Notes indicated the resident arrived on [DATE] at 4:45 p.m. via emergency medical services (EMS). An ED Admission Physician Note indicated the resident presented for evaluation of nausea and vomiting, though on arrival had extreme shortness of breath. Resident had altered mental status and was unable to give any information. EMS indicated he was short of breath when they arrived and he was placed on a nonrebreather mask (high flow oxygen). Resident with oxygen saturation in the low 80's on the nonrebreather and severe respiratory distress requiring emergent immediate intubation. Differential diagnoses included severe sepsis, septic shock, pneumonia, aspiration pneumonia. Also found to be severely hypotensive with blood pressure in the 40s to 60s systolic. The resident was given antibiotics and fluids intravenously, and vasopressors (medication to increase his blood pressure). Lab results were consistent with septic shock. The resident remained very clinically unstable throughout the ED stay. An ED Physician's Note, dated [DATE] at 12:29 a.m., indicated he was called to the bedside by the nurse. Resident was bradycardic (low heart rate) and hypotensive on multiple vasopressors. He was given atropine and shortly after became pulseless. Cardiopulmonary resuscitation was started, advanced cardiovascular life support was started. During the first round family requested to stop heroic measures. Time of death was 11:47 p.m. Telephone interview with CNA 2, on [DATE] at 11:10 a.m., indicated she was taking care of the resident during the midnight shift on ,d+[DATE]-[DATE]. He was nauseated, irritated and couldn't sleep. He had asked her for a basin and threw up ,d+[DATE] times in a row. She indicated she reported it to the midnight nurse. Telephone interview with LPN 2, on [DATE] at 11:04 a.m., indicated she was working midnight shift on ,d+[DATE]-[DATE]. The resident had a large BM on arrival then went to bed. He had vomited once. The LPN indicated she asked him if he wanted to go to the hospital but he did not, said he felt better. She had checked if he had Zofran (antiemetic medication) but he did not have an order for it. She indicated she checked his vitals but did not document them, she did not do a physical assessment. Interview with CNA 1, on [DATE] at 10:35 a.m., indicated she took care of the resident on the day shift [DATE]. He had been sick and was vomiting mostly phlegm and spit into the basin. Midnight shift had given her report that he had been sick that night. He also complained of pain to his neck that was common. The Director of Nursing (DON) said to get him some ginger ale and soup, which she did, and to lay him down, which he declined to do. Interview with the DON, on [DATE] at 1:25 p.m., indicated on [DATE] around lunchtime she had seen the resident seated near the nurses' station holding an emesis basin. He said he wasn't feeling well. She asked him to go back to his room if he wasn't feeling well and offered him ginger ale and broth which he agreed to. CNA 1 took him back to his room. She did not hear anything else about the resident until the next shift. Telephone interview with RN 1, on [DATE] at 11:40 a.m., indicated she was the day nurse on [DATE]. During rounds at 6:45 a.m., he was sleeping and she had received report he had vomited that night. He woke up around 10 or 11 a.m., and indicated his stomach had been upset the previous day and he thought it was something he ate. The resident had asked for his medications to be crushed and put in applesauce. He wasn't complaining of feeling ill that day, just the previous day. She checked his vitals, she did not do a physical assessment. Telephone interview with LPN 1, on [DATE] at 10:29 a.m., indicated he was the evening nurse on [DATE]. He had received report from RN 1 that the resident wasn't feeling well that day, but did not specify what was wrong. After report, around 3:15 p.m., he went to assess the resident. He complained of pain to neck which was common, also complained of abdominal pain. There was a basin next to him with spit in it. The resident wanted to go to the hospital. The LPN called the Physician for an order to send to ED, and then called medical transport. He went back to assess the resident and found his oxygen saturation very low, he was unable to get a blood pressure and his temperature was elevated. The LPN then decided to call 911. He placed oxygen on the resident and awaited transport. During the Exit Conference, on [DATE] at 1:08 p.m., the Regional Nurse Consultant indicated they had initiated an investigation and an Action Plan related to Change of Condition policies following the adverse event. The Action Plan was provided at that time for review. This Federal tag relates to Complaint IN00412791. 3XXX,d+[DATE](a)(3)

Based on record review and interview, the facility failed to ensure a resident received the necessary treatment and services, related to not obtaining glucometer checks (blood sugar monitoring) for a resident with a [DIAGNOSES REDACTED]. The resident was subsequently admitted into the hospital with a high blood sugar and a diagnosis, which included, but was not limited to, diabetic hyperosmolar non-ketotic state (extremely high blood sugar level) for 1 of 3 residents reviewed for treatment for [REDACTED]. (Resident #G) Finding includes: Resident #G's record was reviewed on 10/12/16 at 8:45 a.m. The resident's [DIAGNOSES REDACTED]. The record indicated the resident was admitted into the facility on [DATE]. A Pre-admission History and Physical, dated 07/23/16, indicated the resident's [DIAGNOSES REDACTED]. The Admission physician's orders [REDACTED]. There were no insulin orders on the admission orders [REDACTED] The Nurses' Progress Notes, dated 08/15/16 at 4 p.m., indicated the resident was admitted into the facility. A Nurses' Progress Note, dated 08/15/16 at 10:15 p.m., indicated the resident was sent to the emergency room due to blood in the urine. A Nurses' Progress Note, dated 08/16/16 at 7:22 a.m., indicated the resident was admitted into the hospital. A Nurses' Progress Note, dated 08/17/16 at 7:13 p.m., indicated the resident returned to the facility. The return admission orders [REDACTED]. The admission orders [REDACTED] The Nurses' Progress Notes, dated 08/17/16 at 7:11 p.m. through 08/24/16 at 10:45 a.m., indicated the Physician had not been notified for clarification of the blood sugar monitoring with the [DIAGNOSES REDACTED]. A Nurses' Progress Note, dated 08/24/16 at 10:45 a.m., indicated, paged (Physician Name) in regard for the resident history of DM (diabetes mellitus). await call back. The Nurses' Progress Notes, dated 08/24/16 after 10:45 a.m. through 08/29/16, indicated the Physician had not returned call to the facility in regard to the resident's [DIAGNOSES REDACTED]. The resident's Nurses' Progress Notes, Medication Administration and Treatment Administration Records, dated 08/2016, indicated the resident's blood sugar had not been monitored until 08/30/16. A Nurses' Progress Note, dated 08/30/16 at 9:55 a.m., indicated the Nurse was called into the room by the resident's family due to the resident being lethargic. The resident's blood sugar was obtained by the glucometer, the result was HI, the Physician was notified and an order for [REDACTED].>A Nurses' Progress Note, dated 08/30/16 at 12:42 p.m. indicated the resident's blood sugar remained high and the resident was transferred to the hospital. A Hospital emergency room Physician History and Physical, indicated the resident's blood sugar was 1165 (normal 80-120) and the resident was admitted into the Hospital with a [DIAGNOSES REDACTED]. During an interview on 10/12/16 at 1:15 p.m., with RN #2 and the DON (Director of Nursing), the DON indicated the resident was initially admitted to the facility at 4 p.m. and was transferred to the hospital and admitted at the same evening. The DON stated she was unsure what orders were sent with the resident and the resident did not return to the facility with orders to monitor the resident's blood sugar. During an interview on 10/12/16 at 1:35 p.m., LPN #1 indicated the resident's family frequently visited the facility and had came to the Nurses' Station to ask if the facility was doing glucometer checks (blood sugar monitoring). LPN #1 notified the Physician with the family concern that glucometer checks were not being completed. LPN #1 stated if there was no note the Physician called back, then the Physician had not called back and she had not called the Physician again. A facility policy, titled, Notification of Change in Resident Health Status, dated 09/30/16, and received from the DON as current, indicated, .To ensure that proper notifications are made when a resident has a change in health .Depending on the nursing assessment appropriate notification may be immediate to 48 hours . This Federal Tag relates to Complaints IN 333. 3.1-37(a)

Based record review and interview, the facility failed to notify a resident's Physician in a timely manner, related to a family concern about blood sugar monitoring, for which a resident had [MEDICAL CONDITION] (high blood sugar) and was admitted into the hospital with a [DIAGNOSES REDACTED]. (Resident #G) Finding includes: Resident #G's record was reviewed on 10/12/16 at 8:45 a.m. The resident's [DIAGNOSES REDACTED]. A Nurses' Progress Note, dated 08/24/16 at 10:45 a.m., indicated, paged (Physician Name) in regard for the resident history of DM (diabetes mellitus). await call back. The Nurses' Progress Notes, dated 08/24/16 after 10:45 a.m. through 08/29/16, indicated the Physician had not returned the call to the facility in regard to the resident's [DIAGNOSES REDACTED]. A Nurses' Progress Note, dated 08/30/16 at 9:55 a.m., indicated the nurse was called into the room by the resident's family due to the resident being lethargic. The resident's blood sugar was obtained by the glucometer, the result was HI, the Physician was notified and an order for [REDACTED].>A Nurses' Progress Note, dated 08/30/16 at 12:42 p.m. indicated the resident's blood sugar remained high and the resident was transferred to the hospital. A Hospital emergency room Physician History and Physical, indicated the resident's blood sugar was 1165 (normal 80-120) and the resident was admitted into the Hospital with a [DIAGNOSES REDACTED]. During an interview on 10/12/16 at 1:35 p.m., LPN #1 indicated the resident's family frequently visited the facility and the had come to the Nurses' Station to ask if the facility was doing glucometer checks (blood sugar monitoring). LPN #1 notified the Physician with the family concern that glucometer checks were not being completed or ordered. LPN #1 stated if there was no note indicating the Physician had called back, then the Physician had not called back and she had not called the Physician again. During an interview on 10/12/16 at 1:40 p.m., the Director of Nursing (DON)indicated if the Physician does not call back, staff should try again and if no answer, then call the Medical Director. The DON was not sure what the policy was at the facility. During an interview on 10/12/16 at 2:45 p.m., the DON indicated the facility did not have a policy and procedure if the Physician does not call back. A facility policy, titled, Notification of Change in Resident Health Status, dated 09/30/16, and received from the DON as current, indicated, .To ensure that proper notifications are made when a resident has a change in health status .A need to alter treatment significantly .Depending on the nursing assessment appropriate notification may be immediate to 48 hours . This Federal Tag relates to Complaints IN 333. 3.1-5(a)(3)

Based on observation, record review, and interview, the facility failed to maintain acceptable nutritional parameters related to tube feedings not administered at the ordered rate and weekly weights not completed which resulted in a significant weight loss for 1 of 3 residents reviewed for enteral feedings in a sample of 3. (Resident # C) Finding includes: On 6/28/16 at 8:21 a.m., Resident #C was observed asleep in bed. The head of the resident's bed was elevated. The resident was receiving a tube feeding through a gastrostomy tube (a tube placed into the abdomen used to administer liquid nutrition and medications). Vital 1.5 tube feeding formula was infusing through the gastrostomy tube via a pump at 35 cc's (cubic centimeters) per hour. On 6/28/16 at 9:36 a.m., 10:55 a.m., 12:20 p.m., and 1:40 p.m., the resident remained in bed. The Vital 1.5 tube feeding continued to infuse at 35 cc's per hour. The resident's record was reviewed on 6/28/16 at 10:40 a.m. The resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. hour was reached. A Physician order [REDACTED]. Review of the 6/8/16 Minimum Data Set (MDS) Admission assessment indicated the resident was rarely or never understood. The assessment indicated the resident was dependent on staff for eating, hygiene and bathing. The assessment indicated the resident received tube feeding and was not on any mechanically altered oral diet. The assessment also indicated the resident received 51% or more of his nutrition via a parental or feeding tube route. Review of the resident's current Care Plans indicated a Nutritional Care Plan was initiated on 6/13/16. The Care Plan indicated the resident was dependent on tube feeding related to a [DIAGNOSES REDACTED]. Care Plan interventions included, but were not limited to administer the enteral tube feeding as ordered and monitor weights. A Nutrition Assessment was completed by the Registered Dietitian on 6/3/16. The assessment indicated the resident was NPO (to receive nothing by mouth) and received nutrition via the tube feeding formula. The Nutrition Assessment also indicated the resident's nutritional status would be monitored by weekly weights. Review of the resident's 6/2016 weights indicated the following weights were recorded: 6/2/2016: 142.0 pounds 6/6/2016: 142.0 pounds 6/22/2016: 138 pounds 6/28/2016: 135.2 pounds. A weight of 135 pounds reflected 5% significant weight loss in less then 30 days. When interviewed on 6/28/16 at 2:50 p.m., the Director of Nursing indicated there was a physician's orders [REDACTED]. The Director of Nursing indicated the tube feeding rate should have been increased as ordered by the Physician on 6/24/16. This Federal tag relates to Complaint IN 155. 3.1-46(a)(1)

Based on record review and interview, the facility failed to ensure safety devices were in place for a resident identified as a fall risk. This resulted in the resident sustaining a fracture from a fall for 1 of 3 residents reviewed for falls in the sample of 11. (Resident #H) Findings include: The closed record for Resident #H was reviewed on 8/14/13 at 7:00 a.m. The resident's [DIAGNOSES REDACTED]. Review of the 8/2013 Physician orders [REDACTED]. An Immediate Plan of Care for Falls was initiated on 8/1/13. The care plan indicted the resident was at risk for falls related to having fallen in the past (30) days had cardiovascular, neuromuscular/functional, and perceptual health problems. Interventions to be in place included, bedside commode, wheel chair for long distances, floor mat, bed in low position, call light in reach, and on a toileting program. Review of the 8/1/13 admission Clinical Health Status assessment form indicated the resident was admitted from the hospital with current [DIAGNOSES REDACTED]. The form also indicate the resident needed assistance with decision making, had right sided weakness, shuffle type gait, unsteady balance with sitting and standing, and was dependent on staff for fluid intake. The "Risk for Falls" section indicated the resident had intermittent confusion, 1-2 falls in the past three months, was chair bound, and had lower extremity weakness. The resident's total score was (17). The scale indicated a total score of (10) or above deemed a resident at risk for falls. The 8/2013 Nursing Progress Notes were reviewed. A note entered on 8/2/13 at 7:04 a.m. indicated the CNA reported the new resident was on the floor. The entry also indicated the resident was laying on the floor by the bed and was confused. Two bruises were noted on the back of the resident's head. The resident displayed no facial grimacing, the Physician, and responsible party were notified. An entry made on 8/2/13 at 2:25 p.m. indicated the resident had hip pain, the Physician was notified, and an order was given to obtain an X-ray. An entry made on 8/2/13 at 3:12 p.m. indicated the results of the X-ray were received and noted a hip fracture. The Physician was notified and orders were obtained to transport the resident to the hospital. A 8/2/13 Radiology Report indicated a right hip X-ray was completed. The results of the X-ray indicated there was an acute right femoral neck fracture. A Verification of Investigation report was completed on 8/2/13. The report indicated the CNA reported the resident was on the floor. The time of the occurrence was listed as 2:30 a.m. The assessment of the resident indicated the resident was seen laying on her back by her bed, two bumps with bruising were found on the back of her head. The areas measured 4 cm (centimeters) in diameter and 3 cm diameter. The "Immediate Resident Protection Initiated" section included to put a floor mat by the bed. When interviewed on 8/14/13 at 8:52 a.m., the Director of Clinical Education indicated the resident's fall occurred around 2:30 a.m. The Director indicated she had interviewed the CNA and the CNA told her the resident's bed was low to the ground at the time and a padded floor mat was implemented. When interviewed on 8/14/13 at 9:40 a.m., the Director of Clinical Education indicated she spoke with the Nurse who was assigned to care for the resident at the time of the 8/2/13 fall. The Director indicated the Nurse verified there was no mat on the floor at the time of the resident's fall. This federal tag relates to Complaint IN 323. 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, record review and interview, the facility failed to ensure the residents' environment was safe and free of hazards, related to an unlocked shower room on a special care unit, where a resident wandered and fell into a bathtub. The fall caused an injury to the resident's head which resulted in the need for emergency care and staples for 1 of 3 residents reviewed for falls. (Resident #F) Findings include: Resident #F was observed during orientation tour on 5/22/13 at 3:00 p.m. The resident was in the activity room of the Alzheimer's Care Unit (ACU). She was seated in a straight back chair. Interview with LPN #2 at the time of the tour, indicated the resident was able to ambulate independently and had 2 recent falls. Observation of the shower room on the ACU on 5/22/13 at 3:25 p.m., indicated there was a key pad lock on the door. The door was secured. The record for Resident #F was reviewed on 5/22/13 at 5:10 p.m. The resident had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment completed on 3/25/13, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 4, which indicated severe cognitive impairment. There was a falls risk assessment completed on 3/26/13, that indicated the resident's risk for falls was 13, (a score of 10 or above deems a resident at risk for falls). There was a current care plan, initiated on 1/2/13, that indicated: "Resident has [DIAGNOSES REDACTED]." One of the interventions was, "Allow resident to ambulate throughout the ACU at will." There was a current care plan, initiated on 1/10/12, that indicated: "At risk for falls related to: fell in the past 30 days, new environment." The care plan was updated on 5/3/13 with a fall. The new interventions were neuro checks and ER (emergency room ) visit. The care plan was again updated with a fall on 5/17/13. The new interventions were day get up, sensor on shower room door and neuro checks. There was an entry in the Progress Notes dated 5/3/13 at 5:35 a.m., that indicated, "Situation: fall, Background: dx (diagnosis) of dementia and HTN (hypertension) resident has full code status Assessment: when assessing resident this writer noticed bright red blood present to back of head. Resident denied any c/o (complaint) pain and was moving extremities freely. Response: MD (physician) called, resident transported to ER. Family called. On call supervisor called. " The "Emergency Department Chart" dated 5/3/13, was reviewed. It indicated: "Chief Complaint Fall - lac (laceration) to back of head. fall at 5:30 a.m. this morning. pt (patient) denies any pain." The section of the Emergency Department Chart titled, "Clinician History of Present Illness" indicated, " Exam started at 6:54 a.m. Presenting problem started minutes ago . . . Patient just fell -no identified proximate cause. Not at risk for chronic falls. Complains of pain affecting posterior scalp. Has soft tissue injury/contusion of the posterior scalp. Has bleeding from the posterior scalp. No visual complaints. Denies headache. Bleeding has been controlled with pressure. From history no significant blood loss." The section of the Emergency Department Chart titled, "Procedures" indicated, "Procedure note: Laceration. 8:26 a.m. The patient identification was correct. 2.5 cm (centimeter) lac (laceration) irrigated and cleaned. 1% lido (lidocaine, an anesthetic medication) for local anesthesia, staple x 2 to close, no complications." The form titled "Verification of Investigation" dated 5/3/13, was reviewed. It indicated: "Fall while ambulating without assistance in shower room/bathroom. Head injury. Physical assessment: skin tear. Resident was found in bath tub in shower room laying on back. Blood present to back of head. No c/o of pain. Resident stated she was trying to go home. Immediate resident protection: the physician and family were called, and the resident was sent to the hospital." The summary and outcome of the investigative findings indicated: "Resident wandered into shower room and was found in bath tub. Resident sent to ER for eval (evaluation) and tx (treatment). Resident returned with 2 staples to scalp. Will re-direct resident as needed." Interview with the Assistant Director of Nursing on 5/23/13 at 9:05 a.m., indicated she had investigated the resident's fall. She indicated the shower room should have been locked at the time of the fall. She indicated she had been unable to determine how the resident was able to get into the shower room. She indicated the key lock to the shower room door was replaced with a key pad lock, that required a code. CNA #4 was interviewed on 5/28/13 at 4:15 a.m., she was working the night shift on the ACU. She indicated she did not work on the night that Resident #F fell and hurt her head in the bath tub. She indicated she frequently worked the night shift on the ACU. She indicated that prior to Resident #F falling, the shower room had a lock on the door that required a key to open it. She indicated it was to be kept locked at all times. Continued interview with CNA #4, indicated that after Resident #F fell on [DATE], the Maintenance Supervisor put a keypad lock on the door, which required a special code to be entered. Continued review of the resident's record on 5/22/13 at 5:10 p.m., indicated an entry in the Progress Notes dated 5/17/13 at 6:07 a.m. The entry indicated, "Situation: fall Background: [AGE] year old female with dx of dementia, depressive disorder and HTN Assessment: Resident was found in shower room in bath tub. Resident stated she was trying to take a bath. No s/s (signs and symptoms) of pain. No new injury's (sic) noted. No internal/external rotation of extremities noted. Response: MD aware. Family aware. On call nursing supervisor aware." The form titled "Verification of Investigation" dated 5/17/13, was reviewed. It indicated: "Resident was dressed in bath tub in shower room on buttocks. Resident stated she wanted to take a bath and relax. No injury noted. Immediate resident protection: MD aware, family aware. Resident is now a day get up. Sensor for shower door. " The summary and outcome of the investigative findings indicated: "The door was found unlocked. Will have maintenance fix so the door automatically locks and keep key pad entry. Will change resident to day get up." Interview with the Assistant Director of Nursing on 5/23/13 at 9:05 a.m., indicated she had investigated the resident being found in the bath tub of the shower room on 5/17/13. She indicated the shower room should have been locked. She indicated the new lock that had been placed on the door after the 5/3/13 fall had a latch on the inside of the door. She indicated the latch could be turned to disengage the locking mechanism. It was determined that the latch had been turned and the lock disengaged. She indicated the latch was removed by maintenance. Interview with the Maintenance Supervisor on 5/23/13 at 8:05 a.m., indicated he had changed the lock on the ACU shower room to a key pad lock after Resident #F was found in the bath tub on 5/3/13. He indicated he then had to remove the latch on the key pad lock that could disengage the locking mechanism after the resident was found in the shower room in the bath tub a second time. He indicated the door to the shower room on the ACU was to be locked at all times. This Federal tag relates to Complaint IN 216. 3.1-45(a)(1)