Every finding on record at Casa of Hobart

Based on record review and interview, the facility failed to initiate and update effective resident-specific interventions to prevent the elopement from the facility of a recently admitted resident with a diagnosis of schizophrenia, a court-appointed guardian and history of running away for 1 of 4 residents reviewed for elopement risk. The resident signed out of the building and exited through the main front door entrance. The nursing staff was unaware of the resident's whereabouts. The resident ambulated approximately 1.5 miles from the facility on a highly traveled road that had no sidewalks. The fire department was dispatched to a private residence after the resident knocked on their door and transported the resident to the hospital. (Resident H)The Immediate Jeopardy began on 5/29/26 when the facility was unaware that the resident had exited the facility without supervision. The resident walked independently and knocked on a stranger's door at 6:55 p.m. The Administrator and Director of Nursing (DON) were notified of the immediate jeopardy on 7/22/26 at 11:49 a.m. The immediate jeopardy was removed and the deficient practice corrected on 6/1/26, prior to the start of the survey, and was therefore Past Noncompliance. Finding Includes: Resident B's closed record was reviewed on 7/21/26 at 3:00 p.m. Diagnoses included, but were not limited to, schizoaffective disorder, brief psychotic disorder, and obesity. The resident was admitted to the facility on [DATE]. On 4/23/36, a temporary guardianship was ordered for the resident, who was declared an incapacitated adult. A Nurse's Progress Note, dated 5/14/26, indicated the resident was admitted to the facility from the Behavioral Health hospital for schizophrenia and a bipolar episode. A Nurse's Progress Note, dated 5/15/26 and written by the Unit Manager, indicated she had called the resident's emergency contact and was told the resident had a court-appointed guardian due to being removed from her home by Child Protective Services (CPS) for abuse from her mom and dad. The emergency contact indicated that the resident would run away and steal in high school. A Wander/Elopement Risk Evaluation, dated 5/17/26, indicated the resident was an elopement risk. There was no elopement care plan. A Progress Note, dated 5/18/26, indicated social services received a return call from Adult Protective Services (APS) and verified the resident had a legal court-appointed guardian. An Initial Psychiatric Evaluation, dated 5/21/26, indicated the resident had a previous history of schizoaffective disorder, bipolar type. She was referred for assessment/management of mood lability and auditory hallucinations. The admission Minimum Data Set (MDS) assessment, dated 5/25/26, indicated the resident was cognitively intact for daily decision making. The resident required set up and supervision for personal hygiene and upper body dressing. All other activities of daily living and transfers were done independently. A Psychiatric Note, dated 5/28/26, indicated the resident had a history of running away from home. Judgment and insight had moderate impairment, and the resident's thought process was delayed /slowed. There were no physician's orders or safety assessment indicating the resident could leave the facility independently. There was no documented guardian approval for the resident to be allowed to leave the facility. A Facility Reported Incident (FRI), dated 5/29/26 at 7:30 p.m., indicated the resident was alert and oriented with a BIMS of 13, and went for a walk down the street. The resident was questioned on the street by the police and transferred to the hospital for evaluation. The resident returned to the facility with no injuries and no new orders. The guardian, family, and physician were notified, and the resident was placed on 1:1 supervision upon her return. A few days after the resident returned to the facility, she started to hear voices and hallucinate. She was sent to the neurobehavioral hospital for evaluation and treatment. Care plans and assessments were updated, and safety interventions were in place upon her return. The facility investigation included the following:A statement, written on 5/29/26 by the receptionist, indicated she refused to give a statement. A statement, written on 5/29/26 by QMA 1, indicated she had last seen the resident at 5:15 p.m. to 5:30 p.m., she had eaten her dinner tray and her roommate's tray. She was in good spirits and walked towards the main (entrance) as always. A statement, written on 5/29/26 by CNA 1, indicated he saw the resident last in the hallway on [NAME] Unit and she had walked right past him. A statement, written on 5/29/26 by CNA 2, indicated she had last seen the resident after picking up meal trays at around 6:00 p.m. Hospital records, dated 5/29/26, indicated the resident was seen in the emergency room at 7:32 p.m. on 5/29/26 and was brought in by the local Fire Department. The resident was discharged two weeks prior from an inpatient psychiatric facility. She had run away from her current long term care facility earlier that day and had knocked on a stranger's door. She was covered in brush. She ran away because that was not her home. She had a history of a learning disability and was suitable for discharge. During an interview on 7/21/26 at 4:11 p.m., LPN 1 indicated the resident's emergency contact reported that the resident would run away because of the abuse at her home and feeling unsafe, not that she ran away from facilities, but she didn't specify that in the progress note. The resident would not talk to facility staff at first, she would lay in her bed with the blanket over her head. She eventually came out of her room a few days later to get snacks or eat a meal. LPN 1 did not feel Resident H was an elopement risk at all, she was alert and oriented to person, place and time, and she was cooperative with no behaviors. During an interview on 7/21/26 at 4:33 p.m., the Administrator indicated the facility did not have a police report because they found out it was not a police matter but a fire department matter. They called the fire department, and they refused to send them any report and said they would need to go through legal. The facility then sent the fire department the guardianship paperwork and the signed guardian HIPPA paperwork but they would still not give the facility any run report, so they were unable to establish an exact timeline. The resident was last seen through staff interviews at 6:00 p.m. During a phone interview on 7/22/26 at 9:01 a.m., a fire department representative indicated 911 was notified by a homeowner at 6:55 p.m. on 5/29/26. The homeowner was told by the resident that she was from the facility, and she had appeared alert and diaphoretic. The homeowner had called 911 due to the resident knocking on her door and asking for help, she had seemed confused. The fire department was dispatched at 7:01 p.m. and arrived at 7:06 p.m. The resident was then transferred to the hospital for evaluation. During an interview on 7/22/26 at 10:57 a.m., the Nurse Consultant indicated the resident resided in a group home prior to going to the behavioral health hospital. She had no indicators that she would elope from the facility, she was alert and oriented and independent. The resident came there for supervision of her medications and some help with activities of daily living (ADLs). The facility reported the incident, investigated it and educated the staff. The resident was on 1:1 supervision when she came back from the ER until she discharged . The receptionist was at the front desk when the resident had signed herself out and that employee no longer worked at the facility and refused to give a written statement. The Director of Nursing (DON) reported the resident started having behaviors and hallucinating after her return, but the resident was safe because she had 1:1 supervision in place. During an interview on 7/22/26 at 1:32 p.m., the Nurse Consultant indicated the DON had edited the wrong elopement risk assessment on 5/30/26. Documents were provided and reviewed. During an interview on 7/22/26 at 1:33 p.m., the Social Service Director (SSD) indicated the resident was not scored as an elopement risk during her 5/17/26 assessment and her document was edited after the elopement on 5/30/26 by the DON. During an interview on 7/22/26 at 2:41 p.m., Physical therapist Assistant (PTA) 1 indicated he did not know Resident H as she was not receiving therapy. The receptionist asked him when he was leaving the building on 5/29/26 if he knew the resident. She said someone just walked past the door, but he did not see anyone walk past the door. He said he would not even know if it was a resident since she was not in therapy. During confidential interview 1 on 7/22/26, the staff member indicated they had worked with the resident and did 1:1 supervision before she had eloped, she was trying to exit-seek. She would act like she was trying to get to the door and was diverted. A nurse was informed, but not sure which nurse. During confidential interview 2 on 7/22/26, the staff member indicated the resident would try to exit-seek a couple times, would walk up to the door, then would be redirected. A nurse was informed, but they were not sure which nurse. During confidential interview 3 on 7/22/26, the staff member indicated they never saw Resident H exit-seek but were told to watch the doors and they needed to keep an eye on her. During confidential interview 4 on 7/22/26, the staff member indicated Resident H would exit-seek, and they notified both the nurse and the QMA. The resident would go towards the door and say she wanted air, and then she would say she wanted to leave. This was prior to her exiting. The facility Elopement policy, updated 7/2025 and received from the Administrator as current, indicated . 1. In the event that any staff member identifies that they cannot find a resident in a place that the resident is anticipated to be, the staff member will alert their supervisor for assistance once affirming that the resident was not signed out on leave .6. In the event that a staff member observes a resident attempting to leave the premises without supervision and is concerned that the resident would not normally be appropriate to do so independently, the staff member will: a. Call for assistance then calmly approach the resident, (attempt to initiate a friendly chat as possible), and in a courteous manner attempt to re-direct or guide the resident back into the facility; b. If the resident is upset or agitated and is not easily re-directed or guided, the staff member will continue walking with the resident either next to or behind them to provide support, supervision, and safety; and c. If the resident is not able to be re-directed or guided and is out of the facility, the staff member will alert another staff member or supervisor for assistance while staying with the resident ( e.g., use of cellular phone, tell the next person the staff member see's to please get assistance, may need to verbally yell out, etc.) . The facility Resident Pass and Sign-Out, policy dated 5/1/23 and received from Administrator as current, indicated . Residents who lack decision making capacity or who have court-appointed guardians shall have passes coordinated with the legal representative and interdisciplinary team (IDT), as appropriate . The past noncompliance immediate jeopardy began on 7/22/26. The immediate jeopardy was removed and the deficient practice corrected by 6/1/26 after the facility implemented a systemic plan that included the following: a full house head count was completed immediately, all residents identified as an elopement risk were reassessed by social services and care plan/interventions were reviewed and updated, staff members were inserviced on sign out procedure, residents at risk for elopement, elopement, how to respond to door alarms and the elopement policy and procedures, elopement drills were conducted on every shift, the exit doors and wander guards were all tested, the elopement book was reviewed for accuracy, and an emergency QA meeting was conducted with the entire leadership team and medical director. Staff were interviewed and indicated that residents who exhibited signs of possible elopement would be reported to the Charge Nurse, DON, and Administrator. Care Plans would be implemented and interventions followed. If a resident was unable to be found, a code pink would be called and an immediate search of the building and surrounding area would be completed, and the Administrator would be notified immediately. The facility will continue to inservice all new staff and remaining staff who have not yet been educated prior to working. Elopement drills will be completed monthly, weekly audits will be completed for wander guards and exit doors, questionnaires with elopement policy will be conducted with 5 staff members three times a week for at least 4 months and reported to QA monthly for 4 months, and resident behaviors would be reviewed/discussed in morning meeting with the interdisciplinary team to ensure residents at risk for elopement had the appropriate interventions in place. The facility will also review progress notes three times a week for exit-seeking behaviors to ensure interventions were in place and review in QA for 4 months. 410 IAC (Indiana Administrative Code) 16.2-3.1-45 (a)(2)

Based on record review and interview, the facility failed to implement their written policies and procedures for reporting an allegation of abuse, related to an allegation of abuse not reported to the Administrator by staff for 1 of 6 residents reviewed for abuse. (Resident L)Finding includes: Resident L's record was reviewed on 7/21/26 at 4:11 p.m. The diagnoses included, but were not limited to, stroke.An admission Minimum Data Set assessment, dated 6/12/26, indicated an intact cognitive status, was dependent on staff for toileting and bed mobility, and was frequently incontinent of bowel.A Nurse's Progress Note, dated 6/10/26 at 6:37 a.m., indicated approximately 30 minutes after incontinence care was provided to the resident by the CNA, the resident was found without the incontinence brief on, feces on the right hand, and smeared on the right side of the stomach and back. The resident indicated someone had been in the room and tied him up, played with his buttocks and smeared the feces on him. An investigation indicated the resident had not been restrained and no one had been in the room since having the earlier incontinent care.During an interview on 7/21/26 at 4:48 p.m., the Nurse Consultant, Director of Nursing, and Administrator indicated they were unaware of the allegation. They indicated the nurse should have reported the allegation immediately to administrative staff.A facility abuse policy, dated 9/1/20 and received from the Administrator as current, indicated the employees of the facility were required to report an allegation of abuse to the administrator immediately.This citation relates to intakes 3013800, 3037666 and 3049740.410 IAC (Indiana Administrative Code) 16.2-3.1-28(a)

Based on observation, record review and interview, the facility failed to ensure infection control practices were in place and implemented related to staff failing to perform hand hygiene after glove removal and direct resident contact for 4 of 8 residents observed during medication administration. (Residents 93, J, 25, and 85)Findings include:The following was observed during medication administration with LPN 5 on 4/6/26:On 4/6/26 at 5:03 p.m., LPN 5 checked Resident 93's blood sugar level busing a glucometer. The LPN did not sanitize her hands prior to putting on her gloves or after she took them off. At 5:10 p.m., LPN 5 checked Resident J's blood sugar level using a glucometer. Again, the LPN did not sanitize her hands prior to putting on her gloves or after she took them off. At 5:20 p.m., LPN 5 proceeded to Resident 25's room to apply a Lidocaine 4% patch (a pain relief patch). The LPN donned a pair of gloves and applied the patch to the resident's left shoulder. The LPN removed her gloves and left the resident's room. She did not sanitize her hands prior to or after removing her gloves. At 5:35 p.m., LPN 5 was preparing Resident 85's medications. She dispensed two pills into the medication cup and proceeded into the resident's room. The LPN did not sanitize her hands prior to preparing the resident's medications. The LPN explained to the resident what medications he was receiving and handed him a glass of water. After the resident was done taking his medications, she took the plastic cup from him and some other things from his overbed table to throw in the garbage. She did not sanitize her hands after leaving the resident's room.During an interview on 4/7/26 at 11:30 a.m., the Administrator indicated the LPN should have sanitized her hands after glove removal and after direct resident contact. The facility Hand Hygiene policy was provided by the Administrator on 4/7/26 at 12:36 p.m., the policy indicated the following:Examples of When to Perform Hand Hygiene (Either Alcohol Based Hand Sanitizer orHandwashing):- Before and after having direct contact with a patient's intact skin (taking a pulse or bloodpressure, performing physical examinations, lifting the patient in bed)- After contact with inanimate objects (including medical equipment) in the immediatevicinity of the patient-After glove removal410 IAC (Indiana Administrative Code) 16.2-3.1-18(b)

Based on observation, record review, and interview, the facility failed to ensure residents were assessed to self-administer medications and had Physician's Orders for the medication for 1 of 1 resident reviewed for accident hazards (Residents C)Finding includes:During random observations on 3/30/26 at 11:00 a.m., on 3/31/26 at 10:02 a.m., and 2:17 p.m., on 4/1/26 at 9:20 a.m., 11:24 a.m., 2:30 p.m., and 4:00 p.m., and on 4/2/26 at 2:10 p.m., there was a bubble pack of over the counter generic laxative medication and a Salonpas patch (a medicated patch used for pain) laying on Resident C's over bed table. During an interview on 3/30/26 at 11:00 a.m., Resident C indicated he used the laxative medication when he was constipated and he liked using those medicated pain patches better than what the facility had. The record for Resident C was reviewed on 4/2/26 at 10:39 a.m. Diagnoses included, but were not limited to, neuromuscular dysfunction of the bladder, anxiety, quadriplegia, and hypotension (low blood pressure). The 1/23/26 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and had an indwelling Foley (urinary) catheter. There was no care plan for the resident to self-administer his own medications and there was no self-administration of medications assessment completed for the resident. There were no Physician's Orders for the Salonpas patch or an over the counter laxative tablet. A Nurses' Note, dated 3/4/26 at 10:55 a.m., indicated the resident refused the Lidoderm Patch 5 % as he had his own patch and refused what the facility offered. During an interview on 4/2/26 at 3:30 p.m., the Unit Manager indicated she was unaware the resident had his own medicated pain patches and the over counter laxative medication. During an interview on 4/2/26 at 3:30 p.m. the Director of Nursing indicated the resident needed to be assessed to self-administer his own medications. A policy titled, Self-Administration of Medications-Clinically Appropriate, received as current from the Director of Nursing on 4/2/26 at 3:16 p.m., indicated, . The resident has right to self-administer medications if the interdisciplinary team has determined that this practice is clinically appropriate. When a resident requests to self-administer medication(s), it is the responsibility of the interdisciplinary team (IDT) to determine that it is safe before the resident exercises that right. A resident may only self-administer after the IDT has determined which medications may be self-administered. 410 IAC (Indiana Administrative Code) 16.2-3.1-11(a)

Based on record review and interview, the facility failed to ensure a resident's Responsible Party was notified of a change in condition related to increased behaviors and being placed on one-to-one supervision for 1 of 1 resident reviewed for notification of change. (Resident D)Finding includes:The record for Resident D was reviewed on 3/31/26 at 3:29 p.m. Diagnoses included, but were not limited to, vascular dementia with mild agitation and muscle weakness. The Quarterly Minimum Data Set (MDS) assessment, dated 12/27/25, indicated the resident was cognitively impaired for daily decision making.A Behavior Note, dated 2/6/26 at 8:50 p.m., indicated the resident was ambulating in the dining room and pushing on the doors. The resident was noted to set off the alarm for the back door. The staff were able to redirect the resident back to her wheelchair. The resident then proceeded to get up and go back to the door and begun to open the door, she indicated she was going down the street to get a pop. The resident became resistive and verbally aggressive with staff with redirection. A different staff member was able to redirect the resident back to her wheelchair. The resident was assisted to her room and she put herself to bed. One-to-one care was initiated. A Behavior Observation Form, dated 2/6/26 at 9:40 p.m., indicated the resident was exit-seeking and wanting to go to the store to get a pop. There was no date and time on the form when the physician was notified. The resident's name was listed as family or responsible party notified and there was no date and time documented. There was no documentation in the nurses' notes on 2/7/26 and 2/8/26 of the resident's family being notified of the behaviors and one to one care. A Behavior Note, dated 2/9/26 at 12:28 p.m., indicated the resident remained on 15 minute checks. No complaints of pain or signs and symptoms of distress were noted. The resident was observed attempting to rub toast on her legs during breakfast. The resident indicated she was trying to heal myself. The resident was easily redirected. The family and physician were made aware and a urinalysis was ordered due to the behaviors. During an interview on 4/6/26 at 4:30 p.m., the Bakersfield Unit Manager indicated the resident's family was not notified of the resident's behavior and being placed on 1:1's on 2/6/26. The facility policy titled, Change in Condition Process, was provided by the Administrator on 4/7/26 at 4:30 p.m. The purpose of the policy was to ensure the facility promptly informed the resident, consulted the resident's physician; and notified, consistent with his or her authority, the resident's representative when there was a change requiring notification. The facility must inform the resident, consult with the resident's physician and notify the resident's family member or legal representative when there was a change requiring such notification. Situations requiring notification include:A significant change in the resident's physical, mental, or psychosocial status that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications. This citation relates to Intake 2785036.410 IAC (Indiana Administrative Code) 16.2-3.1-5(a)(2)

Based on record review and interview, the facility failed to ensure allegations of abuse were promptly reported by staff for 1 of 2 residents reviewed for abuse. (Resident 28)The finding includes:During an interview on 3/30/26 at 10:37 a.m., Resident 28 indicated on 3/28/26, she had an interaction with LPN 1 that was very distressing. At approximately 4:00 p.m., she asked the CNA to ask her nurse for her medication. LPN 1 then came to her room, cursed and spoke to her in a rude and insulting manner. LPN 1 told the resident that she knew the previous nurse already told her when her medication was due, and now she had to waste her time by coming to talk to her. The resident indicated she was so upset by the way she was treated that she became physically ill and vomited in the garbage can. She shut down and was crying. CNA 2 came in to deliver her food tray, and asked the resident if she was OK. LPN 1 told CNA 2 that the resident was fine. A few minutes later, CNA 1 entered the resident's room, saw the resident was upset, and went to get LPN 2. The record for Resident 28 was reviewed on 4/1/26 at 9:51 a.m. Diagnoses included, but were not limited to, chronic pancreatitis, depression, and anxiety.The Quarterly Minimum Data Set (MDS) assessment, dated 12/20/25, indicated the resident was cognitively intact for daily decision making, and was dependent in ADLs.The record lacked any documentation about any staff / resident interactions on 3/28/26.During an interview on 4/2/26 at 3:37 p.m., CNA 2 indicated when he came in with the resident's dinner tray on 3/28/26, the resident was visibly upset and crying. He knew the resident was upset about something with her nurse and not getting medication, but he did not witness any interaction between LPN 1 and the resident. During an interview on 4/6/26 at 1:13 p.m., LPN 1 indicated that the resident was upset that she could not get her medication early, and the resident was acting like she always did. The nurse before her told her she already talked to the resident about when the medication was due. The resident told LPN 1 the other nurses always gave her medication early if she needed it. LPN 1 told her not to tell on the other nurses to her. LPN 1 indicated she did not see the resident get physically ill, but that she did tell LPN 1 she was rude and that she was going to report her. During an interview on 4/6/26 at 1:20 p.m., CNA 1 indicated when she entered the resident's room on 3/28/26 to feed her roommate, the resident was upset and crying. The resident told CNA 1 that LPN 1 was rude and did not give her the medication she needed. CNA 1 went and asked LPN 2 to come see the resident. During an interview on 4/6/26 at 3:10 p.m., LPN 2 indicated she was called to the resident's room by CNA 1. She could hear something was going on at the end of the hall, it was loud, but could not tell what exactly it was. When LPN 2 entered the room, the resident was very upset, sobbing, and indicated LPN 1 had yelled and cursed at her. LPN 2 indicated she would consider what the resident reported to her as abuse. She indicated she reported the incident verbally to RN 1 (oncoming midnight nurse) and the DON. LPN 2 indicated they did not really have a charge nurse on off shifts, and that she reported the incident to RN 1 because she was a seasoned nurse. During an interview on 4/6/26 at 4:01 p.m., the Administrator, DON, and Unit Manager indicated they were not aware of the allegations of verbal abuse. The DON indicated LPN 2 did not call her about the incident. During an interview on 4/6/26 at 4:34 p.m., the Administrator indicated she was the Abuse Coordinator, and staff had been educated to contact her directly, at any time, for any suspected abuse. She had not been informed of the interaction between Resident 28 and LPN 1. LPN 2 should have called her. A policy titled, Abuse Prevention and Reporting, received as current from the Administrator on 3/30/26 at 3:50 p.m., indicated, . Employees and volunteers are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, or to an immediate supervisor who must then immediately report it to the administrator . 410 IAC (Indiana Administrative Code) 16.2- 3.1-28(c)

Based on observation, record review, and interview, the facility failed to ensure activities of daily living (ADLs) were completed for dependent residents related to nail care for 2 of 7 residents reviewed for ADLs. (Residents 4 and 5) Findings include:1. During an interview on 3/30/26 at 3:24 p.m., Resident 4 indicated he would like his fingernails shorter and he guessed he would wait until next week when activity staff could take care of it. The resident's fingernails were observed to be long on both hands. On 3/31/26 at 2:47 p.m., the resident's fingernails remained long. On 4/1/26 at 9:25 a.m. and 3:30 p.m., the resident's fingernails remained long. On 4/2/26 at 10:01 a.m. and 2:30 p.m., the resident's fingernails remained long. The record for Resident 4 was reviewed on 4/2/26 at 1:25 p.m. Diagnoses included, but were not limited to, type 2 diabetes and history of spinal fusion at the cervical region. A Care Plan, dated 2/19/26, indicated the resident required assistance with ADLs including bed mobility, eating, transfers, toileting, and bathing related to obstructive uropathy, sleep apnea, spinal stenosis, weakness, sepsis, and decreased mobility. Interventions included, but were not limited to, assist with personal hygiene including dressing and grooming as needed. Encourage self participation as able. The admission Minimum Data Set (MDS) assessment, dated 2/26/26, indicated the resident was cognitively intact and required supervision or touching assistance for personal hygiene. Documentation in the Task section of the resident's record indicated his shower days were on the day shift on Tuesday and Friday. The resident received a shower on 3/17, 3/24, and 3/31/26. The resident received a complete bed bath on 3/20/26 and a partial bed bath on 3/27/26. Nail care was documented as being provided on 3/17, 3/20, 3/24, and 3/31/26. During an interview on 4/2/26 at 3:31 p.m., the Director of Nursing indicated the resident's fingernails would be cut and he didn't have to wait for activity staff. 2. On 3/30/26 at 10:05 a.m., Resident 5 was seated in his wheelchair in his room. The fingernails on the resident's left hand and right thumb were extremely long. During an interview on 3/30/26 at 2:15 p.m., the resident nodded his head yes when asked if he would like his fingernails shorter. On 3/31/26 at 10:00 a.m. and 10:40 a.m., the resident was seated in the hallway in his wheelchair. The fingernails on his left hand and right thumb remained long. The record for Resident 5 was reviewed on 4/2/26 at 2:35 p.m. Diagnoses included, but were not limited to, type 2 diabetes, stroke, and aphasia (difficulty speaking). The Quarterly Minimum Data Set (MDS) assessment, dated 2/20/26, indicated the resident was cognitively impaired and was dependent on staff for personal hygiene. A Care Plan, reviewed on 2/20/26, indicated the resident required assistance with ADLs including bed mobility, eating, transfers, toileting, and bathing related to decreased mobility, weakness, anemia, gastric ulcer, aphasia following stroke, and aneurysm of other specified arteries. Interventions included, but were not limited to, assist with personal hygiene including dressing and grooming as needed. Encourage self participation as able. Documentation in the Task section of the resident's record indicated he received his shower on the day shift on Monday and Thursday. Documentation indicated the resident received a shower on 3/5, 3/9, 3/12, 3/19, 3/23, and 3/26/26. A complete bed bath on 3/16 and 3/30/26 and a partial bed bath on 4/2/26. Nail care was documented as being provided on 3/16/26. During an interview on 4/2/26 at 3:35 p.m., the Administrator indicated the resident had his fingernails cut the afternoon of 3/31/26. 410 IAC (Indiana Administrative Code) 16.2-3.1-38(a)(3)(E)

Based on record review and interview, the facility failed to ensure insulin was given as ordered for 1 of 5 residents reviewed for unnecessary medications. The facility also failed to ensure documentation was completed after a change in condition related to elevated blood pressure for 1 of 1 resident reviewed for hospitalization and lack of follow up documentation regarding an anti-diarrheal medication for 1 of 1 resident reviewed for constipation and diarrhea. (Residents N, B, and M)Findings include: 1. The record for Resident N was reviewed on 4/6/26 at 11:41 a.m. Diagnoses included, but were not limited to, type 2 diabetes and bipolar disorder without psychotic features. A Physician's Order, dated 1/27/26, indicated the resident was to receive Insulin Aspart (a rapid acting insulin), five units subcutaneously (SQ) with meals for diabetes. The resident was also to receive Glargine Insulin (a long acting insulin) 22 units SQ at bedtime for diabetes. The admission Minimum Data Set (MDS) assessment, dated 2/2/26, indicated the resident was cognitively intact and she had received insulin injections during the assessment reference period. A Care Plan, dated 2/2/26, indicated the resident was at risk for complications related to the diagnosis of type 2 diabetes mellitus with hyperglycemia (high blood sugar). The resident did receive injectable insulin. Interventions included, but were not limited to, administer diabetes medications as ordered by the physician. Monitor and/or document for side effects and effectiveness. The March 2026 Medication Administration Record (MAR) indicated the resident did not receive the Aspart Insulin on the following dates and times because the resident's blood sugar was outside of the parameters: -8:00 a.m., 3/17 blood sugar 191, 3/18 blood sugar 102, 3/19 blood sugar 200, and 3/23/26 blood sugar 163. -12:00 p.m., 3/14 blood sugar 143, 3/17 blood sugar 178, 3/18 blood sugar 102, 3/21 blood sugar 93, 3/24 blood sugar 178, and 3/25/26 blood sugar 142. -6:00 p.m., 3/2 blood sugar 194, 3/7 blood sugar 185, 3/13 and 3/24 no blood sugar level documented but the insulin was held, 3/29 blood sugar 93, and 3/30/26 no documentation of blood sugar level but the insulin was held. There was no order to hold the Aspart Insulin based on blood sugar parameters. The 3/2026 MAR indicated the Glargine Insulin was held at bedtime due to the resident's blood sugar being outside of parameters on the following dates: 3/7, 3/8, 3/13, 3/21, 3/22, 3/28, 3/29, and 3/30/26. There were no blood sugar levels documented and there was no order to hold the insulin based on parameters. During an interview on 4/7/26 at 11:30 a.m., the Nurse Consultant indicated the standing insulin orders did not have orders for parameters and the insulin should have been given as ordered. 2. The record for Resident B was reviewed on 4/1/26 at 2:48 p.m. Diagnoses included, but were not limited to, dysphagia (difficulty swallowing), heart failure, dementia without behaviors, high blood pressure, and syncope. The 3/3/26 Quarterly Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making. A Care Plan, revised on 12/16/25, indicated the resident had high blood pressure. The approaches were to administer anti-hypertensive medications as ordered and monitor for side effects and effectiveness. The resident's blood pressure was checked and recorded on 4/3/26 at 10:16 a.m. and was 191/78, and on 4/4/26 at 10:39 a.m. was 174/106. A Physician's Order, dated 5/28/25, indicated Isosorbide Mononitrate ER (a medication used to treat chest pain) Oral Tablet Extended Release 24 Hour 60 milligrams (mg) give one tablet by mouth one time a day. The medication was signed out as being administered on 4/3 and 4/4/26 during the morning. A Nurses' Note, dated 4/4/26 at 4:55 p.m., indicated the Emergency Medical System (EMS) had arrived to the facility to transport the resident to the hospital. There were no nursing progress notes documented on 4/3/26 and none prior to 4/4/26 at 4:55 p.m. There were no blood pressures documented or checked after 4/4/26 at 10:39 a.m. A Change in Condition Report, with an effective date of 4/4/26 at 5:00 p.m. and a created dated of 4/6/26, indicated the resident had neurological signs of a stroke. The vital signs at the time of the evaluation were blood pressure 174/106 at 10:39 a.m., pulse of 82 on 4/2/26 at 9:38 p.m., respirations were 18 on 4/2/26 at 9:38 p.m., and pulse oximetry was 91% on 4/4/26 at 10:32 a.m. The resident was not receiving an anticoagulant. A question indicating were these the most recent vital signs the answer was checked yes. The blood pressure of 174/106 on 4/4/26 at 10:39 a.m. A question indicating was the the diastolic (bottom number) blood pressure greater than 90 mmHg (millimeters of mercury) but less than 115 mmHg was not checked and none of the above was marked on the assessment. A Nurses' Note, dated 4/4/26 at 5:02 p.m., indicated the resident was observed sitting in her wheelchair, with left sided facial droop and slurred speech. The resident had no loss of consciousness and oxygen was already in use. The physician was notified of the change in condition and orders were received to transfer to hospital and 911 was called. A Nurses' Note, dated 4/4/26 at 9:30 p.m., indicated the resident was admitted to the hospital for signs of a stroke. There was no documentation the physician was notified of the high blood pressures, nor was there any documentation the blood pressures were rechecked. During an interview on 4/56/26 at 1:30 p.m., the Unit Manager indicated they think the resident had a stroke, and was sent out to the hospital over the weekend. During an interview on 4/7/26 at 2:00 p.m., Resident B's son indicated his mother was admitted to the hospital on Saturday 4/4/26 with high blood pressure. During an interview on 4/7/26 at 2:50 p.m. the Director of Nursing indicated there was no follow up of an assessment after the high blood pressures on 4/3 and 4/4/26 or documentation the resident's blood pressure was rechecked. She was unsure if the physician had been notified of the high blood pressure. She was alerted at 4:42 p.m. that 911 was called on 4/4/26. 3. During a random observation on 4/1/26 at 2:20 p.m., Resident M was sitting in his wheelchair in his room. He was holding his head up with his hand, was slow to speak, and kept his eyes closed during conversation. He indicated he did not sleep well the night before due to diarrhea. He reported the diarrhea to staff, but did not receive medication for it. At that time, a staff member entered to take the resident to dialysis. He refused dialysis due to diarrhea. LPN 3 then entered the room, and spoke with the resident about refusing dialysis. She indicated she would contact the physician and ask about getting an anti-diarrheal medication. The record for Resident M was reviewed on 4/1/26 at 3:43 p.m. Diagnoses included, but were not limited to, heart disease, acute respiratory failure, dependence on dialysis, fluid overload, and anxiety. The admission Clinical Observation, dated 3/21/26, indicated the resident was cognitively intact for daily decision making. The clinical record indicated the resident had diarrhea/loose stool on 3/28/26, 4/1/26, and 4/2/26. The resident was incontinent of stool on three additional occurrences from 4/2/26 to 4/3/26, but the consistency of those stools was not documented. A Nurse's Note by LPN 3, dated 4/1/26, indicated, Pt [patient] was notified that dialysis services was ready for him. Pt told CNA he did not want to go to dialysis today d/t [due to] diarrhea, CNA reported to this nurse. Upon review of pt chart, pt does not currently have any active orders for an anti-diarrheal . Pt reports that wife plans to bring an anti-diarrheal that was prescribed during previous hospital stay. Educated the pt that medication and specific order would have to be cleared with PCP, so that we may enter the specific order in his chart, for documentation and safety purposes . PCP [primary care physician] notified and in agreement to continue medication once order is communicated to him. Floor staff for evening shift notified of interaction and pending arrival of medication from wife. Nursing management staff notified as well. There was no documentation of any follow up and no anti-diarrheal medication ordered. During an interview on 4/7/26 at 10:05 a.m., the DON indicated she attended a care conference with the resident's wife on 4/2/26, but she was not aware of the resident's untreated diarrhea and lack of follow-up on obtaining an order for an anti-diarrheal medication. This citation relates to Intake 2797209. 410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure suprapubic catheter (urinary catheter inserted directly into the lower abdomen) care was completed and the catheter was changed as ordered by the physician for 1 of 1 resident reviewed for catheters. (Resident C)Finding includes:During an observation on 3/30/26 at 11:12 a.m., Resident C was observed in bed. At that time, he indicated staff do not provide catheter care every day and his catheter had not been changed for over a month. The resident lifted up the bed sheets, and his supra pubic catheter was observed. The stoma (insertion site opening) was scabbed over and there was a moderate amount of bloody drainage noted around the catheter. There was no bandage over the stoma site. During an observation on 4/1/26 at 2:30 p.m., the resident was observed in bed. At that time, he lifted the bed sheets and the catheter tubing had a moderate amount of dried drainage on it, and there was no bandage covering the stoma site. The resident indicated no one had done catheter care in the last couple of days. The record for Resident C was reviewed on 4/2/26 at 10:39 a.m. Diagnoses included, but were not limited to, neuromuscular dysfunction of the bladder, anxiety, quadriplegia, and hypotension (low blood pressure). The 1/23/26 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and had an indwelling foley (urinary) catheter. A Care Plan, dated 7/25/25, indicated the resident was risk for complications secondary to requiring a suprapubic catheter. A Physician's Order, dated 1/26/26, indicated suprapubic catheter, size 18 French, balloon size 30 cubic centimeters (cc), change every month and as needed for dislodgement, leaking, or blockage on the 8th of every month. The Treatment Administration Record (TAR) for the months 12/2025, 1/2026, and 2/2026, indicated the supra pubic catheter change was signed out as being done and completed by a QMA.The 3/2026 TAR, indicated on 3/8/26 a 9 was coded, indicating see progress notes. A Nurses' Note, dated 3/8/26 at 10:24 a.m., indicated Patient recently sent to ER (Emergency Room) for Suprapubic catheter change on 2/22/26.The suprapubic catheter had not been changed since 2/22/26. A Physician's Order, dated 7/16/25, indicated catheter care every shift.The TAR for the months of 1/2026, 2/2026 and 3/2026, and 4/2026, indicated the Wound Nurse provided catheter care for the resident every day shift and signed his initials as doing so. The catheter care was signed out as being completed every evening and midnight shift as well.During an interview on 4/2/26 2:10 p.m. the resident indicated the Wound Nurse had never performed catheter care for his suprapubic catheter. During an interview on 4/2/26 at 3:15 p.m., the Wound Nurse indicated he did sign out treatments if there were holes in the record. He had not completed catheter care for the resident, however, he did sign that he completed the catheter care. During an interview on 4/2/26 at 3:30 p.m., the Director of Nursing indicated QMAs were not able to change a suprapubic catheter. She indicated the Wound Nurse should not have signed out the catheter care if he did not complete it. This citation relates to Intake 2793463.410 IAC (Indiana Administrative Code) 16.2-3.1-41(a)(2)

Based on observation, record review, and interview, the facility failed to ensure a resident received individualized services and other interventions related to dementia care while residing on a memory care unit for 1 of 5 residents reviewed for dementia care. (Resident 89)Finding includes:During a random observation on 4/1/26 at 10:55 a.m., Resident 89 was observed in a wheelchair at a table in the activity/dining room on the memory care unit. At that time, the resident turned her wheelchair away from the table, Activity Aide 2 got up from reading questions to the other residents, picked up her wheelchair from behind and moved her back in front of the table. The resident stated whoa and grimaced slightly. Activity Aide 2 said nothing to the resident, just moved her back and then went back over to the group and continued the activity. At 10:57 a.m., the resident stood up from the chair and Activity Aide 2 yelled from across the room Miss [name of resident] sit back down. She did not get up and try any interventions, just kept on reading to the other residents. During a random observation on 4/1/26 at 2:35 p.m., the resident was seated in her wheelchair at a table in the activity/dining room and was not participating in any activity. At 2:50 p.m., a CNA sitting across the room yelled out loud [resident name] sit down. The CNA did not get up to assist the resident with anything, just yelled at her from across the room.During a random observation on 4/2/26 at 10:05 a.m., Resident 89 was observed seated in a wheelchair at a table next to the Activity Aide 1, who was reading a bible story out loud to those residents seated near her. Resident 89 was anxious and mumbling under her breath, saying curse words and trying to grab at the book the aide was reading, The resident reached across the table and went to grab another book by Activity Aide 1. She picked up the book and quickly Activity Aide 1 stated no you cannot have that. I have to read that next. She removed the book from the resident's hands. The resident then became more anxious and started crying and rubbing her eyes, and begun swearing again, under her breath. She continued to have these swearing outbursts and attempted to stand up several times. The activity aide just simply stated stop cussing and sit down. The resident continued to stand up several times and Activity Aide 1 stated have a seat Miss [resident name]. Activity Aide 1 offered no other interventions for the resident, she offered no other activities for the resident. She continued to read the book to the other residents, while Resident 89 kept having the same behaviors. At 10:18 a.m., the resident banged her hand on the table, and started yelling out loud, a nurse entered the room and indicated she would take her out and stated she probably needs a change of scenery. The resident was wheeled out of the room. The record for Resident 89 was reviewed on 4/6/26 at 12:57 p.m. Diagnoses included, but were not limited to, repeated falls, high blood pressure, anxiety disorder, Alzheimer's disease, and stroke.The 3/5/26 Quarterly Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making. The resident had other behaviors towards others physical symptoms such as hitting or scratching. The resident received an antipsychotic and an antidepressant medication. There was no care plan for dementia care with individualized interventions or approaches in place for any of her behaviors.A 2/13/26 Quarterly Social Service Note indicated there was no change in status for speech, cognition, social interaction, mood status, behavioral status, or adjustment difficulties. The resident was not receiving any psychoactive medication, and was not currently receiving psychological/psychiatric services. A Physician's Order, dated 8/27/25, indicated Abilify (a antipsychotic medication) 2 milligrams (mg) one time a day. The resident currently received services from an outside behavioral center. The Nurse Practitioner saw the resident at least monthly and sometimes more often. During an interview on 4/6/26 at 1:30 p.m., the Unit Manager indicated there was no care plan regarding the resident's dementia with approaches or interventions when she had behaviors. The activity aide should have given the resident something else to have in her hands rather than just taking the book out of her hands. She also indicated staff should have gone over to the resident when she was standing up and tried to redirect her rather than just telling the resident to just sit down without any interventions. During an interview on 4/6/26 at 1:45 p.m., the Director of Nursing indicated they have been looking at the memory care unit, the behaviors and the structured activities over the last couple of weeks and determined there needed to be some changes with staff and how they help those residents with behaviors. 410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on record review and interview, the facility failed to ensure each resident received medically related social services related to the timeliness of vision and dental visits for 1 of 2 residents reviewed for vision and 1 of 1 resident reviewed for dental. (Resident B)Finding includes:The record for Resident B was reviewed on 4/1/26 at 2:48 p.m. Diagnoses included, but were not limited to, dysphagia (difficulty swallowing), heart failure, dementia without behaviors, high blood pressure, and syncope.The 12/1/25 Annual Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making. The resident's vision was adequate with no corrective lens and staff were unable to examine the resident's mouth for dental. The 3/3/26 Quarterly MDS assessment indicated the resident was not cognitively intact for daily decision making. The resident's vision was adequate with corrective lenses and she had no oral problems. A History and Physical from the hospital, dated 11/13/24, indicated the resident was edentulous (no natural teeth). A Nursing admission Assessment, dated 11/23/24, indicated the resident had no issues with teeth.A readmission Nursing Assessment, dated 5/27/25, indicated the resident had no issues with teeth.A Care Conference, dated 5/12/25, indicated referrals were sent to the Dentist and Optometrist. A Care Conference, dated 10/8/25, indicated the family would like her to be put on the list to see the eye doctor.A Dental Exam Note, dated 11/5/25, indicated the resident had no teeth in both the upper and lower and right and left quads. This was the first time the resident had seen a dentist.An Optometrist Exam Note, dated 12/18/25, indicated the resident had hypermetropia (close objects were blurry) in the right eye and Myopia (difficulty seeing objects far away) in the left eye. The resident had cataract noted in both the right and left eyes. A new eye glasses prescription was left by the Optometrist. This was the first time the resident had seen an eye doctor. A Dental Exam Note, dated 3/6/26, indicated the resident had no teeth and was edentulous. There were no concerns at this time and honey ridges were non existent to facilitate upper or lower dentures. The patient's compliance was poor.An Optometrist Exam Note, dated 3/19/26, indicated staff requested glasses prescription. The exam was the same as 12/18/25.There was no documentation in Social Service Progress Notes regarding any of the visits and if the eyeglasses had been ordered, or if the family had been notified about the resident's dental exam. During an interview on 4/2/26 at 3:50 p.m., Social Service (SS) 1 indicated she had just started the position last year and was responsible for all of the ancillary services for the residents, like getting the referrals and setting up appointments for them. If the resident needed a consultation, nursing would do that. She was unsure why the resident was not seen by the dentist before 11/2025 and by the eye doctor before 12/2025 and was unaware a prescription for the eyeglasses was written on that visit. She would check into when the glasses were ordered as they came in today on 4/2/26. She also was not aware the resident had a cataract issue and what needed to be done by the facility. During an interview 4/6/26 at 10:04 a.m., SS 1 indicated she reached out to the eye doctor and they told her the glasses were ordered on 3/20/26 and they arrived on 4/2/26. The Optometrist indicated they were just watching the cataracts and surgery was not recommended at this time.During an interview on 4/6/26 at 11:30 a.m., SS 1 indicated during the care conference in February 2026, the resident's son indicated that his mom needed glasses. She indicated the eye doctor said they had the script for her glasses in 12/2025, however they reached out to the son for consent to order the glasses, and when he did not return the calls they did not order them. She said after the care plan conference she reached out to Optometrist and asked for them to resend the script so they could get the son's consent and order the glasses. The Optometrist was in the facility performing eye exams on 9/9/25, 11/21/25 and 12/18/25. She indicated the resident was not a candidate for dentures according to the last dental visit. The Dentist and Dental Hygienist were in the facility on the following days: Dentist on 7/11/25, 8/15/25, 9/10/25, 10/3/25, and 12/12/25, and the Hygienist on 7/18/25, 8/29/25, 9/26/25, 10/17/25, and 12/1/25.During an interview on 4/6/26 at 11:30 a.m., the Administrator indicated the facility identified a quality assurance issue with residents not receiving ancillary services in a timely manner and created a performance improvement plan (PIP), dated 5/2025 through 7/2025. She indicated this was created prior to her arrival at the facility. During an interview on 4/6/26 at 1:30 p.m., the Director of Nursing had no additional information to provide. This citation relates to Intake 2797209.410 IAC (Indiana Administrative Code) 16.2-3.1-34(a)

Based on observation, record review, and interview, the facility failed to ensure prescription medications were properly labeled for 2 of 8 residents observed during medication administration. (Residents 104 and 12)Findings include:1. On 4/6/26 at 9:41 a.m., LPN 4 was observed preparing medications for Resident 104. LPN 4 dispensed one 75 milligram (mg) Pregabalin capsule (a medication for nerve pain) into the medication cup. The label on the medication card indicated the resident was to receive one capsule every 12 hours. The record for Resident 104 was reviewed on 4/6/26 at 10:15 a.m. Diagnoses included, but were not limited to, polyneuropathy (nerve damage in the hands and feet). A Physician's Order, dated 3/31/26, indicated the resident was to receive a Pregabalin capsule, 75 mg three times a day. The label on the medication did not match the medication order and there was no label on the medication card indicating the order had been changed. 2. On 4/6/26 at 9:56 a.m., LPN 4 was observed preparing medications for Resident 12. LPN 4 dispensed two 1 milligram (mg) tablets of Bumetanide (a diuretic) into the medication cup. The label on the medication card indicated the resident was to receive 1 mg daily. The record for Resident 12 was reviewed on 4/6/26 at 10:20 a.m. Diagnoses included, but were not limited to, edema. A Physician's Order, dated 3/26/26, indicated the resident was to receive Bumetanide 2 mg daily. The label on the medication did not match the medication order and there was no label on the medication card indicating the order had been changed. During an interview on 4/7/26 at 11:30 a.m., the Nurse Consultant indicated the pharmacy would be contacted regarding the labeling of the medications. 410 IAC (Indiana Administrative Code) 16.2-3.1-25(j)

Based on record review and interview, the facility failed to ensure clinical records were complete and accurately documented related to dietary supplement consumption for 1 of 1 resident reviewed for nutrition and a dental assessment for 1 of 1 resident reviewed for dental. (Resident 20 and B)Findings include: 1. The record for Resident 20 was reviewed on 2/31/26 at 2:24 p.m. Diagnoses included, but were not limited to, Alzheimer's disease, adjustment disorder, dementia with psychotic disturbance, vascular dementia, high blood pressure, atrial fibrillation, and chronic kidney disease. The 12/31/25 Modification of the Quarterly Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making and had no oral problems or weight loss. A Physician's Order, dated 3/5/26, indicated High-Calorie liquid Supplement two times a day for weight. The Medication Administration Records (MAR) for 3/2026 and 4/2026 indicated the high calorie liquid supplement was signed out as being administered, however, the amount consumed was not documented. During an interview on 4/7/26 at 10:15 a.m. the Director of Nursing indicated she would have to check to see if the consumption needed to be documented. During an interview on 4/6/26 at 11:45 a.m., the Director of Nursing indicated the amount consumed of the high calorie supplement should have been documented on the MAR. 2. The record for Resident B was reviewed on 4/1/26 at 2:48 p.m. Diagnoses included, but were not limited to, dysphagia (difficulty swallowing), heart failure, dementia without behaviors, high blood pressure, and syncope.The 12/1/25 Annual Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making and staff were unable to examine the resident's mouth for dental. The 3/3/26 Quarterly MDS assessment indicated the resident was not cognitively intact for daily decision making. The resident had no oral problems. A History and Physical from the hospital, dated 11/13/24, indicated the resident was edentulous (no natural teeth). A Nursing admission Assessment, dated 11/23/24, indicated the resident had no issues with teeth.A readmission Nursing Assessment, dated 5/27/25, indicated the resident had no issues with teeth.A Dental Exam Note, dated 11/5/25, indicated the resident had no teeth in both the upper and lower right and left quads.During an interview on 4/6/26 at 1:30 p.m., the Director of Nursing indicated the nursing admission dental assessments were not accurate.During an interview on 4/7/26 at 2:00 p.m., Resident B's son indicated the resident's dentures were lost at the hospital and she had no natural teeth.410 IAC (Indiana Administrative Code) 16.2-3.1-50(a)(1)410 IAC (Indiana Administrative Code) 16.2-3.1-50(a)(2)

Based on record review and interview, the facility failed to ensure laboratory tests were completed as ordered, related to a vancomycin trough for 1 of 3 residents reviewed for laboratory testing. (Resident D)Finding includes: Resident D's closed record was reviewed on 2/3/26 at 1:36 p.m. Diagnoses included, but were not limited to, cellulitis, diabetes mellitus, atrial fibrillation and osteoarthritis. The resident had been discharged to the hospital on 1/20/26 due to abnormal labs. The Quarterly Minimum Data Set assessment, dated 12/13/25, indicated the resident was cognitively intact and required moderate assist with transfers.A Physician's Order, dated 1/14/26, indicated to give vancomycin HCL (an antibiotic), 1 gram, intravenously daily for cellulitis.A lab result, dated 1/14/26, indicated the resident had a vancomycin trough (a blood test to determine medication level) of less than 3.0.A Nurse Note, dated 1/15/25, indicated the vancomycin trough results had been communicated to the pharmacy and the next vancomycin trough should be done on 1/19/26. There was no order for the trough in the record, and no indication the trough had been completed on 1/19/26.During an interview on 2/3/26 at 3:52 p.m., the Executive Director and Director of Nursing indicated the nurse had filled out a lab requisition for the test on 1/19/26 but had not entered the order and the test had not been completed.This citation is related to Intake 2732385.3.1-49(f)(2)

Based on record review and interview, the facility failed to ensure activities of daily living (ADLs) were completed for dependent residents related to showers for 2 of 3 residents reviewed for ADLs. (Residents D and B) Findings include: 1. The record for Resident D was reviewed on 6/17/25 at 10:11 a.m. Diagnoses included, but were not limited to epilepsy, psychotic disorder with delusions, high blood pressure, and alcohol dementia. The Quarterly 5/15/25 Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making and was dependent on staff for bathing. The Care Plan, revised on 2/13/24, indicated the resident required assistance with ADLs. The showers in the CNA Task Section indicated the resident was to receive a shower on Wednesday and Saturday evenings. The resident did not receive a shower on 4/2, 4/5, 5/17, 5/28, and 6/7/25. During an interview on 6/17/25 at 11:55 a.m., the Director of Nursing indicated the resident was to receive at least two showers a week. 2. Resident B's record was reviewed on 6/17/25 at 9:05 a.m. The diagnoses included, but were not limited to, osteomyelitis (infection of bone and muscle), diabetes, COPD, asthma, and hypertension (high blood pressure). The 4/9/25 admission Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and was dependent on staff for bathing, toileting, personally hygiene and oral hygiene. The Care Plan, dated 4/9/25, indicated the resident required assistance with ADLs including bathing. Interventions were to assist with bathing as needed, offer a shower at least 2 times daily, and offer a full/partial bed bath on non-shower days or refusals. The shower documentation in the CNA Task Section indicated the resident did not receive a shower on the following dates. 4/15/25 4/16/25 4/17/25 4/18/25 4/19/25 4/20/25 4/26/25 4/27/25 4/28/25 4/29/25 4/30/25 5/1/25 5/2/25 5/6/25 5/7/25 5/8/25 5/9/25 5/10/25 5/11/25 There were no documented refusals or offered attempts on the missed showers dates. During an interview on 6/17/25 at 11:48 a.m., the Nurse Consultant indicated she understood the concern and there were no shower sheets for the resident. During an interview on 6/17/25 at 11:55 a.m., the Director of Nursing (DON) indicated the resident was to receive at least two showers a week. This Citation relates to Complaint IN00460159. 3.1-38(a)(2)(A)

Based on observation, interview, and record review, the facility failed to ensure infection control practices were in place and implemented related to the opening of a medication capsule without gloves during medication administration for a random observation for infection control. Finding includes: On 6/16/25 at 12:07 p.m., medication administration was observed with LPN 1 for Resident G. The resident received his medication crushed. LPN 1 opened a Gabapentin (given for nerve pain or anticonvulsant) 300 mg capsule with her bare hands and emptied the powder contents inside the medication cup with another crushed medication. During an interview on 6/16/25 at 12:17 p.m., the Assistant Director of Nursing (ADON) indicated she understood the concern and had no further information to provide. During an interview on 6/16/25 at 1:10 p.m., the Director of Nursing (DON) indicated she understood the concern and would re-educate the staff. She indicated LPN 1 thought it was okay to touch the outside capsule since she did not touch the inside contents. This Citation relates to Complaint IN00460159. 3.1-18(b)

Based on observation, record review, and interview, the facility failed to provide a safe and sanitary environment to help prevent the potential for transmission of communicable diseases and infections related to a glucometer (blood sugar monitor) not sanitized after it was used for 1 of 2 glucometer tests observed. (LPN 3, Resident S) This had the potential to affect 5 residents with glucometer orders assigned to the nurse. The facility also failed to ensure correct Personal Protective Equipment (PPE) was used by a staff member (CNA 4) when providing care to a resident (Resident F) who was in Enhanced Barrier Precautions (EBP) for 1 random observation for infection control. Findings include: 1. During an observation on 5/12/25 at 8:07 a.m., LPN 3, entered Resident S's room and performed a glucometer test. After the test was completed, LPN 3 removed her gloves and exited the room and placed the glucometer in the top drawer of the medication cart with sanitizing the monitor. During an interview on 5/12/25 at 8:15 a.m., LPN 3 indicated the glucometer was to be sanitized after each use. A facility glucometer cleaning policy, dated 9/1/20, and received from the Director of Nursing (DON) as current, indicated the glucometer was to be cleaned and disinfected between each resident test. 2. During an observation on 5/12/25 at 4:25 a.m., CNA 4 entered Resident F's room to provide care. There was a sign on the resident's room door that indicated EBP was required. CNA 4 indicated the resident was in need of incontinence care due to having had a bowel movement. She donned gloves. When CNA 4 was asked which resident in the room required EBP, she indicated she was unsure and continued to provide incontinence care to Resident F without the required PPE of a gown. Resident F's record was reviewed on 5/13/25 at 11:08 a.m. The diagnoses included, but were not limited to, end stage renal disease and dialysis. An Annual Minimum Data Set (MDS) assessment, dated 3/7/25, indicated an intact cognitive status, required moderate assistance with toileting, dressing, hygiene, and bed mobility and maximum assistance with bathing and transfers. She was always incontinent of bowel and bladder and was receiving dialysis. A Care Plan, dated 3/31/25, indicated hemodialysis was required. The interventions included to check the dialysis access site and EBP was to be utilized. A Physician's Order, dated 4/30/25, indicated EBP was required related to dialysis. The interventions included an EBP sign would be posted outside of the room and a gown and gloves were required for high contact resident care activities. The Director of Nursing (DON) was informed of the above observation on 5/12/25 at approximately 6:30 a.m. and had no further information to provide. A facility EBP protocol, undated, received from the DON as current, and reviewed on 5/12/25 at 3:00 p.m., indicated EBP was required with dressing or bathing and other high-contact resident care activities. 3.1-18(b)

Based on record review and interview, the facility failed to ensure the resident's physician was notified of medication being held for 1 of 1 resident reviewed for notification of change. (Resident T) Finding includes: The record for Resident T was reviewed on 5/14/23 at 12:33 p.m. Diagnoses included, but were not limited to, kidney failure, hypotension (low blood pressure), and heart failure. The Admission Minimum Data Set (MDS) assessment, dated 3/31/25, indicated the resident was cognitively intact for daily decision making. A Physician's Order, dated 3/25/25, indicated the resident was to receive Midodrine (medication that increases blood pressure) 5 milligrams (mg) three times a day for hypotension. A Nurses Note, dated 5/2/25 at 8:10 a.m., indicated a medication administration note documented a blood pressure (BP) of 156/86. A Nurses Note, dated 5/2/25 at 1:14 p.m., indicated a medication administration note documented a blood pressure of 155/92. A Nurses Note, dated 5/12/25 at 9:07 a.m., indicated a medication administration note documented a blood pressure of 156/86. The Medication Administration Record (MAR) indicated Midodrine was held on the following dates: 5/2/25 - am dose held 5/2/25 - mid day dose held 5/12/25 - am dose held There was no documentation of the resident's physician being notified the medication was held on 5/2/25 and 5/12/25. During an interview on 5/12/25 at 2:13 p.m., during a medication pass observation, RN 1 indicated the resident's BP was 112/74 and she was unsure if she was going to give the medication. She was debating whether or not she should hold the dose because the medication did not have parameters. She indicated she held Resident T's Midodrine pill that morning because his BP was in the 150s. During an interview on 5/13/25 at 3:51 p.m., the DON indicated she understood the concern and had no additional information to provide. 3.1-5(a)(2)

Based on observation, record review, and interview, the facility failed to ensure the services provided met the profession standards of quality related to a medication pass observation for 2 of 8 residents observed for medication administration. (LPN 3, Residents K & S) Finding includes: During a medication pass observation on 5/12/25 at 8:07 a.m., LPN 3 indicated she was preparing Resident K's morning medications, which included potassium (supplement) 20 mEq (milliequivalents) two tablets, a multivitamin one tablet, Cinacalcet (hyperparathryoid medication) 30 mg one tablet, vitamin D (supplement) 50,000 units one capsule, amlodipine (calcium channel blocker) 5 milligrams (mg), clonazepam (anti-anxiety) 0.5 mg, and Cortef (hydrocortisone, a steroid) 20 mg one tablet. She indicated there were eight tablets/capsules in the plastic medication cup. LPN 3 then indicated she needed to get a glucometer and placed the cup of medications in the top drawer of the medication cart, locked the medication cart and went to another medication cart and retrieved a glucometer. The medication cart was not unlocked until LPN 3 returned. She then unlocked the cart, took the plastic cup with the medications out of the cart and proceeded into the room and gave the resident who resided in the bed closest to the door the medications, approximately half of the medications at a time, until all the medications were administered. She checked the resident's blood sugar with the glucometer and indicated the result was 108. LPN 3 then initialed the Medication Administration Record (MAR) for Resident K. The medications were reconciled on 5/14/25 at 10:00 a.m. and the medications were correct for Resident K. Upon review of the chart, the resident in the bed closest to the door who was observed receiving medications from LPN 3 was actually Resident S and possible medication errors were reported to the Director of Nursing (DON). During an interview on 5/14/25 at 10:48 a.m., the DON indicated she notified LPN 3, who informed the DON she was nervous and had already set up Resident S's (resident by the door) medications and had placed the medications in a plastic medication cup in the top drawer of the medication cart. LPN 3 was then asked to observe a medication pass and indicated she was going to pass medications to Resident K. She indicated after the medications were prepared, she needed to get a glucometer and placed the medication cup with Resident K's medications in the top drawer of the medication cart with Resident S's medication cup and locked the medication cart. When she returned to the medication cart, she took out Resident S's already prepared medication cup and gave Resident S the medications. LPN 3 had not informed the surveyor she was giving Resident S her medications instead of Resident K, for whom she was observed preparing the medications. The DON indicated Resident S had not received the incorrect medications. During an interview on 5/14/25 at 11:19 a.m., LPN 3 indicated she had already set up Resident S's medication and placed them in the medication cart. She was asked if she had a glucometer test complete, so she thought that was what needed to be observed. LPN 3 indicated she focused on getting a blood sugar test completed, so she set up the medication for Resident K and locked the medications in the cart when she needed to obtain a glucometer. When she returned to the cart, she grabbed the cup of medications for Resident S and not Resident K, proceeded to administer the medications to Resident S and obtained a glucometer reading for Resident S. LPN 3 failed to inform the surveyor she was not giving the observed medications to Resident K. LPN 3 indicated she was unaware the observation required watching the resident received the medications for which preparation was already observed. A medication administration policy, dated 11/3/14 and received from the DON as current, indicated the five rights of medication was to be followed: right resident, right drug, right dose, right route, and right time. Medications were to be administered at the time they were prepared. Medications were not to be pre-poured. A Job Specific Orientation, dated and signed by LPN 3, indicated orientation to the medication pass routine was completed on 4/28/25. This citation relates to Complaint IN00458693. 3.1-35(g)(1)

Based on observation, record review and interview, the facility failed to assist a dependent resident with incontinent care in a timely manner related to a delay in answering the call light for 1 of 5 residents reviewed for activities of daily living (ADLs). (Resident J) Finding includes: During an observation on 5/12/25 at 5:15 a.m., the call light for Resident J's room was activated. At 5:47 a.m., the Director of Nursing (DON) responded to the call light and indicated Resident J had reported he had a bowel movement and needed care. At 5:49 a.m., CNA 2 entered the resident's room and began care. The resident had been incontinent of bowel. Resident J's record was reviewed on 5/14/25 at 8:04 a.m. The diagnoses included, but were not limited to, end stage renal disease with dialysis required and stroke. A Care Plan, dated 1/31/25, indicated there was a risk for skin breakdown. The intervention included assistance with incontinent care would be provided. A Quarterly Minimum Data Set (MDS) assessment, dated 3/14/25, indicated a moderately impaired cognitive status and was dependent for toileting, dressing, bathing, hygiene, and transfers, and was always incontinent of bowel and bladder. During an interview on 5/13/25 at 4:30 p.m., the Director of Nursing indicated care was provided soon after the call light was answered. She had no further information to provide after being informed what time the call light was activated and the length of time until it was answered. This citation relates to Complaints IN00457998 and IN00458693. 3.1-38(a)(3)

Based on observation, record review and interview, the facility failed to ensure services to prevent the development of pressure injuries were effectively provided to Resident D, who was admitted to the facility without a pressure ulcer and developed a facility-acquired unstageable pressure ulcer (pressure ulcer known but not stageable due to coverage of wound bed by slough and/or eschar) and also failed to ensure services were provided to Resident E, who developed a facility-acquired stage three (full thickness tissue loss) pressure ulcer, in accordance with the physician orders, for 2 of 3 residents reviewed for pressure ulcers. This deficient practice resulted in Resident D developing a facility-acquired wound initially identified by the facility as an unstageable pressure injury on the sacrum, that required surgical debridement after re-admission into the hospital. Findings include: 1. Resident D's closed record was reviewed on 3/25/24 at 2:02 p.m. The diagnoses included, but were not limited to, pneumonia, respiratory failure, and dementia. The resident was readmitted from the hospital on 2/8/24. A Quarterly Minimum Data Set assessment, dated 11/18/23, indicated a severely impaired cognitive status, dependent for all activities of daily living, was a risk for pressure ulcers, and had not pressure ulcers. A Care Plan, dated 8/11/23, indicated a potential for alteration in skin integrity. The interventions, last dated 10/4/23, included to avoid scratching and keep hands and body parts from excessive moisture, keep fingernails short, educate the resident/family/caregivers of causative and measures to prevent skin injury, follow facility protocols for treatment of injury, identify/document potential causative factors and eliminate/resolve where possible, keep skin clean and dry, use lotion on dry skin, use a draw sheet or lifting device to move the resident, weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. The Nurse's Re-admission Assessment, dated 2/8/24 indicated no skin impairment was observed. A Weekly Skin Assessment, dated 2/9/24, indicated the skin was intact and there were no concerns. The CNA Bathing Task form, indicated bathing had been completed by the staff on February 9, 10, 11, 12, 13, and 14, 2024. The CNA Skin Condition Task Form, dated 2/10/24 at 10:59 p.m., indicated, red area, discoloration, open area was found and the nurse had been notified. The CNA Skin Condition Task Forms did not include documentation to indicate a red discolored open area was observed on February 11, 12, 13, and 14, 2024. A Nurse Practitioner (NP) Progress Note, dated 2/13/24 at 9:08 a.m., indicated the NP observed Resident D lying in a soiled bed with an unstageable pressure ulcer on the coccyx. The note indicated the NP notified the Wound Care Nurse and Director of Nursing (DON), and the resident was placed on a low air loss bed. The area was described by the NP as a bruising wound. There were no measurements or further description of the area documented and no treatment orders given. A NP Progress Note, dated 2/14/24 at 12:37 p.m., indicated the Administrator had informed her the resident had been declining. The resident was assessed as cachectic (wasting with loss of muscle mass) and was unresponsive to verbal stimuli. The blood pressure was 84/53 and temperature was 101.9 and the resident had a new pressure area. An order was received to transfer him to the emergency room for an evaluation. The clinical record did not include documentation to indicate an assessment of the open area had been completed by a licensed nurse between 2/10/24 when it was observed by staff and 2/13/24 when the area was observed and documented by the Nurse Practitioner. The clinical record did not include documentation to show treatment orders for the unstageable coccyx wound were received from the NP or the physician between 2/10/24 when an open area was first documented by facility staff and 2/14/24 when the resident was sent to the hospital for a change in condition. A Significant Change Minimum Data Set (MDS) assessment, dated 2/14/24, indicated a severely impaired cognitive status, no behaviors, dependent for all activities of daily living, was always incontinent of bowel and bladder, dependent on tube feedings, and had one unstageable pressure ulcer that was not present on admission. There was no updated Pressure Ulcer Care Plan which included interventions to provide complete pressure relief to the coccyx wound. An emergency room Physician's Note, dated 2/14/24, indicated Resident D was evaluated at 1:23 p.m. The resident's blood pressure measurement was 114/95 mm/Hg, the heart rate measurement was 102 bpm (beats per minute), and the temperature measurement was 98.5 degrees Fahrenheit. The resident was assessed to have bilateral pneumonia and was admitted for antibiotic treatment and also debridement of a pressure ulcer on the sacrum (coccyx). Hospital Wound Care Notes, dated 2/14/24. indicated the wound was assessed as a full thickness wound, stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) with palpable bone palpable. The wound measured 15.0 centimeters (cm) L (length) by 10.0 cm W (width). There was no depth documented. The note indicated the wound had no drainage and the the peri-wound was fragile. The Debridement Procedure Notes of the sacral wound, dated 2/19/24, indicated the preoperative diagnosis was unstageable sacral decubitus ulcer and postoperative diagnosis was a stage four sacral decubitus ulcer. A scanned photograph of the area from the hospital, dated 2/14/24, was reviewed on 3/28/24. The photograph indicated the wound was a large area with a blackened/brown covering on the sacrum/coccyx skin area, with a reddened partial thickness loss area on the left buttock under the blackened/brown area. The Hospital Wound Care Notes indicated the area on the coccyx was debrided on 2/19/24 and a wound vacuum was placed. During an interview, on 3/27/24 at 1:15 p.m., the Nurse Consultant indicated the facility had determined the Wound Program was not being implemented correctly and had made some changes to improve the program. She had not realized it was that bad. During an interview, on 3/27/24 at 2:25 p.m., the Administrator indicated the NP had asked her to come to the resident's room to look at the wound. The Administrator acknowledged she was not a nurse and was unable to assess the area. The Nurse Consultant indicated the resident's health was declining and acknowledged skin areas were not being assessed at that time and the Director of Nursing was responsible for ensuring the pressure areas were assessed. The Director of Nursing and the Wound Nurse at the time were no longer employed at the facility. During an interview, on 3/27/24 at 3 p.m., the Administrator indicated the CNA who had found the skin concern on 2/10/24, was no longer employed at the facility. A facility skin condition policy, dated 9/1/20, and received as current from the Nurse Consultant, indicated a wound assessment would be initiated and documented in the resident's record when pressure and/or other non-pressure skin conditions were identified by a licensed nurse. 10770 2. During an observation on 3/27/24 at 9:15 a.m., CNA 1 was observed repositioning Resident E onto the left side so the Wound Nurse could perform a treatment to a pressure ulcer on the sacrum. The Wound Nurse was observed to remove the bandage from the resident's sacral area, and the pressure ulcer was noted to be red with minimal drainage. The record for Resident E was reviewed on 3/27/24 at 11:15 a.m. Diagnoses included but were not limited to, type 2 diabetes, weakness, anemia, anxiety, and high blood pressure. The 12/27/23 Quarterly Minimum Data Set (MDS) assessment, indicated the resident was cognitively intact for daily decision making and had no pressure ulcers. The resident needed partial to moderate assistance with rolling to the left and the right, and was at risk for pressure ulcers, however there were none. A Skin/Wound Note, dated 3/14/24 at 8:16 a.m., indicated the resident was observed with a facility-acquired pressure wound to the sacrum with blanchable erythema (redness of the skin) covering 10% of the area and 90% of the wound was noted with slough (necrotic tissue) that was non-adherent. A Wound Assessment Details Report, dated 3/14/24, indicated the resident experienced a facility-acquired stage three (Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.) injury to the sacrum that measured 0.8 centimeters (cm) L (length) by 0.5 cm (width) by unknown depth. The report indicated the wound contained 90% slough. Physician's Orders, dated 3/14/24, indicated a new order was received to cleanse the facility-acquired sacral wound with wound cleanser and pat dry, apply a thin layer of Medi Honey (a debriding agent indicated for dry to moderately exuding wounds such as: pressure ulcers (partial- and full-thickness) to the wound bed, and cover with a dry dressing in the morning every Monday, Wednesday and Friday. There was no documentation on the March 2024 Treatment Administration Record (TAR), for 3/14, 3/15, and 3/18/24 to indicate the Medi Honey treatment was completed as ordered to the sacral pressure ulcer. A Care Plan, revised on 3/26/24, indicated the resident had impaired skin breakdown to the sacrum, related to mobility and weakness. The approaches were to administer treatments as ordered and monitor for effectiveness. During an interview, on 3/27/24 at 2:30 p.m., the Nurse Consultant indicated the treatment of the Medi Honey was not transcribed onto the TAR, so the nurses could not sign it out after it had been completed. She was unable to provide any documentation to show the treatment was completed in accordance with the physician's orders. The current and reviewed 11/1/23 Skin Condition Assessment and Monitoring Pressure and Non-Pressure policy, provided by the Nurse Consultant on 3/27/24 at 2:50 p.m., indicated physician ordered treatments shall be initialed by the staff on the electronic Treatment Administration Record after each administration. Other measurements not involving medications shall be documented in the weekly wound assessment or nurses notes. This citation relates to Complaint IN00430628. 3.1-40(a)(2)

Based on record review and interview, the facility failed to implement measures to ensure a moderately impaired dependent resident was not lying flat in bed while an enteral (administered into the gastrointestinal tract) tube feeding was infusing, which led to labored breathing, audible crackle lung sounds, projectile vomiting, unresponsiveness, intubation, and ultimately death for 1 of 3 residents reviewed for tube feeding. (Resident B) The immediate jeopardy began on [DATE] when the resident was observed several times by staff during the early and late morning hours with the head of bed flat and the enteral tube feeding infusing. Later that day at 11:15 a.m., the resident was observed with labored breathing, crackles upon auscultation (listening with stethoscope), gurgling and severe projectile vomiting which required suctioning. The resident became unresponsive, was intubated, and transported to the emergency room (ER) where she died . The Administrator, [NAME] President of Operations, and both Nurse Consultants were notified of the immediate jeopardy at 2:30 p.m. on [DATE]. The immediate jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity level of actual harm that is not immediate jeopardy. Finding includes: During a phone interview on [DATE] at 10:58 a.m. with Resident B's mother, she indicated her daughter had just come back from the hospital the day before. The family member indicated she visited her daughter every day and arrived at the facility between 10:30 a.m. and 11:00 a.m. She entered her daughter's room and observed her breathing very hard and loud the bed was completely flat. The mother indicated she even knew the head of the bed could not be flat when someone had a feeding tube running. She immediately turned the call light on, and kept calling her daughter's name, but she was not responding. She knew her daughter was gone dead. She went out into the hall to get help, but could not find anyone, so she called for help, and CNA 1 came towards her. She told the CNA the head of the bed was flat and her daughter was breathing very hard and she needed help. The CNA entered the room and raised the head of the bed. The resident's mother indicated after her head was raised, all the fluid came out, she threw up everything and it had been built up in there for a long time. There was no suction machine in the room to help her daughter. The nurse RN 1 came into the room and asked her to leave the room so they could work on her. The mother was not aware if her daughter was suctioned or not, but did see the nurses bring in a machine to do that. She was also not aware if they initiated CPR while at the facility in her room. The paramedics came into the room and when they took her out, they worked on her for a long time in the parking lot. She said they pronounced her dead in the ER. The closed record for Resident B was reviewed on [DATE] at 10:40 am. The resident was admitted to the facility on [DATE]. Diagnoses included, but not were not limited to, dementia, stroke, bipolar disorder, high blood pressure, multiple sclerosis, schizophrenia, dysphagia, pressure sore, peg tube (a tube in the stomach which was used for nutrition), hemiplegia, type 2 dm, and Candida sepsis. The resident was discharged to the hospital on [DATE] and readmitted back to the facility on [DATE]. The Modification of the Admission Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident was moderately impaired for decision making and was an extensive assist with a 2 person physical assist for bed mobility. The resident had swallowing issues such as food running out of her mouth and holding food in her mouth. She received 51% of her nutrition through enteral feedings. A Care Plan, dated [DATE], indicated the resident was at risk for complications secondary to requiring a tube feeding. The approaches were the head of the bed was to elevated to 30 to 45 degrees. A Care Plan, dated [DATE] and revised on [DATE], indicated the resident was at risk for impaired nutritional status due to being NPO, peg tube feedings and weight loss. The approaches were to ensure all staff were informed of the resident's special dietary and safety needs. Physician's Orders, dated [DATE], indicated NPO (Nothing By Mouth) and Jevity 1.5 (enteral feed)via the peg tube at 50 cubic centimeters (cc) per hour. The resident was also in isolation for Candida Auris. The Medication Administration Record for the month of ,d+[DATE] indicated the enteral feeding was signed out as being turned on and infusing on the midnight shift on ,d+[DATE] and the day shift for [DATE]. Nurses' Notes, dated [DATE] at 11:09 p.m., indicated the resident was alert and oriented with some confusion. She returned to the facility tonight with a picc line to the left upper arm, a foley (urinary)catheter, and was to be in isolation for Candida Auris. The resident also had a wound to the sacral area. The Physician and family were notified. Nurses' Notes, dated [DATE] at 11:51 a.m., indicated, Resident sent to ER due to unresponsive to stimuli vigorous shake on multiple attempts, crackle noted on auscultation. feeding paused, resident was suctioned. HOB [head of bed] elevated. POA [power of attorney] at bedside, MD notified. Nurses' Notes, dated [DATE] at 3:26 p.m., indicated the hospital had called to let the facility know the resident was deceased . A Hospital Note, dated [DATE] at 11:59 a.m., indicated the patient presented with cardiac arrest and EMS was called to the nursing home for difficulty breathing. EMS reported the patient was supine with agonal breathing, and went into pulseless electrical activity upon arrival to ER and ACLS (advanced cardiac life support) therapy was initiated. EMS intubated the patient in the field, however, no life saving medications were administered. A physical exam indicated the patient was ill and toxic appearing and her pupils were dilated at 6 millimeter bilaterally. There was no palpable pulse or heart sounds heard with auscultation and breath sounds were heard with bagging bilaterally. The patient's critical condition was discussed with the mother and the decision was made to take her off life support. The patient was pronounced dead at 12:11 p.m. A written time line of events, provided by Nurse Consultant 2, indicated on Friday [DATE] the resident was readmitted to the facility at 7:00 p.m. At 10:00 p.m., 2 staff members indicated the head of the bed was elevated. On Saturday [DATE] at 12:00 a.m., LPN 1 indicated the resident was lying flat in bed, but the peg tube was not running. The head of the bed was elevated and the peg tube was infusing again. At 5:00 a.m., LPN 1 indicated she had checked on the resident but did not recall if the bed was flat or elevated. On [DATE] at 9:00 a.m., the Admissions Director was the manager on duty and observed the resident's head of the bed flat and the enteral feeding was infusing. At that time, she notified RN 1 of the situation. At 10:00 a.m., RN 1 observed the resident's head of bed was flat and the tube feeding was infusing, he raised the head of the bed up at that time. At 11:15 a.m., the resident's mother alerted CNA 1 to come to the room due to the head of bed was flat again and the tube feeding was infusing. At 11:25 a.m., 911 was called and at 11:51 a.m., the resident was sent to the ER. The following interviews were conducted as part of the facility investigation: A statement from the Admissions Director on [DATE], indicated she was the manager on duty that day. She walked down to the resident's room at 9:00 a.m. She noticed there were no isolation gowns available so she told RN 1 about that and he filled the bin right away. She looked in the room and observed the resident lying flat in bed and could see she was breathing. She informed RN 1 the resident was a tube feeding and should not be lying flat in bed. A telephone statement from CNA 1 on [DATE], indicated she was walking down Blueberry hall and noticed the resident's mother coming out of the room and wanting to know who her daughter's CNA was and stated Anyone who knows anything about tube feeds knows they can't lie flat. She donned ppe and raised the head of the bed. CNA 1 went to wash her hands with soap and water and heard the resident's mother say Oh my god, my baby is going to die! She came out of the bathroom and observed the resident throwing up large amounts of her tube feeding. LPN 2 entered the room with the suction machine and started to suction her mouth. A telephone statement from LPN 2 on [DATE], indicated she was at the nurses' station and overheard the resident's mother yelling. She saw CNA 1 enter the room and heard her say help me! When she arrived to the room the resident was throwing up and she listened to her breathing and knew she needed to be suctioned. RN 1 grabbed the suction machine and gave it to her and she started to suction immediately. The resident's mother was in the hallway and could be heard saying, She shouldn't been laying flat. He don't know what he is doing. EMS arrived and continued to suction the resident and she was still breathing when she left the facility. She could hear the paramedics say, Sounds like she has been like this for a couple of days. A telephone statement from RN 1 on [DATE] indicated he was the day shift nurse assigned to the resident. He observed the resident lying flat in bed around 10:00 a.m. He raised the head of the bed at that time with no additional concerns. He indicated around 11:00 a.m., the resident had a change in condition and was sent to the ER. There was no written statement from CNA 2 or any of the midnight shift CNAs who had worked the early morning hours on [DATE]. An inservice, (no date or time), indicated Attention all Nurses, ensure the resident's head of bed is elevated (minimum of 30 degrees) when providing water flush, medication, and feeding via gastric tube. Check placement of gastric tube prior to administering feeding, medication, or water flush. Be sure to start and stop tube feeding per physician orders. Always administer tube feeding and water flush per physician orders .The inservice was signed by the Director of Nursing (DON), Assistant Director of Nursing, the Wound Care Nurse and a QMA. The next page indicated Peg tube HOB elevated at least 30 degrees. The inservice was signed by 5 day shift CNAs, the DON, ADON, Wound Nurse, 3 day shift nurses, 1 day shift QMA, and 1 evening shift CNA. During an interview on [DATE] at 11:30 a.m., RN 1 indicated he was the nurse on duty and was taking care of the resident. He arrived to work late around 7:30 a.m. and received report from the midnight nurse, The resident had come back from the hospital the night before and was now on IV antibiotics, and in isolation for Candida. He indicated her medications were not in from pharmacy so he had nothing to give her that morning. RN 1 indicated he started med pass and around 8:15 a.m., he had some blood sugars to do and other medications to give. He observed the resident sometime after that and the head of bed was flat while the enteral feeding was infusing, so he raised it up to 35 degrees and left the room, as he did not have her medications yet. Around 10:45 a.m., he was finished with med pass, and was seated at the nursing station, when the resident's mother came in and asked who her daughter's nurse was, he told her he was. She then walked down to her room and minutes later, CNA 1 came to nursing station and told him the resident was vomiting. LPN 2 and himself went to the room together to assess the situation and 911 was called. They could not get her to respond after shaking her. He also suctioned about 100 cc of tube feeding out of her mouth, and her breathing was very bad as he heard crackles. The paramedics arrived and she left to go to the hospital. He indicated he could not find the resident's CNA at that time, the one who was assigned to her. During an interview on [DATE] at 11:35 a.m., CNA 1 indicated she was working the other hall and stepped out of a room and heard the resident's mom yelling for help. She went to see what she needed and when she entered the room the resident was lying flat in bed and the tube feeding was infusing. The resident was breathing very hard and did not look like she was responding. She raised the head of the bed and started to leave the room to get the nurse and at that time, the resident's mom yelled, she turned around and the resident was vomiting tube feeding from her mouth, like projectile vomiting. She got the nurse and they brought the suction machine in and started to suction her. CNA 1 indicated CNA 2 was her aide that day, but she thinks she might have been in another room taking care of someone else. During an interview on [DATE] at 1:07 p.m., the Admissions Director indicated she was the manager on duty on [DATE] came in around 8:15 a.m., started doing her rounds in the facility, making sure staffing was ok and the residents were ok. At 9:00 a.m., she checked on the resident and observed her from the hallway, the head of the bed was flat and the tube feeding was infusing. She informed RN 1 right away, who was across the hall passing medications. She did not stay to make sure RN 1 raised the head of the bed immediately, she walked away. During an interview on [DATE] at 1:20 p.m., the Director of Nursing (DON) indicated CNA 2 was interviewed and she had not even entered the resident's room from the start of her shift to when the resident left the facility with EMS. During an interview on [DATE] at 1:30 p.m., the [NAME] President of Operations (VPO) indicated she was aware of the incident and was told by her clinical team the investigation was being taken care of. The Administrator who investigated the incident was no longer employed at the facility. During an interview on [DATE] at 10:42 a.m., CNA 2 indicated she had asked RN 1 why the resident was in isolation and he threw his hands up in the air, suggesting he did not know. She told him she was uncomfortable taking care of the resident not knowing what kind of infection she had. She saw Restorative CNA and RN 1 talking about the care for the resident so she assumed the Restorative CNA would be taking care of the resident that day. She did not enter the resident's room at any point during the day on [DATE]. The American Nurse Association (ANA) website www.myamericannurse.com information, titled, Tube Feeding Aspiration and dated [DATE], indicated .Acute aspiration of tube feeding can result in a respiratory emergency A Memorial [NAME] article found at www.mskcc.org/cancer-care/patient-education/how-prevent-aspiration#section-1 and titled, How to Prevent Aspiration, dated [DATE], indicated signs of aspiration include: coughing, choking, gagging, throat clearing, vomiting, trouble breathing, wheezing, painful breathing A policy titled, Enteral Tube Feeding via pump dated [DATE], provided by Nurse Consultant 2, indicated it was the policy of the facility to provide enteral feeding via pump, as ordered by the physician, to ensure adequate nutrition for residents who were unable to maintain their nutrition orally. The head of the bed should be positioned to 30 to 45 degrees unless medically contraindicated. The immediate jeopardy that began on [DATE] was removed on [DATE] when the facility completed an all nursing staff inservice regarding feeding tubes, positioning of the resident in bed while the feeding tube was infusing, identifying signs and symptoms of aspiration, and educating nurses to make sure to find the root cause when the head of the bed was flat more than once, but the noncompliance remained at the lower scope and severity of actual harm that is not immediate jeopardy because the resident was lying flat in bed while the feeding was infusing through the peg tube which led to labored breathing, projectile vomiting, aspiration, unresponsiveness, intubation, pulseless, and ultimately death. This citation relates to Complaint IN00421764. 3XXX,d+[DATE](a)(2)

Based on observation, record review, and interview, the facility failed to ensure pressure relieving devices were in place and the resident's foot was repositioned from against the foot board which resulted in an acquired deep tissue injury pressure ulcer to the bottom of the left lateral foot for 1 of 3 residents reviewed for pressure ulcers. (Resident 23) Finding includes: On 6/27/21 1:45 p.m., Resident 23 was observed in bed. At that time, his left foot was pressed against the foot board of the bed and was laying directly on the mattress. His foot was not elevated, nor was there any pressure relieving devices under the foot. The resident had a specialty air mattress on his bed. On 6/28/21 at 10:00 a.m., the resident was observed in bed. At that time, his left foot was pressed against the foot board of the bed and was laying directly on the mattress. His foot was not elevated, nor was there any pressure relieving devices under the foot. On 6/29/21 at 9:26 a.m., 12:05 p.m., and 2:51 p.m., the resident was observed in bed. At those times, his left foot was pressed against the foot board of the bed and was laying directly on the mattress. His foot was not elevated, nor was there any pressure relieving devices under the foot. On 6/30/21 at 9:35 a.m., the resident was observed in bed. At that time, his left foot was pressed against the foot board of the bed and was laying directly on the mattress. His foot was not elevated, nor was there any pressure relieving devices under the foot. On 6/30/21 at 1:27 p.m., the resident was observed in bed. At that time, his left foot was laying directly on the mattress and was not elevated, nor was there any pressure relieving devices under the foot. 7/1/21 at 9:45 a.m., CNA 3 and CNA 4 were going to provide morning care to the resident. The resident was wearing a sock to his left and it was elevated on a pillow. CNA 3 removed his sock and the resident's great toenail was observed with dried blood. There was a small open area noted in the corner of his toe. There was a large dark red/maroon unopened area on the bottom of the left lateral foot. The resident's foot was very dry and had a large amount of dried scaly skin. There was dried skin flakes observed all over the mattress. After morning care, the Wound Nurse was informed of the open areas on the resident's body. Interview with the Wound Nurse on 7/1/21 at 10:30 a.m., indicated the resident had no open areas currently at the present time. She indicated she would assess the open areas immediately. The record for Resident 23 was reviewed on 6/29/21 at 1:50 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Quarterly Minimum Data Set (MDS) assessment, dated 4/30/21, indicated the resident was alert and oriented. The resident needed extensive assist with 1 person physical assist for dressing, and extensive assist with 2 person physical assist for personal hygiene. The resident had no pressure ulcers, but was at risk for pressure ulcers. The Care Plan, dated 5/3/21, indicated the resident had limited functional status in regards to the ability to independently change positions in bed. The Care Plan, dated 5/3/21, indicated the resident had potential for impairment to skin integrity related to immobility, incontinence, and a history of pressure ulcers. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The last documented weekly skin assessment was dated 6/24/21 which indicated the resident had no open areas or new skin issues. Nurses' Notes, dated 7/1/21 at 10:50 a.m., indicated the resident had current skin issues. A Deep Tissue Injury (DTI) to the left lateral foot which measured 3.5 centimeters (cm) by 3.0 cm. The wound bed was necrotic with no drainage. A skin tear was observed to the left great toe, which measured 1 cm by 0.5 cm. There was granulation to the wound bed with some drainage. The Physician was notified and new orders were obtained. The Wound Physician would see the resident on the next rounding day. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply skin prep daily until resolved. May apply as needed every shift for DTI. [MEDICATION(S)] ointment to left great toe topically every day shift for skin tear until resolved. Interview with Wound Nurse on 7/1/21 at 11:30 a.m., indicated she had completed the skin assessment for the resident. She observed a Deep Tissue Injury (DTI) to the bottom of the left lateral foot and a skin tear which looked like an ingrown toenail to the left great toe. She notified the Physician and orders were received for skin prep every shift for the DTI and for the wound Doctor to see the resident on his next visit which was next week. She indicated his heel boot was not in the room, so a new one was obtained. Her last skin assessment was completed on 6/24/21 approximately 1 week ago and the resident had no open areas. The resident's foot was to be offloaded while in bed and should not be touching or pressed against the foot board. The current 3/13/21, Wound Prevention policy, provided by the Director of Nursing on 7/1/21 at 11:45 a.m., indicated weekly skin checks will be conducted by the licensed nurse and will be documented in the resident's electronic medical record. Daily, during routine care, the CNA will observe the resident's skin. When abnormalities were noted this will be communicated to the licensed nurse and the licensed nurse will proceed and complete a wound or skin event. All residents will have the following nursing care procedures as recommended and indicated. Pressure relief: As needed position and reposition the resident with pillows and other supportive devices. Skin hygiene: Daily with care lubricant the skin with lotion, to keep it soft. During care inspect the skin for signs and symptoms of skin breakdown. 3.1-40(a)(1)