Every finding on record at Brickyard Healthcare - Terrace Care Center

Based on observation, record review, and interview, the facility failed to ensure the residents' environment was clean and in good repair related to a dirty shower room, dirty and discolored floor tiles, marred walls, loose baseboards, stained sheets, the storage of bedpans and urinals, and call lights lacking pull cords on 3 of 3 units. (Residents 5, 106, and 1, Rainbow, Reflections, and Memory Units) The facility also failed to ensure the kitchen was clean and in good repair related to the following dirty items: window screens, a fan, vents and ceiling tiles, and walls and floors for 1 of 1 kitchen. (The Main Kitchen) Findings include: 1. During an interview on 8/18/26 at 11:00 a.m., Resident 5 indicated the shower room on the Rainbow Unit smelled and there was feces on the floor. He also indicated he wouldn't take a shower when the shower room was like that. During an interview on 8/18/26 at 2:38 p.m., Resident 106 indicated the shower room on the Rainbow Unit was disgusting. The last time she was in the shower room, someone had pooped and they didn't clean it up. She indicated she was not going to take a shower if the shower room was left like that again. During an interview on 8/19/26 at 12:06 p.m., Resident 1 indicated she had a shower that morning and there was feces on the floor in the Rainbow Unit shower room. During a random observation on 8/20/26 at 10:54 a.m., the Rainbow shower room had hair in the drain. There was also a brown and green substance in the drain with some brown splatter on the floor. During an interview at that time, CNA 1 indicated she had no idea what was in the drain and on the floor. At 10:55 a.m., the Infection Preventionist was shown the shower room and she indicated she would get someone to clean the area. 2. During the Environmental tour with the Maintenance and Housekeeping Supervisors on 8/24/26 at 1:39 p.m., the following was observed: Rainbow Unit a. In room [ROOM NUMBER] there was debris on the floor behind bed 1. There was a urinal hanging from the grab rail in the bathroom and the walls were marred. Two residents resided in the room and shared the bathroom. b. In room [ROOM NUMBER] there was a large amount of debris and food crumbs under bed 3. There was also clothes and food containers on the floor in the bathroom. The fan blades next to the resident's night stand for bed 3 were dirty and dusty. Two residents resided in the room and shared the bathroom, c. In room [ROOM NUMBER] the walls were marred and the bathroom floor tile was marred underneath the toilet. The baseboard was peeling by the bathroom door. One resident resided in this room and used the bathroom. d. In room [ROOM NUMBER] there was a uncontained urinal hanging from the toilet riser in the bathroom. The floor tile behind the toilet was also discolored and dirty. Two residents shared the bathroom. e. In room [ROOM NUMBER] the floor tile in the bathroom was discolored and peeling in front of the sink. Two residents shared the bathroom. Reflections Unit a. In room [ROOM NUMBER] the plastic electrical outlet cover behind bed 2 was cracked and pieces were missing. The bathroom walls were marred, there was no drain plug in the sink, and there was no pull cord for the emergency call light. Two residents resided in the room and shared the bathroom. b. In room [ROOM NUMBER] the paint on the wall behind the toilet was warped in sections. There was no pull cord for the emergency call light located in the bathroom. Two residents resided in the room and shared the bathroom. c. In room [ROOM NUMBER] the wall next to bed 2 was marred and the baseboard in the corner of the room located next to the resident's table was cracked and peeling away from the wall. The emergency call light located in the bathroom did not have a pull cord. There was no drain plug in the bathroom sink. One resident resided in the room and used the bathroom. d. In room [ROOM NUMBER] the walls were marred. The bathroom walls were also marred and the bathroom floor tile was discolored. There was no drain plug for the bathroom sink. Two residents resided in the room and used the bathroom. e. In room [ROOM NUMBER] the walls in the bathroom were marred and there was no pull cord for the emergency call light located in the bathroom. One resident used the bathroom. f. In room [ROOM NUMBER] the walls were marred. The bathroom walls were also marred and the baseboard was peeling away from the wall underneath the toilet. One resident resided in the room and used the bathroom. Memory Unit a. In the bathroom of room [ROOM NUMBER] there was an uncontained wash basin with a nun's cap (a specimen collection device) stacked inside. There was also a soiled washcloth with a brown substance inside of the collection device. One resident used the bathroom. b. In room [ROOM NUMBER] there was dried yellow stains on the fitted sheet located at the foot of the resident's bed. During an interview at that time, the resident indicated the stains were from the wound on his foot. One resident resided in the room. c. In room [ROOM NUMBER] there were three bedpans stacked on top of each other on the dresser near the television. One resident resided in the room. During an interview at that time, the Maintenance Supervisor indicated all of the above were in need of cleaning and/or repair. The current facility policy titled, Disinfection of Bedpans and Urinals was provided by the Administrator on 8/24/26 at 4:19 p.m. The policy indicated bedpans and urinals were to be stored in the resident's bedside cabinet or drawer after being placed in a plastic bag. 3. During the Initial Kitchen Sanitation Tour on 8/18/26 at 9:14 a.m. with the Kitchen Manager, the following was observed: a. In the food preparation area, a window screen had a buildup of a white/gray substance on it. At that time, the Kitchen Manager indicated they opened the window sometimes, but not often. A collection of cobwebs was observed in the corner of the ceiling, and a splatter of a dark substance was on wall. b. In the dry storage area, the floor was dirty. There was a buildup of dust and dirt along the baseboards. c. In dish area, the ceiling tiles and ceiling vents had a black buildup and chipped paint. There was a fan with a large accumulation of dust. During an interview on 8/18/26 at 9:30 a.m., the Kitchen Manager indicated all of the above were in need of cleaning. A Policy titled, Sanitation Inspection, received as current from the Administrator on 8/24/26 at 11:50 a.m., indicated all food service areas should be kept clean and sanitary. 410 IAC (Indiana Administrative Code) 16.2-3.1-19(f) This citation relates to Intake 3045754.

Based on observation, record review, and interview, the facility failed to ensure activities of daily living (ADLs) were completed for dependent residents related to bathing for 1 of 5 residents reviewed for ADLs. (Resident B) Finding includes:During a random observation on 8/18/26 at 11:48 a.m., Resident B was resting in bed. His hair was disheveled and his face was unshaven. At that time, the resident indicated he really wanted to take a shower. He had only received one shower since his arrival to the facility on 8/6/26 and had not received any bed baths. The record for Resident B was reviewed on 8/20/26 at 11:30 a.m. Diagnoses included, but were not limited to, acute osteomyelitis (bone infection), diabetes, and enterocolitis due to Clostridium difficile (an inflammation of the intestines caused by bacteria).The admission Minimum Data Set (MDS) assessment, dated 8/12/26, indicated the resident was cognitively intact for daily decision making and was dependent in activities of daily living (ADLs).A review of the Shower Sheets from admission to current indicated the resident received a full bath on 8/10/26 and a shower on 8/13/26. There was no documentation of a bath or shower being provided from 8/14/26 to 8/20/26. A Care Plan, dated 8/18/26, indicated the resident had an ADL self-care performance deficit.During an interview on 8/24/26 at 2:00 p.m., the Director of Nursing indicated the resident should have received two full baths or showers per week.410 IAC (Indiana Administrative Code) 16.2-3.1-38(a)(3)This citation relates to Intake 3045754.

Based on observation, record review, and interview, the facility failed to administer medications as ordered related to not following pain indicator parameters for 1 of 3 residents reviewed for medication administration. (Resident C) Finding includes: Resident C's record was reviewed on 6/11/26 at 10:00 a.m. The diagnoses included, but were not limited to, dementia, high blood pressure, COPD, depression, and anxiety. The Quarterly Minimum Data Set (MDS) assessment, dated 5/11/26, indicated the resident was severely impaired for daily decision making. Eating and oral hygiene required substantial to maximum assistance. All other Activities of Daily Living (ADLs) required dependent care. A Physician's Order, dated 2/4/25, indicated to administer Morphine Sulfate 0.25 milliliters every four hours as needed for severe pain rated seven to ten, or for shortness of breath (SOB). The Medication Administration Record (MAR) was reviewed from April 2026 through June 2026. The PRN order for Morphine indicated to administer for severe pain rated from seven to ten. The following dates did not have a pain rating of seven or higher and did not indicate SOB before administered. April 8, 12, 19, 20, and 22, 2026May 13, 15, and 19, 2026June 3, 6, and 9, 2026 A Care Plan, revised on 5/20/26, indicated the resident had impaired cognitive function/dementia. Interventions were to administer medications as ordered and observe for side effects and effectiveness. During an interview on 6/11/26 at 2:57 p.m., the Director of Nursing indicated she understood the concern and had no additional information to provide. This citation relates to Intake 3017728. 410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on record review, and interview, the facility failed to ensure fall interventions were updated and in place to prevent injury for a resident with two falls in one day for 1 of 3 residents reviewed for accidents. (Resident B)Finding includes:Record review for Resident B was completed on 12/1/25 at 10:31 a.m. Diagnoses included, but were not limited to, dysphagia (difficulty swallowing), weakness, anxiety, osteoarthritis, diabetes, and high blood pressure.The admission Minimum Data Set (MDS) assessment, dated 10/13/25, indicated the resident was cognitively intact for daily decision making. The resident required substantial/maximum assistance with shower/bathing, toileting, upper/ lower body dressing, and putting on footwear.A Care Plan, dated 10/14/25, indicated the resident was at risk for falls related to deconditioning and balance problems. Approaches were to keep environment well lit, clutter free, and keep personal items within reach. There were no revisions or updates added.During the month of October 2025, Resident B had two falls on 10/26/25.A Progress Note, dated 10/26/25, indicated the resident was lowered to the floor after she had felt weak when working with therapy.A Progress Note, dated 10/26/25, indicated the resident was lowered to the floor in the bathroom while being transferred after feeling weak.A policy titled, Fall Prevention Program, received as current from the Director of Nursing on 12/1/25 at 10:25 a.m. indicated, .If there is a loss of balance during supervised therapeutic interventions and the resident comes to rets on the ground, floor, or next lower surface despite the clinician's effort to intercept loss of balance, it is considered a fall.When any resident experiences a fall, the facility will . e. review the resident's care plan and update as indicated.During an interview on 12/2/25 at 1:18 p.m., The Assistant Director of Nursing Services (ADNS) indicated she did not update the care plan with new interventions after the falls.This citation relates to Intake 2672564.3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to maintain clinical records that were complete and accurately documented related to incontinence logs for 1 of 3 residents reviewed for Activities of Daily Living (ADLs). (Resident C)Finding includes:On 12/2/25 at 8:37 a.m., CNA 2 was observed going into Resident C's room to perform ADL care. The resident was calm and sitting up in his bed wearing a hospital gown. No concerns were noted. The record for Resident C was reviewed on 12/2/23 at 9:18 a.m. Diagnoses included, but were not limited to, Alzheimer's, diabetes, weakness, depression and dysphagia (difficulty swallowing).The Quarterly Minimum Data Set (MDS) assessment, dated 11/14/25, indicated the resident was severely impaired for daily decision making. The resident required dependent care with toileting, shower/bathing, dressing, personal hygiene, and putting on footwear.A Care Plan, last reviewed on 9/3/25, indicated the resident had an ADL self-care deficit. Interventions were to provide incontinence care as needed, and to observe/document/report to the physician a significant decline in functional ability.The October and November 2025 Incontinence Reports indicated the bladder and bowel incontinence log was filled out only once a day on the following dates:- 10/23 bowel incontinence documented one time- 10/27 bladder incontinence documented one time-10/30 bladder incontinence documented one time- 11/16 bladder incontinence documented one time-11/18 bladder incontinence documented one time- 11/25 bowel and bladder incontinence documented one time-11/26 bladder incontinence documented one time-11/30 bowel incontinence documented one time During an interview on 12/1/25 at 10:33 a.m., the Assistant Director of Nursing Services (ADNS) indicated the expectation was to check and change the residents every 2 hours and as needed.During an interview on 12/1/25 at 11:38 a.m., RN 1 indicated they checked and changed residents every 2 hours or sooner if needed.During an interview on 12/2/25 at 8:31 a.m., CNA 1 indicated they checked and changed the residents every 2 hours or as needed.During an interview on 12/2/25 at 12:44 p.m., CNA 2 indicated she checked her residents every 2 hours.During an interview on 12/2/25 at 1:12 p.m., the Director of Nursing Services indicated she understood the documentation concern and had no additional information to provide.This citation relates to Intake 2672564.3.1-50(a)(1)3.1-50(a)(2)

Based on observation, record review, and interview, the facility failed to ensure infection control practices were in place and implemented related to the storage of wash basins, urinals, and bed pans, the changing of gloves during wound care for 1 of 2 residents reviewed for pressure ulcers, and the lack of personal protective equipment (PPE) during 1 of 1 intravenous (IV) medication administration. (The Memory Unit, Residents 15 and 109) Findings include: 1. During the Environmental Tour on 6/27/25 at 2:12 p.m., with the Maintenance Supervisor and the Administrative Consultant, the following was observed: The Memory Unit a. In the bathroom of room [ROOM NUMBER], there were two urinals hanging from the grab bar located next to the toilet. The closet located in the bathroom had one wash basin and two bed pans stacked on top of each other. The wash basin and bed pans were not contained. Two residents shared the bathroom. b. There was a wash basin on the floor underneath the sink in the bathroom of room [ROOM NUMBER]. Two residents shared the bathroom. c. There was a urinal hanging from the grab bar located next to the toilet in the bathroom of room [ROOM NUMBER]. Two residents shared the bathroom. During an interview on 6/27/25 at the time, the Administrative Consultant indicated the urinals, bedpans, and wash basins should have been placed in bags. The facility policy titled Disinfection of Bedpans and Urinals was provided by the Director of Nursing on 6/27/25 at 2:38 p.m. and identified as current. The policy indicated to store bedpans and urinals in the resident's bedside cabinet or drawer after placing in a plastic bag as per facility policy. 2. Wound care for Resident 15 was observed on 6/26/25 at 9:19 a.m. RN 2 donned a gown and a pair of gloves prior to entering the resident's room. Upon entering the room, the RN removed the top sheet from the resident's bed and placed it on the floor. The resident's heel boots were also removed and placed on the floor. The RN proceeded to remove the dressing to the resident's sacrum. She then cleansed the sacral wound with wound cleanser, packed the wound with Dakin's (a wound disinfectant) soaked gauze, and covered the area with a foam dressing. After completing the treatment to the sacrum, the RN proceeded to reposition the resident and provide incontinence care with the assistance of the CNA. The RN did not change her gloves after completing the treatment to the sacrum. After providing incontinence care, the RN removed a dressing to the resident's chest. She cleansed the area with wound cleanser, tore a calcium alginate pad (a type of wound dressing) in half and placed the pad on the wound bed wearing the same gloves and covered the area with a dry dressing. The RN then proceeded to remove a dressing from the resident's right breast. After removing the dressing, the RN cleansed the area with wound cleanser and packed the wound with Dakin's soaked gauze and covered the area with a dry dressing. The RN was wearing the same pair of gloves that she used to complete the treatment to the sacrum, provide incontinence care, and complete the treatment to the chest and breast areas. During an interview on 6/26/25 at 10:25 a.m., the Infection Preventionist indicated the RN should have changed her gloves going from dirty to clean areas and she should have changed her gloves between each treatment. During an interview on 6/26/25 at 3:20 p.m., the Director of Nursing indicated the RN should have changed her gloves in between treatments and the linen should not have been placed on the floor. The current facility policy titled Clean Dressing Change was provided by the Director of Nursing on 6/27/25 at 11:30 a.m., the policy indicated gloves were to be changed after soiled dressings were removed and in between each dressing change. 2. During medication pass on 6/25/25 at 7:53 a.m., RN 3 was observed preparing to administer an Intravenous (IV) antibiotic medication through Resident 109's PICC line. There was a sign on the resident's room door which indicated he was in Enhanced Barrier Precautions (EBP). Staff that were to come in contact with the resident should don gloves and an isolation gown. The RN entered the resident's room with the IV antibiotic and two 10 cubic centimeters (cc) normal saline pre-filled syringes. She washed her hands with soap and water and donned clean gloves to both hands. She did not don an isolation gown. She flushed the resident's PICC line with one of the pre-filled normal saline syringes, connected the IV antibiotic and turned on the pump. She told the resident she would be back in 30 minutes to disconnect the IV. At 8:56 a.m., RN 3 entered the resident's room to disconnect the IV antibiotic medication from the pump. She washed her hands with soap and water and donned a clean pair of gloves to both hands. She did not don an isolation gown. She removed the IV tubing from the PICC line port, and threw it away. She flushed the PICC line with a pre-filled normal saline syringe and clamped the line. She removed her gloves, performed hand hygiene and walked out of the room. During an interview on 6/25/25 at 2:32 p.m., RN 3 indicated she was aware the resident was in EBP and she should have worn a gown while administering the IV antibiotic medication. During an interview on 6/25/25 at 3:00 p.m., the Director of Nursing (DON) indicated the RN should have worn a gown during the administration of the IV antibiotic during medication pass. The current 2025 Enhanced Barrier Precautions policy provided DON on 6/25/25 at 3:10 p.m., indicated EBP will be followed in high contact resident care activities such as device care or use of PICC lines. 3.1-18(b)

Based on observation, record review, and interview, the facility failed to ensure medications were held based on insulin and blood pressure parameters for 1 of 2 residents reviewed for insulin and 2 of 5 residents reviewed for unnecessary medications. (Residents G, E, and H) The facility also failed to ensure discolorations were monitored and treatments were obtained for venous stasis ulcers and frequent diarrhea for 2 of 5 residents reviewed for skin conditions non-pressure related (Residents F and D) and 1 of 3 residents reviewed for constipation and diarrhea. (Resident C) The facility also failed to ensure recommendations were carried out from specialty physicians for 1 of 1 resident reviewed for change in condition. (Resident H) Findings include: 1. The record for Resident G was reviewed on 6/25/25 at 12:57 p.m. Diagnoses included, but were not limited to, type 2 diabetes and Parkinson's disease. The Quarterly Minimum Data Set (MDS) assessment, dated 4/4/25, indicated the resident was cognitively intact and received insulin injections. A Care Plan, reviewed on 4/28/25, indicated the resident had type 2 diabetes without complications. Interventions included, but were not limited to, diabetes medications as ordered by the physician. A Physician's Order, dated 5/13/25, indicated the resident was to receive 22 units of Glargine insulin (a long acting insulin) one time a day at 8:00 a.m. The insulin was to be held if the resident's blood sugar was less than 150. The resident was also to receive 20 units of Glargine insulin at 8:00 p.m. and the resident's insulin was to be held if his blood sugar was less than 150. The May 2025 Medication Administration Record (MAR) indicated the resident received his insulin when his blood sugar was below 150 on the following dates at times: 8:00 a.m.: 5/14, 5/15, 5/18, 5/19 & 5/28/25 8:00 p.m.: 5/29/25 The June 2025 MAR indicated the resident received his insulin when his blood sugar was below 150 on the following dates at times: 8:00 a.m.: 6/2, 6/4, 6/5, 6/9, 6/15, 6/16, 6/19, & 6/23/25 8:00 p.m.: 6/3 & 6/16/25 During an interview on 6/26/25 at 3:20 p.m., the Director of Nursing indicated the resident's insulin should have been held as ordered. 2. The record for Resident E was reviewed on 6/26/25 at 2:38 p.m. Diagnoses included, but were not limited to, mild dementia with anxiety and hypertension. The Significant Change Minimum Data Set (MDS) assessment, dated 5/16/25, indicated the resident was moderately cognitively impaired for daily decision making. A Care Plan, reviewed on 5/19/25, indicated the resident had hypertension (high blood pressure) and hyperlipidemia (high cholesterol). Interventions included, but were not limited to, give medications as ordered. A Physician's Order, dated 6/1/25, indicated the resident was to receive Metoprolol Tartrate (a heart medication) 25 milligrams (mg) 1 tablet every morning and at bedtime. Hold and notify the physician of systolic blood pressure (top number) less than 110 or diastolic (bottom number) less than 60. The June 2025 Medication Administration Record (MAR) indicated the resident received the Metoprolol when his systolic blood pressure was below 110 and the diastolic blood pressure was less than 60 on the following dates and times: AM dose: - 6/5/25 blood pressure 98/68 PM dose: - 6/4/25 blood pressure 105/70 - 6/23/25 blood pressure 108/61 - 6/24/25 blood pressure 110/58 During an interview on 6/26/25 at 3:20 p.m., the Director of Nursing indicated the resident's Metoprolol should have been held as ordered. 3. On 6/24/25 at 10:15 a.m., Resident F was observed in his room sitting on the side of his bed. His pants were slightly pulled down and a large area of purplish discoloration was observed on his left hip. The record for Resident F was reviewed on 6/26/25 at 11:42 a.m. Diagnoses included, but were not limited to, fall from bed and history of aneurysm of lower extremity. The Quarterly Minimum Data Set (MDS) assessment, dated 5/29/25, indicated the resident was cognitively intact and he received an anticoagulant (a blood thinner). A Care Plan, dated 3/5/25, indicated the resident was on anticoagulant therapy related to personal history of pulmonary embolism. Interventions included, but were not limited to, daily skin inspections and report abnormalities to the nurse. A Physician's Order, dated 4/8/25, indicated the resident was to receive Apixaban (a blood thinner) 5 milligrams (mg) twice a day. Nurse's Notes, dated 6/18/25 at 5:30 a.m., indicated the resident was noted to have bruising on his left hip. A Weekly Skin Review, dated 6/18/25, indicated the resident had a pre-existing bruise to the left hip. A Weekly Skin Review, dated 6/25/25, indicated the resident's skin was intact. There was no documentation related to the bruising to the left hip. During an interview on 6/26/25 at 3:20 p.m., the Director of Nursing indicated the bruising to the resident's left hip should have been documented on the weekly skin review sheet. The current facility policy titled, Skin Assessment, was provided by the Director of Nursing on 6/27/25 at 11:30 a.m. The policy indicated a full body, or head to toe, skin assessment would be conducted by a licensed or registered nurse upon admission, re-admission, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. 4. During an interview on 6/23/25 at 11:04 a.m., Resident D indicated she had diarrhea on a regular basis and received no medications for it. The record for Resident B was reviewed on 6/25/25 at 11:40 a.m. Diagnoses included, but were not limited to, vascular dementia, constipation, pain, and stroke. The 5/7/25 Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making and was always incontinent of bowel. The bowel incontinence log in the CNA task section indicated the resident had loose/diarrhea on the following days: - 5/27, 5/28, 5/29 times two, 5/30, 6/1, 6/2 times three, 6/3 times two, 6/5, 6/7 times three, 6/9 times two, 6/10, 6/11 times two, 6/12 times two, 6/13, 6/14 times three, 6/15, 6/16, 6/17 times two, 6/18 times four, 6/21 times two, 6/22 times three, 6/23, and 6/24/25 times two. A Nurses' Note by the Infection Preventionist, dated 6/13/25 at 9:39 a.m., indicated the resident had loose stools often. The stools had no characteristics of C-diff, they were not a watery diarrhea, and she had no cramping or tenderness to the abdomen. There were no scheduled or as needed medications ordered for diarrhea. A Physician's Order, dated 4/9/25, indicated Senna (a medication used for constipation) Oral Tablet 8.6 milligrams (mg), give two tablets by mouth at bedtime. During an interview on 6/26/25 at 2:10 p.m., RN 1 indicated she was not made aware of the resident having diarrhea from the morning shift report. During an interview on 6/26/25 at 2:10 p.m., CNA 1 indicated the resident had not had a bowel movement yet that day, but he had taken care of her in the past, and all of her stools were loose like diarrhea. He indicated they had reported the diarrhea to the nurses, they all know about it. During an interview on 6/26/25 at 2:25 p.m., the Unit Manger indicated there was no documentation in nursing notes regarding the diarrhea. During an interview on 6/26/25 at 3:20 p.m., the Director of Nursing indicated there was no documentation regarding the diarrhea in the record and she had no additional information to provide. 5. During an observation on 6/23/25 at 2:15 p.m., Resident C was observed in bed. At that time, there was a large amount of flaking skin on the bed sheets as well as streaks of blood. The resident's right outer shin was observed to be raw, open and red. During an observation on 6/24/25 at 2:54 p.m., the resident was in bed. The right outer shin was red and open with dry flakes of skin noted on the bed sheets. During an observation on 6/25/25 at 10:03 a.m. and 11:49 a.m., the resident was observed in bed. At those times, his right outer shin was observed to be red, open and raw with flakes of skin on the bed sheets. During an interview at that time, the resident indicated his right leg had been that way the last couple of days, it gets worse then it gets better. He indicated there was no treatment being done at the present time. On 6/26/25 at 2:20 p.m., RN 1 was in the resident's room. At that time, there was a bandage that was falling off the resident's right lower leg. The bed sheets were bloody. During an interview at that time, RN 1 indicated the Unit Manager just got a new treatment for his leg as she was made aware of it that day. The record for Resident C was reviewed on 6/25/25 9:23 a.m. Diagnoses included, but were not limited to, COPD, stroke, heart failure, atrial fibrillation, chronic venous hypertension with ulcer of right lower extremity and high blood pressure. The 3/26/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making and needed assistance with personal hygiene. The resident had no rashes or open lesions and had an application of ointments other than to the feet. There was no care plan for skin impairment. There were no current Physician Orders for a treatment to the right lower leg. A treatment, dated 6/3/25 and discontinued on 6/17/25, indicated clean right anterior lower leg with wound cleanser, pat dry, apply Xerofoam gauze to wound and wrap with rolled gauze three times a week and as needed. A Nurse Practitioner (NP) Wound Note, dated 6/2/25, indicated the resident had a venous stasis ulcer to the right anterior lower leg that measured 13 centimeters (cm) in length, by 6 cm in width with a scant amount of drainage. A NP Wound Note, dated 6/16/25, indicated the stasis ulcer was resolved. A Weekly Skin Review assessment, dated 6/21/25, indicated there was redness that continued to bilateral lower extremities. The areas were monitored and treated as ordered. During an interview on 6/26/25 at 2:25 p.m., the Unit Manager indicated she was just made aware of the open area this morning and notified the NP, who gave new orders for treatment. During an interview on 6/26/25 at 3:20 p.m., the Director of Nursing had no additional information to provide. 6. During an interview on 6/23/25 at 3:04 p.m., Resident H indicated he was getting emails from his specialists that he had been missing appointments and tests they had ordered. The record for Resident H was reviewed on 6/24/25 at 2:59 p.m. Diagnoses included, but were not limited to, heart failure and chronic obstructive pulmonary disease (COPD). The 3/20/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making, and required supervision with activities of daily living (ADLs) and transfers. A 5/2/25 Physician's Order from the resident's nephrologist (kidney doctor) indicated to log the resident's blood pressures for one week and fax them to the doctor's office. The record lacked evidence of a blood pressure log being sent to the doctor. A 5/8/25 Physician's Order from the resident's oncologist (cancer doctor) indicated, . CBC, CMP, Vit B12, Folate, Lactate dehydrogenase, Ferritin, Hepatic Panel, Periph [peripheral] smear pathology review [lab work]. Labs are scheduled at Main Hospital 6-4-25 at 11 a.m . The record lacked evidence of the lab work being completed. A 6/1/25 Physician's Order indicated midodrine HCl (a medication to treat low blood pressure) every 8 hours, hold if systolic (top number in a blood pressure reading) blood pressure was above 125. The June 2025 Medication Administration Record (MAR) indicated: a. The following scheduled midodrine doses were blank on the MAR: 6/5/25 and 6/15/25 at 10:00 p.m., 6/11/25, 6/12/25, 6/13/25, 6/14/25, 6/15/25, 6/16/25, 6/18/25, and 6/19/25 at 6:00 a.m b. The following scheduled midodrine doses were held, but no blood pressure was documented: 6/3/25 2:00 p.m. and 10:00 p.m., 6/11/25 2:00 p.m., 6/22/25 6:00 a.m., and 6/23/25 2:00 p.m. c. The following midodrine doses were administered despite a systolic blood pressure over 125: 6/7/25 at 2:00 p.m.- blood pressure 127/69, 6/7/25 at 10:00 p.m.- blood pressure 126/76, and 6/17/25 at 10:00 p.m.- blood pressure 130/87. The Care Plan, last revised on 4/7/25, indicated the resident had high cholesterol, coronary artery disease, and difficulty breathing. Interventions included administering medications as ordered, documenting and reporting vital signs as ordered, and obtaining/reporting lab work as ordered. During an interview on 6/26/25 11:35 a.m., the DON was informed of the findings and indicated she had no additional information or documentation to provide. This citation relates to complaints IN00460458 and IN00460504. 3.1-37

Based on observation, record review and interview, the facility failed to ensure proper medication storage related to pre-filled saline syringes used to flush PICC (peripherally inserted central catheter) lines not stored securely, an expired insulin vial, and an expired emergency drug kit (EDK) box for 1 of 1 resident observed during medication pass, 1 of 3 medication carts observed and 1 of 2 medication rooms observed. (Resident 109, a Rainbow Unit medication cart and the Memory Unit medication room) Findings include: 1. During medication pass on [DATE] at 7:53 a.m., RN 3 was observed preparing to administer an Intravenous (IV) antibiotic medication through Resident 109's PICC line. The RN entered the resident's room with the IV antibiotic and two 10 cubic centimeters (cc) normal saline pre-filled syringes. She flushed the resident's PICC line with one of the pre-filled normal saline syringes, connected the IV antibiotic and turned on the pump. She told the resident she would be back in 30 minutes to disconnect the IV. At that time, the RN walked out of the room, leaving the other pre-filled normal saline syringe on the resident's over bed table. During an interview on [DATE] at 2:32 p.m., RN 3 indicated she was unaware she should not have left the saline syringe on the over bed table in the resident's room. 2. On [DATE] at 9:10 a.m., RN 2 was observed in the Memory Unit medication room. At that time, inside the locked refrigerator there was an EDK box with an expiration date of 5/25. During an interview at that time, RN 2 indicated the pharmacy comes to the facility weekly and checked the medication room. During an interview on [DATE] at 11:30 a.m., the Director of Nursing indicated pharmacy was supposed to be checking the EDK box in the refrigerator every Thursday during their visit. 3. On [DATE] at 9:23 a.m., LPN 1 was observed by a Rainbow Unit medication cart. At that time, there was one multi-vial of Lispro Insulin with an open date of [DATE] and an expiration date of [DATE]. During an interview on [DATE] at 11:30 a.m., the Director of Nursing (DON) indicated the open vial of insulin should have been discarded after it had expired. The current 2025 Medication Storage policy, provided by the DON indicated all drugs and biologicals will be stored in a locked compartment, cabinet, drawer or refrigerator. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication cart. 3.1-25(m) 3.1-25(o)

Based on observation, record review, and interview, the facility failed to ensure oxygen was set at the correct flow rate for 1 of 3 residents reviewed for respiratory care. (Resident F) Finding includes: On 6/24/25 at 10:15 a.m. and 3:00 p.m., Resident F was observed in his room seated on the side of his bed. The resident had oxygen in use by the way of a nasal cannula. The resident's oxygen concentrator was set at 3 1/2 liters. On 6/25/25 at 9:10 a.m., the resident was again observed in his room with oxygen per nasal cannula in use. The oxygen concentrator was set at 3 1/2 liters. The record for Resident F was reviewed on 6/26/25 at 11:42 a.m. Diagnoses included, but were not limited to, acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), and dyspnea (difficulty breathing). The Quarterly Minimum Data Set (MDS) assessment, dated 5/29/25, indicated the resident was cognitively intact for daily decision making. A Care Plan, dated 2/22/25, indicated the resident had oxygen therapy related to COPD and ineffective gas exchange. Interventions included, but were not limited to, oxygen via nasal cannula at two liters continuously. A Physician's Order, dated 2/23/25 and listed as current on the June 2025 Physician's Order Summary (POS), indicated the resident was to receive 2 liters of oxygen per minute continuously via nasal cannula. During an interview on 6/26/25 at 3:20 p.m., the Director of Nursing indicated the resident's oxygen concentrator should have been set at 2 liters. 3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure food consumption logs were completed for residents with a history of weight loss for 1 of 1 resident reviewed for nutrition. (Resident 107) Finding includes: The record for Resident 107 was reviewed on 6/24/25 at 3:50 p.m. Diagnoses included, but were not limited to, pneumonitis due to inhalation of food and vomit, dementia, Huntington's disease, Parkinson's disease, bipolar disorder, chronic kidney disease, high blood pressure, depression, and dysphagia (difficulty swallowing). The 5/7/25 Annual Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making, needed supervision with eating and weighed 171 pounds with no current weight loss. A Physician's Order, dated 6/19/25, indicated a regular mechanical soft/easy chew regular thin liquid diet. The recorded weights were: 4/2/25 180 pounds 4/14/25 169 pounds 4/20/25 169 pounds 4/22/25 171 pounds 4/27/25 171 pounds 5/5/25 171 pounds 6/2/25 173 pounds 6/22/25 175 pounds The resident was admitted to the hospital on [DATE] and returned to the facility on 4/12/25. A Registered Dietitian (RD) assessment, dated 4/17/25, indicated the resident's weight was 169 pounds which was a significant weight loss greater than 5% in the last 30 days, a loss of 5.6% related to recent hospitalization. The food consumption logs in the CNA task section indicated there was no documentation of all three meals on the following dates and times: breakfast: 4/14, 4/23, 5/4 5/30, 6/4, 6/17, 6/18, 6/19, and 6/22/25 lunch: 4/2, 4/14, 4/21, 4/23, 5/4, 5/12, 5/21, 5/26, 5/30, 6/4, 6/5, 6/17, 6/18, 6/19, and 6/22/25 dinner: 4/13, 4/14, 4/16, 4/19, 4/21, 4/28, 4/29, 5/9, 5/16, 5/18, 5/31, 6/5, 6/8, 6/12, and 6/16/25 During an interview on 6/27/25 at 9:00 a.m. the Director of Nursing indicated food consumption logs were to be completed after every meal. 3.1-46(a)(1)

Based on observation, record review, and interview, the facility failed to ensure residents had physician's orders for medications and an assessment to self-administer their own medications for 2 of 2 residents reviewed for self-administration of medication. (Residents B and H) Findings include: 1. During random observations on 6/23/25 at 3:07 p.m. and 6/25/25 at 8:41 p.m., a bottle of carboxymethylcellulose sodium ophthalmic solution (an eye lubricant) eye drops and a Ventolin HFA (an inhaled breathing medication) inhaler were observed on Resident H's bedside table. During an interview on 6/25/25 at 8:41 a.m., the resident indicated he self-administered the eye drops and inhaler when he needed them. The resident's record was reviewed on 6/24/25 at 2:59 p.m. Diagnoses included, but were not limited to, heart failure and chronic obstructive pulmonary disease (COPD). The 3/20/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making, and required supervision with activities of daily living (ADLs) and transfers. A Physician's Order, dated 10/2/24, indicated carboxymethylcellulose sodium ophthalmic solution 0.5 %, 1 drop in both eyes every 12 hours as needed for dry eyes. A Physician's Order, dated 11/7/24, indicated Ventolin HFA, 2 puffs inhaled orally, every 4 hours as needed for shortness of breath. There was no physician's order or assessment for self-administration. During an interview on 6/25/25 at 2:40 p.m., LPN 3 indicated there should be a self-administration assessment and an order for a resident to keep medications at their bedside, but she did not see either for Resident H. 2. On 6/25/25 at 11:54 a.m., three sealed lidocaine patches (topical pain medication patch) were observed on Resident B's bedside table. At that time, the resident indicated staff left the patches for him to put on himself. He indicated he usually applied them, unless he wanted to use one in a place he could not reach. On 6/25/25 at 12:27 p.m., Resident B was observed opening a new lidocaine patch and applying it to his left knee. The resident's record was reviewed on 6/25/25 at 12:41 p.m. Diagnoses included, but were not limited to, encephalopathy (damaged brain function), dementia, and opioid abuse. The 6/6/25 Quarterly Minimum Data Set assessment indicated the resident had severe cognitive impairment, and required supervision with activities of daily living (ADLs) and transfers. A Physician's Order, dated 4/28/25, indicated lidocaine pain relief 4% patch, apply one time a day and remove per schedule. There was no order or assessment for self-administration. During an interview on 6/25/25 at 2:40 p.m., LPN 3 indicated Resident B liked to put his own lidocaine patches on, but there was no self-administration assessment or physician's order. During an interview on 6/25/25 at 3:26 p.m., the interim Director of Nursing Services indicated self-administration assessments and physicians' orders were required for a resident to keep medications at their bedside and the staff needed to be re-educated. A policy titled, Resident Self-Administration of Medication, received as current from the Director of Nursing on 6/26/25 at 12:22 p.m., indicated, . A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely . This citation relates to complaint IN00460504. 3.1-11(a)

Based on observation, record review, and interview, the facility failed to administer medications as ordered related to antibiotic therapy for 3 of 3 residents reviewed for Intravenous Therapy and failed to ensure wound treatments were completed and signed out as ordered for 1 of 3 residents reviewed for non-pressure related skin conditions. (Residents C, F and G) Findings include: 1. Resident C's record was reviewed on 5/19/25 at 9:38 a.m. The diagnoses included, but were not limited to, local infection of the skin and subcutaneous tissue unspecified, depression, hypertension (high blood pressure), kidney failure, asthma, and pain in unspecified hip. The Admission Minimum Data Set (MDS) assessment, dated 4/24/25, indicated Resident C was cognitively intact for daily decision making. Eating, oral hygiene, personal hygiene, and upper body dressing required set up or clean up assistance. Toileting required supervision or touching assistance. Shower and bathing required partial/moderate assistance, and lower body dressing and putting on footwear required substantial/maximum assistance. The resident had a surgical wound that was present on admission. A Nurse Note, dated 4/16/25 at 11:00 p.m., indicated communication was received regarding a new admission. Medication orders had been reviewed and verified and compared to discharge medication reconciliation. Antibiotic required an end date and rounding was notified. A Hospital Patient Summary Report, dated 4/1/25, indicated the resident had a recent history of a prosthetic antibiotic spacer implantation that became infected. The Hospital Discharge Report, dated 4/17/25, indicated 1 of 2 doses of Cefazolin was received. The last dose was administered on 4/17/25 at 3:15 p.m. and the next dose was due at bedtime. The Hospital Discharge Summary, dated 4/17/25, indicated the resident required 6 weeks of antibiotic therapy. A Care Plan, dated 4/17/25, indicated the resident had a surgical incision to the left hip. Interventions were to keep the incision site clean and dry, assess skin condition weekly, and to monitor for signs and symptoms of infection. A Nurses Note, dated 4/17/25 at 8 :35 p.m., indicated the resident arrived via private transportation service, the resident had pain to his left hip where there was a surgical incision on the left hip with a clean and dry dressing intact. The resident was on antibiotics and had a patent PICC line. A Physician's Order, dated 4/18/25 indicated to administer Cefazolin (antibiotic) 2 grams (GM) intravenously (IV) every 8 hours for infection of the left hip. A Medication Administration Note, dated 4/18/25 at 5:53 a.m., indicated Cefazolin intravenous solution 2 gm was not given due to waiting on delivery from pharmacy. The April 2025 Medication Administration Record (MAR) indicated Cefazolin was documented as view progress notes on 4/17/25 and was not signed out, on 4/18/25 the medication was marked as discontinued. The resident did not receive the 4/17/25 Cefazolin dose. There was no follow up documented with the surgeon or infectious disease physician to verify an antibiotic end date or course of treatment. An Advance Care Planning Note, dated 4/20/25 at 11:00 p.m., indicated the resident was at the facility for rehabilitation for a post infection of his prosthetic limb (sic) and was post antibiotics. A Physician's Order, dated 4/21/25 indicated to apply betadine swab sticks to left hip every day shift and cover with an island bordered gauze dressing. The April 2025 Treatment Administration Record (TAR) indicated the wound treatment for the left hip was not signed out on 4/25/25, 4/28/25, and 4/29/25. A Physician's Order, dated 4/29/25 indicated to discontinue PICC (Peripherally Inserted Central Catheter) line. During an interview on 5/19/25 at 10:00 a.m., the Director of Nursing (DON) indicated Resident C's discharge instructions indicated he had received 1 of 2 doses of Cefazolin. She indicated the Nurse Practitioner (NP) came in and discontinued the order and indicated the antibiotic was completed. She was not here on that day but when she returned, she questioned the order. The NP notes indicated they were completed, and they were following physician's orders. No other clarification was completed. During an interview on 5/19/25 at 11:14 a.m., the DON indicated the NP who discontinued the antibiotic was no longer with the facility. During a phone interview on 5/19/25 at 11:37 a.m., the NP indicated indicated she reviewed the record and the discharge instructions had indicated the antibiotic would be completed on 4/17/25. She indicated, as far as I knew he completed the antibiotic before I got there on the 18th. The infectious disease nurse had told her the resident was finished with antibiotics as well. She usually talked with the nursing staff to verify any medications because she did not have an active MAR available on her screen. During a phone interview on 5/19/25 at 1:51 p.m., Resident C's orthopedic surgeon indicated Resident C had been readmitted to the hospital for a small collection of fluid at the infection site (left hip) and for worsening back pain. The resident was failing treatment due to the lack of antibiotics. The resident had a known infected total hip and he had completed two surgeries on the resident. The resident had a big abscess and osteomyelitis of the spine. The resident should have been treated with at least 4-6 weeks of antibiotic treatment outpatient; one dose of the medication would not even make sense. There was no follow up with my office. He indicated this was not the resident's first hip surgery and the resident knew he needed antibiotics, and he indicated that he asked the staff frequently why he wasn't receiving any. He indicated he looked over the discharge paperwork in the system and the instructions for continued antibiotics were correct at that time. The resident had capacity, and this should have been followed up with regardless if there was a communication deficit in the paperwork. During an interview on 5/19/25 at 4:10 p.m., the Infection Prevention (IP) nurse indicated there were no active signs of infection and the resident had never mentioned he should have been on antibiotics, the resident was very talkative, and he had been at the facility before, he was comfortable here. The paperwork indicated the Cefazolin antibiotic stop date was 4/17/25. She did not recall a conversation with the NP regarding this resident. There was no warmth or redness at the site. During an interview on 5/20/25 at 12:01 p.m., the DON and the Administrator indicated they understood the concerns about the wound treatment and medication not being given as ordered and had no additional information to provide. 2. Resident F's record was reviewed on 5/20/25 at 10:48 a.m. The diagnoses included, but were not limited to, chronic non-pressure ulcer of the left foot, major depression, insomnia, osteomyelitis (infection of bone and muscle) and high blood pressure. The Admission Minimum Data Set (MDS) assessment, dated 4/29/25, indicated the resident was cognitively intact for daily decision making and the resident received IV therapy. A Care Plan, dated 4/23/25, indicated the resident had an infection related to a wound. Interventions were to administer antibiotics and treatment as ordered. A Physician's Order dated 4/23/25 indicated to administer Cefazolin (antibiotic) 2 grams (GM) intravenously (IV) every 8 hours for wound infection until 5/5/25. The April 2025 Medication Administration Record (MAR) indicated Cefazolin was not signed out on the following dates: 4/24/25 at 10:00 p.m. 4/25/25 at 2:00 p.m. 4/28/25 at 10:00 p.m. 4/30/25 at 6:00 a.m. During an interview on 5/20/25 at 1:15 p.m., the DON indicated she could not find any documentation indicating why the Cefazolin antibiotics were not given. 3. Resident G's record was reviewed on 5/20/25 at 12:11 p.m. The diagnoses included, but were not limited to, osteomyelitis (bone and muscle infection), stroke, heart disease, and hypertension (high blood pressure). A Care Plan, dated 5/13/25, indicated the resident had an infection. Interventions were to administer antibiotics per physician orders, monitor temperature, and maintain universal precautions when providing care. A Baseline Care Plan, dated 5/15/25, indicated the resident was cognitively intact. A Physician's Order, dated 5/14/25, indicated to administer Ampicillin-Sulbactam (antibiotic) 3 grams (GM) intravenously (IV) every 8 hours for osteomyelitis to the left foot until 6/18/25. The May 2025 Medication Administration Record (MAR) indicated Ampicillin-Sulbactam was not signed out on the following dates: 5/15/25 at 6:00 a.m. and 10:00 p.m. 5/16/25 at 6:00 a.m. 5/18/25 at 10:00 p.m. During an interview on 5/20/25 at 2:00 p.m., the DON indicated she could not find any documentation indicating why the Ampicillin antibiotics were not given. This citation relates to Complaint IN00458815. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure activities of daily living (ADLs) were completed for a dependent resident related to incontinence care and providing assistance in getting out of bed in a timely manner for 1 of 3 residents reviewed for ADLs. (Resident D) Finding includes: On 5/19/25 at 8:50 a.m., Resident D was observed lying in her bed with her breakfast covered and sitting on her bedside table. The resident indicated she had not been able to eat breakfast yet because she was told wound care was supposed to come see her next and that was 40 minutes ago. She liked to get up and out of bed to eat and they told her they would get her up after her wound treatment. The resident also indicated a nurse's aide had put her diaper on wrong during the night and that's why I peed the bed all night long, so now I'm stuck sitting in this puddle. The resident lifted the blanket to the side and lifted her body up to reveal a large wet spot in the middle of her bed that covered the middle half of the bed. The resident's brief was dry and had been changed that morning. On 5/19/25 at 8:59 a.m., CNA 1 was observed asking a nurse if the resident could get up and eat. She wanted to get out of bed to eat but was waiting on wound care. The nurse indicated the resident could be up. CNA 1 did not re-enter resident D's room, she gowned up and went into another resident's room to provide care. During an interview on 5/19/25 at 9:04 a.m., CNA 1 indicated she knew the resident's bed was soiled and she had changed the resident's brief, but did not change the bed because the resident wanted to get out of bed to eat and she was going to be seen by wound care. She was going to change her bed at that time. Resident D's record was reviewed on 5/20/25 at 9:31 a.m. The diagnoses included, but were not limited to, kidney failure, ileostomy status, weakness, and history of falling. A Care Plan, dated 4/18/25, indicated the resident had an ADL self-care performance deficit related to weakness and difficulty in walking. Interventions were to provide AM preferred routine of dressing and grooming before breakfast and assist with toilet and transfer. The Admission Minimum Data Set (MDS) assessment, dated 4/24/25, indicated the resident was cognitively intact for daily decision making. Eating and oral hygiene required set up and clean up assistance. The resident required substantial/maximum assistance for toileting and shower/bathing. The resident required dependent care with lower body dressing and the resident was frequently incontinent. During an interview on 5/19/25 at 9:14 a.m., the Administrator indicated she understood the concern and would re-educate CNA 1 immediately. This citation relates to Complaint IN00456969. 3.1-38(a)(2)(B) 3.1-38(a)(2)(C)

Based on record review and interview, the facility failed to ensure a resident's safety after an exit alarm sounded for 1 of 1 resident reviewed for accidents. (Resident C) The deficient practice was corrected on 10/4/24, prior to the start of the survey, and was therefore past noncompliance. The facility completed an investigation and inserviced staff and families regarding elopement and alarm procedures. Finding includes: The record for Resident C was reviewed on 10/24/24 at 11:23 a.m. Diagnoses included, but were not limited to, sleep disorder, weakness, fall, dementia with anxiety, major depressive disorder, and fracture of the neck of the left femur. The 7/15/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making. She had no behaviors and no episodes of wandering. The resident utilized a walker for ambulation. The Elopement Risk Evaluation, dated 7/14/24, indicated the resident was not at risk to elope at the time, placement on the elopement risk protocol was not indicated. The resident had no Care Plan related to wandering based on the Quarterly MDS and elopement risk assessment. An Indiana Department of Health (IDOH) reported incident, dated 10/3/24 at 11:15 p.m., indicated Resident exited the building by entering door code to release door and exiting building. Resident noted to have an unwitnessed fall off property. 911 notified and resident transferred to ER for evaluation and treatment. Resident returned to facility. The resident sustained abrasions to the left side of her face and to her finger. A Nurse's Note, dated 10/4/24 at 1:14 a.m., indicated the resident returned to the facility from the hospital accompanied by her daughter. The resident was alert and oriented to self, place, and situation. The resident was noted with an abrasion to the left side of her face. The resident was able to transfer herself and ambulate with the use of a rolling walker. The Interdisciplinary Team (IDT) Note, dated 10/4/24 at 1:24 p.m., indicated the team met to review last night's event in which the resident was noted to have exited the facility. The IDT found in the late evening, the resident entered the code to exit the facility using the ambulance bay exit door. The resident had her shoes and coat on, her laundry basket, and money for her hair cut that upcoming weekend with her. Upon her return, the resident appeared calm, and she indicated that she used the code and was wanting to walk to her daughter's home. The resident's daughter indicated she had the resident exit the facility using the ambulance bay on the weekends using the code. The daughter stated the code out loud in front of the resident. The resident nodded her head in agreement. A Social Service Progress Note, dated 10/4/24 at 2:24 p.m., indicated a meeting was held with the resident's daughter. The resident's daughter reported that her mother often waited for her by the door to take her out on pass. The daughter indicated her mother knew how to enter the code and exit the door. The resident's daughter reported she was not sure why her mother would have left the facility unattended. She indicated her mother did call her earlier on Wednesday afternoon asking her to come and get her. The resident's daughter reported her mother was frustrated that her mother-in-law was living at home with her. The daughter was educated on the sign in and out procedures when taking her mother out on pass. The daughter was escorted to the nurses' station and shown the procedure and expressed understanding. Review of the facility investigation, initiated on 10/4/24, indicated the resident was seen by CNA 1 at approximately 10:00 p.m. - 10:15 p.m. The resident was provided a brief and assisted to the toilet as that was her routine. The resident had her shoes and clothing on but that was normal for the resident. Nothing seemed unusual with her. RN 1's statement indicated, between 10:45 p.m. and 11:00 p.m., he responded to the ambulance bay door alarm. Earlier in the shift, he believed that an ambulance had come into the facility. A CNA responded to the door alarm around 8:00-9:00 p.m. and the ambulance staff reported they were there for a resident on the Gardens Unit. He believed the door was being used by the ambulance staff again to return a resident and he did not have a reason to believe that a resident had exited, as he looked out into the bay area and did not see anyone in the yard. During an interview on 10/24/24 at 2:15 p.m., the Interim Director of Nursing (DON) indicated the resident, upon her return, had indicated she was going to her daughter's house. Follow up interview with the Interim DON at 2:34 p.m., indicated the last time somebody laid eyes on the resident was between 10:00 p.m. and 10:15 p.m. A late hospital return arrived at the facility and staff thought the alarm was possibly related to that. Only the ambulance bay area was checked, and no residents were observed. The Interim DON indicated staff responded to the alarm, but a resident head count was not completed, and it should have been. Multiple inservices had been held and changes were being implemented with the exit doors. Families were informed residents would need to be signed out for leave and the door codes were not to be shared. The current facility policy titled, Elopements and Wandering Residents indicated the facility was equipped with door locks/alarms to help avoid elopements, alarms were not a replacement for necessary supervision and staff were to be vigilant in responding to alarms in a timely manner, and the facility shall establish and utilize a systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk evaluation and analysis of hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure continuity of care was provided after a resident was discharged home with orders for intravenous (IV) antibiotic medications and the care of a PICC (a peripherally inserted central catheter) line for continued treatment for a bone infection for 1 of 3 residents reviewed for discharge. (Resident C) Finding includes: The closed record for Resident C was reviewed on 6/17/24 at 2:05 p.m. The resident was admitted to the facility on [DATE] and discharged to home on 5/30/24. Diagnoses included, but were not limited to, osteomyelitis (bone infection) of the left ankle and foot, type 2 diabetes, abscess of the left lower limb, heart disease, acute kidney failure, high blood pressure, and obesity. The Admission Minimum Data Set (MDS) assessment, dated 5/14/24, indicated the resident was cognitively intact for daily decision making. A Nurses' Note, dated 5/7/24 at 6:40 p.m., indicated the resident was admitted to the facility from the hospital. He recently had surgery for an incision and drainage of the left foot and ankle, and was on IV antibiotic therapy for 6 weeks. The resident had a single lumen PICC line to the right upper extremity. Physician's Orders, dated 5/7/24, indicated IV-PICC change transparent dressing on admission, then weekly and prn thereafter every night shift on Sunday. Give Piperacillin Sod-Tazobactam (an antibiotic medication) Intravenous solution reconstituted 4.5 (4-0.5) grams (gm). Use 4.5 gram intravenously every 8 hours for osteomyelitis until 6/9/24. The Medication Administration Record for 5/2024 indicated the transparent dressing for the PICC line was last completed on 5/26/24. The Piperacillin was scheduled to be administered at 6:00 a.m., 2:00 p.m., and 8:00 p.m. The last dose administered to the resident was on 5/30/24 at 2:00 p.m., before he was discharged home. A Discharge Summary, dated 5/28/24, indicated the resident was to be discharged to home and was living with his parents. The resident had a wound that was in need of daily skin treatments. The resident would be going home with the PICC line to continue IV antibiotic therapy until 6/9/24. The resident wanted to leave the nursing facility and return home to finish up the IV antibiotics, and also wanted a new home health agency, as he was not happy with his previous one. A new (incorrect) home health agency was listed with a telephone number as well as follow up physician appointments. A Nurses' Note, dated 5/30/24 at 3:42 p.m., identified as a late entry with unknown date, indicated the resident finished therapy and was able to be discharged home. The resident left the facility with his mother and was given the transfer discharge order, bed hold policy, and medication list. An IDT (Interdisciplinary Team) Note, dated 5/31/24 at 12:01 p.m. and documented as a late entry on 6/1/24, indicated Writer went to talk with resident regarding discharge planning and resident was informed that Writer would call previous home care agency and to resume services with the intent of continuing IV treatment at home per request of resident. Writer called [name of home health agency] this day and confirmed referral sent and confirmed resuming IV treatment to resume at home with services. Writer called pharmacy [name] stated they contracted with and Writer confirmed that [pharmacy name] is contracted with [home health agency name] and would continue IV treatment. Resident and family aware. Resident was also given phone contacts to each agency if there were any questions or concerns. Resident did not state any further concerns with the facility or discharge. An IDT Note, dated 6/4/24 at 3:11 p.m., indicated followed up with home health agency and spoke with their Director of Nursing regarding the post discharge follow up on 5/30/24. The home health agency confirmed they would be able to help with the IV medication. On 5/30/24 the home health pharmacy was notified regarding the IV antibiotics for the resident. The pharmacy indicated they needed a flush order and a line report to complete the referral. Both were faxed over to the pharmacy by the end of the day on 5/30/24. A confirmation was not received from either the home health agency or the home health pharmacy. A follow up phone call was made on 6/4/24 to the pharmacy home health agency and they informed the facility they did not receive any of the information that was requested and did not communicate any further information. On day of discharge, the resident and his parents were provided phone numbers for the home health agencies and the pharmacy home health. Both IDT notes were written and documented by the facility's Social Worker (SW). The resident was discharged home on 5/30/24. The discharge instructions, dated 5/28/24, did not have the current home health agency or the pharmacy home health agency contact names or phone numbers. There were 2 fax cover sheets, both dated 5/30/34, one with the home health agency contact and telephone number and one for the pharmacy home health agency. The SW had checked urgent on the cover sheets and also checked please reply back. There was no follow up by the SW with either the pharmacy or home health agency the next day on 5/31/24, to confirm the resident would be able to receive the IV antibiotics at home every 8 hours and for the care of PICC line. During an interview on 6/17/24 at 3:06 p.m., the SW indicated the resident told her the first week he was at the facility that he did not want to be there, but each time she had talked him into staying to complete the IV antibiotic therapy. He also told her he would like a new home health agency because the one he had used before had many problems. She was informed on 5/28/24 that the physician gave the ok to discharge the resident to home and to continue the IV antibiotics there. She reached out to several home health agencies for a referral, however, none of them would take his commercial insurance, so she ended having to go back to his previous home health agency. She phoned the home health agency and was given a verbal consent they would be able to provide the IV antibiotics, pump and take care of the PICC line. She also faxed all of the information to both the home health and the pharmacy home health agencies. The pharmacy replied back to her and indicated they needed an order for the flushes and a line report for the PICC line. The SW indicated she faxed all of that information back to them, but did not hear anything from either agency. She did not follow up with either home health agency on 5/31/24, which was a Friday, before the weekend. The Administrator called her on Saturday 6/1/24 and wanted some information about the discharge because the resident did not have the antibiotics. The discharge instructions were not updated and had a different home health agency listed with contact names and numbers. The SW indicated she had given the resident a post-it note with the phone numbers of both agencies. She came back to work after the weekend and on 6/3/24, there was no report from the home health agencies. On 6/4/24 she called both agencies to see why the IV antibiotics had not been started. During an interview on 6/17/24 at 3:10 p.m., the Administrator indicated she was notified by the on call manager on Saturday 6/1/24 the resident had called in and indicated he did not have his antibiotics yet. She called the SW right away to get the resident's history. She indicated she told the on call manager to call him back and tell him to go the emergency room (ER) for treatment. During an interview on 6/17/24 at 3:25 p.m., the MDS Coordinator indicated she was the manager on duty on 6/1/24. The resident had called the facility and informed her he had not received his IV antibiotics. She notified the on call nursing supervisor and also notified the administrator. The administrator called back and told her to call the resident back and tell him to go to the ER, so she did. The resident was very mad and upset and asked if the facility was going to pay for his ER bill once he was treated. This citation relates to Complaint IN00436047. 3.1-12(a)(3)

Based on observation, record review and interview, the facility failed to ensure all covered individuals (anyone who was an owner, operator, employee, manager, agent, or contractor of the facility) was notified annually of their obligation and requirement to comply with the reporting of reasonable suspicion of crimes against a resident, related to an allegation of sexual abuse for 1 of 2 residents reviewed for abuse. (Resident B) Finding includes: During an observation on 6/17/24 at 9:40 a.m., Resident B was observed in bed and awake. At that time, she was able to confirm she was going home soon and no longer need hemodialysis. During an interview at the time, the resident indicated that she did not remember any male nurse forcing her to take her medications or asking her for sexual favors. The resident indicated she remembered on one night, the room was very dark, and a male came into her room and that scared her. She did not know who he was, but the room was so dark, it had just startled her. The record for Resident B was reviewed on 6/17/24 at 11:20 a.m. The resident was admitted to the facility on [DATE] and was on hemodialysis. Diagnoses included, but were not limited to, stroke, cardiac arrest, respiratory failure, atrial fibrillation, anemia, end stage renal disease, anoxic brain damage, alcohol abuse, cocaine abuse, heart failure, high blood pressure, and altered mental status. The Admission Minimum Data Set (MDS) assessment, dated 5/19/24, indicated the resident was not cognitively intact for daily decision making and was dependent on staff for toileting and transfers in and out of bed. The 5 day Medicare MDS assessment, dated 6/1/24, indicated the resident was not cognitively intact for daily decision making. A Care Plan, dated 5/22/24, indicated the resident had impaired cognition and dementia related to a stroke. The approaches were to explain all procedures and reason before performing them. A Nurses' Note, dated 5/27/24 at 2:05 p.m., indicated the resident had arrived back to the facility from the hospital where she was treated for an urinary tract infection with Vancomycin-Resistant Enterococci (an organism that was resistant to powerful antibiotics). A Nurses' Note, dated 5/27/24 at 9:53 p.m., indicated the resident refused to take her medications and sent the nurse away. The nurse explained the importance of taking the medications, but the resident declined. A Nurses's Note, dated 5/28/24 at 12:19 a.m., indicated the resident refused a bolus enteral feeding through the peg tube. The nurse explained the importance of taking the feeding, but the resident declined. A Pre/Post Dialysis Evaluation, dated 5/28/24 at 6:31 a.m., indicated the resident was chronically confused. A Nurses' Note, dated 5/29/24 at 7:54 p.m., indicated the resident refused the enteral feedings through the peg tube. The resident continued to state she doesn't like the nurse (this writer). The 5/2024 Medication Administration Record indicated the resident had refused all of her 8:00 p.m. medications on 5/27/24 and the 6:00 a.m. medications on 5/28/24. A Hemodialysis Patient Note, dated 5/28/24 at 11:10 a.m., indicated Pt [patient] came in to facility talking and asked another pt to use her phone to call her daughter. Pt was alert and was speaking on phone. When pt came back to treatment floor pt stated she was not feeling well and that she was sick, at this time patient was refusing to get into the treatment chair. She seemed scared, anxious, and was very tearful. Vitals were stable 124/90 Heart Rate 77 Pulse Ox 99%. Writer accessed [sic] pt, lungs diminished with edema to the abdomen. Pt feeding tube has yellow tint to it, and pt had a Hoyer lift under her but it was completely tangled and criss crossed. Writer called [doctor name] to please come and access [sic] the patient In the meantime, pt reported to a teammate that last night a male nurse stood over her and was trying to force her to take medicine. The patient states she refused the medication and that she felt as if the RN was trying to give her medication so he can do 'something' to her. Pt states the male nurse said to her 'take your clothes off and bend over so I can get in that bootyhole' pt states she refused and states RN then said 'then take your clothes off and spread your legs' pt states she refused again and told the RN that she is 'not allowed to do that.' Pt states she stayed up all night trying to make sure the RN did not come back. During a phone interview on 6/17/24 at 9:52 a.m., the Dialysis Nurse indicated she was the charge nurse the day the resident made the allegation of sexual abuse. She reported the incident to the Dialysis Facility Administrator at the dialysis center. The Social Worker (SW) and the patient's daughter were also notified. The Dialysis Nurse indicated she did not notify the long term care facility where the resident resided, but the Dialysis Administrator tried contacting them. During a phone interview on 6/17/24 at 10:08 a.m., the Dialysis Facility Administrator indicated she was made aware of the situation on the day the allegation was made. She notified the SW who then notified APS (Adult Protective Service). She tried calling the nursing home for 3 days in a row on 5/28, 5/29 and 5/30/24, and was told the Director of Nursing (DON) was not available. On 5/28/24 at 11:48 a.m., she spoke with someone, asked for the DON, and they told her she was not available. She called again at 12:38 p.m. and was directed to the DON's voicemail, which was full so she was not able to leave a message. She tried calling on 5/29 and 5/30/24, each time asking for the DON and was directed to voicemail where the mail box remained full, so therefore, she was not able to leave a message. The SW tried calling the nursing home several times and was not able to leave a message because the DON's mailbox was full. The Dialysis Administrator indicated in circumstances like these, she has always notified the DON, she would never speak to the patient's nurse as that was not appropriate because that nurse could have been the perpetrator. She had never received any information on how to report the incident to the facility and only learned of the DON's name the first day she called the facility. The local police were not notified of the allegation of sexual abuse. During an interview on 6/17/24 at 10:45 a.m., the administrator was informed of the allegation of sexual abuse. She was not aware of the allegation and indicated she would start an investigation right away. At 11:10 a.m., the administrator indicated there was a male nurse who worked on 5/27 and 5/28/24 on the resident's unit. The nurse was notified they were suspended pending an investigation. The 5/27 and 5/28/24 nurses' notes were documented by the male RN who worked with the resident those nights. The Administrator indicated no one from the dialysis center had notified her of any allegation of abuse. During an interview on 6/17/24 at 1:01 p.m., the [NAME] President of Operations indicated there have been no annual letters sent to covered individuals regarding their obligation and the facility's protocol for reporting a suspicious crime. This citation relates to Complaints IN00435794 and IN00435885. 3.1-28(c)

Based on observation and interview, the facility failed to prepare a pureed (blended smooth) diet designed to meet the needs of the residents. This had the potential to affect 10 of 10 residents who received a pureed diet. Finding includes: On 4/17/24 at 11:12 a.m., Cook 1 was observed preparing a pureed cabbage braised recipe. Cook 1 added 10 scoops of cabbage to the mixer and turned on the mix cycle. Cook 1 then added 2 cups of sauerkraut juice. The mixer was turned back on and stirred. The mixture was observed to be watery and Cook 1 added a tablespoon of thickener. The mixer was turned back on and then stirred to review consistency. Cook 1 then added another tablespoon of thickener and turned on the mixer. A total of 7 tablespoons of thickener were added to the recipe. Once the mixture was completed, the pureed meal was appropriate consistency and was free of lumps or chunks. During an interview on 4/17/24 at 11:25 a.m., Cook 1 indicated the cabbage was too watery and she had to add more thickener. During an interview on 4/17/24 at 11:29 a.m., Cook 1 indicated the recipe would not make 10 servings and she would have to make more. During an interview on 4/17/24 at 12:00 p.m., the Director of Nursing (DON) indicated the dietary recipe should have been followed. A recipe titled; Pureed Cabbage Braised was provided by the Dietary Manager on 4/17/24 at 11:10 a.m. This current recipe indicated, . Add water if product needs thinning . 3.1-21 )(a)(3)

Based on observation and interview, the facility failed to ensure palatable and attractive food was served for 1 of 2 meals observed and for 2 of 3 residents reviewed for food. (The breakfast meal, Residents 34 and 41) Findings include: 1. During the Resident Council interview on 4/16/24 at 1:57 p.m., 10 residents were in attendance. Over half of the residents in attendance indicated breakfast was not good that morning. They indicated the bacon looked raw and the eggs were discolored. One resident indicated her bacon was raw on one end and burnt on the other. Several of the residents indicated the fried eggs looked green and they didn't want to eat them. One resident stated, the eggs looked like the Dr. Seuss book Green Eggs and Ham. Some of the residents also indicated the sausage patties served for the breakfast meal on 4/14/24 were hard like hockey pucks. During an interview on 4/16/24 at 2:30 p.m., the Administrator indicated the facility had a new Dietary Food Manager and the Resident Council concerns would be addressed. 10770 2. During an interview on 4/14/24 at 9:41 a.m., Resident 34 indicated the food was horrible and overcooked. During an interview on 4/15/24 at 1:30 p.m., the resident indicated the chicken served for lunch was tough and she did not eat. During a random observation on 4/16/24 at 7:30 a.m., the resident was observed in bed and her breakfast tray was on the over bed table with the dome lid on top of it. The lid was removed and an overcooked fried egg (crisp all around the edges) and an under cooked piece of bacon was observed. The resident indicated at that time, the bacon looked raw and she was not eating the overcooked egg. During an interview on 4/17/24 at 1:30 p.m., the resident indicated she had enjoyed the lunch meal, however, she did not eat any of her breakfast because it looked disgusting. 3. During a random observation on 4/16/24 at 10:00 a.m., a resident's breakfast tray was observed on an over bed table. The fried egg was green and light gray in color, there was 1 piece of bacon that was burned and the other piece was looked like it was raw. At 10:10 a.m., the Dietary Food Manager (DFM) was asked to observe the breakfast meal that had been served to a resident. During an interview on 4/16/24 at 10:20 a.m., the DFM indicated she was going to do an inservice on cooking and preparing breakfast food. 4. During an interview on 4/14/24 at 11:40 a.m., Resident 41 indicated the food was overcooked. He stated The sausage patties were so hard you could throw it at a wall and it would make a hole. During an interview on 4/18/24 at 10:00 a.m., the Administrator indicated the dietary staff were contracted and not employed by the facility. She indicated it was time for a change. 3.1-21(a)(2)

Based on observation and interview, the facility failed to ensure meals were served as scheduled for 2 of 2 meal observations. (The lunch meal) Findings include: 1. On 4/16/24 at 12:20 p.m., residents were observed seated at their tables in the main dining room. Staff started passing beverages to the residents at 12:35 p.m. and the first tray served to the residents was at 1:15 p.m. The residents were observed becoming impatient and wanting their food. On 4/17/24 at 1:01 p.m., a food cart was taken to the Memory Lane Unit from the kitchen. At 1:10 p.m., a second cart was sent to Memory Lane. At 1:11 p.m. on 4/17/24, the first tray in the main dining room was served. The posted meal times indicated Memory Lane was to be served lunch at 12:30 p.m. and the Main Dining Room at 1:00 p.m. During an interview on 4/18/24 at 10:00 a.m., the Administrator indicated the dietary staff was a contracted service for the facility and the meals should have been served on time. 2. During the Resident Council interview on 4/16/24 at 1:57 p.m., 10 residents were in attendance. The majority of the residents indicated they ate their meals in the main dining room. The residents in attendance indicated breakfast was served late on Sunday morning (4/14/24) and lunch was late today. They also indicated that dinner was sometimes served late on bingo night. 3.1-21(c)

Based on observation, record review, and interview, the facility failed to ensure a self-medication administration assessment was completed for residents with medications at the bedside for 2 of 2 random observations. (Residents 105 and 2) Findings include: 1. On 4/15/24 at 9:34 a.m., Resident 105 was observed sitting on the side of her bed. There was a medication cup that contained a small amount of medication solution on top of the bedside table. The record for Resident 105 was reviewed on 4/15/24 at 2:15 p.m. The diagnoses included, but were not limited to, depression, diabetes, traumatic amputation of left foot, hypertension (high blood pressure), and urinary tract infection. The Admission Minimum Data Set (MDS) assessment, dated 1/29/24, indicated the resident was cognitively intact for daily decision making. A Physicians' Order, dated 3/30/24, indicated to give 30 milliliters (ml) of ProT Gold (supplement) once a day. There was no self-medication administration assessment. There was no Physician order to self-administer medications. During an interview on 4/16/21 at 11:20 a.m., the Director of Nursing (DON) indicated she understood the medication should not have been left at the bedside and had no additional information to provide. 2. On 4/14/24 at 11:39 a.m., Resident 2 was observed sitting in her wheelchair eating a snack. There was a bottle of acetaminophen on top of the bedside table. On 4/15/24 at 9:48 a.m., Resident 2 was observed knitting in her wheelchair. There was a bottle of acetaminophen on the bedside table along with 2 tubes of pain-relieving cream. The record for Resident 2 was reviewed on 4/16/24 at 9:25 a.m. The diagnoses included, but were not limited to, heart failure, anxiety, depression, hypertension (high blood pressure), muscle weakness, and low back pain. The Quarterly Minimum Data Set (MDS) assessment, dated 3/28/24, indicated the resident was cognitively intact for daily decision making. A Physician's Order, dated 1/9/24 at 6:45 p.m., indicated to give Tylenol (Acetaminophen) 250 milligrams (mg) by mouth every 4 hours as needed for pain. There was no self-medication administration assessment. There was no Physician's Order to self-administer medications. There was no Physician's Order for topical pain cream. During an interview on 4/16/21 at 11:25 a.m., the Director of Nursing (DON) indicated she understood the medication should not have been left at the bedside and had no additional information to provide. 3.1-7(a)(2)

Based on observation, record review, and interview, the facility failed to provide the necessary treatment and services related to not assessing a residents complaints of discomfort and failure to offer as needed pain medication after a fall resulting in the resident having pain for 1 of 3 residents reviewed for falls in a sample of 3. (Resident #E)(LPN #1) Finding includes: During Orientation Tour on 11/24/15 at 9:00 a.m., Resident #E was observed in bed. An assist rail was up on the the right side of the bed. Non skid strips were in place on the floor next to the resident's bed. The record for Resident #E was reviewed on 11/24/15 at 9:15 a.m. The resident's [DIAGNOSES REDACTED]. Review of the 9/24/15 Minimum Data Set quarterly assessment indicated the resident's BIMS score was (15). A score of (15) indicated the resident's cognitive patterns were intact. The assessment indicated the resident did not display any behaviors or mood disorders. The assessment indicated the resident required extensive assistance of one staff member for bed mobility, transfers, dressing, and personal hygiene. The assessment indicated the resident had no falls since the prior assessment. A Post Fall Analysis/Plan report was reviewed. The report indicated Resident #E fell on [DATE] at 7:00 a.m. as she was attempting to self transfer and lost her balance. The report also indicated the resident was alert and orientated and had a BIMS score of (15). The Verification of Investigation form indicated the resident attempted to transfer unassisted and fell before staff were able to intervene. No injuries were noted, the resident was assessed and assisted off the floor. The 10/2015 Progress Notes were reviewed. A Change in Condition note was entered on 10/16/15 at 12:01 p.m. This entry indicated the resident was being assisted to the wheel chair from the bed when she lost her balance and fell . The resident landed on her left side. The resident had slight c/o pain to her left side. No bruising or injuries were noted. The resident was assisted back into the wheel chair. The next entry was made on 10/16/15 at 12:06 p.m. This entry indicated the resident's lungs were clear and her respirations were unlabored. This entry did not address the resident's left sided soreness. The next entry was made 10/16/15 at 7:00 p.m. This entry indicated the resident continued to complain of increased pain to the left hip throughout the day and pain was present upon palpitation and while at rest. PRN (as needed) [MEDICATION NAME] was given with only slight relief. The Physician was notified and orders were received to send the resident to the hospital. There was no documentation of the resident being asked to rate her discomfort using the numeric pain assessment scale in the 10/16/15 Progress Notes. The resident's hospital records were reviewed. The records indicated the resident had an X-ray completed in the emergency room . The X-ray was positive for a left [MEDICAL CONDITION]. The resident had surgery to repair the [MEDICAL CONDITION] on 10/17/15. The 10/2015 Medication Administration Record [REDACTED]. The order was originally written on 6/4/15. There was also an order [REDACTED]. Continued review of the 10/2015 Medication Administration Record [REDACTED]. No as need [MEDICATION NAME] or [MEDICATION NAME] doses were signed out as administered on 10/16/15. When interviewed on 11/24/15 at 1:05 p.m., LPN #1 indicated she worked on 10/16/15 and was assigned to care for Resident #E. The LPN indicated she was called to the room as the resident fell when a CNA was trying to assist the resident into a chair. LPN #1 indicated she assessed the resident at the time and the resident had no hip rotation. The resident complained her left side was sore. The LPN indicated the fall occurred around 7:30 a.m. on 10/16/15. LPN #1 indicated she notified the Physician of the fall at that time. LPN #1 indicated she checked with the resident in the morning and through the afternoon at times and the resident continued to say her side was a little sore. The LPN indicated between 6:00-7:00 p.m. she checked the resident and at that time she could tell there was a change in the resident by her body language as she appeared to really be having pain. LPN #1 indicated prior to this she had not offered the resident any pain medication through the day when she had stated her side was sore. The LPN indicated she had not asked the resident to rate her pain on a pain scale when the resident complained of soreness on her side. When interviewed on 11/24/15 at 1:50 p.m., Resident #E indicated she fell at 7:30 a.m. in the morning and two Nurses had to get her off the floor. The resident indicated she had pain all day and was not offered any pain medications until the Nurse came and gave her the 8:00 p.m. dose of her pain medications. The resident indicated she would have taken pain medication prior to her regular time if it had been offered to her. She further indicated, It hurt so bad. I could hardly move all day. When interviewed on 11/24/15 at 2:05 p.m., the Director of Nursing indicated the resident continued to have discomfort after the fall and the Nurse continued to look in at the resident through the day. The LPN worked from 7:00 a.m. to 8:00 p.m. on the day of the fall. The Director of Nursing indicated there were orders for the resident to have PRN pain medications and they were not offered to the resident through the shift. The Director of Nursing also indicated the Numeric Rating Scale was not used to assess the resident's pain scale after the fall. The facility policy titled Pain Management Guideline was reviewed on 11/24/15 at 1:15 p.m. The policy was dated 2/10/15. The Director of Nursing provided the policy and indicated the policy was current. The policy indicated a Numeric Rating Scale could be used to assess the pain level for cognitively intact residents with the resident identifying their pain level on a scale of 1-10. The policy also indicated after an acute change in condition when pain was suspected and after any fall, licensed Nurses were to use the appropriate pain scale. This Federal tag relates to Complaint IN 634. 3.1-37(a)

Based on observations, interviews and record reviews, the facility failed to ensure 2 of 2 residents reviewed with falls in the sample of 4 received supervision and assistance to prevent accidents related to the fall from a mechanical lift of a dependent resident (Resident C), which resulted in a head laceration requiring 14 staples and the fall of a resident (Resident E) with a recent below the knee amputation, during a transfer using a sliding board without the proper training/instructions from the physical therapy department. Findings include: 1. During tour on 3/16/11 at 9:35 a.m., Resident C was observed in bed. Dressing were noted on the resident's head. The Unit Manager (#1) accompanying tour indicated the resident had a fall during a transfer using a mechanical lift. She indicated the resident supposedly pulled on the bar of the lift, which released pressure, causing the attachment clip to become undone. The resident was in mid air when the fall occurred. He was immediately sent to the hospital and returned with 14 staples for a head wound. Clinical record review for Resident C on 3/16/11 at 2:40 p.m., indicated the [DIAGNOSES REDACTED]. The quarterly minimum data set (MDS) assessment dated [DATE], indicated the resident was alert and had no long or short term memory impairments. The resident was identified as being totally dependent for transfers and required the physical assistance of two + persons. The resident required limited to total assistance with all other activities of daily living (ADL). This MDS identified the resident's weight at 218 pounds. The plan of care identified a problem dated 10/20/10, as "resident requires total assistance with transfers with mechanical lift and two person assist. He requires extensive assistance with personal hygiene, bed mobility, toileting and dressing due to [DIAGNOSES REDACTED]." The interventions included, but were not limited to, "...Mechanical lift for transfers with 2 staff members." The CNA assignment sheet (Resident Information Sheet) updated on 3/15/11, indicated the resident was to be transferred with the "M" lift, indicating the Maximove lift. The CNA's ADL Flow Sheet for the month of March 2011, which included all shifts, indicated from 3/1/11 to 3/16/11, the resident was coded as requiring the assistance of 2 people for transfers 21 times and 9 times was coded as requiring the assistance of one person. The nurses' notes dated 3/13/11 at 11:44 a.m., indicated "... at 7:00 a.m., this morning, resident was being transferred to his wheelchair via the mechanical lift when one of the clips slipped off and the resident fell to the ground. This writer was called into his room, and found him lying on his right side, his head resting on the front wheel with a pool of blood underneath. Resident was alert and oriented...." The resident was sent to the emergency room (ER) and treated. He returned from the ER with 14 staples to his head. Review of the fall investigation on 3/16/11 at 3:00 p.m., indicated the resident was being transferred with one assistant. During interviews with the Administrator and the Director of Nursing Service (DNS) on 3/16/11 at 3:30 p.m., they both indicated the resident was able to be transferred with only one assistant. They further indicated the facility had obtained new lifts, (exact time unknown) and these lifts required only one person transfers. When a policy was requested, they provided a form from their policy manual, which indicated to follow the manufacturer's instruction related to the use of the lift. They provided a undated form entitled "Arjo's Back Injury Prevention Program Skills Check- Off Sheet", which identified the procedure for the use of Sara and Maximove lift (brand name of lifts). This procedure did not mention the number of persons required during a mechanical lift transfer. The Administrator further stated even if there were two assistants present, it would not have prevented the fall. Both the Administrator and the DNS were unaware of how the incident had occurred. The DNS had interviewed the CNA (#1) who had transferred the resident, and she insisted the clips were securely fastened before the transfer. On 3/17/11 at 11:00 am., the Administrator provide a facility form entitled "Lift Program Guide" which included, but was not limited to: All resident care will be provided in a safe, appropriately and timely manner in accordance with the individual's care plan. All residents will be assessed by (name of Facility) Care Plan team with regard to the need for assistance with transfer activities, mobility or repositioning in accordance with MDS procedures and requirements. Under the section entitled, "Resident Handling and Movement Requirements": Transfer assistance, assistance and other resident handling and movement tasks are to be carried out in accordance with the MDS, the Care Plan and written implementation instructions pertaining to the individual resident. If a variance from the MDS and the Care Plan is necessary, the supervisor will be contacted. Interview on 3/17/11 at 10:00 a.m., with a randomly selected CNA, indicated they (CNAs) would look at the plan of care (Resident Information Sheet) to determine how many assistants were needed for a mechanical transfer. She further indicated it also depended on the mood of the resident, if they were combative, then she would seek the help of another CNA. 2. During tour on 3/16/11 at 9:50 a.m., Resident E was observed seated in a wheelchair. The resident had a below the knee amputation on the left side. The Unit Manager (#2) accompanying tour indicated the resident had a fall during a transfer using a sliding/transfer board. According to the Unit Manager, the transfer board apparently shifted and the resident was lowered to the floor. No injuries were sustained. Review on 3/17/11 at 1:00 p.m., of the clinical record for Resident E indicated the [DIAGNOSES REDACTED]. The admission minimum data set (MDS) assessment dated [DATE], indicated the resident was alert and required the assistance of two + persons physical assist for transfers and bed mobility. The resident was identified as being unsteady when moving on and off the toilet and for surface to surface transfers (transfer between bed and chair). This MDS identified the resident's weight at 282 pounds. The care plan with an original date of 3/7/11, identified the resident at risk for falls related to: Left below the amputation. A hand written, undated intervention indicated the transfer board was to be used for transfers from the wheelchair to bed and bed to wheelchair. Two Resident Information Sheets, both dated 3/15/11, were provided on 3/17/11, one at 10:00 a.m. and one at 11:30 a.m. The first CNA plan of care sheet indicated the resident was to be transferred with the Sara (brand name) lift. The second plan of care was updated to include the mode of transfer was the slide board from bed to wheelchair and from wheelchair to bed. The nurses' notes dated 3/13/11 at 11:34 a.m., indicated the resident was lowered to the floor by the staff that morning. The resident was using the slide board and slid off, but the staff was present and able to lower her to the floor with no injury. During interview on 3/17/11 at 1:50 p.m., with the resident, she indicated she slid from the sliding board during a transfer and went down on both knees. She indicated her knees were sore after she went down to the floor. During interview on 3/17/11 at 1:20 p.m., with Unit Manager #2 and LPN #1, they indicated the family had brought in the sliding board, but they were unsure of the date. They indicated the resident had used the board at home, but this was before the amputation. The only information the Unit Manager had from the recent hospital stay was a P.T. discharge note, which indicated the resident was "... moderately independent/SBA sliding board transfers wheelchair - bed...." Review on 3/17/11 at 3:30 p.m., of the physical therapy's plan of treatment dated 3/14/11 at 5:57 p.m.., indicated the resident presented to the therapy with chief complaints of muscle weakness and impaired ability to perform transfers. The initial assessment indicated functional deficits with sit to stand, pivoting and sliding board transfers. The short term goal was to safety transfer from the bed to wheelchair with SBA (stand by assistance) using the sliding board. The goal date was 3/31/11. During interview on 3/17/11 at 1:30 p.m., with the Physical Therapist (P.T.) and the COTA (certified occupational therapy assistant) they indicated the resident had not completed the transfer board training and they had not trained any of the nursing staff on this transfer board transfer. The COTA indicated the resident tries to lean forward and goes too far. The P.T. indicated it was not safe to use the transfer board even if it was her own board. It was not that the resident didn't know how, but the fact she was off balance now due to the amputation. The P.T. indicated he was unaware the family had brought in her board from home. During interview on 3/17/11 at 2:30 p.m., with the P.T. he indicated the physical therapy department would first assess the resident, then train the resident and then train the nursing staff, but the physical therapy department hadn't gotten that far yet. He further indicated the resident would give a return demonstration to ensure a safe transfer. The estimated time of treatment was two weeks. During interview on 3/17/11 at 2:00 p.m., with the Administrator and the DNS, the Administrator indicated there was a mix up in the communication between the therapies and the nursing staff. The DNS stated they were now transferring the resident with a mechanical lift until the resident and the staff were properly training for safe transfers with a sliding board. 3.1-45(a)(2)

BASED ON INTERVIEWS AND RECORD REVIEWS, THE FACILITY FAILED TO IDENTIFY AND SEEK TIMELY MEDICAL INTERVENTIONS FOR 1 OF 12 RESIDENTS IN THE SAMPLE OF 24 WHO HAD AN URINARY TRACT INFECTION, UPPER RESPIRATORY INFECTION, WHO EXPERIENCED A DAILY DECLINE IN EATING AND TAKING FLUIDS, WAS EXPERIENCING NAUSEA, VOMITING AND DIARRHEA AND WHO HAD A PAST HISTORY OF ELECTROLYTE IMBALANCE WITH DEHYDRATION, CORRECTED WITH INTRAVENOUS FLUIDS. IN ADDITION, THIS RESIDENT HAD A CRITICAL LABORATORY LEVEL AND REQUIRED hospitalization FOR REHYDRATION. RESIDENT: C FINDINGS INCLUDE: REVIEW OF THE CLOSED CLINICAL RECORD OF RESIDENT "C" ON 11/15/10 AT 1: 30 P.M., INDICATED THE [DIAGNOSES REDACTED]. THE RESIDENT'S MEDICATION INCLUDED, BUT WERE NOT LIMITED TO [MEDICATION NAME] FOR DEPRESSION, [MEDICATION NAME] AND [MEDICATION NAME] FOR ESSENTIAL HYPERTENSION, [MEDICATION NAME] FOR UNSPECIFIED CEREBRAL ARTERY OCCLUSION AND POTASSIUM CHLORIDE FOR UNSPECIFIED NUTRITIONAL DEFICIENCY. THE RESIDENT WAS ON A MECHANICAL SOFT DIET, HOUSE SHAKE DAILY WITH BREAKFAST AND 2 CAL SUPPLEMENT 90 CC. (CUBIC CENTIMETERS) 3 OUNCES ORALLY TWICE A DAY. THE QUARTERLY MINIMUM DATA ASSESSMENT (MDS), dated ,[DATE]//10, INDICATED THE RESIDENT'S LONG AND SHORT TERM MEMORY WAS IMPAIRED AND SHE REQUIRED CUES AND SUPERVISION RELATED TO HER COGNITIVE SKILLS FOR DAILY DECISION MAKING. SHE REQUIRED ASSISTANCE IN ALL AREAS OF ACTIVITIES OF DAILY LIVING (ADLS). THE PLAN OF CARE WITH AN ORIGINAL DATE OF 3/16/10, IDENTIFIED THE RESIDENT AT NUTRITIONAL RISK RELATED TO CONSUMING LESS THAN 75% OF MEALS. THE APPROACHES INCLUDED, BUT WERE NOT LIMITED TO: MONITOR ORAL INTAKE, OBSERVE FOR SIGNS AND SYMPTOMS OF DEHYDRATION, DRY CRACKED LIPS, ABNORMAL LABORATORY VALUES, INCREASED CONFUSION AND LETHARGY. SOCIAL SERVICE PROGRESS NOTES, DATED 11/3/10 AT 14:08 P.M., INDICATED "OVER THE PAST TWO WEEKS RESIDENT HAS BEEN QUIET AND APPEARED DOWN. HER INTAKE HAS BEEN MINIMAL. THERE HAVE BEEN EPISODES OF VOMITING AND DIARRHEA, AND SHE HAS BEEN SLEEPING MORE. RECEIVING ABT (ANTIBIOTICS) FOR UTI AND URI (UPPER RESPIRATORY INFECTION). NO BEHAVIORS. RESIDENT WAS admitted TO (NAME OF HOSPITAL ) ON 11/2/10." DIETARY PROGRESS NOTES, DATED 8/31/10 AT 2:55 P.M., INDICATED THE RESIDENT HAD LOST 6.13% WEIGHT IN THE PAST 180 DAYS, BUT WAS STABLE FOR THE MONTH. HER ORAL INTAKE FOR THE LAST 7 DAYS WAS 56% AND THE CURRENT ORAL AND SUPPLEMENT INTAKES WERE ADEQUATE TO MEET NUTRITION NEEDS AT THIS TIME. WILL CONTINUE TO MONITOR WEIGHTS, ORAL INTAKES AND LABS AS AVAILABLE. NO ADDITIONAL DIETARY PROGRESS NOTES WERE AVAILABLE FOR REVIEW. REVIEW OF THE PHYSICIAN'S PROGRESS NOTES ON 11/16/10 AT 10:00 A.M., INDICATED ON 3/10/10, THE RESIDENT HAD A PROGRESSIVE DECLINE, WAS LESS ALERT AND EATING ONLY SMALL AMOUNTS. HER ELECTROLYTES AND RENAL FUNCTION WERE BEING MONITORED AND SHE WAS NOTED TO HAVE SOME [MEDICAL CONDITION] (ELEVATED SODIUM LEVEL) AND A LITTLE HYPOKALEMIA (DECREASED POTASSIUM). SHE WAS REHYDRATED WITH INTRAVENOUS FLUIDS AND KEPT AT THE FACILITY. ON 3/19/10, LABORATORY REPORT INDICATED ALL THE ELECTROLYTES WERE WITHIN NORMAL RANGE. THE NEXT LABORATORY REPORT, DATED 5/5/10, WHICH INCLUDED A COMPREHENSIVE METABOLIC PANEL (CMP) INDICATED NO ABNORMALITIES. THE NURSES' NOTES INDICATED ON 10/20/10 AT 11:10 A.M., THE PHYSICIAN WAS IN TO SEE THE RESIDENT AND ORDERED AN URINALYSIS WITH A CULTURE AND SENSITIVITY, IF INDICATED, AND A CMP AND LIPID PROFILE IN NOVEMBER AND THEN EVERY 6 MONTHS. THE FACILITY WAS UNABLE TO OBTAIN THE URINE SPECIMEN UNTIL 10/23/10 AND RECEIVED THE REPORT THAT NIGHT. THE PHYSICIAN ORDERED [MEDICATION NAME] 100 MG. (MILLIGRAMS)TWICE A DAY [MEDICATION NAME] TABLETS FOR 13 DAYS. ON 10/24/10, THE [MEDICATION NAME] WAS CHANGED TO KEFLEX 250 MG, 4 TIMES A DAY FOR 10 DAYS. ON 10/25/10, THE RESIDENT'S TEMPERATURE WAS 101.3 AT 4:15 A.M. AND BY 10:41 A.M., SHE WAS NOTED TO HAVE CRACKLES IN THE POSTERIOR BASES OF HER LUNGS. SHE ALSO HAD 2 SMALL EMESIS, MOSTLY PHLEGM. AT 12:13 P.M., THE KEFLEX WAS CHANGED TO [MEDICATION NAME] 500 MG. DAILY FOR 10 DAYS. AT 14:35 P.M., [MEDICATION NAME] 25 MG. WAS ORDERED AS NEEDED FOR NAUSEA OR VOMITING. AT 18:32 P.M., THE DOCUMENTATION INDICATED THE RESIDENT HAD AN EPISODE OF VOMITING AND DIARRHEA AT 14:30 P.M., A SECOND EPISODE OF DIARRHEA AT 16:30 P.M. AND 18:45 P.M. NO [MEDICATION NAME] WAS ADMINISTERED FOR THE NAUSEA OR VOMITING PER REVIEW OF THE Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. THE NURSES' NOTES, ON 10/25/10 INDICATED THE RESIDENT TOOK APPROXIMATELY 200 C.C. OF FLUID. ON 10/26/10, THE NOTES INDICATED THE RESIDENT WAS GETTING CLEAR LIQUIDS (NO AMOUNT LISTED). ON 10/28/10, THE RESIDENT WAS UP FOR BREAKFAST BUT REFUSED TO EAT, ON 10/30/10, THE RESIDENT WAS REFUSING TO EAT BREAKFAST AND TAKING ONLY SMALL AMOUNT OF FLUIDS AT A TIME. ON 10/31/10 AT 10:17 A.M., THE NOTES INDICATED THE RESIDENT WAS STILL RECEIVING THE ANTIBIOTIC FOR THE URINARY TRACT INFECTION AND FOR AN UPPER RESPIRATORY INFECTION. HER APPETITE REMAINED POOR. THE NOTES ALSO INDICATED THE RESIDENT WAS FLUSHED AND UNCOMFORTABLE AND HER TEMPERATURE WAS 99.4. ON 11/1/10 AT 15: 58 P.M., THE LABORATORY RESULTS INDICATED A CRITICAL SODIUM LEVEL OF 164 (NORMAL 134-145), ELEVATED BLOOD UREA NITROGEN OF 54 (NORMAL 8-23), POTASSIUM OF 3.0 (NORMAL 3.6-5.2) AND CHLORIDE OF 118 (NORMAL 96-108). THE RESIDENT WAS SENT TO THE HOSPITAL. THE HOSPITAL MISTAKENLY RETURNED THE RESIDENT TO THE FACILITY AND SHE WAS readmitted TO THE hospital on [DATE]. REVIEW ON 11/16/10 AT 10:30 A.M., OF THE EMERGENCY DEPARTMENT NOTES, DATED 11/1/10, INDICATED THE DIFFERENTIAL [DIAGNOSES REDACTED]. THE Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. SUPPLEMENT ON 10/26, 10/27, 10/28, 10/29, 10/30 AND 10/31/10, BUT DID TAKE 100% OF THE EVENING SNACK (90 CC). THIS DOCUMENTATION WAS DIFFERENT FROM THE AMOUNT OF FLUID RECORDED ON THE "RESIDENT MEALS BY DAY FOR MDS". THE FACILITY FORM ENTITLED "RESIDENT MEALS BY DAY FOR MDS" INDICATED THE FOLLOWING: 10/25/10 75% FOR BREAKFAST 0 % FOR LUNCH, DINNER AND EVENING SNACK. 10/26/10 75% FOR BREAKFAST 100% FOR LUNCH, 0% FOR DINNER AND EVENING SNACK. 10/27/10 0% FOR BREAKFAST, LUNCH, DINNER AND EVENING SNACK. 10/28/10 0% FOR BREAKFAST, LUNCH, DINNER AND EVENING SNACK. 10/29/10 0% FOR BREAKFAST, 75% FOR LUNCH, 100% DINNER, 0% EVENING SNACK. 10/30/10 25% FOR BREAKFAST, 0% FOR LUNCH, DINNER AND EVENING SNACK. 10/31/10 25% FOR BREAKFAST, 0% FOR LUNCH, 50% FOR DINNER AND 0% EVENING SNACK. DURING INTERVIEW ON 11/17/10 AT 1:30 P.M., WITH THE DIRECTOR OF NURSING (DON), SHE INDICATED THE RESIDENT DID TAKE SMALL AMOUNTS OF FOOD AND FLUID EVEN IF THE ABOVE FORM INDICATED A 0%. SHE FURTHER INDICATED THAT ALTHOUGH THERE WAS NO DOCUMENTATION, SHE WAS SURE HER NURSING STAFF AND THE PHYSICIAN WERE AWARE OF THE RESIDENT'S POOR ORAL INTAKE. WHEN QUERIED AS TO WHY NO INTERVENTIONS WERE IMPLEMENTED SOONER, SHE INDICATED A CONCERN WITH THE FAMILY'S DECISION REGARDING THE COURSE OF TREATMENT. THERE WAS NO DOCUMENTATION RELATED TO ALTERNATIVE METHODS OR INTERVENTIONS THAT COULD BE IMPLEMENTED TO PROVIDE SUFFICIENT ORAL INTAKE FOR THIS HIGHLY COMPROMISED RESIDENT, INCLUDING A DISCUSSION OF IV FLUIDS, PLACEMENT OF A [DEVICE] OR THE POSSIBILITY OF HOSPICE SERVICES, ETC. ON 11/19/10 AT 10: A.M., THE DON PROVIDED A FAX COPY, DATED 10/25/10,WHICH WAS SENT TO THE PHYSICIAN INFORMING HIM OF THE NAUSEA AND VOMITING AND THE FACT SHE WAS NOT ACCEPTING LIQUIDS. THE PHYSICIAN ORDERED THE [MEDICATION NAME] FOR THE NAUSEA AND VOMITING. THE DON INDICATED THIS FAX WAS NOT A PART OF THE PERMANENT CLINICAL RECORD AND WAS KEPT IN THE FAX BOOK AT THE NURSES STATION. THIS FEDERAL TAG RELATES TO COMPLAINT NUMBER IN 033. 3.1-37(a)