Every finding on record at Brickyard Healthcare - Twelfth Street Care Center

Based on observation, interview and record review, the facility failed to serve food at a safe temperature from 1 of 1 kitchen observed. (Main Kitchen) This had the potential to affect 55 out 55 residents who received their meals from the kitchen. Finding includes:During an observation of the breakfast meal service on 9/9/2025 at 8:03 A.M., the breakfast temperature log had not been filled out but meal trays had been given to residents. The CDM tempted a cup of milk and the temperature had been 44 degrees Fahrenheit. During the observation, 4 meal trays with cups of milk were taken from the kitchen window and delivered to residents. During an interview on 9/9/2025 at 8:04 A.M., the Certified Dietary Manager indicated the milk temperature was out of range and should not have been served. During an interview on 9/9/2025 at 8:05 A.M., the Chef 4 indicated everything that would be served at breakfast, including milk, had a temperature checked prior to meal service, but he had forgotten to fill out the temperature log. During an interview on 9/9/2025 at 8:07 A.M., RN 3 indicated she had served all twelve residents in the dining hall the milk that had been sitting in front of the residents. RN 3 indicated she had poured the milk from the gallon of milk sitting in a bowl of ice on the drink cart in the dining hall. RN 3 indicated she had nothing to do with temping milk and the kitchen had been responsible for that task. During an observation on 9/9/2025 at 8:09 A.M., the CDM checked a temperature of the milk sitting in a bowl of ice on the drink cart in the dining hall. The CDM indicated the temperature of the milk had been 54 degrees Fahrenheit, and had been out of range of safe serving temperatures and should not have been served. On 9/10/2025 at 9:20 A.M., the Executive Director provided an undated policy titled, Record of Food Temperatures and indicated it was the policy currently used by the facility. The policy indicated, . It is the policy of this facility to record food temperatures daily to ensure food is at proper serving temperatures before trays are assembled . 1. Food temperatures will be checked on all items prepared in the dietary department . 4. Potentially hazardous cold food temperatures will be kept at or below 41 degrees Fahrenheit . 14. Food temperatures will be verified using a thermometer which is both clean, sanitized and calibrated to ensure accuracy 3.1-21(a)(2)

Based on observation and interview, the facility failed to protect a resident's right to privacy for 1 of 1 resident reviewed for resident rights. (Resident 48) The facility also failed to ensure residents' dignity was maintained related to unprofessional verbal statements made by contracted staff for 3 of 5 residents reviewed for dignity. (Residents 5, 40 and 27)Findings include:1. During an observation on 9/12/2025 at 12:05 P.M., the surveyor knocked on Resident 48's door and the roommate opened the door all the way. Resident 48 was laying in bed naked except for a brief. The privacy curtain was open and the window curtain was partially open. CNA 12, who was providing care, turned to see who was at the door, turned back to Resident 48, and then turned to the door again. The surveyor had to instruct CNA 12 to pull the privacy curtain. During an interview on 9/12/2025 at 12:42 P.M., CNA 12 indicated she pulled the curtain to remind the roommate to use her walker when she gets up. She further indicated the privacy curtain and window curtain should have been closed. During an interview on 9/12/2025 at 1:15 P.M., the DON indicated the privacy and window curtain should have been closed. On 9/12/2025 at 12:57 P.M., the ED provided a policy, dated 2024, and titled, Promoting/Maintaining Resident Dignity. The policy indicated, .All staff members are involved in providing care to residents to promote and maintain resident dignity and .Maintain resident privacy 2. The clinical record of Resident 5 was reviewed on 9/10/2025 at 10:20 A.M. The resident's diagnoses included, but were not limited to: dementia, epilepsy, bipolar disorder, depression, anxiety, restless leg syndrome, chronic pain, post-traumatic stress disorder, borderline personality disorder and mild intellectual abilities. A Social Services note, dated 9/3/2025 at 4:47 P.M., indicated Resident 5 was tearful after a visit with the doctor. An e-mailed statement from the visiting Medical Doctor, dated 9/9/2025, indicated the visiting provider had an interaction on 9/3/2025 with an unnamed resident who told him she had lost 70 pounds when the provider congratulated her and told her she must have been a porker. The visiting MD indicated he had seen another resident for a routine visit and noted she had tattoos. The provider indicated, there were no naked people or obscene tattoos so she must be right, and also repeated a tasteless joke about an amputee at the license bureau needing a new license. During an interview, on 9/8/2025 at 7:28 P.M., Resident 5 indicated on 9/3/2025, a visiting doctor was here whom she did not know. Resident 5 indicated this visiting provider was looking for Resident 40 and she informed him there were 2 residents named with the name he was looking for the bigger one was in a wheelchair. Resident 5 indicated the visiting doctor said, it seems like all the bigger residents were in wheelchairs. Then, the resident told the provider she had lost over 70 pounds and he said, oh, you must have been a porker and I am just picking on you, I will stop assaulting you. 3. The clinical record for Resident 40 was reviewed on 9/10/2025 at 10:19 A.M. The resident's diagnoses included, but were not limited to: diabetes mellitus, morbid obesity, chronic obstructive pulmonary disease, depression, anxiety, venous insufficiency and hypertension. A review of alleged verbal abuse report, reported by Resident 40 to the Director of Nursing (DON), indicated on 9/3/2025, the Medical Doctor (MD) asked Resident 40 if she had any naked tattoos and Resident 40 indicated to the DON she was a little creeped out. Resident 40 indicated to the DON what upset her about the encounter with the MD was him repeating a joke he had told about Resident 40's friend who also lived at the facility. During an interview, on 9/11/2025 at 11:10 A.M., the Social Services Director (SSD) indicated Resident 40 had a history of trauma. The SSD indicated there was a verbal incident on 9/3/2025 with a visiting medical provider. The visiting medical provider had joked about other people in the facility, and the situation made Resident 40 feel uncomfortable. The SSD indicated the resident would be going to a new therapist and a new psychiatrist through [provider name], so she had extra support through those resources. Resident 40 indicated to the SSD she has no further concerns since the medical provider of concern was no longer coming to the facility. 4. The clinical record for Resident 27 was reviewed on 9/11/2025 at 11:40 A.M. The resident's diagnoses included, but were not limited to: diabetes mellitus, neuropathy, hypertension, bullous pemphigoid and anxiety. During an interview, on 9/10/2025 at 9:39 A.M., Resident 27 indicated on 9/3/2025 she had been outside in the smoking area when the physician made inappropriate remarks about overweight residents. Resident 27 indicated she did not recall exactly what was said but indicated the physician used the word porker and it caused her to feel angry. During an interview on 9/11/2025 at 11:37 A.M., Resident 39 indicated he was witness to the incident that happened on 9/3/2025. Resident 39 indicated he and 2 other residents were outside the facility smoking when a doctor came out and looked for another resident. Resident 39 indicated the visiting provider made a reference to all of the fat people at the facility. Resident 39 indicated Resident 27 became very upset after this comment by the provider. Resident 39 indicated the doctor had never been at the facility before, was not familiar with any of the residents they were aware of, and they were shocked at his behavior. Resident 39 indicated he did not have any concerns currently as the provider was not returning to the facility. On 9/9/2025 at 8:30 A.M., the Administrator provided a policy titled, Abuse, Neglect and Exploitation, dated 2022 and indicated the policy was the one currently used by the facility. The policy indicated, .verbal abuse means the use of.communication.that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability.Identifying, correcting and intervening in situations in which abuse.is more likely to occur with the deployment of trained and qualified.staff.and assure that the staff have knowledge of the individual residents' care needs and behavioral symptoms. 3.1-3(p)(4)

Based on observation and interview, the facility failed to ensure medications were stored appropriately related to opened and undated medications and failed to ensure medication carts were locked (100 hall) for 1 of 2 medication carts reviewed and medications were not stored in the pantry refrigerator for 1 of 2 medication rooms reviewed. (200 hall)Findings include:1.During an observation of the 200 hall medication cart on 9/10/2025 at 10:48 A.M. with Employee 15, the following was observed:There were 5 opened and undated bottles of polyethylene glycol.During an interview, on 9/10/2025 at 10:56 A.M., QMA 15 indicated the opened bottles of polyethylene glycol should have had open dates.2. Upon entrance to the facility, on 9/8/2025 at 5:55 P.M., the 100 hall medication cart was observed to be unlocked and a laptop was opened with resident information visible to passersby. During an interview, on 9/8/2025 at 5:58 P.M., RN 5 indicated she had left to attend to a resident's needs and she should have locked the medication cart and closed the laptop. On 9/9/2025 at 8:05 A.M., the Administrator provided a policy titled, Medication Storage, dated 2025 and indicated the policy was the one currently used by the facility. The policy indicated .all medications housed on our premises .to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security .Charts are kept on each refrigerator and temperature levels are recorded daily by the charge nurse or other designee . 3. During an observation of the 200 Hall Pantry with the Certified Dietary Manager (CDM) on 8/8/2025 at 6:05 P.M., a bottle of Gavilyte (medication for colostomy prep) was found in the refrigerator door. During an interview on 8/8/2025 at 6:06 P.M., the CDM indicated Resident medications should not be stored in pantry refrigerators. During an interview on 8/8/2025 at 6:10 P.M., LPN 3 indicated resident medications that require refrigeration should be in the medication refrigerator in the locked medication room. On 9/9/2025 at 8:05 A.M., the Administrator provided a policy titled, Medication Storage, dated 2025 and indicated the policy was the one currently used by the facility. The policy indicated .all medications housed on our premises .to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security .Charts are kept on each refrigerator and temperature levels are recorded daily by the charge nurse or other designee .3.1-25(j)3.1- 25(m)3.1 -25 (n)

Based on interview and record review, the facility failed to respect the right of a resident/resident's POA (Power of Attorney) to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers related to a WanderGuard (bracelet device which alarms at exit doors) for 1 of 1 resident reviewed for a WanderGuard. (Resident 11)Finding includes:During an interview on 9/10/2025 at 9:45 A.M., CNA 8 indicated they had been employed at the facility for fours years and regularly worked with Resident 11. CNA 8 indicated they had never seen Resident 11 confused, and Resident 11 was slow to respond, but had always been able to make his needs known. Resident 11 had seemed more depressed recently and CNA 8 indicated it was related to death of Resident 11's roommate and Resident 11's inability to leave the facility due to a WanderGuard.During a confidential interview in the course of the survey, Anonymous Employee (AE) 14 indicated they had worked with Resident 11 regularly. AE 14 indicated they had never observed Resident 11 confused and had concerns about Resident 11's WanderGuard. AE 14 had been present when the POA expressed they did not want Resident 11 to be restricted with the WanderGuard, but all the documentation in the record would indicate Resident 11's POA was agreeable. AE 14 indicated the Social Services Director (SSD) inquired about Resident 11's medication compliance, and SSD indicated medication compliance was required for the removal of Resident 11's WanderGuard. AE 14 indicated they had expressed concern that giving Resident 11 a condition to have his WanderGuard removed was a violation of Resident 11's rights to the SSD, but nothing had been done and no facility staff had followed up after the conversation. AE 14 described Resident 11 as always being alert and oriented, no issues making needs known to staff, but the resident was slow to respond and sometimes had difficulty finding his words. AE 14 indicated Resident 11 had regularly been noncompliant with his medications and interactions with staff the resident had not been familiar with increased his non-compliance. AE 14 indicated Resident 11 did not like to be told to do anything, especially by women. AE 14 indicated they were not present for any conversation with Resident 11 or his POA when the facility had promised a two-week time frame, but both Resident 11 and the POA had complained about not having the WanderGuard off after two weeks multiple times. AE 14 indicated they had never witnessed the resident threatening staff before the incident or after.On 9/10/2025 at 2:24 P.M., Resident 11 was alert to person, place, time and situation and reported living at the facility for over a decade. Resident 11 was observed to be slow to respond and had a hard time finding his answer for who the current President of the United States was. Although the Resident could not find the name, he was able to reply with blond hair and red hat. During an interview on 9/10/2025 at 2:25 p.m., Resident 11 indicated his only concern had been that he wanted the monitor (WanderGuard) on his ankle taken off. Resident 11 described an incident that happened six weeks prior when he had left the facility and staff had tried to stop him. He indicated he had not understood what was happening because he had always been permitted to go to the park whenever he had wanted. Resident 11 regretted not following staff commands related to going back into the building and signing himself out. Resident 11 indicated staff who he had not known had told him and his POA the ankle WanderGuard would only be for two weeks and that had been at least six weeks prior. Resident 11 indicated the POA had expressed to the facility staff that the WanderGuard should be removed, but at the end of the meetings, the staff had convinced his POA he was confused and the ankle monitor remained on Resident 11. During an interview on 9/10/2025 at 3:38 P.M., Resident 11's POA indicated her father had lived at the facility for 13 years and had always been allowed to leave without signing himself out. At baseline, the POA described her father as having had delayed responses but had not been confused and had always been able to communicate his needs to her and staff. The POA indicated she had a concern related to the facility requiring her father to wear a WanderGuard when she had not believed it was necessary. The POA indicated after the incident, her father had not been confused and described her father as angry related to the WanderGuard and nothing else. The POA expressed concern that the [NAME] President of Operations (VPO), who was the interim Executive Director on the date of the incident, was rude to her on the date of the incident and during the Care Plan meeting on 6/24/2025. The POA indicated she had a concern related to what was being added to the chart and felt the only information going into the Resident 11's medical record was being added by staff that had not known her father, and the information was not an accurate representation of her father or how her father was immediately after the incident. The POA indicated she had not been agreeable to the WanderGuard and had only agreed to the WanderGuard because she had been told it was temporary and would be removed after two weeks. During the 6/24/2025 Care Plan meeting, it was communicated to Resident 11 and his POA that the WanderGuard would remain until Resident 11 passed an assessment and was compliant with his medications. The POA indicated at the end of July, the Interim Administrator had called her and reported the resident had received an assessment to evaluate his cognition and the resident had passed with flying colors with a score of 28 out 30 correct answers and that the facility had only been waiting for the resident to been seen by doctor before the WanderGuard would be removed. The POA indicated the WanderGuard was never removed and my father had done everything the facility asked, including passing a test and he still had been restricted from leaving. The POA indicated she had been at the facility two weeks prior and met with the Interim Executive Director, who was new but was the same person who had called her to report Resident 11 had passed the assessment, as well as the SSD to demand the WanderGuard be removed. During that meeting, the POA indicated she had been told that if she wanted the WanderGuard removed, she would need to take her father to an assisted living facility. The POA indicated that conversation had been upsetting because her father had lived at the facility for 13 years without any other incident related leaving the facility and does not have money to pay for assisted living.During a meeting on 9/11/2025 at 1:45 P.M., the VPO indicated she had been the acting Executive Director at the time of the incident. The VPO indicated the resident had been impulsive and darted out into the street when two staff members had tried to stop him. The VPO denied Resident 11 had been unfamiliar with the staff and expressed concerns related to Resident 11's safety. The VPO indicated after dinner, around 6:30 or 6:45 P.M., she had received a phone call from the Administrator in Training who had described Resident 11 as refusing to move from the center of the entrance to the facility and had darted into on-coming traffic while on his electric scooter. After darting into the street, Resident 11 was then reported as driving down the middle of the street on his scooter with cars driving in both directions around the resident. The VPO indicated she called the police because not only was the resident impulsive, but it had also been dark and the amount of light had been a real concern and she had been worried he would be hit by a car. The VPO denied knowing Resident 11 was slow to respond at baseline or had any difficulty finding his words and found the resident was confused when she had assessed him. The VPO indicated the POA had always been agreeable to the WanderGuard and had not expressed concern. The VPO indicated, the facility's nursing staff did not have the knowledge or skill set to assess a resident's true cognition. The VPO indicated the facility had never bargained with Resident 11 or the POA.An interview was completed on 9/11/2025 at 2:15 P.M. with the Regional Healthcare Facility Administrator (RHFA), who had been the Interim Executive Director at the time the facility and had reported Resident 11's assessment score of 28 out of 30 to the resident's POA and who had been present at the July Care Plan Meeting. The RHFA indicated while the resident had passed his Mini Mental Assessment, the facility had a Risk meeting and found Resident 11 was still unsafe and would still be required to wear the WanderGuard. The RHFA indicated the POA had recently questioned her and SSD about the WanderGuard, but they had not told the resident's POA if she wanted to remove the WanderGuard the resident would need to be moved to assisted living. The RHFA denied there had been any bargaining in the July Care Plan meeting. During an interview on 9/11/2025 at 2:15 P.M., the SSD indicated he had not been at the facility at the time of the incident. The SSD denied any bargaining had been done with Resident 11 or his POA. The SSD indicated medication compliance was to help the resident be less angry so the resident's mental assessment could be completed. The SSD did acknowledge Resident 11's POA had concerns related to the WanderGuard, but after the facility had explained their reasoning and concern for Resident 11's safety, he believed the POA was agreeable.During an interview on 9/12/2025 at 10:04 A.M., CNA 17 indicated she had been employed at the facility for three years and regularly worked with Resident 11. CNA 17 indicated she had been responsible for Resident 11 the day of the incident, and had not noted the resident to be confused prior to the incident. CNA 17 indicated the only time she had witnessed Resident 11 to be confused had been when he had some type of infection and confusion was how the staff had identified the resident had an infection because confusion was unusual for Resident 11. CNA 17 denied being present for the start of the incident, but had been the staff member that walked back to the facility with Resident 11 after the incident. CNA 17 indicated when she caught up to Resident 17 and asked him to go back to the facility, Resident 11 immediately complied. CNA 17 described Resident 17 as calm, not angry, and did not appear to be confused while they went back to the facility. CNA 17 indicated it was daylight outside at the time of the incident and it had not been close to sunset or dusk and light had not been a concern. CNA 17 indicated Resident 17 did become angry after staff had tried to put the WanderGuard on the resident. CNA 17 denied the resident had ever made threats of violence toward staff before or after the incident . CNA 17 indicated Resident 11 had always been slow to respond to questions, but when given time, had always been able to answer correctly. CNA 17 indicated Resident 11 had not been receptive to staff that were not known to the resident, and Resident 11's non-compliance with meals, medications and showers were always worse when he had been assigned an unfamiliar staff member. CNA 17 indicated she had reported to the Administrator in Training the day the WanderGuard was placed on Resident 11 that he did not need the WanderGuard and the incident had been situational because Resident 11 had always been allowed to leave without signing out and Resident 11 was not familiar with the Administrator in Training or the nurse that had been involved in the situation. CNA 17 denied knowledge of any conditions or bargaining with Resident 11 or his POA, but did indicate the resident's POA had been in the facility multiple times expressing concern about the WanderGuard to staff and leadership. During an interview on 9/12/2025 at 9:02 A.M., the Certified Dietary Manager (CDM) indicated the facility's Administrator had asked her to make a statement to the Survey Team regarding Resident 11's June and July Care Plan meetings for which the CDM had been present. The CDM indicated the facility staff had never given Resident 11 or his POA a timeline for when the WanderGuard would be removed in either the June or July Care plan meeting and witnessed the SSD re-explain there would be no time frame for the WanderGuard numerous times to the resident's POA in both meetings. The CDM indicated Resident 11's POA had not been agreeable to the WanderGuard and had been forceful about not wanting Resident 11 to have the WanderGuard in both the June and the July Care Plan meetings. The CDM indicated in the June and July Care Plan meeting, the facility staff had bargained with Resident 11's POA when they told the POA there would be conditions to remove the WanderGuard other than the cognitive assessment. In the June Care Plan meeting, facility staff had told Resident 11's POA the resident would have to be compliant with his medications to have the WanderGuard removed. In the July Care Plan meeting, the facility staff had told Resident 11's POA the resident had to be compliant with all medications and treat therapy staff well before he would be reassessed. The CDM indicated she was unsure why Resident 11 would be required to treat any staff well because the resident had a right to treat staff however he chose without fear of retaliation. During an interview on 9/12/2025 at 9:15 A.M., the VPO indicated Resident 11 was required to treat therapy staff well in order for the WandGuard to be removed. Resident 11's record review was completed on 9/12/2025 at 10:30 A.M., diagnoses included, but were not limited to: cerebral infarction, vascular dementia, major depressive disorder, hypertension, chronic kidney disease, anemia and chronic obstructive pulmonary disease.A Quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated Resident 11 had clear speech, was able to make himself understood and understood others, and had no hearing or vision problems. A Brief Interview for Mental Status (BIMS) assessment indicated an assessment was not administered due to the resident rarely being understood. He had not had any physical or verbal behaviors and had not rejected any care or had wandered. Resident 11 had not had a WanderGuard or any alarm or restraint. Care Plan meeting minutes dated 6/24/2025, indicated nursing, dietary, social worker, resident, resident representative, administration and nursing administration had been present. The family/resident concerns were, Family has questions about WanderGuard, medications, and whether resident is taking his medications. Family would like WanderGuard to be re-evaluated after med-compliance. Resident has agreed to start taking his medications.A Mini-Mental State Examination (MMSE) (30-point screening tool used to measure cognitive impairment) dated 7/28/2025, indicated the resident had a score of 24 out of 30. An interpretation of the MMSE, attached to Resident 11's MMSE, indicated he had no cognitive impairment.Care Plan meeting minutes dated 7/29/2025, indicated nursing, dietary, social worker, resident and resident representatives had been in the Care Plan meeting. The resident/family had expressed concerns about residents' independence. The Interdisciplinary Team review noted, Nursing: Resident is taking his medications which is an improvement at this time. WanderGuard reviewed with resident, his family was in attendance. Developed a plan of care and options for safety. His son and daughter were receptive but understood our need for safety. Will continue to monitor, WanderGuard stays intact, will have risk call and complete assessment and review.An ad hov (as needed) BIMS assessment dated , 7/29/2025, indicated the resident had moderate cognitive impairment.A Social Services note dated, 8/01/2025, indicated the administrator contacted Resident's POA for a status update on the WanderGuard. It was reported to the POA Resident 11's WanderGuard would stay on due to the history and severity of the prior event and to promote his safety. The POA asked about the resident's recent assessments and medication compliance, and it was explained to her the Wanderguard would need to remain on to monitor his safety. Resident 11's POA acknowledged and stated she would come and speak with her father that night.A Care Plan, dated, 6/23/2025, indicated Resident 11 was at risk for elopement and had a goal to his safety maintained through the review. The Care Plan had one intervention, WanderGuard on left ankle.A Care Plan, revised on 6/6/2024, indicated Resident 11 had incidents of refusing care, medications, treatments and showers. The goal was for the behavior to stop with staff intervention. Interventions included, but were not limited to: Come back at a different time to provide care if I refuse. Ask resident if he would like a different staff member to provide care and observe for compliance, document and report noncompliance to MD and educate as needed.A Care Plan dated, 12/8/2020 and last revised on 3/30/2021, indicated Resident 11 had behaviors including making sexually inappropriate comments towards staff, watching sexually inappropriate shows in common areas with fellow residents present, hiding medications from staff and isolating himself in his room. The goal was for the resident's behavior's to improve with staff intervention. Interventions included, but were not limited to: notify physician if behaviors interviewed with activities of daily living, staff to observe resident to be sure he swallows medications and verbally redirect me when making inappropriate comments.Resident 11's record lacked the documentation to indicate his POA had not been agreeable to the WanderGuard after meeting with facility staff, or the resident had any other Care Plans related to behaviors, the WanderGuard or being verbally and physically aggressive toward staff. The resident's record lacked any notes or behavior monitoring to indicate the resident had been physically or verbally aggressive to staff, had been impulsive, or attempted to the leave the facility since the WanderGuard had been placed on the resident's ankle. 3.1-4(d)

Based on interview, observation and record review, the facility failed to notify the physician of a resident's low blood pressure for 1 of 5 residents who were reviewed for medications and treatments. (Resident 39)Finding includes:The clinical record of Resident 39 was reviewed on 9/10/2025 at 3:13 P.M. The resident's diagnoses included, but were not limited to: chronic obstructive pulmonary disease, acute and chronic respiratory failure with hypoxia, anxiety, depression, opioid dependence and mild cognitive impairment.A Quarterly Minimum Data Set (MDS) assessment, dated 7/3/2025, indicated Resident 39 was cognitively intact and had received an antidepressant, an anticoagulant, an opioid and a diuretic. A Physician's Order, dated 1/13/2025, indicated blood pressure checks were to be completed every shift to monitor for blood pressure drops. The September 2025 Medication Administration Record (MAR) indicated Resident 39 had a blood pressure measurement of 79 over 44 (normal adult = 120 over 80) on the night shift of September 1, 2025. Resident 39's clinical record failed to evidence provider notification of the blood pressure measurement on the night shift of 9/1/2025. During an interview, on 9/11/2025 at 9:07 A.M., QMA 6 indicated if a resident had a low blood pressure, she would have notified the nurse in charge and charted the blood pressure in the Electronic Medical Record (EMR). During an interview, on 9/11/2025 at 9:08 A.M., RN 5 indicated if a resident's blood pressure had been low, she would have first checked the resident and assessed the resident. RN 5 indicated she would have looked at the resident's medication list to see if they have Midodrine (a prescription medication used to treat certain types of low blood pressure). RN 5 indicated if the blood pressure was out of the normal for the resident, she would have notified the provider. During an interview, on 9/11/2025 at 9:19 A.M., the Director of Nursing (DON) indicated if a resident's blood pressure was out of their normal range, the nurse should have notified the physician. The DON indicated if the resident did not have vital sign notification parameters, the nurse should have used their nursing judgement. The DON confirmed there were no nursing notes documenting provider notification. On 9/11/2025 at 10:20 A.M., the DON provided a policy titled, Notification of Changes, dated 2024 and indicated the policy was the one currently used by the facility. The policy indicated, .The facility must .consult with the resident's physician .when there is a change requiring such notification. Circumstances requiring notification include .Significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include .clinical complications .3.1-5 (a)(2)

Based on observation, record review and interview, the facility failed to follow a physician's order for a hypotensive medication for 1 of 3 residents reviewed for medication administration. (Resident 9)Finding includes:During an observation of medication administration on 9/10/2025 at 9:33 A.M. with QMA resident 9 was administered Midodrine Hydrochloride 5mg (milligrams) by mouth. Resident 9's blood pressure was142/58 mm/Hg (millimeters per mercury).A record review was completed for Resident 9 on 9/11/2025 at 11:24 A.M. Diagnoses included, but were not limited to: acute on chronic systolic heart failure, sick sinus syndrome, hypertension and stage 4 chronic kidney disease.A Physician's Order, dated 6/13/2025 indicated Resident 9 was to be administered Midodrine Hydrochloride 5mg by mouth three times per day. Additional instructions also indicated to hold Midodrine Hydrochloride 5mg if the resident's systolic blood pressure was greater than 140 mm/Hg.A review of Resident 9's EMAR (Electronic medication administration record) indicated the resident had been administered Midodrine Hydrochloride 5mg by mouth when the resident's systolic blood pressures were greater than 140 mm/Hg on the following dates and shifts:On 7/8/2025 evening shift, Resident 9's blood pressure reading was 141/71 mm/Hg.On 7/9/2025 evening shift, Resident 9's blood pressure reading was 143/67 mm/Hg.On 7/21/2025 evening shift, Resident 9's blood pressure reading was 146/74 mm/Hg.On 7/28/2025 morning shift, Resident 9's blood pressure reading was 169/62 mm/Hg.On 7/29/2025 day shift, Resident 9's blood pressure reading was 151/69 mm/Hg.On 7/30/2025 morning shift, Resident 9's blood pressure reading was 167/80 mm/Hg.On 7/31/2025 morning shift, Resident 9's blood pressure reading was 167/75 mm/Hg,On 8/4/2025 morning shift, Resident 9's blood pressure reading was 144/77 mm/Hg and on evening shift Resident 9's blood pressure reading was 141/51 mm/Hg.On 8/5/2025 morning shift, Resident 9's blood pressure reading was 144/73 mm/Hg and on day shift Resident 9's blood pressure reading was 169/70 mm/Hg.On 8/6/2025 morning shift, Resident 9's blood pressure reading was 167/74 mm/Hg.On 8/7/2025 day shift, Resident 9's blood pressure reading was 160/69 mm/Hg and on evening shift Resident 9's blood pressure reading was 141/60 mm/Hg.On 8/21/2025 evening shift, Resident 9's blood pressure reading was 141/75 mm/Hg.On 8/26/2025 day shift, Resident 9's blood pressure reading was 144/69 mm/Hg and on evening shift Resident 9's blood pressure reading was 146/72 mm/Hg.On 8/27/2025 evening shift, Resident 9's blood pressure reading was 160/70 mm/Hg.On 8/28/2025 morning shift, Resident 9's blood pressure reading was 155/65 mm/Hg and on day shift Resident 9's blood pressure reading was 160/79 mm/Hg.On 8/31/2025 evening shift, Resident 9's blood pressure reading was 146/74 mm/Hg.On 9/1/2025 morning shift, Resident 9's blood pressure reading was 165/75 mm/Hg and on day shift Resident 9's blood pressure reading was 144/68 mm/Hg.On 9/2/2025 morning shift, Resident 9's blood pressure reading was 144/80 mm/Hg and on evening shift Resident 9's blood pressure reading was 149/71 mm/Hg.9/3/2025 morning shift, Resident 9's blood pressure reading was 148/60 mm/Hg.On 9/4/2025, morning shift, Resident 9's blood pressure reading was 144/70 mm/Hg and on day shift Resident 9's blood pressure reading was 158/78 mm/Hg.On 9/9/2025 morning shift, Resident 9's blood pressure reading was 158/71 mm/Hg and on day shift Resident 9's blood pressure reading was 155/80 mm/Hg.On 9/10/2025 morning shift, Resident 9's blood pressure reading was 142/58 mm/Hg.A Physicians Order, dated 9/10/2025, indicated to monitor the resident for any adverse reactions related to Midodrine Hydrochloride 5mg being administered and blood pressure was not in parameters every two hours until 9/10/2025 at 11:59 P.M.During an interview, on 9/12/2025 at 9:23 A.M. the DON indicated Resident 9 should not have received the Midodrine Hydrochloride when his systolic blood pressure had been greater than 140 mm/Hg.On 9/11/2025 a policy was requested regarding following physician's orders but one was not provided prior to the survey exit.

Based on observation, interview, and record review, the facility failed to safely transfer a resident which resulted in the resident falling for 1 of 1 resident reviewed for falls. (Resident 7)Finding includes:A record review for Resident 7 was completed on 9/10/2025 at 1:41 P.M. Diagnoses included, but were not limited to, urinary tract infection, type 2 diabetes mellitus, mild cognitive impairment, major depressive disorder, and chronic pain disorder. An admission Minimum Data Set (MDS) assessment, dated 7/31/2025, indicated Resident 7's cognition was intact, had functional limitations of the upper extremities on one side, used a wheelchair, required substantial to maximal assist for transfers and had one fall prior to reentry to the facility and no falls since reentry. A Care Plan problem, initiated on 7/28/2025, indicated Resident 7 had an Activities of Daily Living deficit with an intervention, revised on 9/5/2025, that required assist of 2 staff for transfers. Nursing Progress Notes, dated 8/26/2025, indicated Resident 7 was transferred with assist of one staff. His legs became weak and he was lowered to the floor. The note indicated the resident would be a 2 person transfer henceforth. No care plan updates were found in the record. A Nursing Progress Note, dated 9/4/2025, indicated Resident 7 and CNA 9 fell during a transfer from the wheelchair to bed. CNA 9 transferred the resident alone. Resident 7 hit his head and was sent to the emergency room (ER) where sutures were required to close the wound above his right eyebrow. During an interview on 9/11/2025 at 9:04 A.M., CNA 8 indicated Resident 7 was a 2 person transfer and staff get care information about the residents from the electronic medical record Kardex. During an interview on 9/11/2025 at 9:58 A.M., LPN 2 indicated she was working the day Resident 7 had gone to the ER. She indicated he was transferred with assist of 1 and no gait belt. During an observation on 9/11/2025 at 9:04 A.M., Resident 7 was transferred from he wheelchair to bed using a mechanical lift and 2 staff members. There was a note taped to the window next to his bed indicating Resident 7 was a 2 person assist for transfers. During an interview on 9/11/2025 at 9:16 A.M., the DON indicated the mechanical lift was a nursing judgment because Resident 7 indicated at times felt like he could not stand. The mechanical lift was not on the care plan and should have been added to individualize the care plan to meet the resident's needs. During an interview on 9/11/2025 at 1:42 P.M., CNA 9, who was the person that transferred Resident 7 on 9/4/2025, indicated at the time he was a 1 person transfer. During the transfer the resident's legs became weak and the floor was wet when they both went down. When she needed to know how to care for a resident, she would get report from the previous shift, or check the electronic medical record Kardex. Therapy had not addressed falls on 8/26/2025 or 9/4/2025. During an interview on 9/11/2025 at 2:09 P.M., the Director of Therapy indicated transfers was a task therapy was working on with Resident 7. After the 8/26/2025 fall, there were no changes in the transfer assist per discussion with the family and Interdisciplinary Team. The family's and resident's concern was he cannot go home if he is a 2 person transfer and they had been educated on the risks of a 1 person transfer. The discussion was not entered into the record. After the 9/4/20205 fall he became a 2 person transfer. During an interview on 9/11/2025 at 2:18 P.M., Regional Director of Clinical Operations (RDCO) 2 indicated after the fall on 8/26/2025, the family wanted to investigate possible medical reasons for his intermittent weakness. They started to monitor his blood sugars and a referral for a neurological consult was obtained. On 9/12/2025 at 1:15 P.M., RDCO 2 provided a policy, dated 2024, and titled, Fall Prevention Program. The policy indicated, .review the resident's care plan and update as indicated 3.1-45(2)

Based on observation, interview, and record review, the facility failed to monitor nutritional status for 1 of 2 residents reviewed for nutrition. (Resident 4)Finding includes:A record review was completed on 9/11/2025 at 10:11 A.M. for Resident 4. Diagnoses included, but were not limited to, unspecified dementia and adult failure to thrive.An admission Minimum Data Set (MDS) assessment, dated 8/28/2025, indicated Resident 4's cognition was intact, needed set up/clean up assist for eating, and had no swallowing or chewing issues.A Physician Order, dated 8/20/2025, indicated Resident 4's diet was regular with regular texture and no salt packet.A Care Plan, initiated on 8/21/2025, indicated Resident 4 had a nutritional problem related to self-reported chewing issue with prior unspecified weight loss. Staff were to monitor and signs or symptoms of dysphagia (difficulty swallowing) and serve diet as ordered.admission and September weights could not be found in the record. During an interview on 9/8/2025 at 7:15 P.M. Resident 4 indicated she had lost weight but wasn't sure how much. She indicated the physician told her she was taking too much thyroid medicine.A weight of 117 pounds prior to admission was noted in the dietician's note.During an observation on 9/11/2025 at 12:53 P.M., Resident 4's lunch tray still had 50% of her lunch untouched. She indicated she hated the food and did not want a substitute.During an observation on 9/12/2025 at 9:02 A.M., Resident 4's breakfast was almost completely untouched. Only a few bites were taken and she indicated she wasn't hungry.During an interview on 9/12/202 at 9:12 A.M., the Certified Dietary Manager (CDM) indicated the resident refused to be weighed and several attempts had been made. The CDM indicated documentation of attempts and resident refusals, as well as physician notification, were not in the chart.During an interview on 9/12/2025 at 10:21 A.M., Regional Director of Clinical Operations 10 indicated the care plan showed she refused showers and the scale was in the shower room, so if she didn't go in the shower room she would not be able to be weighed. The refusals should have been documented.On 9/12/2025 at 12:57 P.M., the ED provided a policy, dated 2024, and titled, Weight Monitoring. The policy indicated, .Observations pertinent to the resident's weight status should be recorded in the medical record as appropriate 3.1-46(1)

Based on observation, interview and record review, the facility failed to maintain the cleanliness of a resident's personal refrigerator for 1 of 1 personal refrigerator observed. (Resident 2) Finding includes: During an observation on 9/9/2025 at 1:06 P.M., Resident 2's personal refridgerator had pop splattered and spilled on all sides of the inside of the fridge, on the inside door and on the shelf of the fridge. A container with grapes was removed and pop spilled onto the floor because pop accumulated on the lid of the grapes. There had not been a received on date or use by date on the grapes. An opened jar of nacho cheese had not been labaled with an opened on date or used by date. During an interview on 9/9/2025 at 1:08 P.M., Resident 2 indicated nobody checked the temperature of his fridge or cleaned it out. He believed his sister had been the one cleaning the fridge in the past. During an interview on 9/9/2025 at 1:10 P.M., the Executive Director (ED) indicated Resident 2's personal fridge was dirty and should not have been and all opened food should have an opened on or used by date. On 9/12/2024 at 12:53 P.M., the ED provided an undated policy titled, Resident Refrigerators, and identified it as the policy currently used by the facility. The policy indicated, .Staff/resident or family shall clean the refrigerator . Leftovers shall be dated upon receipt and discarded within three days 3.1-19(f)

Based on observation and interview, the facility failed to provide at least 60 square feet per resident in 22 multiple occupancy resident rooms for 2 of 2 units (100 and 200). (Rooms 100, 101, 103, 104, 108, 109, 110, 111, 112, 114, 116, 118, 204, 205, 206, 207, 211, 213, 215 and 226) In addition, the facility failed to ensure 100 square feet per resident in single resident rooms was provided. (rooms [ROOM NUMBERS]) Finding includes: During an environmental tour, conducted on 9/11/2025 between 11:00 A.M. - 11:45 A.M., the following multiple rooms were observed to contain less than 80 square feet per resident. The following rooms were certified SNF/NF (Skilled Nursing Facility/ Nursing Facility) for three beds and measured from 70.5 - 72 square feet per resident: room [ROOM NUMBER], 2 beds, 211.5 total square feet, 105.75 square feet per resident.room [ROOM NUMBER], 2 beds, 216 total square feet, 108 square feet per resident.room [ROOM NUMBER], 2 beds, 216 total square feet, 108 square feet per resident.room [ROOM NUMBER], 2 beds, 216 total square feet, 108 square feet per resident.room [ROOM NUMBER], 2 beds, 216 total square feet, 108 square feet per resident.room [ROOM NUMBER], 2 beds, 216 total square feet, 108 square feet per resident.room [ROOM NUMBER], 2 beds, 216 total square feet, 108 square feet per resident.room [ROOM NUMBER], 2 beds, 216 total square feet, 108 square feet per resident.room [ROOM NUMBER], 2 beds, 216 total square feet, 108 square feet per resident.room [ROOM NUMBER], 2 beds, 212.9 total square feet, 108.45 square feet per resident.room [ROOM NUMBER], 2 beds, 2 beds, 215.3 total square feet, 107.55 square feet per resident.room [ROOM NUMBER], 2 beds, 213.6 total square feet, 108.8 square feet per resident.room [ROOM NUMBER], 2 beds, 213.6 total square feet, 108.8 square feet per resident.room [ROOM NUMBER]. , 2 beds, 213.6 total square feet, 108.8 square feet per resident.room [ROOM NUMBER], 2 beds, 213.6 total square feet, 108.8 square feet per resident.room [ROOM NUMBER], 2 beds, 216 total square feet, 108 square feet per resident.2. The following resident rooms were certified SNF/NF for 2 beds and measured between 70.5 and 71.5 square feet per resident.room [ROOM NUMBER], 1 bed, 141 total square feet, 141 total square feet per resident.room [ROOM NUMBER], 1 bed, 144 total square feet, 144 total square feet per resident.room [ROOM NUMBER], 1 bed, 143 total square feet, 143 total square feet per resident.room [ROOM NUMBER], 1 bed, 143 total square feet, 143 total square feet per resident.3. The following resident rooms were certified SNF/NF for one bed and measured less than 100 square feet.room [ROOM NUMBER], 1 bed 91.6 total square feet, 91.6 square feet per resident.room [ROOM NUMBER], 1 bed, 91.6 total square feet, 91.6 square feet per resident.During an interview with the Administrator, on 9/11/2025 at 1:40 P.M., she confirmed these were the rooms which had the room variance waivers and did not provide the required square footage.

Based on interview and record review, the facility failed to ensure the physician was notified in a timely manner when a resident was given a medication in the incorrect form, refused all medications for six consecutive medication passes and experienced a decline in level of consciousness, for 1 of 3 residents review for medication administration. (Resident B). Finding includes: On 3/17/25 at 11:28 A.M., Resident B's medical record was reviewed. Diagnoses included, but were not limited to: history of stroke, seizures, heart failure, hypertension, diabetes, hyperlipidemia, dementia, chronic obstructive pulmonary disease, other symptoms involving emotional state. A Quarterly Minimum Data Set (MDS) assessment, dated 2/5/25, indicated Resident B was severely cognitively impaired, was sometimes able to make his his needs and ideas known and had rejected care 1 to 3 days in the 7 day look back period of the assessment. Physician orders for medications and supplements included- Glyburide 5 mg tablet 2 times daily for type 2 diabetes Ploglitazone HCL 15 mg tablet 1 time daily for type 2 diabetes Sitaglipin Phosphate 100 mg tablet every evening for type 2 diabetes Steglatro 15 mg tablet every evening for type 2 diabetes Fluvoxamine Maleate 100 mg tablet at bedtime for Obsessive-compulsive disorder Geodon 40 mg capsule at bedtime for psychiatric condition Seroquel 25 mg tablet at bedtime for vascular dementia Aricept 10 mg tablet 1 time daily for dementia Doxepin HCL 10 mg capsule at bedtime for memory Furosemide 40 mg tablet every 24 hours as needed for extremity swelling Trelegy Ellipta inhalation Aerosol Powder Breath Activated, 1 puff inhale every afternoon for chronic obstructive pulmonary disease Hydralazine HCL 100 mg tablet 2 times daily for hypertension Lorsartan Potassium 100 mg tablet daily for hypertension Metoprolol Tartrate 50 mg tablet 2 times daily for hypertension Nifedipene extended release 90 mg tablet every morning for hypertension Spironolactone 25 mg tablet daily for hypertension Depakote ER (extended release) 500 mg tablet, 2 tablets 2 times daily Aspirin 81 mg tablet every evening for pain related to stroke and hypertension Atorvastatin Calcium 80 mg tablet daily for hyperlipidemia Flonase nasal suspension 1 spray in each nostril daily for allergic rhinitis Gabapentin 300 mg capsule 3 capsules 3 times daily for neuropathy Megestrol Acetate Suspension 20 milliliter in the morning for anorexia 2 cal supplement 60 ml 4 times daily with medications Methotrexate Sodium 6 -2.5 mg tablets every Monday for Rheumatoid Arthritis. A review of Resident B's Medication Administration Record (MAR) from 3/1/25 to 3/3/25, indicated the resident did not receive any of the prescribed medication as follows: On 3/2/25 charted as not given due to nausea and vomiting- 8:00 P.M., Doxepin, Fluvoxamine, Geodon, 9:00 P.M., Seroquel, Depakote ER, Glyburide, Hydralazine, Metoprolol Tartrate, Gabapentin, 2 cal supplement. On 3/3/25 charted as resident refusals- 9:00 A.M., Aricept, Flonase, Depakote ER, 2 cal supplement, 11:00 A.M., Atorvastin, Losartan, Megestrol, Methotrexate, Nifedipine, Pioglitazone, Spironolactone, Glyburide, Hydralazine, Metoprolol Tartrate, 1:00 P.M., Trelegy Ellipta, 2 cal supplement, 2:00 P.M., Gabapentin. Review of the resident's nursing progress notes included no notes of any kind on 3/2/25. There were no progress notes regarding the resident's condition until 3/3/25 at 3:00 P.M. that indicated the Nurse Practitioner was called at the request of the resident's representative and orders given for a STAT (immediate) Valproic acid (Depakote) blood level because the resident was unresponsive and not eating. On 3/3/25 at 3:05 P.M., a nursing progress note indicated the lab company did not have available staff for a STAT blood collection so the resident's representative requested the resident be sent to the hospital and RN 6 notified the Nurse Practitioner and received an order to send the resident to the hospital. A Nursing progress note, on 3/3/25 at 3:52 P.M., indicated Resident B was transported via a local ambulance service to a local hospital for an evaluation and treatment. Review of the Prehospital Care Report Summary from the ambulance service, dated 3/3/25 from 2:47 P.M. to 3:23 P.M., indicated the onset of Resident B's condition began on 3/2/25 at 11:00 P.M. and the resident had been reported as semi-responsive for 3 days. The Narrative History Text indicated, .Nurse relays that the pt [patient, Resident B] started to become less responsive on the 28th and the nurse relays that they were administering his Depakote wrong. Nurse further relays that pt has not been given any of his medications today due to his responsiveness. Nurse relays that she believed that the pts Depakote levels are too high. Review of Resident B's Emergency Department Note dated 3/3/25 at 10:13 P.M., indicated, .apparently on the past Friday he was receiving doses of Depakote and there is a possibility that he was receiving the wrong dose . Physical examination at 4:36 P.M. indicated an elevated blood pressure of 190/82. and his blood glucose level was 18 mg/DL (milligrams/deciliter) which was corrected after treatment. The Valproic acid level (blood test to determine Depakote level) was within normal range. The Clinical Impression from the Emergency Department assessment indicated Resident B was hypoglycemic (low blood sugar), and had unspecified altered mental status. During an interview on 3/18/25 at 11:00 A.M., LPN 4 indicated Resident B was very difficult to arouse on 3/3/24 and did not take his medications that day because he was not alert enough to take them. LPN 4 indicated the resident had been sleeping more and had been declining for the past few days. LPN 4 indicated she did not notify the physician or the Nurse Practitioner of the residents lack of responsiveness or that he had not been taking his medication, but did report the issues to the Unit Manager, RN 6. LPN 4 indicated she had been checking his vital signs and they had remained within normal limits. There was no documentation LPN 4 had assessed Resident B ' s blood sugar level, even though the resident had a diagnosis of diabetes and had not been eating. During an interview on 3/18/25 at 11:03 A.M., RN 6 indicated on 3/3/25, sometime in the afternoon, LPN 4 requested that she see Resident B. RN 6 indicated the resident's responsible party was upset and concerned that the resident was difficult to arouse. RN 6 indicated she had worked the day shift on 3/3/25 and it had been reported to her that Resident B was very sleepy and had not gotten up for breakfast or lunch and had not taken his medications. RN 6 indicated she notified the Nurse Practitioner of the responsible party's concern and had received an order for Depakote levels per the responsible party's request. and the NP had informed her that if the family was adamant about sending him to the ER, they could send him out. During an interview on 3/18/24 at 11:14 A.M., QMA 2 indicated she was Resident B's QMA on 3/3/25 from 7:00 A.M. to 3:00 P.M. QMA 2 indicated the resident refused his meals and medications on 3/3/25 and she had notified LPN 4 of the refusals. During an interview on 3/19/25 at 10:00 A.M., Registered Nurse (RN) 5, indicated Resident B had been having trouble swallowing his medications and so she had crushed his DepakoteER on the evening of 2/28/25. RN 5 indicated she was not aware that Depakote ER was not supposed to be crushed and had reported to RN 6, who was the Unit Manager, that she had crushed the Depakote ER. RN 5 indicated on 3/2/25 she worked 7:00 P.M. to 7:00 A.M. with Qualified Medication Aide (QMA) 1. RN 5 indicated QMA 1 reported to her that Resident B did not receive his night medications because after she gave them to him, he spit them out refusing to take them. She indicated the resident did not have nausea or vomiting and QMA 1 incorrectly charted nausea and vomiting. RN 5 indicated she should have documented the incident in the progress notes but did not. On 3/18/25 at 10:30 A.M., the Director of Nursing provided an undated policy titled, Notification of Changes, and indicated it was the current facility policy. The policy indicated, .The purpose of this policy is to ensure the facility promptly informs .the resident's physician .when there is a change requiring notification .Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health . This citation relates to Complaint IN00455136 3.1-5(a)(2)

Based on interview and record review, the facility failed to ensure a comprehensive care plans related to type 2 diabetes, seizures, bipolar disorder, congestive heart failure and anxiety were in place for 1 of 3 residents reviewed for care plans, (Resident B) Finding includes: On 3/17/25 at 11:28 A.M., Resident B's medical record was reviewed. Upon admission in September 2024, Resident B had diagnoses which included type 2 diabetes, cerebral infarction (stroke) with other symptoms and signs involving emotional state, vascular dementia, congestive heart failure, chronic obstructive pulmonary disease, hypertension, and seizures. A Quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated Resident B had diagnoses that included stroke, heart failure, hypertension, diabetes, hyperlipidemia, dementia, chronic obstructive pulmonary disease, other symptoms involving emotional state. The assessment indicated the resident received the following High risk medications: antipsychotics, antidepressants, and a diuretic. Review of the resident's MDS dated [DATE] for A Discharge MDS assessment dated [DATE], indicated Resident B was also taking hypoglycemic medications. Physician's orders for medications, included the following: -Glyburide 5 mg tablet 2 times daily for type 2 diabetes, with a start date of 9/26/24. -Ploglitazone HCL 15 mg tablet 1 time daily for type 2 diabetes, with a start date of 9/26/24. -Sitaglipin Phosphate 100 mg tablet every evening for type 2 diabetes, with a start date of 9/26/24. -Steglatro 15 mg tablet every evening for type 2 diabetes, with a start date of 9/26/24. -Fluvoxamine Maleate 100 mg tablet at bedtime for Obsessive-compulsive disorder, with astart date of 11/1/24. -Geodon 40 mg capsule at bedtime for psychiatric condition, with a start date of 10/25/24. -Seroquel 25 mg tablet at bedtime for vascular dementia, with a start date of 11/6/24. -Aricept 10 mg tablet 1 time daily for dementia, with a start date of 1/20/25. -Doxepin HCL 10 mg capsule at bedtime for memory, with a start date of 9/30/24. -Furosemide 40 mg tablet every 24 hours as needed for extremity swelling, with a start date of 9/27/24. -Trelegy Ellipta inhalation Aerosol Powder Breath Activated, 1 puff inhale every afternoon for chronic obstructive pulmonary disease, with a start date of 11/29/24. -Ventolin HFA inhalation aerosol solution 2 puffs inhale every 3 hours as needed for shortness of breath related to obstructive pulmonary disease, with a start date of 9/26/24. -Hydralazine HCL 100 mg tablet 2 times daily for hypertension, with a start date of 9/27/24. -Lorsartan Potassium 100 mg tablet daily for hypertension, with a start date of 9/27/24. -Metoprolol Tartrate 50 mg tablet 2 times daily for hypertension, with a start date of 10/3/24. -Nifedipene extended release 90 mg tablet every morning for hypertension, with a start date of 9/26/24. -Spironolactone 25 mg tablet daily for hypertension, with a start date of 9/26/24. -Depakote extended release 500 mg tablet, 2 tablets 2 times daily, with a start date of 12/3/24. Resident B had no care plans in place to address these conditions nor the medications listed above. During an interview on 3/18/24 at 2:10 P.M., the Minimum Data Set (MDS) nurse, indicated Resident B did not have care plans for diagnoses of type 2 diabetes, cerebral infarction with other symptoms and signs involving emotional state, vascular dementia, congestive heart failure, chronic obstructive pulmonary disease, hypertension, and seizures. The MDS nurse indicated the care plans should have been in place for all diagnoses on admission and for the associated medications when the medications were prescribed. On 3/18/25 at 10:30 A.M., the Director of Nursing provided an undated policy titled, Comprehensive Care Plans, and indicated it was the current facility policy. The policy indicated, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial need and ALL services that are identified in the resident's comprehensive assessment .the comprehensive care plan will describe, at a minimum, .The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . This citation relates to Complaint IN00455136. 3.1-35(a)

Based on interview and record review the facility failed to ensure Physician Orders were in place for the treatment of low blood glucose and failed to ensure hypoglycemia was assessed timely for 1 of 3 residents reviewed for diabetic treatment, (Resident B). Finding includes: On 3/17/25 at 11:28 A.M., Resident B's medical record was reviewed. Diagnoses included history of stroke, seizures, heart failure, hypertension, diabetes, hyperlipidemia, dementia, chronic obstructive pulmonary disease, other symptoms involving emotional state. A Quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated Resident B was severely cognitively impaired and was sometimes able to make his his needs and ideas known. Physician's orders included the following medications: -Glyburide 5 mg tablet 2 times daily for type 2 diabetes, ordered 9/26/24. -Ploglitazone HCL 15 mg tablet 1 time daily for type 2 diabetes, ordered 9/26/24. -Sitaglipin Phosphate 100 mg tablet every evening for type 2 diabetes, ordered 9/26/24. -Steglatro 15 mg tablet every evening for type 2 diabetes, ordered 9/26/24. There were no orders for hypoglycemia management and no plan of care to address Resident B 's diabetes diagnosis. Review of the resident's nursing progress notes indicated on 3/3/25 at 3:00 P.M., the Nurse Practitioner was notified by Registered Nurse (RN) 6, that Resident B's family wanted the resident sent to the hospital because he was not very responsive. On 3/3/25 at 3:52 P.M., Resident B was transported via local ambulance service to a local hospital for an evaluation and treatment. Review of Resident B's Emergency Department Note, dated 3/3/25 at 10:13 P.M., indicated the resident had a blood glucose of 18 mm/dl. The Clinical Impression indicated the Resident B was hypoglycemic (had low blood sugar) and had unspecified altered mental status. During an interview on 3/18/25 at 11:00 A.M., LPN 4 indicated Resident B was very difficult to arouse on 3/3/24 and did not take his medications that day because he was not alert enough to take them. LPN 4 indicated the resident had been sleeping more and had been declining for the past few days. LPN 4 indicated she had not notified the physician or the Nurse Practitioner of the resident 's lack of responsiveness or that he had not been taking his medication, but she had reported Resident B 's condition to the Unit Manager, RN 6. LPN 4 indicated she was checking his vital signs routinely and they had remained within normal limits, but she had not checked the resident ' s blood sugar. During an interview on 3/18/25 at 11:03 A.M., RN 6 indicated on 3/3/25, sometime in the afternoon, LPN 4 had requested that she go see Resident B. RN 6 indicated the resident's responsible party was present and they were upset and concerned that the resident was difficult to arouse. RN 6 indicated she had worked the day shift on 3/3/25 and it had been reported to her that Resident B was very sleepy, and had not gotten up for breakfast or lunch and had not taken his medications. RN 6 indicated she notified the Nurse Practitioner of the responsible party's concern, on 3/3/35 at 3:00 P.M. and had received an order to send the resident to the emergency room (ER), per the family's request. During an interview on 3/18/24 at 11:14 A.M., QMA 2 indicated she was Resident B's QMA on 3/3/25 from 7:00 A.M. to 3:00 P.M. QMA 2 indicated the resident had refused his meals and medications on 3/3/25 and she had notified LPN 4 of the refusals. On 3/18/25 at 3:30 P.M., the Director of Nursing provided an undated policy titled, Hypoglycemia Management, and indicated it was the current facility policy. The policy indicated, .The facility will identify residents that are at risk for hypoglycemia and observe them for signs and symptoms of low blood sugar .Residents that have a diagnosis of diabetes or on medications that could lower the blood sugar should have orders for glucose monitoring and treatment of hypoglycemia .a bedside blood glucose test should be administered for any resident reporting or experiencing symptoms of hypoglycemia such as .Confusion .Feeling sleepy, Weakness or having no energy . This citation relates to Complaint IN00455136 3.1-37(a)

Based on observation, record review, and interview the facility failed to notify the physician for significantly elevated blood glucose levels for 1 of 1 resident reviewed for blood glucose (Resident 45). Finding includes: On 9/23/2024 at 11:06 A.M., a record review was completed for Resident 45. Diagnosis included, but were not limited to: Type 2 diabetes A Physicians' order, dated 7/30/2024, indicated the provider was to be notified if Resident 45's blood glucose levels were below 60 mg/dl or above 400 mg/dL. A review of Resident 45's blood glucose results indicated the record lacked documentation the physician was notified of elevated blood glucose levels above 400 mg/dl for the following dates and times: - On 9/13/2024 at 12:33 P.M., Resident 45's blood glucose level was 420n mg/dl. - On 9/15/2024 at 1:08 P.M., the residents blood glucose level was 433 mg/dl. - On 9/20/2024 at 11:41 A.M., the residents blood glucose level was 450 mg/dl and at 5:06 P.M., the residents blood glucose level was 416 mg/dl. During an interview, on 9/23/2024 at 1:37 P.M., the Administrator indicated blood glucose levels that were out of parameters should have been charted in a nursing progress note or the triage book located on the unit. During an interview, on 9/23/2024 at 2:15 PM, the Director of Nursing (DON) indicated Resident 45 switched rooms recently and there were triage binders for each hall. The binder on his previous hall may have contained a notification to the Nurse Practitioner (NP). However, a review of the triage binders on both halls with the DON indicated there were no notes to the NP indicating she was contacted regarding the resident's out of range blood glucose levels. During an interview, on 9/24/2024 at 10:21 A.M., RN 5 indicated when a resident's blood glucose was out of range, he notified the doctor and put in a nursing progress note. RN 5 indicated there should have been a note associated with Resident 45's high blood glucose levels above 400 mg/dl, but there was not. A current facility policy, titled Notification of Changes, undated and received from the Administrator on 9/23/2024 at 3:07 P.M., indicated the following: Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the residents (sic) physician; and notifies, consistent with his or her authority, the residents representative when there is a change requiring notification. 3.1-5(a)(2)

Based on observation, interview and record review, the facility failed to respond to a resident's grievance requesting services in a timely manner for 1 out of 1 residents reviewed for grievances. (Resident L) Finding includes: During an interview on 9/19/2024 at 2:23 P.M., Resident L indicated no one had done range of motion exercises with him, nor had he received any therapy. He indicated he came to the facility so he could get therapy, and he did ask the Administrator for therapy. A record review was completed, on 9/23/2024 at 2:13 P.M., for Resident L. Diagnoses included, but were not limited to: hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, spastic hemiplegia affecting left nondominant side, and colostomy status. A Grievance Form, dated 8/5/2024, indicated Resident L was concerned with the wait time in the morning to get his colostomy bag dumped, and wanting further therapy. The form indicated it was resolved on 8/5/2024 with a response of discussed restorative options upcoming and the Medicaid payer. During an interview on 9/25/2024 at 10:14 A.M., the Director of Rehab indicated she could not evaluate a new admission with straight Medicaid funding for a payer source for rehabilitation services without the permission of the Administrator. She believed the money to pay for skilled services came out of the daily rate Medicaid paid for long term services. She indicated she had been approached by Resident L indicating he wanted therapy. She indicated she had informed the Administrator, after his admission, that Resident L would benefit from therapy. During an interview on 9/27/2024 at 8:55 A.M., the Administrator indicated the facility did not offer a restorative program because she did not have anyone in that position. She indicated if someone came in with Medicaid as their payer source, the facility did not get any reimbursement for the therapy services and the facility had to pay out of pocket. She confirmed there was a resident that had approached her to request therapy services and she had completed a grievance form related to the concern. The Administrator indicated the resident requesting therapy services got around in his motorized wheelchair and went outside and smoked cigarettes. A Physician's Order, dated 9/21/2024, indicated physical therapy three times a week for 12 weeks with skilled therapy services including therapeutic exercises, activities, gait training, group therapy, neuromuscular re-education, patient/caregiver education for the treatment diagnosis of muscle weakness and other abnormalities of gait and mobility. During an interview on 9/27/2024 at 9:49 A.M., the Administrator indicated she gave responses back from a grievance within 5 days. The Administrator gave no explanation as to why the grievance, filed by Resident L on 8/5/2024 was not addressed completely until 9/21/2024 when the resident was evaluated by the therapy department and a physician's order for therapy was received. On 9/26/2024 at 10:10 A.M., the Administrator provided a policy titled, Resident and Family Grievances, revised 2/2023, and indicated it was the policy currently used by the facility. The policy indicated .1. The Executive Director has been designated as the Grievance Official. 10. Procedure: d. The Grievance Official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form. i. Steps to resolve the grievance may involve forwarding the grievance to the appropriate department manager for follow up. ii. All staff involved in the grievance investigation or resolution should make prompt efforts to resolve the grievance and return the grievance form to the Grievance Official. Prompt efforts include acknowledgement of complaint/grievance and actively working toward a resolution of that complaint/grievance. e. The Grievance Official, or designee, will keep the resident appropriately apprised of progress towards resolution of the grievances . 3.1-7(2)

Based on observation, interview and record review the facility failed to provide equal access to services including specialized rehab to a resident with Medicaid payer source for 1 of 1 resident reviewed for rehab services. (Resident L) Finding includes: During an observation and interview on 9/19/2024 at 2:23 P.M., Resident L indicated no one had completed range of motion exercises with him, nor had he received any therapy. He indicated he came to the facility so he could receive therapy and he had asked for therapy. His left leg was no longer straight, he could not open up his hand and had lost range of motion to his left arm. He had received a soft splint to the left hand prior to his admission to the facility but had to ask for someone to put it on him. In addition, he also had an ankle foot orthosis (AFO) for his left foot but felt it was too tight. A record review was completed on 9/23/2024 at 2:13 P.M., for Resident L. Diagnoses included, but were not limited to: hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, spastic hemiplegia affecting left nondominant side, and colostomy status. An Admission Minimum Data Set (MDS) assessment, dated 7/1/2024, indicated Resident 37 needed partial/moderate assistance for personnel hygiene, required substantial/maximal assistance for shower/bathing and transfer needs, and had impaired range of motion, on one side of his body, to the left upper and lower extremity. A Baseline Care Plan, dated 6/26/2024, indicated Therapy 1. Physical functional goals b. improve functional status, c. minimize decline, 2. Therapy services a. Physical therapy, b. occupational therapy. A Physician's Order, dated 9/21/2024, indicated physical therapy 3 times a week for 12 weeks with skilled therapy services including therapeutic exercises, activities, gait training, group therapy, neuromuscular re-education, patient/caregiver education for the treatment diagnosis of muscle weakness and other abnormalities of gait and mobility. A Physical Therapy Evaluation and Plan of Treatment, dated 9/21/2024, indicated Reason for Therapy: Clinical Impression/Reason for Skilled Services: Based upon patient's body regions, systems and structures, patient presents with balance deficits, decreased dynamic balance, decreased functional capacity, decreased ROM, strength impairments and pain and in consideration of history, personal factors, and functional limitations documented in this eval summary, patient requires skilled PT services to increase LE ROM and strength, minimize falls, increase functional activity tolerance, improve dynamic balance and facilitate discharge planning, in order to return to prior level of functional abilities. Due to the documented physical impairments and associated functional deficits, without skilled therapeutic intervention, the patient is at risk for: falls , further decline in function and immobility. During an interview on 9/25/2024 at 10:14 A.M., the Director of Rehab (DOR) indicated she could not evaluate a new admission with Medicaid as a payer source for rehabilitation services without the permission of the Administrator. The DOR had been approached by Resident L who indicated he wanted therapy. She had informed the Administrator after his admission that she believed Resident 37 would benefit from therapy. The only evaluation she was allowed to complete was the power scooter mobility assessment for safety. The Administrator had approved Resident 37's therapy on 9/21/2024 and he was evaluated and placed on therapy services for physical and occupational therapy. She was not certain if Resident 37 had experienced a decline in mobility since she was not allowed to evaluate him upon his admission. There was no other explanation given by the Rehabilitation Director as to why there was a delay regarding completing an evaluation of Resident 37 for therapy needs since his admission and since he had requested to be evaluated. During an interview on 9/25/2024 at 2:00 P.M., the Business Office Manager (BOM) indicated if a Resident who had Medicaid as a payer source had a physician's order for a therapy assessment, a physician's order for therapy services and there was an indication the resident needed therapy, they would be eligible to receive therapy services. During an interview on 9/26/2024 at 8:55 A.M., the Administrator indicated the facility did not offer a restorative program because she did not have anyone in that position. If a resident was admitted with Medicaid as a payer source, the facility did not receive any reimbursement for therapy services for that resident. She indicated the facility had to pay out of the pocket for the resident's skilled rehabilitation therapy. She confirmed there was a resident that had approached her requesting therapy and she indicated she had addressed the request in on a written grievance. She indicated Resident 37 had not experienced a decline and had not needed therapy services because he got around in his motorized wheelchair and went outside and smoked cigarettes. During an interview on 9/26/2024 at 9:49 A.M., the Administrator indicated Resident L came in at his baseline and the reason she offered him therapy services now was because in talking with the Director of Rehab, she indicated Resident L would benefit from upper body strengthening. During an interview on 9/26/2024 at 9:53 A.M., the DOR indicated therapy department would be working on transfers and overall strengthening. The DOR indicated, he currently needed assistance with transfers. On 9/26/2024 at 9:06 A.M., the Administrator provided a policy titled, Specialized Rehabilitation Services, and indicated the policy was the one currently used by the facility. The policy indicated .5. Specialized rehabilitative services are considered a facility service and included within the scope of facility services; therefore, if services are not enumerated in the State plan, the facility will not charge a Medicaid recipient for specialized rehabilitative services . This citation relates to Complaint IN00443668.

Based on record review and interview, the facility failed to complete a Significant Change Minimum Data Set (MDS) assessment timely for 2 of 3 residents reviewed for Hospice services. (Residents 16 & 28) Findings include: 1. Resident 16's record review was completed on 9/23/2024 at 3:10 P.M. Diagnoses included, but were not limited to: chronic obstructive pulmonary disease, traumatic brain injury, depression, bipolar disorder and anxiety disorder. Resident 16 had a signed hospice contract, initiated on 3/28/2024. A current Physician's order indicated Resident 16 had been receiving Hospice services since 3/28/2024. A Quarterly MDS assessment, dated 3/19/2024, indicated Resident 16 was not receiving Hospice services. A Significant Change MDS assessment, dated 6/19/2024, indicated the resident was receiving Hospice services. Resident 16's record lacked the documentation a Significant Change MDS had been completed timely after the Physician's order was received on 3/28/2024 for Hospice services. During an interview on 9/24/2024 at 9:50 A.M., the Regional MDS Nurse indicated a Significant Change MDS should be completed within 14 days of the initiation of Hospice services for any resident. She indicated Resident 16 should have had a Significant Change MDS assessment completed 14 days after 3/28/2024. 2. Resident 28's record review was completed on 9/24/24 at 9:30 A.M. Diagnoses included, but were not limited to: epilepsy, type 2 diabetes mellitus, Chrohn's disease, dysphagia, spinal stenosis and benign prostatic hyperplasia. Resident 28 had a signed Hospice agreement for Heart to Heart Hospice dated 8/2/2024. A current Physician's order indicated Resident 28 had been receiving Hospice services since 8/12/2024. A Quarterly MDS assessment, dated 6/14/2024, indicated Resident 28 was not receiving Hospice services. A Quarterly MDS assessment, dated 8/16/2024, indicated Resident 28 was receiving Hospice services. Resident 28's record lacked the documentation a Significant Change MDS assessment had been completed within 14 days from the Hospice order on 8/2/2024. During an interview on 9/24/2024 at 9:50 A.M., the Regional MDS Nurse indicated a Significant Change MDS assessment should be completed within 14 days of any resident starting hospice services. Resident 28 should have had a Significant Change MDS assessment completed 14 days after he was readmitted to the facility on [DATE] with Hospice services. The Regional Nurse indicated the facility does not have a policy for MDS assessments, but they used the RAI (Resident Assessment Instrument) manual. 3.1-31(d)(1)

Based on observation, record review and interview, the facility failed to complete and maintain grooming for 3 of 4 residents reviewed for activities of daily living (ADLs). (Residents 15, L and 21) Findings include: 1. During an observation and interview on 9/19/2024 at 1:53 P.M., and 9/20/2024 at 1:53 P.M., Resident 15's nails were long with a dark substance under them. He indicated no one had offered to clean or trim his nails. During an observation on 9/23/2024 at 9:14 A.M. and 9/24/2024 at 9:17 A.M., Resident 15's nails were long with a dark substance under them. A record review was completed, on 9/25/2024 at 11:36 A.M., for Resident 15. Diagnoses included, but were not limited to: Parkinson's Disease without dyskinesia, chronic kidney disease stage 3, and chronic embolism and thrombosis of deep veins of right upper extremity. An Admission Minimum Data Set (MDS) assessment, dated 8/9/2024, indicated Resident 15 required substantial/maximal assistance for personal hygiene and bathing. A current Care Plan, initiated on 8/1/2024, for activities of daily living indicated Resident 15 had a self- care deficit with shaving, washing his face and hands and combing his hair. A current Care Plan, dated 9/17/2024, indicated Resident 15 often refused to have his nails, beard and hair cut. A Review of the Electronic Medical Record for Resident 15, specifically of the Nursing Progress Notes and the Task section , indicated there was no documentation of any refusals of nail care since his admission. During an interview, on 9/25/2024 at 10:46 A.M., CNA 2 indicated when he provided morning ADL care he assisted with washing of the face, chest, peri care, applied body spray, dressed and brushed their hair. When he provided a shower, he assisted with washing, rinsing, drying, dressing and combing their hair. During an interview on 9/25/2024 at 10:54 A.M., CNA 3 indicated when she completed morning ADL care she assisted with a partial bath unless they wanted a complete bed bath. She then assisted the residents to get dressed and transferred them. If she provided a shower, she started with washing their hair, then worked her way down the body, dried the resident's body, then she applied lotion, deodorant, dressed the resident and dried their hair. During an interview on 9/25/2024 at 11:02 A.M., CNA 4 indicated when she provided morning ADL care she washed their face and under their arms, provided peri care, applied deodorant body spray, dressed and brushed their teeth. If a shower was provided, she washed their body from clean to dirty, dried their body, applied lotion, clothing and if there were any skin issues, she told the nurse. During an interview on 9/25/2024 at 11:51 A.M., LPN 13 indicated any resident refusals of ADL care would be entered in the nursing progress notes by the nurse and CNA's documented refusals under the electronic application. 2. During an observation and interview on 9/19/2024 at 2:15 P.M., Resident L indicated staff had not offered to shave him. He wanted to grow a mustache and a goatee but wanted the sides/cheek/neck area shaved. He indicated the other day his Dad used the electric shaver but he preferred a closer shave with a razor. His left hand fingers were curled under into a fist and he could not open it unless he opened it with his right hand. Resident L's left arm had limited movement. During an observation and interview on 9/23/2024 at 9:16 A.M., Resident L indicated the Administrator had came into his room this morning and asked if he would like to be shaved and have his nails trimmed . During an observation and interview on 9/23/2024 at 1:32 P.M., he indicated no one had assisted him with shaving or nail care. During an observation and interview, on 9/24/2024 at 9:15 A.M. and 2:00 P.M., Resident L indicated he was not offered a shave and his finger nails were not trimmed yesterday. During an observation and interview on 9/24/2024 at 10:40 A.M., Resident L had increased growth of facial hair on his neck, sides/cheek of his face and a brown substance under his long nails. He indicated no one had offered to assist him with shaving or nail care. A record review was completed, on 9/23/2024 at 2:13 P.M., for Resident L. Diagnoses included, but were not limited to: hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, spastic hemiplegia affecting left nondominant side, and colostomy status. An Admission MDS assessment, dated 7/1/2024, indicated he needed partial/moderate assistance for personnel hygiene and he required substantial/maximal assistance for showering and bathing needs. A current Care Plan, initiated on 6/27/2024, titled ADL self care deficit, included interventions for personal hygiene assistance with shaving, washing his face and hands and combing his hair. During an interview on 9/25/2024 at 10:46 A.M., CNA 2 indicated when he performed morning ADL care he assisted with washing of the face, chest, peri area, applied body spray, dressed and brushed their hair. When he provided a shower, he assisted with washing, rinsing, drying, dressing and combing their hair. During an interview on 9/25/2024 at 10:54 A.M., CNA 3 indicated when she provided morning ADL care she assisted with a partial bath unless they wanted a complete bed bath, dressed them and transferred them. If she provided a shower, she started with washing their hair then worked her way down the body, dried the body, applied lotion, deodorant and then dressed and dried their hair. During an interview on 9/25/2024 at 11:02 A.M., CNA 4 indicated when she provided morning ADL care she washed their face, under their arms and their peri area, applied deodorant body spray, dressed and brushed their teeth. If a shower was provided, she washed their body from clean to dirty, dried the body, applied lotion, clothing and if any skin issues were noted, she told the nurse. During an interview on 9/25/2024 at 11:51 A.M., LPN 13 indicated any refusals of ADL care would be entered in the nursing progress notes by the nurse and CNA's documented refusals under the electronic application. 47419 3. During an observation on 9/20/2024 at 9:44 A.M., Resident 21 was found to have long fingernails with a dark brownish-black substance under them. During an observation on 9/23/2024 at 1:21 P.M., Resident 21's fingernails remained long with a dark brownish-black substance under them. A record review for Resident 21 was completed on 9/24/2024 at 2:52 P.M. Diagnoses included, but were not limited to, dementia, chronic obstructive pulmonary disease and mild intellectual disabilities. A Quarterly Minimum Data Set assessment, dated 7/19/2024, indicated Resident 21's cognition was moderately impaired. There were no behavior concerns and he required partial or moderate assist with showers and set up assist for personal hygiene. A current Care Plan problem, initiated on 7/11/2024, indicated Resident 21 needed staff assist for ADLs and grooming. An intervention indicated the resident required assist of 1 staff member for hygiene and grooming. There was no documentation of Resident 21 had refused any hygiene or grooming assistance. During an interview on 9/25/2024 at 1:58 P.M., CNA 12 indicated when she provided personal care, for bathing or showering, she cleaned the resident from head to toe, assisted with oral care and provided nail care. If the resident refused care, she reported it to the nurse. On 9/25/2024 at 1:26 P.M. the ED provided a current policy, dated February 2023 and titled, Activities of Daily Living (ADLs). The policy included, but was not limited to, .Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care; . 3.1-38(3)(D)(E)

Based on observation, interview and record review, the facility failed to ensure a resident received adequate treatment and monitoring for a pressure ulcer for 1 out of 3 reviewed for pressure ulcers. (Resident 37) Finding includes: During an interview and observation on 9/19/2024 at 11:04 A.M., Resident 37 indicated he had a sore on the back of his left upper thigh. He told the nurse about it 3-4 weeks ago. The dressing covering the sore came off and he told the nurse and she was going to replace it. He indicated the sore was caused by his wheelchair cushion and they gave me a new cushion. The residents skin was observed and there was a circular crater the size of a nickel with swollen, raised edges and loose skin around the edges. Resident 37 indicated staff placed a patch on the wound every couple of days when he asked for one. During an observation and interview on 9/20/2024 at 9:31 A.M., Resident 37 indicated the facility placed a patch on his wound yesterday around 1 P.M. There was a white dressing undated, no initials and there was visible drainage coming through the dressing. During an interview on 9/23/2024 at 3:07 P.M. Resident 37 indicated the dressing had been changed this morning and when he went to the wound clinic, they placed a new dressing on it. During an interview and observation on 9/24/2024 at 2:04 P.M., Resident 37 indicated no one had changed the wound dressing for the day. The wound was observed to have a gauze with tape over it, undated. He indicated he had to ask for the dressing to be changed but RN 7 changed it every weekend. A record review was completed on 9/24/2024 at 1:30 P.M., for Resident 37. Diagnosis included, but were not limited to: chronic venous hypertension with ulcer of bilateral lower extremity, and peripheral vascular disease. A Significant Minimum Data Set (MDS) assessment, dated 7/31/2024, indicated the resident had normal cognition. A Nursing Progress Note, dated 9/11/2024 at 10:32 A.M., indicated resident had 2 open areas on his posterior left leg, the first area measured 2 cm by 1 cm and the other area measured 1 cm by 1 cm. There was no odor, drainage or warmth of the wounds noted. The Physician, Unit Manager and Optum staff were made aware of the wounds, and nursing continued to monitor the wounds. A Weekly Skin Review, dated 9/13/2024, indicated Resident 37 skin was intact. A Weekly Skin Review, dated 9/20/2024, for Resident 37 indicated Pre-existing open areas to BLE treated by wound clinic and wrapped. Continue with current wound care treatment to back and legs. No new open areas or skin concerns noted. A Progress Note from the wound care office, dated 9/16/2024, indicated Patient present for care of wound to posterior leg. He notes it is likely from his wheelchair. He reports soreness. The left thigh measurements 1.5 by 1.7 by 0.1 depth, wound depth full, stage 2. The Assessment & Plan-[no debridement due to tenderness. We will dress with medihoney to help with enzymatic debridement. Follow up in 1-2 weeks. Wound Care Orders: Cleanse with mild soap water, Change Frequency: once daily, Cover with: dry gauze secure with tape. A Progress Note from the wound care office, dated 9/23/2024, indicated Patient presents for follow up to posterior left thigh. Measurement Pre Debridement 1.3 cm by 1.5 cm by 0.1 cm. moderate amount of serosanguineous exudate, Wound Depth: full, stage 2. Measurement Post Debridement: 1.4 by 1.6 by 0.1. The Assessment & Plan-was to continue with medihoney dressings. Follow up in 1 week. Wound Care Orders: Cleanse with soap and water, Change Frequency: once daily, Dressing: Medihoney Gel, Cover with: dry gauze secure with tape. Offloading:cushion/Pressure relief. During an interview on 9/24/2024 at 9:21 A.M., RN 6 indicated Resident 37 did not have any wounds the facility monitored or treated. RN 6 indicated the resident received three different creams: one for his knee pain, Clotrimazole to his knee redness and Cetaphil lotion for his back. During an interview on 9/24/2024 at 11:18 A.M., RN 8 indicated if she found a new open area, she would do an assessment, document the location, measurements, note any drainage and stage the area. Under the assessment tab of the electronic medical record, she would document the wound on a skin weekly review form. She would notify the doctor, family and the manager on duty and then she would complete a risk assessment if it was a pressure area. During an interview and observation, on 9/24/2024 at 2:14 P.M., RN 7 indicated after reviewing his orders he did not have any dressing changes ordered, he used to have a wound treatment but now went to the wound clinic for his lower legs. RN 7 was requested and completed a skin assessment and noted the following area to the back of the upper thigh- a 1.5 centimeters (cm) by 2.0 cm, by 0.1 cm in depth circle with moderate amount of green yellow drainage with erythema (redness) around the area, measuring 3 cm by 4 cm. RN 7 indicated if had possibly been a blister that had popped and he was going to have the wound nurse asses the wound and notify the DON. There was an undated dressing on the wound when RN 7 began his assessment. During an interview on 9/26/2024 at 10:01 A.M., the DON indicated a wound was measured once a week during wound rounds by the wound nurse. Staff documented wounds on the UDS's (Electronic Medical Record) under the assessment tab called Skin Only Evaluation. If a nurse found a wound on a weekly skin assessment, the DON expected the nurse to document the new area, notify the nurse practitioner and obtain an order for treatment of the wound. In addition, a care plan would be initiated after the order for treatment was received. On 9/25/2024 at 9:20 A.M., the Regional Nurse provided a policy titled Notification of Changes, dated 2/2023, and indicated the policy was the one currently used by the facility. The policy indicated . Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Compliance Guidelines: 3. Circumstances that require a need to alter treatment. This may include: a. New Treatment. On 9/25/2024 at 9:20 A.M., the Regional Nurse provided a policy titled, Skin Assessment, dated 2/2023, and indicated the policy was the one currently used by the facility. The policy indicated . It is our policy to perform a full body skin assessment as part of our systemic approach to pressure injury prevention and management. The policy includes the following procedural guidelines in performing the full body skin assessment. Policy Explanation and Compliance Guidelines: 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury . On 9/26/2024 at 11:12 A.M., the Administrator provided a policy titled, Clean Dressing Change, dated 2021, and indicated the policy was the one currently used by the facility. The policy indicated . It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Physician's orders will specify type of dressing and frequently of changes . 3.1-40(a)(2)(3)

Based on observation, interview, and record review, the facility failed to ensure the lint trap of two dryer vents were removed every two hours to prevent a fire. This deficient practice had the potential to affect 58 of 58 residents who reside in the facility. Finding includes: During a tour of the laundry room on 9/26/2023, from 9:06 A.M. to 9:15 A.M. two of the dryers' lint traps were inspected and both had a thick layer of white lint covering the filter and pieces of lint on the floor of the machine. Both dryers were full of a completed load inside. A log titled, Dryer Clean Out Schedule, was taped to the first dryer without an initial from the laundry aide indicating that it was cleaned at 6:00 A.M. and 8:00 A.M. for 9/26/2023. During an interview, on 9/26/2023 at 9:06 A.M., The Maintenance Director indicated that the lint trap is emptied every 2 hours. During an interview, on 9/26/2023 at 9:11 A.M., the Laundry Aide indicated that she did not clean out the lint traps since she has been here this morning and it should have been cleaned out every two hours at 6 and 8 A.M. On 9/26/2023 at 10:55 A.M., the Transitional Executive Director provided a policy from the Environmental Services Operational Manual titled, C. Lint Screens, revised 9/5/2017, and indicated the policy was the one currently used by the facility. The policy indicated .These lint screens must be brushed and cleaned after every two hours. If not, the screen will become packed with lint. When this occurs, the warm air moving through the system is blocked, raising the temperature in the basket and causing a potentially dangerous situation: i.e, where one spark on lint can cause a fire : 3.1-19

Based on observation, interview and record review, the facility failed to assess and provide interventions to prevent a contracture which resulted in 10 of 10 pain (a pain scale from 0-10, 0 being no pain and 10 being worst pain they ever felt) for 1 of 2 residents reviewed for contractures. (Resident #13) Findings include: On 4/26/17 at 10:00 AM, Resident #13 was observed to have a wash cloth rolled up in her left hand. A clinical record review was conducted on 4/28/17 at 11:00 A.M., and indicated Resident #13 was admitted to the facility on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. The admission Minimum Data Set assessment (MDS) completed on 4/13/17, indicated for Resident #13 had no impairment to upper extremity (shoulder, elbow, wrist, hand). A form titled Clinical Health Status assessment, dated 4/6/17, indicated for Resident #13 had no limitations for range of motion (ROM). A form titled Joint Mobility Assessment, dated 4/6/17, indicated Resident #13 was unable to make a fist and fully open hand. A Occupational Therapy plan of care, dated 4/6/17, indicates .left hand presents with 3rd, 4th and 5th digits contracted in flexion. During an interview, on 5/1/2017 at 9:34 A.M., the Director of Nursing (DON) indicated Resident #13 did not have a contracture and did not know why she has a wash cloth in her hand. DON indicated that contracture assessments were completed on admission and quarterly. A review of the care plans, on 5/1/2017 at 9:37 A.M., indicated no care plan related to contractures or ROM had been created for Resident #13. During an interview, on 5/1/2017 at 9:57 A.M., the Occupational Therapy assistant (OTA) #5 demonstrated ROM to left hand and indicated that her fingers on left hand are contracted and she had initiated placing a wash cloth in her hand. OTA #5 indicated that Occupational Therapy (OT) does ROM 5 times a week in therapy. OTA #5 indicated therapy care plan and interventions are not in the computer. During an interview at this time, Resident #13 indicated she had a pain level of 10 out of 10 while grimacing and guarding her left hand. During an interview, on 5/1/17 at 10:10 A.M., the MDS RN and DON indicated that therapy care plans and interventions are not in the computer. DON indicated there was no documentation related to ROM interventions for nursing staff. During an interview, on 5/1/2017 at 4:31 P.M., the DON indicated Resident #13 has tightness to one finger and tightness to hand. She indicated nursing doesn't make decision on contractures and nursing does not do anything in the mean time, nothing is done until therapy makes evaluation and gives order. A policy was provided by Medical Records employee, on 5/1/17 at 2:00 P.M., titled GOLDEN LIVING CENTER - MISHAWAKA CONTRACTURE ASSESSMENT POLICY, dated 3/2/16, and indicated this was the policy currently used by the facility. .Residents will be assessed for ROM/contracture(s) upon admission to facility and quarterly thereafter utilizing the admission/quarterly assessment tool. The assessing nurse will document that either no worsening of contracture is noted or that worsening of contracture is noted. If worsening of contracture is noted, nursing will notify therapy, MD and family and will document in IPN. If any changes are noted by C.N.A., C.N.A. will report changes to charge nurse. Charge nurse will report any changes to Unit Manager for follow up A policy was provided by Medical Records employee, on 5/1/17 at 2:00 P.M., titled Pain Management Guideline, dated 2/5/15, and indicated this was the policy was currently used by the facility. .GUIDELINE STATEMENT: To provide guidance for consistent assessment, management and documentation of pain in order to provide maximum comfort and enhanced quality of life, in concert with the patient's/resident's plan of care and goals for pain management 3.1-42(a)(2)

Based on interview and record review, the facility failed to monitor and assess for signs and symptoms of a failing pacemaker, resulting in a fall and subsequent broken nose for 1 of 3 residents reviewed for falls. (Resident #10) Findings include: A clinical record review was conducted on 4/27/17 at 10:49 A.M., and indicated Resident #10 was admitted on [DATE]. Her [DIAGNOSES REDACTED]. A nurses note, dated 3/24/17, Resident #10 had indicated .I CAN'T WAIT TO GET THIS PACEMAKER FIXED and indicated she did not have much energy. A nurses note, dated 3/25/17, indicated Resident #10 complained about dizziness and indicated .I JUST FEEL SO DIZZY, I JUST DON'T FEEL GOOD A nurses note, dated 3/25/17, Resident #10 had indicated I AM NOT FEELING WELL A nurses note, dated 3/28/17, Resident #10 indicated she was feeling tired and weak. A review of nurses notes for 3/29/17 indicated Resident #10 complained of not feeling well at 10:39 A.M., and complained of feeling tired and weak at 3:03 P.M. A nurses note, dated 3/29/17 at 8:54 P.M., indicated Resident #10 was found on the floor with a pool of frank blood under her head. A nurses note, dated 3/30/17, indicated Resident #10 had a broken nose. A review of Resident #10's clinical chart indicated no revisions for monitoring or interventions related to her weakness, dizziness, and failing pacemaker until 3/28/17. During an interview, on 4/27/17 at 10:30 A.M., the DON (Director of Nursing) indicated the care plan had not been revised prior to Resident #10's fall. During an interview on 4/27/17 at 11:00 A.M. the MDS (Minimum Data Set) staff indicated there should have been a care plan when she started to complain of dizziness. During an interview on 4/27/17 at 11:12 A.M., Certified Nursing Assistant #7 indicated the nurses did not educate her on any new things to watch for, in regards to caring for a resident with a pacemaker prior to and following a fall. A policy was provided by the E.D. ( Executive Director) on 4/27/17 at 10:57 A.M., titled Falls Management Guidelines, dated 4/3/17, and indicated this was the policy that is currently used by the facility. .Appropriate interventions are implemented. (See tool: Resource for Resident Interventions to Prevent Falls attached.) .Care plan is updated And .Residents at risk for falls are care planned with individualized interventions And '' .Communication system to identify the residents at risk for falls 3.1-45(a)(2)

Based on observation, record review and interview, the facility failed to provide adequate supervision to prevent an accident that resulted in the resident sustaining blistering burns to her breast and abdomen that required ongoing treatment and assessment for healing and prevention of infection for 1 of 1 residents reviewed for accidents. (Resident B) Finding includes: On 6/2/15 at 9:05 A.M., the clinical and electronic medical record for Resident B was reviewed. Resident B was admitted to the facility, on 11/19/14. The [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment, dated 3/23/15, indicated a BIMS (Brief Interview for Mental Status) of 2 out of a possible 15, which indicated severe cognitive impairment. Resident B required one person physical assist for eating her meals. Review of the Certification of Investigation, dated 5/17/15, indicated, .Location Event Occurred: Resident's Room.Date/Time of Occurrence 5/17/15 at 18:37 (6:37 P.M.).Provide A Detailed Description of Event/Allegation: during supper on Sunday evening resident spilled coffee to her left breast, when area was assessed later found several fluid filled blisters to left breast and to an area slightly under her left breast.Assessment of Resident/Describe Injury: found an area to her left breast that is slightly pink in color measures 6 x 4 cm (centimeters)with several fluid filled blisters measuring from 0.2 x 0.2, 1 x 1, and an L shaped area with 3 fluid filled blisters largest 3.8 x 1 cm and smallest is 2 x 1.2 cm and and area slightly under left breast that is slightly raised and slightly pink in color measures 7 x 10 cm with several fluid filled blisters smallest measures 0.2 x 0.2 cm largest measures 2.2 x 2.3 cm.Resident Interview Summary: i spilled my coffee. Immediate Resident Protection Initiated: when she spilled the coffee at supper a cool compress was applied and resident encouraged to not rub or touch area, but was frequently found rubbing area.Causal/Contributing Factors and Observations: was told by (name of certified nursing assistant #1) that resident takes the top of her cup at times and she falls asleep at times at meals. Specify Recommendations/Interventions Taken To Prevent Reoccurrence: resident should not have hot liquids on her own. Review of a Progress Note, dated 5/17/15 18:37 (6:37 P.M.), indicated, .Situation: during supper resident picked up her coffee cup on her own to take and drink and spilled it down the left side of her chest.Background: Dementia, chronic pain, anxiety, needs assist with ADLs.Assessment: resident called out her breast hurt, staff went to see why resident was calling out, noted her shirt was wet on the left side, resident stated she spilled her coffee, coffee was in a cup with a lid, shirt was removed and area checked, noted a area of approximately 6 x 4cm slightly pink to her left breast and nipple, cool compress was applied, resident continue complains of pain, TLC (tender loving care) given, taken to her room and put to bed, daughter was informed.Responses: MD (medical doctor) and daughter informed of spill, no new orders. Review of a Progress Note, dated 5/17/15 at 21:12 (9:12 P.M.) indicated, . resident resting now, assessed area to left breast, breast continues with a slightly pink area, and now has a slightly pink area to her chest under her left breast , area is 7.5 x 6 cm. Review of a Progress Note, dated 5/18/15 at 1:11 A.M., indicated . follow up spilled coffee, now has several fluid filled blisters to breast and to area under left breast, entire area to left breast is slightly raised measures 6 x 4cm, has 2 small fluid filled blister above the nipple measuring 0.2 x 0.2 cm, to the right of the nipple and slightly above is a slightly filled blister 1 x 0.6 cm, to the right and below the nipple area fluid filled blister measures 1 x 1 cm, and to the left and slightly below the nipple is an L shaped area with 3 fluid filled blisters top measures 2.7 x 1 cm, middle one measures 2 x 1.2 cm and the lower one measures 3.8 x 1 cm, the area slightly below her breast is slightly raised and slightly pink measures 7 x 10 cm, has several different sizes of fluid filled blisters, 4 of them measure 0.2 x 0.3 cm, 0.5 x 0.5 cm, 1.7 x 1cm, 1.6 x 0.8 cm, 1.8 x 1cm, and the largest measures 2.2 x 2.3 cm, resident shows no signs of pain or discomfort at this time. Review of physician's orders [REDACTED].M., indicated, . Cleanse blisters to left breast and below left breast gently with normal saline, apply bacitracin to blisters and reddened areas in thin layer, cover with ABD's to completely cover areas. Change BID (twice daily) and PRN (as needed) until resolved. On 6/2/15 at 10:00 A.M., an observation of the blisters was conducted with the Director of Nursing Services (DNS) while she did wound rounds. 3 areas were observed on the left side of the resident the 1st was located just below her left breast, the 2nd just below on the abdomen and the 3rd on the lower part of the abdomen off to the side. Each of the areas were circular in shape with brown scabbing and yellow slough. The two larger blisters had a small amount of yellow drainage when the old bandage was removed. Each of the blisters had pink surrounding tissue noted with no odor or other indicators of infection. Each blister was treated with Bacitracin (an antibiotic ointment) and covered with an ABD (dressing) pad. During an interview with the DNS conducted at that time, the DNS indicated Bacitracin was clinically indicated related to Resident B's allergy to Sulfa drugs which is a component in the medication normally used to treat burns. On 6/2/15 at 12:00 P.M., an observation was made of Resident B in her room eating her lunch. Resident B's food was served on a divided plate with white weighted looking utensils and she had a brown cup with a white plastic lid on top of it with a small straw sticking out of it. CNA #2 was cueing and assisting Resident B to eat and drink. On 6/2/15 at 3:47 P.M., an interview was conducted with CNA #2. CNA # 2 indicated that Resident B took her meals in the Fireside diningroom where her meals were supervised because she needed cues to eat. CNA # 2 indicated when Resident B was alert she would feed herself and hold the cup and drink the coffee. She loved her black coffee no cream/no sugar when she was alert she would take the lid off of her coffee she didn't want help and wanted to still be in control. On 6/2/15 at 4:10 P.M., an interview was conducted with CNA # 3. CNA #3 indicated that Resident B ate her meals in the Fireside diningroom.Fireside diningroom is an assisted diningroom. We go from table to table to feed resident's. Resident B loves coffee. We would put a lid on her coffee cup and she would take the lid off on occasion and move her drinks around. On 6/3/15 at 2:03 P.M., an interview was conducted with the Director of Nursing Services. The Director of Nursing Services indicated there was no policy related to hot liquids but that anyone who eats in the assisted diningroom had a lid placed over their hot liquids for safety. The Director of Nurses further indicated she was not made aware that Resident B had a history of [REDACTED]. On 6/3/15 at 2:17 P.M., an interview was conducted with the 100 Hall Unit Manager. The Unit Manager indicated that it had not been reported to her that Resident B had a history of [REDACTED]. She further indicated that if she would have known she could have implemented an alternative plan for her. On 6/3/15 at 2:30 P.M., a Kardex (a tool used by the CNA's to alert them to the care needs of a resident) for Resident B was reviewed. The Kardex indicated .Lid on cup all hot liquids and staff supervision. On 6/3/15 at 2:45 P.M., a current policy, provided by the Director of Nursing Services and titled, Feeding the Resident (Dependent Eating), and effective May 2011, was reviewed. The policy indicated, .The purpose of feeding the resident who needs assistance is to: Assist the resident with feeding as necessary.General guidelines for assessment may include, but are not limited to: Need for assistive devices.Diet as ordered.Assistive Devices as needed.Give the resident your complete attention. This Federal tag relates to Complaint #IN 996. 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to monitor an identified area of redness at the edge of a leg cast which resulted in the development of a pressure area for 1 of 3 residents reviewed with leg immobilizer devices in the sample of 3. (Resident #D) Findings include: During orientation tour on 6/20/12 at 8:35 a.m., Resident #D was observed sitting on the side of her bed. The resident had a scar over her right knee area. The resident did not have a cast or immobilizer on her right knee area. On 6/20/12 at 9:30 a.m., the resident was assisted into bed by the DON (Director of Nursing) and the Unit Manager. The resident was positioned on her right side . The resident had two open areas noted to the upper right posterior thigh area. The first area was an open area form the inside of the posterior thigh to the middle of the thigh. The area was approximately 7 cm (centimeters) across and 1.5 cm width. The open area appeared to be in a skin fold of the resident's thigh. There was pale yellowish non stringy patches to the top of the area. The Director of Nursing (DON) cleansed the area and used a cotton tip applicator to open the wound and measured the depth at .3 cm. No odor was noted. The second area was in line with the first area and was measured by the DON at 8.3 cm in length. The tissue was red with small pale whitish raised area. There was no odor noted. The record for Resident #D was reviewed on 6/20/12 at 10:50 a.m. The resident's [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE] from the hospital. The resident had surgery to repair a tendon in her right knee in the hospital on [DATE]. The resident was admitted to the facility with a long leg cast in place to the right lower extremity. The 5/30/12 Minimum Data Set (MDS) admission assessment indicated the resident required limited assistance of staff for toilet use, bed mobility, personal hygiene, and dressing. The assessment also indicated the resident required extensive assistance from staff for transfers. Review of the 5/2012 Nursing Progress Notes indicated an entry was made on 5/31/12 at 8:44 p.m. This entry indicated the cast to the right leg was dry and intact and the resident was able to wiggle her toes freely. There was no further documentation in the 5/12 Nursing Progress notes related to the red area in the upper right thigh in the 5/12 Nursing Progress Notes. Review of the 6/2012 Nursing Progress notes indicated there was no documentation of the red area to the thigh on 6/1/12. An entry made on 6/2/12 at 10:25 p.m. indicated the resident did not complain of cast pain and a red area remained on the upper right thigh to the back of the leg and cushioning to the cast edge was intact. There was no further assessments of the red area between 6/2/12 and 6/7/12. An entry made on 6/7/12 at 5:00 p.m. indicated the resident returned from the orthopedic appointment with the right leg cast removed. The entry also indicated "Has wound issues at the edge of where the cast was." A Physical Therapy Progress Note completed on 5/30/12 indicated the resident was observed to have a sore to the right proximal leg approximately where the long leg cast ends. The Physical Therapist and the Occupational Therapist tried to use a washcloth or mole skin to the area, however the resident indicated it was very tender to touch and the therapist asked the resident if they could try and push the skin in the area a little to place the moleskin and the resident refused. The nursing staff was also informed. An Occupational Therapy Progress Notes completed on 5/30/12 indicated the resident was seen by Occupational Therapy and the resident stated "my cast is cutting and hurting in the back." A red area with a thin line where the cast ended on the resident was noted. The Occupational Therapist informed Physical Therapy about the area and both suggested padding the end of the cast with either a soft wash cloth or a mole skin. When Occupational Therapy and Physical Therapy stood the resident and Occupational Therapy attempted to apply a small amount and when they pushed the resident's skin away from the cast the resident said "no, that are hurts." The therapist asked again and the resident refused. The area appeared "swollen somewhat over top of cast." The resident refused the padding and nursing staff was notified. A 6/7/12 Physician note completed by the Orthopedic surgeon indicated large ulcers were noted as the top of her cast and the ulcers "are plainly visible as the top of the cast is stuck down in them." The note also indicated the cast was removed to see them completely and the medial ulcer was the worst and measured about 2 cm (centimeters) x 12 cm x 2 cm in size. The note also indicated the Physician indicated "doubted this could have gotten this severe in the last 5 days." Physician orders [REDACTED]. The 6/12 Wound Evaluation Flow Sheets were reviewed. A flow sheet initiated on 6/8/12 indicated the resident had a wound related to the cast on the right posterior thigh. The wound measured 14.3 cm x 0.5 cm x 0 cm. Thin serous (bloody) drainage was observed and wound margins were attached with the surrounding skin purple/red in color. An entry for 6/13/12 indicated the wound measured 10.6 cm x 0.3 cm with a scant amount of serous drainage and the surrounding tissue was intact. An entry made on 6/20/12 indicated the wound measured 8.3 cm x 1.5 cm and the surrounding tissue was reddened. A second Wound Evaluation Flow Sheet was initiated on 6/8/12 for a wound to the right thigh medial to posterior. The wound measured 7.7 cm x 0.5 cm with 100% granulation and the surrounding tissue was red and purple. An entry for 6/13/12 indicated the wound measured 7.4 cm x 0.3 cm x 0.2 cm and was healing well. An entry for 6/20/12 indicated the wound measured 6.5 cm x 1.5 cm 0.3 cm. with 90% granulation and the surrounding tissue was reddened. When interviewed on 6/20/12 at 4:30 p.m., LPN #1 indicated she was assigned to care for Resident #D on 6/2/12. The LPN indicated she completed the entry on 6/2/12 at 10:25 p.m. The LPN indicated the resident complained the area was feeling a little sore and the LPN assessed the area. LPN #1 indicated there was a little bit of redness at the area at the top of the cast and she applied gauze to the area. The LPN indicated she had to push the skin to see the area and the area was down inside the cast. When interviewed on 6/20/12 at 12:30 p.m., LPN #2 indicated she had taken care of Resident #D during the time she had a cast in place. The LPN indicated there had been redness along the cast line and staff had been putting ABD (a type of bandage) to the area. LPN #2 indicated the area was red and appeared like an abrasion and the skin was irritated. The LPN indicated the staff encouraged the resident to get out of her chair more and to elevate her legs. The LPN did not recall what day this was but indicated she thought it was on Tuesday and the resident had the cast taken off on Thursday. When interviewed on 6/20/12 at 11:50 a.m., Occupational Therapy (OT) staff #1 indicated Resident #D was admitted with a cast and the resident had talked about it bothering her on 5/30/12. The OT staff indicated she informed the Physical Therapist of the concern and they stood the resident and when she went behind the resident and started to push the skin in by the cast the resident stated it hurt and the resident said not to do it. OT #1 indicated the red line was visible and right on the edge of the cast. When also interview on 6/20/12 at 11:50 a.m. with the above OT staff, Physical Therapist (PT) #1 indicated there was a red line across the area at the cast edge and the area was approximately 4 cm across and she informed the Nurse also. PT #1 indicated she observed the redness more then once and sometimes the area was padded. When interviewed on 6/20/12 at 11:10 a.m., the Director of Nursing (DON) indicated Resident #D was admitted to the facility with a long leg cast to the right leg after surgery. The DON indicated therapy staff reported they observed red area to the resident's posterior thigh area and it appeared to be where the cast ended on 5/30/12. The DON indicated the Nursing staff had attempted to call the Orthopedic Surgeon's office on 5/30/12 and got no answer. PT staff also called the Surgeon's office and told the office staff they could not do cast revision and the office staff told them the surgeon would see the resident at her next appointment. The DON indicated she did have the Medical Director look at the area on 5/31/12 and he indicated maybe it was an abrasion and he did not think she needed anything different at this time. The DON indicated the resident went to the Surgeons office on 6/7/12 and the cast had been taken off. The DON indicated she called the Surgeon after the resident returned to the facility on [DATE] to clarify orders for wound care. The DON indicated the Surgeon informed her he thought the wound looked "deplorable." The DON indicated she observed the area on 5/30/12 an the area looked like it was a red abrasion from rubbing and staff put Kerlix (a bandage that wraps around areas) on the cast area. The DON indicated the resident did not complain anymore and her nursing staff did not report any further problems with the area. The DON indicated she assesses and measures the wounds in the facility once a week and she did not assess the red area after 5/31/12 until the resident returned from the 6/7/12 office appointment. When interviewed via telephone on 6/20/12 at 3:15 p.m., a member of the Surgeon's staff who identified herself as the Surgeon's Medical Assistant indicated she was present with the Surgeon on 6/7/12 when Resident #D was seen in the office. The staff indicated the there was an area present on the inner side of the right thigh and the wound was approximately 6 inches long and one inch deep and it was an open wound and a foul odor was present. The staff indicated the area started in the groin area and went around to the upper posterior thigh area. The staff also indicated a second area on the lateral side appeared as a red blister and was not open. The staff member indicated both of the areas were visible prior to the cast being removed. This federal tag relates to Complaint IN 653. 3.1-40(a)(2)