Every finding on record at Castleton Health Care Center

Based on observation, interview, and record review the facility failed to complete weekly skin assessments for Resident B and Resident F, failed to ensure a low air loss mattress was in place and functioning for Resident F, and failed to follow physician orders for wound treatments for Resident B. This deficient practice affected 2 of 3 residents reviewed for skin management. (Resident F and Resident B). 1. The clinical record for Resident F was reviewed on 8/17/2026 at 3:20 PM. The medical diagnosis included, but were not limited to, dementia and arterial ulcers. A Significant Change Minimum Data Set (MDS) assessment, dated 5/18/2026, indicated Resident F had mild cognitive impairment, did not exhibit behaviors, and did not reject care. The assessment indicated the resident had no pressure areas and had four non pressure ulcers with treatment in place. The resident used pressure reducing devices for the bed and wheelchair. The assessment indicated she required supervision assistance with rolling, partial assistance with toilet hygiene, and was dependent for dressing, personal hygiene, and showers. Resident F was always incontinent of bowel and bladder. A skin care plan, dated 8/11/2024 and last revised 7/6/2026, indicated Resident F was at risk skin impairments related to comorbidities. The interventions included, but were not limited to, administering treatments as ordered. A physician Orders Details, dated 2/19/2026, indicated for Resident F to have a low air loss mattress. A low air loss mattress is a specialized mattress used for pressure redistribution via continuous airflow. A nursing progress note, dated 7/9/2026, indicated Resident F's low air loss mattress had lost inflation. Resident F was transferred to a .regular cushioned mattress. A wound care note, dated 8/10/2026, indicated the recommendation for Resident F to utilize a low air loss mattress. During an interview and observation, on 8/17/2026 at 2:05 PM, Resident F was laying in bed. Resident F indicated she had not been on an air mattress for some time and was currently on a foam mattress. During an interview and observation, on 8/17/2026 at 2:25 PM, Resident F was laying in a regular bed. QMA 5 verified Resident F was on a standard pressure reducing mattress. Weekly skin observations for Resident F indicated no weekly skin assessments completed between 6/17/2026-7/5/2026, 7/7/2026-7/27/2026, or 8/5/2026-8/18/2026. The Weekly Skin Check assessment, dated 8/4/2026, indicated a status of In Progress but no details were completed inside of the assessment. 2. The clinical record for Resident B was reviewed on 8/18/26 at 9:57 a.m. The diagnoses included, but were not limited to, morbid (severe) obesity and major depressive disorder. The Quarterly Minimum Data Set (MDS) assessment, dated 5/25/26, indicated Resident B was cognitively intact. During an observation and interview with Resident B on 8/17/26 at 1:11 p.m., indicated they were supposed to have both of their lower legs were supposed have lotion applied and wrapped every day and staff were not doing it. Bilateral lower legs observed with no wraps on. A physician's order, dated 12/8/25, indicated complete weekly skin assessments and notify DON (Director of Nursing)/ADON (Assistant Director of Nursing) with any new skin impairments. The EHR (Electronic Health Record) indicated Resident B had weekly skin assessments on 6/15/26, 7/6/26, 7/28/26, and 8/17/26. The weekly skin assessment, dated 8/17/26, indicated Resident B had skin impairments to the upper/mid vertebrae and the front of both lower legs. The weekly skin assessment indicated to complete a weekly wound progress assessment. A physician's order, dated 1/7/24, indicated to open and complete skin observation. Complete the assessment in its entirety. Assure that all current and new skin issues are documented. Open New Skin Issue in risk management for any new skin issue identified during assessment, including progress note. Notify MD and family as indicated. During an observation and interview with Resident B on 8/18/26 at 10:45 a.m., indicated they had a spot on their back that had been there a couple months, and the wound care nurse indicated it was fungus. Resident B indicated they had over the counter anti-fungal powder that staff will apply for them when it starts irritating them and they complained about it. The area to Resident B's back appeared raw and irritated and was approximately 6 inches long by 3 inches wide. Resident B indicated the regular nurse looked at it yesterday and said she would notify the wound care nurse about the new finding. Both lower legs observed unwrapped. Resident B indicated they did not apply lotion to his lower legs. During an interview with Qualified Medical Assistant (QMA) 9 on 8/18/26 at 10:52 a.m. indicated they did not know Resident B had an area to his upper back until yesterday when he told her and she put powder on it. QMA 9 indicated she notified Licensed Practical Nurse (LPN) 12 yesterday about the place to Resident B's back. During an interview with LPN 12 on 8/18/26 at 10:55 a.m., indicated she was told yesterday by someone but could not remember who, the aide or the nurse, and she did a skin assessment around 11:00 p.m. and documented there was an area to his upper mid back. LPN 12 indicated she notified the ADON and DON at 11:00 p.m. last night when she found it. LPN 12 indicated when a new area was identified, they will do a skin and pain assessment, and notify the physician and wound care nurse of the finding. No documentation in Resident B's EHR indicated that a new skin issue was opened in risk management for the new skin issue, no progress note, and no notification for the MD. Resident B had physician's orders, dated 5/30/25, that indicated Dakins (1/4 strength) External Solution 0.125% (Sodium Hyochlorite). Apply to bilateral lower legs topically every day shift for wound care. A physician's order, dated 8/18/25, indicated wound care to lower right leg: Cleanse with dakins, pat dry; apply lotion and wrap with Kerlix then ace bandage; every day shift and prn (as needed). During an interview with the Director of Nursing (DON) on 8/18/26 at 12:49 p.m. indicated the provider should have been notified upon findings of any new skin area to a resident and implement any new orders the provider puts into place depending on the observation. The DON indicated she was informed of Resident B's new back findings today from LPN 12. The DON indicated Resident B did not have any open area to his legs, so the Dakin's solution is not being given, because there are no open areas to the legs and the orders should have been discontinued. Per review of the July/August 2026 Medication Administration Record (MAR), nursing was documenting this medication/treatment was being completed. The DON indicated whoever was following Resident B's leg wounds at the time should have discontinued the Dakin's order. A plan of care, dated 9/9/22, indicated Resident B had potential for pressure ulcer development related to history of ulcers, immobility, and incontinence. The interventions included, but were not limited to, administer treatments as ordered and monitor effectiveness and to inform resident/family/caregivers of any new areas of skin breakdown. A Wound Management policy was provided by the DON on 8/18/26 at 1:00 p.m. It indicated .Purpose: To ensure that residents with wounds, including pressure and non-pressure injuries, receive appropriate treatment and management to promote healing, prevent infection, and decrease the risk of new wound development.Procedure: I. Assessment: 1. A Licensed nurse will conduct skin assessments weekly and as needed, and document findings in the facility's EHR.2. When a new wound is identified: measure the wound, initiate a Wound Monitoring Record, and implement physician-ordered treatments immediately.6. Treatment Implementation: pressure redistribution measures will be used.7. The attending physician will be notified of new wounds. This Federal citation relates to intake 3093735. This Federal intake relates to intake 3117385. 410 IAC (Indiana Administrative Code) 3.1-37

Based on observation, interview and record review, the facility failed to promote a resident's dignity when requesting assistance with hygiene and medications as requested. (Resident C & Confidential Resident) Findings include: 1. The clinical record for Resident C was reviewed on 8/18/26 at 2:46 p.m. The diagnoses included, but were not limited to, hemiplegia (medical condition that causes paralysis on one side of the body) and hemiparesis (weakness or partial loss of movement on one side of the body) affecting the right dominant side, anxiety disorder, dry eye syndrome, and age-related cataract. The Quarterly Minimum Data Set (MDS) assessment, dated 7/30/26, indicated Resident C was cognitively intact, had upper extremity impairment on one side, and needed supervision/touching assist with personal hygiene. A Facility Reported Incident (FRI), dated 5/1/26, indicated a family member of Resident C reported to management staff that Resident C had been verbally berated by Qualified Medical Assistant (QMA) 15 when she asked for assistance on medications. During an observation and interview with Resident C on 8/17/26 at 1:00 p.m., Resident C was sitting up in bed with a sling to her right arm and right hand was visibly deformed. Resident C indicated she was able to use her left arm, but the right side of her body was weak and she needed assistance still with certain things, like applying lotion. Resident C indicated QMA 15 was not putting her cream on her face and neck or assisting her with her eye drops as requested. Resident C indicated QMA 15 was short tempered, mean to her, and made her feel bad about asking for help. A facility provided statement from Executive Director (ED) 22, dated 5/1/26, indicated Resident C's sister reported that Resident C had complained to her that QMA 15 refused to apply lotion to her face and declined to administer her prescribed eye drops. When Resident C had requested assistance with applying lotion to her face and hands, QMA 15 responded in an aggressive manner, stating that if Resident C was able to paint her nails on one hand, she should be able to apply lotion herself. When QMA 15 was asked about this matter in the presence of the DNS (Director of Nursing Services), she reiterated the statement, indicating if Resident C was able to paint her nails, she should be able to apply lotion herself. A facility provided statement from the Treatment Nurse, dated 5/1/26, indicated on April 30th, Resident C had presented to her office visibly upset and crying. Resident C indicated QMA 15 would not put lotion on her face and told her she could do it herself. Resident C indicated to the Treatment Nurse that she was unable to apply lotion independently. A facility provided statement from Resident C, dated 4/29/26 at 7:00 p.m. indicated QMA 15 would not give her her eye drops because she was mad at her for reporting the lotion incident. Resident C indicated she cried. A psychological services progress note, dated 5/2/26, indicated Resident C was worried, anxious, irritable, and stressed. A plan of care, dated 4/22/25, indicated Resident C required setup, cues, supervision, and assistance at level required ADLs (Activities of Daily Living) related to hemiplegia and hemiparesis. 2. The clinical record for a confidential resident was reviewed. The medical diagnoses included, but were not limited to, depression and anxiety. A Significant Change MDS indicated the resident had mild cognitive impairment, did not exhibit behaviors, and did not reject care. The assessment indicated the confidential resident required supervision assistance with rolling, partial assistance with toilet hygiene, and was dependent for dressing and personal hygiene. A confidential interview conducted during the survey indicated the confidential resident resided at the facility. The confidential resident indicated staff talked to them bad, got smart with the residents, and would often tell the resident they would be back in a minute and not return. The confidential resident reported this made them feel bad and like they don't care. The privacy and dignity policy provided by the Executive Director on 8/18/26 at 9:05 a.m., indicated the purpose was to ensure that care and services provided by the facility promote and enhance , dignity and overall quality of life. The facility promotes resident care in a manner and an environment that maintains or enhances dignity and respect, in full recognition of each resident's individuality. This Federal citation relates to Intake 301160. Indiana Administrative Code 16.2-3.1-3(t)

Based on interview and record review, the facility failed to ensure residents reviewed for receipt of medications routinely received their physician-ordered medications and the medication receipt was documented in each resident's clinical record to reflect the receipt of the medications for 4 of 4 residents reviewed for pharmacy services. (Residents B, C, D and E) Findings include:1.The clinical record of Resident C was reviewed on 4-24-26 at 11:46 a.m. His diagnoses included, but were not limited to, ankylosing spondylitis (a chronic inflammatory autoimmune arthritis resulting in spinal stiffness and pain) of unspecified sites in the spine. His medication orders included, but were not limited to, Humira (a biologic medication used in the treatment of autoimmune disorders, such as ankylosing spondylitis) 40 milligrams (mg) to be injected every 14 days subcutaneously (under the skin) for ankylosing spondylitis of unspecified sites in the spine. His medication administration record (MAR) for March, 2026, indicated he received the 3-10-26, dose, but the 3-24-26, dose was blank, indicating it had not been administered as ordered. A review of the progress notes and the MAR for the time period failed to provide any documentation of why the medication was not administered as ordered.In an interview with a friend of Resident C's on 4-24-26 at 9:58 a.m., she indicated Resident C had not received at least two (2) doses of his Humira, but was unable to specify what those dates were. She had notified the Director of Nursing (DON) at that time and he received one of the two doses, but it was late by a few days. In an interview with the DON, Corporate Nurse and Executive Director (ED) on 4-27-26 at 3:05 p.m., the Corporate Nurse indicated when the issue of the undocumented dose of Humira was brought to the facility's attention on 4-24-26, the facility began an investigation. The DON indicated the facility learned the medication for the 3-24-26, was delivered to the facility on 3-13-26, thus meaning it was available to be administered on 3-24-26. She added the nurse who should have administered the injection was no longer employed by the facility which did not allow her to follow up with that nurse to address the discrepancy. 2.The clinical record of Resident B was reviewed on 4-24-26 at 2:33 p.m. His diagnoses included, but were not limited to, necrotizing fasciitis (a rare, life-threatening bacterial infection that destroys skin, fat, and the tissue covering muscles) and anxiety.A review of his medication administration record (MAR) for February, 2026, indicated one physician-ordered medication was not documented as administered as identified by the administration block, was blank, which signifies the medications were not administered. Corresponding documentation in the MAR or the progress notes failed to identify the reason the medications were not administered. Buspar 5 milligrams (mg) three times daily by mouth was not documented to have been administered on 2-2-26 at 1:00 p.m. 3.The clinical record of Resident D was reviewed on 4-27-26 at 12:10 p.m. His diagnoses included, but were not limited to, type 2 diabetes and chronic pain.A review of his medication administration record (MAR) for April, 2026, indicated multiple physician-ordered medications were not documented as administered as identified by the administration block, was blank, which signifies the medications were not administered. Corresponding documentation in the MAR or the progress notes failed to identify the reason the medications were not administered. The undocumented medications were as follows:-Gabapentin 300 milligrams (mg) 2 tablets for a total of 600 mg three times daily at 6:00 a.m., 2:00 p.m. and 10:00 p.m., for neuropathy (nerve damage) were not documented as administered on 4-1-26 and 4-4-26 at 10:00 p.m.-HumaLOG KwikPen (short-acting insulin) 100 UNIT/ML strength inject subcutaneously (under the skin) three times daily on a sliding scale basis (based on the blood glucose level). The MAR failed to identify the blood glucose was obtained and the corresponding insulin was administered on 4-16-26 and 4-18-26 at 8:00 a.m. and 12:00 p.m., and 4-19-26 at 8:00 a.m. 4.The clinical record of Resident E was reviewed on 4-23-26 at 2:42 p.m. Her diagnoses included, but were not limited to unspecified psychoses, anxiety, depression, type 2 diabetes, polyosteoarthritis (degenerative disease where osteoarthritis affects five or more joints) and polyneuropathy (damage to multiple nerves throughout the body).A review of her medication administration record (MAR) for April, 2026, indicated multiple physician-ordered medications were not documented as administered as identified by the administration block, was blank, which signifies the medications were not administered. Corresponding documentation in the MAR or the progress notes failed to identify the reason the medications were not administered. The undocumented medications were as follows:-Buspar (an anti-anxiety medication) 15 milligrams (mg) three times a day for anxiety was not administered on 4-1-26 at 5:00 p.m.-Eliquis (an anticoagulant medication) 2.5 mg twice daily for anticoagulation therapy was not administered on 4-1-26 at 6:00 p.m.-Lyrica (an anticonvulsant and pain medication) 75 mg twice daily for pain was not administered on 4-1-26 at 6:00 p.m.-Ropinirole (a dopamine antagonist used in the treatment of restless leg syndrome) 1 mg twice daily for restless leg syndrome was not administered on 4-1-26 at 6:00 p.m.-Quetiapine Fumarate (an anti-psychotic medication) 50 mg at bedtime for depression was not administered on 4-1-26 at 9:00 p.m.-Famotidine (a histamine receptor antagonist used to decrease stomach acid production) 10 mg at bedtime for stomach discomfort was not administered on 4-1-26 at 9:00 p.m. On 4-27-26 at 3:16 p.m., the Director of Nursing provided a copy of an undated policy entitled, Medication Error Reporting. This policy indicated its purpose as To develop policies and procedures for proper distribution of resident's medications. It indicated, The facility Administrator shall ensure that all nursing employees who distribute medication [sic] are oriented and comply with the facility's medication distribution policy. If a medication error should occur, the nursing employee making the medication error, or if different, the Nurse finding the medication error shall complete a medication report. A Medication Error Report shall be completed whenever it is indicated that there is a medication error, treatment error or documentation error. The form shall be initiated by the Licensed Nurse who discovered the error. The Director of Nursing or Assistant Director of Nursing shall be notified .shall direct the investigation, notification of the physician and family, and appropriate follow-up. The completed Medication Error Report shall be signed by the Director of Nursing and forwarded to the Administrator .The Administrator and Director of Nursing shall analyze the occurrence and determine the appropriate counseling . On 4-27-26 at 3:16 p.m., the Director of Nursing provided an undated copy of an educational training entitled, Medication Not Available in the Medication Cart. This training information indicated, When a prescribed medication is not available in the medication cart, prompt action is essential to ensure resident safety, maintain continuity of care and comply with regulatory requirements. Immediate Steps: Verify the order .Check the Emergency Drug Kit .Contact the Pharmacy .Notify the Provider .Notify the Resident and Family/Responsible Party .Document thoroughly in the medical record, including: medication name, dose and scheduled administration time, steps taken to locate the medication, pharmacy contact, including date, time and representative spoke to, provider notification and any orders received, family/responsible notification, resident assessment and any observed effects, follow-up actions taken .follow facility policies and procedures at all times, report recurring medication availability issues to nursing leadership. On 4-26-26 at 12:26 p.m., the Executive Director and Director of Nursing were electronically requested to provide copies of the facility's policies and procedures for medication and treatment administration documentation. As of exit from the survey on 4-27-26, this information had not been provided. This citation relates to Intakes 2975067 and 2981085. 410 IAC (Indiana Administrative Code 3.1-25(b)(3)410 IAC (Indiana Administrative Code 3.1-25(b)(9)

Based on interview and record review, the facility failed to ensure controlled medications were reconciled accurately during delivery for 3 of 3 residents reviewed for pharmaceutical services. (Resident B, Resident C, Resident D) Findings include:1. On 3/5/26 at 10:45 a.m., the Administrator provided a copy of a pharmacy delivery slip and a Controlled Drug Record for Resident B. A review of the documents indicated the following:- A pharmacy delivery slip, dated 1/8/26 at 5:02 p.m., indicated prescription number ****921, 40 tablets of oxycodone/acetaminophen 10/325 mg (millgrams) was delivered for Resident B. The space next to Received By: was left blank, the space next to Delivery Date/Time: was left blank, and the space next to Print Name: was left blank.- A Controlled Drug Record, dated 1/8/26, indicated prescription number ****921, 40 tablets of oxycodone/acetaminophen 10/325 mg were delivered for Resident B. The space next to Starting balance was left blank, the space next to Checked in By was left blank, and the space next to Date was left blank. No tablets were signed out as administered from the controlled drug record. 2. The clinical record for Resident C was reviewed on 3/6/26 at 9:12 a.m. The diagnoses included, but was not limited to, paraplegia, diabetes, and anxiety.A Narcotic Administration Record, dated 1/28/26 at 7:00 p.m. until 2/17/26 at 5:58 p.m., indicated Resident C's prescription number ****8204, oxycodone/acetaminophen 5/325 mg, the space next to Checked in By was left blank and the space next to Date was left blank.A Narcotic Administration Record, dated 2/17/26 at 5:58 p.m., indicated Resident C's prescription number ****9542, oxycodone/acetaminophen 5/325mg, the space nest to Starting Balance was left blank.3. The clinical record for Resident D was reviewed on 3/6/26 at 9:31 a.m. The diagnoses included, but were not limited to, dementia, epilepsy, and cognitive communication deficit.A Controlled Drug Record, dated 2/9/26 at 4:00 p.m. until 2/18/26 at 1:00 p.m., indicated Resident D's prescription number ****9277, hydrocodone/acetaminophen 5/325mg, the space next to Checked in By' was left blank and the space next to Date was left blank.During an interview on 3/6/26 at 11:45 a.m., LPN 3 indicated the pharmacy delivery slips and the Controlled Drug Record for Resident B, Resident C, and Resident D should have been filled in completely by the nurse that received those medications from the pharmacy.On 3/5/26 at 10:45 a.m., the Administrator provided a copy of an undated facility policy, titled Receiving Medications from Pharmacy, and indicated this was the current policy used by the facility. A review of the policy indicated when medications are delivered check the delivery manifest at the time of delivery against what is being delivered. If the manifest is correct, manually sign the appropriate space with name, date and time.This citation relates to Intake 2708112.410 IAC (Indiana Administrative Code) 16.2-3.1-25(e)(2)

Based on interview and record review, the facility failed to ensure a resident had a comprehensive person-centered discharge care plan in place for 1 of 3 residents reviewed for discharge. (Resident F) Findings include:The clinical record for Resident F was reviewed on 3/4/26 at 10:15 a.m. The diagnoses included, but were not limited to, traumatic brain injury, acute respiratory failure, cannabis dependence, and alcohol dependence.A progress note, dated 2/10/26 at 4:30 p.m., indicated Resident F discharged with medications and belongings.The clinical record for Resident F lacked a person-centered discharge care plan.During an interview on 3/6/26 at 12:10 p.m., Licensed Practical Nurse (LPN) 1 indicated Resident F should have had a person-centered care plan for discharge in place and a copy of the discharge care plan should have been provided when he discharged .On 3/4/26 at 9:30 a.m., the Administrator provided a copy of a facility policy, titled Transfer and Discharge, dated 6/2020, and indicated this was the current policy used by the facility. A review of the policy indicated the resident will have a comprehensive person-centered discharge care plan.This citation relates to Intake 2743057.410 IAC (Indiana Administrative Code) 16.2-3.1- 3.1-35(a)

Based on interview and record review, the facility failed to report two allegations of misappropriation of the residents' narcotic pain medications with complete and accurate information and within the appropriate time frames for 2 of 3 incidents reviewed for reporting. Findings include:1. On 3/4/26 at 9:02 a.m., the Administrator provided a copy of a facility reportable incident, dated 1/23/26 at 1:15 p.m. A review of the reportable incident indicated the following:- The resident Involved was left blank- The staff involved was left blank- The Brief Description of Incident, dated 1/31/26 (eight days after the initial allegation was reported to the Administrator), indicated, on 1/23/26 at 1:25 p.m., a Qualified Medication Aide (QMA) reported that she called the pharmacy to request a refill of a resident's oxycodone (narcotic pain medication) 10 milligrams (mg) /325mg. The pharmacy informed the QMA that it was too early to refill. The resident should have had 40 tablets at the facility. The QMA reported that the Director of Nursing (DON) removed the medication from the medication cart earlier in the shift. The DON had been placed on administrative restrictive leave.- Type of Injury, dated 1/31/26, indicated not applicable.- Immediate Action Taken, dated 1/31/26, indicated the DON was suspended pending the investigation.- Follow-up, dated 2/5/26 (13 days after the incident was initially reported to the Administrator), indicated the facility was unable to substantiate the allegation of misappropriation of a resident's narcotic pain medication.2. On 3/5/26 at 9:34 a.m., the Administrator provided a copy of a facility reportable incident, dated 2/17/26 at 10:45 p.m. A review of the reportable incident indicated the following:- The resident Involved was left blank- The staff involved was left blank- Brief Description, dated 2/18/26, indicated during routine controlled drug reconciliation at the beginning of the shift, a discrepancy was identified. The discrepancy was immediately reported to the Assistant Director of Nursing (ADON) and the Administrator.- Follow up, dated 3/5/26 (16 days after the initial report was made to the state health department), indicated the investigation had been completed and the individual had been released from their duties with the facility. A complete audit was conducted on all of the medication cart. Education was provided to all clinical staff. Audits were in place to monitor continued compliance.During an interview on 3/5/26 at 10:45 a.m., the Administrator indicated the staff and residents' names involved in each of the facility reportable incidents should have been included in the initial report. The misappropriation incidents should have been reported to the state health department within 24 hours, and the follow-ups should have been reported within five days of the incident.On 3/6/26 at 10:00 a.m., the Administrator provided a copy of a facility policy, titled Abuse Prevention and Prohibition Program, dated 8/2020, and indicated this was the current policy used by the facility. A review of the policy indicated the facility promptly and thoroughly reports and investigates allegations of allegations of abuse.This citation relates to Intake 2708112.410 IAC (Indiana Administrative Code) 16.2-3.1-28(c)

Based on interview and record review, the facility failed to protect the resident's right to be free from misappropriation of property for 3 of 3 residents reviewed. Narcotic pain medication was missing, and extra doses were documented as given. (LPN 2, Resident B, Resident C, Resident D) Findings include:1. During an interview on 3/4/26 at 7:12 a.m., Resident B indicated staff told him that his pain medication was missing a few weeks ago.The clinical record for Resident B was reviewed on 3/4/26 at 9:12 a.m. The diagnoses included, but were not limited to, ankylosing spondylitis (a chronic inflammatory autoimmune arthritis causing pain) and muscle weakness.A quarterly Minimum Data Set (MDS) assessment, dated 1/28/26, indicated Resident B was cognitively intact.A current physician's order started on 5/19/25, indicated oxycodone (narcotic pain medication)/acetaminophen 10 milligrams (mg)/325mg administer one tablet orally every six hours for pain.On 3/5/26 at 10:45 a.m., the Administrator provided a copy of a facility investigation, dated 1/23/26, and indicated this was the investigation regarding Resident B's missing oxycodone/acetaminophen 10/325mg. The investigation included the following:- A signed statement, dated 1/23/26, indicated the Director of Nursing (DON) removed Resident B's oxycodone/acetaminophen 10/325mg from the locked medication cart. The statement was signed by Qualified Medication Aide (QMA) 1.- A signed statement, dated 1/23/26, indicated the DON had removed several medications from the medication carts. The DON did not remove any medication for Resident B. The DON was not aware of what happened to Resident B's oxycodone/acetaminophen 10/325mg. The statement was signed by the DON.- A pharmacy delivery slip, dated 1/8/26 at 5:02 p.m., indicated prescription number ****921, 40 tablets of oxycodone/acetaminophen 10/325mg was delivered for Resident B.- A Controlled Drug Record, dated 1/8/26, indicated prescription number ****921, 40 tablets of oxycodone/acetaminophen 10/325mg, starting balance 40 tablets. No tablets were signed out as administered from the controlled drug record. During an interview on 3/5/26 at 10:45 a.m., the Administrator indicated the facility was unable to substantiate any staff who took Resident B's oxycodone/acetaminophen 10/325mg. The pharmacy reported Resident B should have had 40 tablets available in the locked medication cart.2. On 3/5/26 at 9:34 a.m., the Administrator provided a timeline of events, dated 2/18/26. A review of the timeline of events indicated the following:- On 2/17/26 at 5:58 p.m., Licensed Practical Nurse (LPN) 2 documented on a narcotic count sheet that she administered two tablets of oxycodone/acetaminophen 5/325mg to Resident C on a Controlled Drug Record for prescription number ****8204.- On 2/17/26 at 5:58 p.m., LPN 2 documented on a narcotic count sheet that she administered two tablets of oxycodone/acetaminophen 5/325mg to Resident C on a Controlled Drug Record for prescription number ****9542. - On 2/17/26 at 8:00 p.m., LPN 2 documented that she administered two tablets of hydrocodone/acetaminophen 5/325mg to Resident D on a Controlled Drug Record.On 3/5/26 at 10:45 a.m., the Administrator provided a copy of a hand-written statement, dated 2/17/26. A review of the statement indicated LPN 2 was made aware that Resident C's physician's order for oxycodone/acetaminophen 5/325mg had been changed. Resident B's oxycodone/acetaminophen 5/325mg had been accounted for at the end of LPN 2's shift. The statement was signed by LPN 2. At that time, the Administrator indicated LPN 2 was terminated for improper handling of controlled substances and documentation discrepancies involving multiple residents. She denied taking any medications. She could not explain her documentation for Resident C or Resident D and the attending physician confirmed LPN 2 was never given a one-time order for one extra tablet of hydrocodone/acetaminophen 5/325mg to administrator to Resident D.The clinical record for Resident C was reviewed on 3/6/26 at 9:12 a.m. The diagnoses included, but was not limited to, paraplegia, diabetes, and anxiety.A quarterly Minimum Data Set (MDS) assessment, dated 2/17/26, indicated Resident C was cognitively impaired.A current physician's order started on 12/16/25, indicated oxycodone/acetaminophen 5/325mg administer two tablets every eight hours as needed for pain.A Narcotic Administration Record, dated 1/28/26 at 7:00 p.m. until 2/17/26 at 5:58 p.m., indicated prescription number ****8204, LPN 2 initialed that she had removed two oxycodone/acetaminophen 5/325mg tablets on 2/17/26 at 5:58 p.m.A Narcotic Administration Record, dated 2/17/26 at 5:58 p.m., indicated prescription number ****9542, LPN 2 initialed that she had removed two oxycodone/acetaminophen 5/325mg tablets on 2/17/26 at 5:58 p.m.The clinical record for Resident D was reviewed on 3/6/26 at 9:31 a.m. The diiagnoses included, but were not limited to, dementia, epilepsy, and cognitive communication deficit.A current physician's order started on 5/30/25, indicated hydrocodone (narcotic pain medication)/acetaminophen 5/325mg administer one tablet orally four times daily for pain.The Controlled Drug Record, dated 2/9/26 at 4:00 p.m. until 2/18/26 at 1:00 p.m., indicated LPN 2 signed that she had removed two hydrocodone/acetaminophen 5/325mg tablets on 2/17/26 at 8:00 p.m.An undated written statement indicated LPN 2 was not given any one-time order to administer one extra table of hydrocodone/acetaminophen 5/325mg on 2/17/26. The statement was signed by the attending physician.On 3/5/26 at 9:34 a.m., the Administrator provided a copy of a letter on company letterhead, dated 2/25/26, and indicated this was a copy of the termination letter that was provided to LPN 2. A review of the letter indicated LPN 2 was terminated effective 2/25/26.On 3/6/26 at 10:00 a.m., the Administrator provided a copy of a facility policy, titled Abuse Prevention and Prohibition Program, dated 8/2020, and indicated this was the current policy used by the facility. A review of the policy indicated each resident has the right to be free from misappropriation.This citation relates to Intake 2708112.410 IAC (Indiana Administrative Code) 16.2-3.1- 3.1-28(a)

Based on observation, interview, and record review, the facility failed to treat residents with dignity and respect related to speaking to residents in a respectful way, providing services timely, answering call lights timely, and providing privacy for 10 of 14 residents reviewed for dignity ( Residents B, C, D, E, H, J, K, L, M, and T).Findings include: 1. A Resident Council Meeting was held on 11/6/25 at 11:01 a.m. The residents in attendance were Resident B, C, E, H, J, K, L, and M. During the Council meeting the residents indicated the staff would come in and turn call lights off without providing the service needed and then leave the room and not return to perform the care requested. At times residents would wait one to two hours to have their call light answered. The staff spoke disrespectfully to them and were rude when providing care. The staff had earbuds in and appeared to be having conversations with other people while providing care for the residents. The staff talk loudly in the hallways, using residents' names, about care that had been provided to other residents, such as those who had soiled themselves and who the staff did not want to care for on their shifts. These concerns presented themselves more often on the evening shift, night shift, and on the weekends. Resident B and Resident L indicated there was fighting going on between the different shifts about what care had been provided. Resident H indicated she was frequently not gotten up for bingo and felt that she was too much work to take care of because of this. Resident C indicated she wondered if the call light system was broken because of the amount of time it took the staff to answer the call lights. The Resident Council representative indicated they had brought these concerns to the management staff, but the problems had not been resolved. On 11/6/25 at 2:52 p.m., the Activities Director (AD) provided the Resident Council Minutes for meetings held on the 10/20/25, 10/27/25, and 11/3/25. The 10/20/25 meeting notes indicated new business included: call lights, when residents ask for something, they are told staff are too busy, staff with phones out continued to be a problem and ear buds being worn while working was still a problem. Staff were on their phones yelling and using profanity. Some of the staff continued to behave unkind and disrespectfully toward residents. Staff discuss what they are not going to do in front of residents. The meeting notes, dated 10/27/25, indicated new business included: weekend and evening staff needed to improve their customer service skills. Call lights are not being answered timely, and staff are still on their phones and wearing ear buds. The meeting notes, dated 11/3/25, indicated new business included: weekend and evening staff needed to improve their customer service skills. Call lights are not answered timely, and staff are still on their phones and wearing ear buds. 2.During an observation on 11/6/25 at 3:20 p.m., Resident D's call light was visibly on above his door and was sounding at the nurses' station. At 3:33 p.m., Certified Nursing Assistant (CNA) 2 was observed in the unit pantry preparing ice water to pass. Resident D's call light continued to be on, and Resident T's call light was also visible above her door and sounding at the nurses' station. Licensed Practical Nurse (LPN) 5 arrived at the unit. At 3:36 p.m., CNA 2 began to pass ice water on the Sunset Boulevard hallway. Resident D's and Resident T's call lights continued to sound. At 3:39 p.m., LPN 4 came to the unit and was standing at a medication cart, working on a computer. CNA 2 continued to pass ice water going from room to room down the Sunset Boulevard hallway until coming to Resident T's room at 3:44 p.m. CNA 2 then entered Resident T's room, and the call light was turned off. CNA 2 then exited Resident T's room and continued to pass ice water. Resident D's call light continued to be visible and was sounding at the nurses' station. At 3:46 p.m., LPN 5 was standing at a medication cart, she left the medication cart and started going from room to room down the Shoreline Court hallway. At 3:50 p.m., LPN 5 entered Resident D's room, and the call light was turned off and LPN 5 exited Resident D's room. At 3:55 p.m., Resident D was observed with the room of his door open, lying in his bed with his pants down at his knees. He had an indwelling urinary catheter leg bag present on his right leg. Resident D indicated his light had been on because he needed to be cleaned up. At 3:59 p.m., LPN 5 and another nursing staff member were at the Shoreline Court medication cart, counting the narcotic medications. Other staff were observed on the unit talking with each other. At 4:04 p.m., CNA 3 indicated she was assigned to care for Resident D on the evening shift. She had not been informed he needed any care. CNA 3 went to Resident D's room and asked him what he needed. Resident D indicated he had been waiting for 2 hours to be cleaned up. CNA 3 covered Resident D with a sheet. Resident D's side of the room did not have a privacy curtain available to close. CNA 3 indicated Resident D was alert and able to answer questions accurately. Resident D did not have a privacy curtain available to pull around his bed. The clinical record for Resident D was reviewed on 11/6/25 at 3:20 p.m. The residents' diagnosis included, but were not limited to, cerebral palsy and depression. A Quarterly Minimum Data Set (MDS) Assessment, completed 9/11/25, indicated he had moderately impaired cognitive ability. He was able to make himself understood and understand what was said to him.The clinical record for Resident T was reviewed on 11/6/25 at 3:30 p.m. The resident's diagnosis included, but were not limited to, muscle weakness and difficulty walking. A Quarterly MDS Assessment, completed 8/13/25, indicated she was cognitively intact. During an interview, on 11/6/25 at 4:15 p.m., the Executive Nurse Consultant (ENC) indicated the call lights should have been answered timely and care should have been provided. A privacy curtain should have been available for use. During an interview, on 11/7/25 at 12:53 p.m., Resident T indicated when her call light was answered on 11/6/25 at 3:44 p.m., she had requested be assisted back to bed. After her call light was answered, Resident T waited an hour and a half before being assisted to go to bed. Resident T indicated that it was too long to wait and waiting that long had caused her to be in some pain. On 11/7/25 at 1:33 p.m., the Executive Director (ED) provided the Resident Rights- Quality of Life policy, revised 8/2020, that read .Each resident shall be cared for in a manner that promotes and enhance the quality of life, dignity, respect and individuality . III. Residents are assisted in attending the activities of their choice. IV. Resident' private pace and property are respected .VII. Facility Staff speaks respectfully to residents at all times .IX. Facility Staff shall maintain an environment in which confidential clinical information is protected .X. Facility Staff promotes, maintains, and protects resident privacy, including bodily privacy, when assisting with personal care and during treatment procedures .On 11/7/25 at 1:33 p.m., the ED provided the Privacy and Dignity policy, revised 6/2020, that read .The Facility promotes resident care in a manner and an environment that maintains or enhances dignity and respect, in full recognition of each resident's individuality . VII. Staff treats residents with respect including respecting their social status, speaking respectfully, listening carefully .This citation relates to Intake 2654328. 3.1-3(a)

Based on observation, interview and record review, the facility failed to ensure a resident was shaved and that a resident received toileting care timely for 2 of 3 residents reviewed for Activities of Daily Living (ADL) care. (Resident J and Resident D)Findings include:1 The clinical record for Resident J was reviewed on 11/5/25 at 11:00 a.m. The resident's diagnoses included, but were not limited to, hemiplegia (paralysis or weakness on one side of the body) and stroke. A care plan, with a revision date 8/24/24, indicated the resident required assistance with self-care. Resident J was to be shaved on shower days. A care plan for bathing, with a revision date of 8/20/24, indicated the resident preferred to receive bed baths and required total staff assistance with his bathing. During an observation, on 11/5/25 at 2:08 p.m., Resident J was observed with long facial hair sitting in his wheelchair in the small dining area on the unit. During a resident council meeting on 11/6/25 at 11:00 a.m., Resident J was observed with long facial hair. He indicated he would like to be shaved, but the staff do not offer to shave him. The October and November 2025 bathing records for Resident J were provided on 11/6/25 at 2:00 p.m., by the Corporate Minimum Data Set (MDS) Coordinator. The following days the resident had received a bed bath, but did not indicate the resident was shaved: 10/24/25, 10/28/25, 10/31/25, and 11/4/25 An interview was conducted with the Executive Director on 11/7/25 at 8:35 a.m. She indicated she was unsure why Resident J was not provided shaving on bathing days. 2. The clinical record for Resident D was reviewed on 11/6/25 at 3:20 p.m. The resident's diagnosis included, but were not limited to, cerebral palsy and depression. A Quarterly Minimum Data Set (MDS) Assessment, completed 9/11/25, indicated the resident had moderately impaired cognitive ability. He was able to make himself understood and understand what was said to him. He required supervision or touch assistance from staff for personal hygiene and toileting. During an observation, on 11/6/25 at 3:20 p.m., Resident D's call light was observed to be on and was answered by Licensed Practical Nurse (LPN) 5 at 3:50 p.m. At 3:55 p.m., Resident D was observed with the door of his room open, lying in his bed with his pants down at his knees. He had an indwelling urinary catheter leg bag present on his right leg. Resident D indicated his light had been on because he needed to be cleaned up. At 4:04 p.m., Certified Nursing Assistant (CNA) 3 indicated she was assigned to care for Resident D on the evening shift. She had not been informed Resident D needed any care. CNA 3 went to Resident D's room and asked him what he needed. Resident D indicated he had been waiting for 2 hours to be cleaned up. He was still lying uncovered on his bed. CNA 3 covered Resident D with a sheet. During an interview, on 11/6/25 at 4:05 p.m., CNA 3 indicated Resident D was alert and able to answer questions and make his needs known. CNA 3 indicated Resident D needed his incontinent brief changed and she would provide the care right away. During an interview, on 11/6/25 at 4:15 p.m., the Executive Nurse Consultant (ENC) indicated the call lights should have been answered timely and care should have been provided. A shaving policy was provided by the Executive Director on 11/7/25 at 1:33 p.m. It indicated, Purpose: To increase cleanliness and improve the resident's self-image. Policy I. The facility provides for the removal of facial hair as a component of the resident's hygienic program. II. Male residents may be shaved daily and female resident may be shaved as needed. Procedure.x. Document procedure or resident's refusal of the shave in the resident's medical record. This citation is related to 2654328. 3.1-38(a)(3)

Based on observation, interview, and record review, the facility failed to ensure a resident at risk for developing pressure ulcers and identified with redness to the right heel upon admission to the facility, had thoroughly completed skin assessments and identification of risk factors to where the resident (Resident BB) complained of pain and was identified with a stage (3) three pressure ulcer (full-thickness skin loss, penetrated through the top two layers of skin and into the fatty tissue beneath) that required ongoing treatment for 1 of 3 residents reviewed for quality of care. (Resident BB)Findings include: The clinical record for Resident BB was reviewed on 9/19/25 at 2:10 p.m. The diagnoses included, but were not limited to, fracture of right femur, hypertension, peripheral vascular disease, congestive heart failure, atrial fibrillation, diabetes mellitus, and muscle weakness. Resident BB was admitted to the facility on [DATE]. An admission assessment, dated 8/9/25, indicated Resident BB had skin issues. That included, but was not limited to, redness to right heel. There was no further description, measurements, or further assessment of the redness to Resident BB's right heel. A Braden Scale (clinical tool for predicting resident's risk of developing pressure ulcers), dated 8/9/25, indicated Resident BB was mild risk for pressure ulcer development. An admission Minimum Data Set (MDS) assessment, dated 8/15/25, indicated Resident BB was cognitively intact, had no pressure ulcers, was at risk for developing pressure ulcers, had no venous and/or arterial ulcers, had a surgical wound, had impairment to one side of lower extremities, required substantial/maximal assistance with rolling left and right, dependent with lower body dressing and putting on/taking off footwear, dependent with sit to lying and lying to sitting, sit to stand and chair to bed, and/or bed to chair transfer. A weekly skin assessment, dated 8/16/25, indicated no skin concerns. A physician's note, dated 8/19/25, indicated Resident BB had fatigue, weakness, pain to back, decreased range of motion, decreased muscle tone, and fragile skin. An activities of daily living (ADL) care plan, dated 8/20/25, indicated Resident BB had an ADL self care deficit related to impaired balance, limited mobility, and recent mechanical fall resulting in right femur fracture. The interventions included, but were not limited to, extensive staff participation to reposition and turn in bed. A care plan for peripheral vascular disease, dated 8/20/25, indicated the interventions included, but were not limited to, encourage resident to change position frequently, monitor the extremities of signs and symptoms of injury, infection, or ulcers, and inspect feet daily. A care plan for right hip fracture, dated 8/20/25, indicated Resident BB had a right hip fracture with surgical intervention completed prior to admitting to the facility. The interventions included, but were not limited to, monitor limb for swelling and skin changes. The medication administration/treatment administration record (MAR/TAR), for August 2025, did not indicate any preventative measures put into place regarding the redness to Resident BB's right heel and/or being at risk for pressure ulcer development. A Nurse Practitioner (NP) note, dated 8/22/25, indicated skin: ulcers to right foot. There were no further assessments conducted pertaining to the ulcers mentioned to Resident BB's right foot. A weekly skin assessment, dated 8/23/25, indicated no skin concerns. A progress note, dated 8/25/25 at 1:35 p.m., indicated Resident BB was complaining of pain to his right heel. An open area was noted on the heel of his right foot. Resident was assessed by the NP, and a treatment was ordered for the area to the right heel. A Change in Condition Evaluation document, dated 8/25/25, indicated Resident BB was noted with an abrasion to the right heel and was complaining of pain to the right heel. There was no further assessment conducted of the area to Resident BB's right heel. A physician's order, dated 8/26/25, indicated Left heel - cleanse area to left heel with normal saline/wound cleanser, pat dry, apply calcium alginate, cover with optifoam dressing q day [every day] and PRN [as needed] for soilage. in the morning. This order was inconsistent with the Change in Condition Evaluation document and progress note, dated 8/25/25, referencing an area located to Resident BB's right heel. The TAR for August of 2025 indicated the initial treatment was signed off, as completed, on 8/27/25, for the treatment to Resident BB's left heel. On 8/28/25, a would culture was ordered for Resident BB's right heel wound. A physician's order, dated 8/28/25, indicated to cleanse the left heel, pay dry, apply silver alginate, cover with optifoam dressing, and change the dressing daily or as needed. The order was discontinued on 9/11/25. This order was inconsistent with the Change in Condition Evaluation, on 8/25/25, and the progress note, on 8/25/25, indicating an open area to Resident BB's right heel. There were no skin assessments, progress notes, or other information that indicated Resident BB had any skin concerns to the left heel. A physician's order, dated 8/28/25, indicated to administer doxycycline (antibiotic) 100 milligrams (mg) every 12 hours for wound care for ten days. A wound provider note, dated 9/4/25, indicated a stage 3 pressure ulcer was noted to Resident BB's right heel. The wound measured 3.5 centimeters (cm) in length x 4.5 cm in width x 0.1 cm in depth. There was a large amount of necrotic tissue to the wound. Resident BB was diagnosed with cellulitis of the right heel and to continue to take doxycycline for ten days. The wound culture result was pending and the resident's potential to heal was poor. A wound provider note, dated 9/11/25, indicated the right heel pressure ulcer was improving. The wound culture results were positive, and Resident BB was started on ciprofloxacin 500 mg twice daily for ten days based on the wound culture results. A wound culture was collected to Resident BB's right heel, on 9/3/25, and reported on 9/12/25. There was heavy growth of Klebsiella Pneumoniae, light growth of Staphylococcus Aureus, moderate growth of Pseudomonas Aeruginosa, and an organism known to possess inducible Beta-Lactamase. A physician's order, dated 9/11/25 and discontinued on 9/13/25, indicated treatment of the left heel with medihoney and silver alginate, cover with optifoam dressing, and change daily. A physician's order, dated 9/13/25, indicated a daily treatment to Resident BB's right heel that was consistent with the wound provider's recommendations. An interview and observation were conducted with Resident BB on 9/17/25 at 2:35 p.m. He indicated he had gone a whole weekend without the bandage being changed to his heel. The bandage was supposed to be changed daily. When he was admitted to the facility, on 8/9/25, his heel/feet were pressed into the footboard. Resident BB was telling the staff for five days in a row that his heel was hurting before they found the wound and then proceeded to remove the footboard from his bed. Resident BB was observed to have a walking/therapy boot to the right foot and no boot to the left foot. Resident BB indicated the staff don't put a boot on his left foot while he's out of bed. An interview and observation were conducted with Resident BB on 9/22/25 at 10:50 a.m. He indicated he had issues with skin impairment to his left heel while he was at the hospital, but it had since healed. He received surgery for his hip fracture and then was admitted to the nursing facility for therapy services. He indicated on Saturday night, 9/20/25, the air mattress he had would not stay inflated. He had to lay in bed and wait for the facility to find a replacement bed and that didn't happen until 9/21/25. The staff put pillows underneath both of his legs and said he would have to wait until they could find another bed. Resident BB pointed to the other bed that was located upon entry into the room. He stated that it was the same type of bed he had when he first admitted , and he was in a room by himself. Resident BB stated, why couldn't I use that bed? Resident BB indicated he was over six feet tall and the bed he had when he first admitted to the facility didn't allow for much room. When he initially complained of pain to his right heel, the staff would give him pain medication but not look at his foot. It was until he kept on complaining of pain, and that's when they identified the open area to his right heel. Resident BB stated he never had any skin concerns to his left heel since he's been at the facility. An interview was conducted with Corporate Nurse 25 on 9/22/25 at 2:05 p.m. She indicated she came to the facility, on 8/26/25, after the area was identified to Resident BB's right heel. The area was open but when she came in to observe the area, on 8/26/25, Resident B was resting his right foot/heel on top of the footboard before the area was assessed. Resident BB was tall and was least measured to be six (6) foot and three (3) inches tall. Resident BB admitted to the facility in a standard bed but when he obtained the open area, the facility placed him in a long bed. The length of a standard hospital bed was 80 inches (6 feet and 8 inches) in length. A policy entitled Pressure Injury Prevention, revised 6/2020, was provided by the Executive Director on 9/22/25 at 1:57 p.m. The policy indicated to complete a Braden Scale Assessment upon admission and quarterly to identify residents at risk for skin breakdown. The nurse would conduct a skin assessment upon admission, readmission, weekly, and as needed. Results of the weekly skin assessment will be documented in the EHR. If the resident was identified as having a wound upon admission, findings will be documented on the admission assessment, and a Wound Monitoring Record will be implemented. A Wound Monitoring Record will be implemented for each identified wound. The nurse will develop a care plan specific to the resident's risk factors such as moisture control, pressure reduction, positioning, mobility, and nutrition in consultation with the attending physician, interdisciplinary team (IDT), registered dietician, and director of rehabilitation services. Nursing staff will monitor interventions for effectiveness and resident tolerance. The care plan will be revised as indicated. The licensed nurse will document effectiveness of pressure injury prevention techniques in the resident's medical record on a weekly basis. 3.1-40(a)(1)3.1-40(a)(2)3.1-40(a)(3)

Based on observation, interview and record review, the facility failed to ensure an infection control program that consisted of surveillance and tracking of infections for 6 out of 12 months reviewed, failed to ensure infection control was maintained by a resident's central catheter/PICC (a tube inserted into a vein near the heart) missing the needless connector for 1 of 1 random observation of a resident's central catheter, and failed to ensure linen was properly stored on a hallway linen cart with the potential to affect 18 of 71 residents residing at the facility. (Resident W)Findings include: 1. The infection control binder was reviewed on 9/18/25 at 11:21 a.m. The Infection Preventionist was listed as the Assistant Director of Nursing (ADON). The monthly tracking logs consisted of the following months: April of 2025, May of 2025, June of 2025, July of 2025, and August of 2025. There were no logs to indicate surveillance and monitoring of trends for infections was conducted prior to April of 2025. An interview conducted with the ADON, on 9/19/25 at 11:24 a.m., indicated she started conducting the infection surveillance and tracking in April of 2025. She was unsure who was conducting the monitoring for infection control prior to April of 2025. An interview conducted with Nurse Consultant 1, on 9/22/25 at 9:00 a.m., indicated the facility was unable to locate any infection surveillance prior to April of 2025. 2. The clinical record for Resident W was reviewed on 9/17/25 at 2:00 p.m. The diagnoses included but were not limited to: heart failure. An observation was conducted of Resident W sitting in her wheelchair in the dining room on 9/17/25 at 2:24 p.m. The resident's PICC was observed missing the needless connector with a dressing dated 9/12/25. An observation was conducted of Resident W's central catheter/PICC with the ADON on 9/17/25 at 2:30 p.m. Resident W had reported to the ADON she had blood drawn that morning, so the lab technician had removed the cap. The ADON indicated it probably was the lab staff that removed the needless connector. She would replace it. 3. On 9/19/25 at 9:43 a.m., the clean linen cart on the Shoreline Hallway was observed to be open to air with the front cover flipped onto the top of the linen cart. The clean linen cart contained a mix of linen and a personal wash basin with two open boxes of facial tissues. There was a urinal on the top shelf of the cart. There were clean incontinent briefs laying scattered on the bottom shelf of the cart. On 9/19/25 at 3:09 p.m., the clean linen cart on the Shoreline hallway was observed with the ADON. The clean linen cart contained a mix of linens, an open box of gloves, alcohol hand gel, a wash basin with two open boxes of facial tissue, a urinal, and multiple clean incontinent briefs scattered on the bottom shelf of the cart. The ADON indicated the urinal on the cart was clean, however it was not recommended that personal care items be mixed with the clean linen. A policy entitled Infection Prevention and Control Program, undated, was provided by the ED on 9/17/25 at 12:30 p.m. The policy indicated the Infection Preventionist (IP) coordinates the development and monitoring of the Facility's established infection control policies and procedures. The Facility provides surveillance of Healthcare-Associated Infections (HAIs) and Community-Associated Infections (CAIs) and calculation of infection rates. On 9/22/25 at 9:14 a.m., the Clinical Nurse Consultant provided the Linen Handling Policy and Procedure, effective May 2017, that indicated .It is the policy of this home that staff will handle linens in a manner to prevent the spread of infection . 3.1-18(b)(1)(A) 3.1-18(b)(1)(B) 3.1-18(b)(1)(C)

Based on observation, interview, and record review, the facility failed to ensure medication storage rooms did not contain expired medication and supplies and failed to ensure medication was stored appropriately and not left unsupervised during the observation of 1 of 2 medication storage rooms and observation of medication administration of 1 of 3 residents. (Resident 80)Findings include: 1. On [DATE] at 10:40 a.m., an observation was conducted of the medication storage room that was located on the rehabilitation hallway of the facility with Licensed Practical Nurse (LPN) 9. In the cabinet there were two boxes of vacutainers (blood collection devices) that expired on [DATE]. The medication storage fridge contained two bottles of liquid medication that were labeled with a sticker that indicated one bottle had expired on [DATE] and the other bottle had expired on [DATE]. Within the fridge, there was a box that contained a vial of tuberculin solution for tuberculosis (TB) skin testing that was opened but had no open date written on the vial nor the box. LPN 9 confirmed the tuberculin solution did not have an open date. 2. An observation of medication administration was conducted with Registered Nurse (RN) 10 on [DATE] at 9:00 a.m. RN 10 had prepared another resident's medication. RN 10 took the medication cup of prepared medications, left the cart, and went down the hallway to administer the medications. While RN 10 was administering the medications, his medication cart remained unlocked and in close proximity to residents in the dining room. There were four residents in the dining room and were able to propel themselves in their wheelchairs while RN 10 left the cart unlocked while administering medications. 3. On [DATE] at 9:07 a.m., RN 10 proceeded to prepare medications for Resident 80. RN 10 retrieved a medication bubble pack for Lomotil (a controlled substance for treatment of diarrhea) and met with resistance while attempting to push the pill medication out of the bubble pack. RN 10 turned the medication card over and there was a white pill but there was a piece of tape covering the pill and making RN 10 not able to press and release the pill from the bubble pack. RN 10 indicated there was an error noted on the narcotic log and the previous nurse might have removed the Lomotil medication by mistake. So, they taped it back into the bubble pack, possibly. RN 10 obtained another pill of Lomotil medication from the bubble pack. At 9:13 a.m., RN 10 accidentally popped a blood pressure medication twice into the medication cup containing Resident 80's medication. RN 10 took a spoon to retrieve the extra blood pressure medication, placed it in another medication cup, and then proceeded to leave the cart to administer medications to Resident 80 but left the medication cup containing the blood pressure medication on top of the medication cart unattended. Nurse Consultant 1 approached the medication cart and indicated the medication should not be left unattended on the medication cart. RN 10 returned to the medication cart, at 9:18 a.m., and Nurse Consultant 1 observed the Lomotil medication and how it was taped to the bubble pack/medication card. Nurse Consultant 1 indicated there was no way to know if the medication taped was the same medication as Lomotil. So, the facility staff was going to destroy the white pill taped on the bubble pack/medication card for Resident 80. On [DATE] at 9:20 a.m., the Director of Nursing (DON) was present and destroyed the medication with RN 10. The DON indicated it was not proper practice regarding taping the medication back into the bubble pack/medication card. A policy entitled Labeling of Medication Containers, revised [DATE], was provided by Nurse Consultant 1 on [DATE] at 12:48 p.m. The policy indicated labels for stock medications to include the expiration date and all medications maintained in the facility were properly labeled in accordance with current state and federal guidelines and regulations. A policy entitled Medication - Administration, undated, was provided by Nurse Consultant 1 on [DATE] at 12:48 p.m. The policy indicated medication administration to be conducted using accepted professional standards and principles and to not leave medications at the bedside. 3.1-25(j)3.1-25(k)(6)3.1-25(o)

Based on observation, interview and record review, the facility failed to obtain blood sugar readings and administer insulin as ordered by the physician, monitor the effectiveness of an as needed anti-anxiety medication, ensure a narcotic pain medication was administered as ordered, to timely address a dosage for an antidepressant medication that was not available from the pharmacy, and administer a resident's eye medication, as ordered, for 2 of 5 residents reviewed for unnecessary medications, 1 of 2 residents reviewed for discharge, and 1 of 2 residents reviewed for vision services. (Resident 2, Resident S, Resident V, and Resident 64). Findings include: 1 a. The clinical record for Resident 2 was reviewed on 9/18/25 at 10:15 a.m. The resident's diagnoses included, but were not limited to, diabetes, anxiety disorder, chronic kidney disease, and acute and chronic respiratory failure. A care plan, last revised on 5/28/24, indicated Resident 2 had diabetes which placed her at risk for hyperglycemic (high blood sugar) or hypoglycemic (low blood sugar) reactions. The goal was for her to have no complications related to diabetes. The interventions included to perform blood sugar checks as ordered, administer medications as ordered, and monitor labs as ordered. A care plan, last revised on 11/2/24, indicated Resident 2 had a diagnosis of anxiety. The goal was for her to have an improved mood state. The interventions included to administer medications as ordered and to monitor and document side effects and effectiveness. A physician's order, dated 12/19/24, indicated Resident 2 was to receive Lantus (long-acting insulin) 10 units injected subcutaneously two times a day at 8:00 a.m. and 8:00 p.m. The order indicated to hold the insulin for a blood sugar less than 150. A physician's order, dated 12/19/24, indicated she was to receive Humalog (short-acting insulin) 15 units injected subcutaneously three times a day at 9:00 a.m., 1:00 p.m., and 5:00 p.m. The order indicated to hold the insulin for a blood sugar less than 150. A physician's order, dated 2/28/25, indicated Resident 2 was to receive Accu checks (blood sugar checks) twice daily at 8:00 a.m. and 8:00 p.m. The August and September 2025 Medication Administration Records (MARs) indicated Resident 2 received her 10 unit dose of Lantus when her blood sugar reading was below 150 on the following days: 8/7/25 at 8:00 a.m.- blood sugar recorded as 149, 8/9/25 at 8:00 p.m.- blood sugar recorded as 126, 8/21/25 at 8:00 a.m.- blood sugar recorded as 135, 8/21/25 at 8:00 p.m.- blood sugar recorded as 135, 8/22/25 at 8:00 a.m. and 8:00 p.m.- blood sugar recorded at 135 for each administration, 8/23/25 at 8:00 a.m.- blood sugar recorded as 135, 8/31/25 at 8:00 a.m.- blood sugar recorded as 70, 9/18/25 at 8:00 a.m. and 8:00 p.m.- blood sugar recorded as 114 for each administration, and 9/19/25 at 8:00 p.m.- blood sugar recorded as 145. The August and September MARs indicated Resident 2 received her 15 unit dose of Humalog ,with no documented blood sugar readings recorded, for the 1:00 p.m. and 5:00 p.m. administrations, with the exceptions of the following days and times: 8/4/25 at 1:00 p.m.- documented as not given, 8/8/25 at 1:00 p.m.- documented as not given, 8/13/25 at 1:00 p.m.- documented as not given, 8/19/25 at 1:00 p.m.- documented as not given, 8/30/25 at 5:00 p.m.- documented as not given, 8/31/25 at 1:00 p.m.- documented as not given, 9/1/25 at 5:00 p.m.- documented as not given, 9/4/25 at 1:00 p.m.- documented as not given, 9/9/25 at 1:00 p.m.- documented as not given, and 9/18/25 at 1:00 p.m.- documented as not given. During an interview on 9/22/25 at 11:47 a.m., the Clinical Nurse Consultant (CNC) indicated the insulin should have been held as ordered by the physician. She was unsure why the blood sugars results were not documented on the MARs for the doses of Humalog given at 1:00 p.m. and 5:00 p.m. 1b. A physician's order, dated 9/10/25, indicated Resident 2 was to receive hydroxyzine (an antihistamine used to treat anxiety) 25 milligram (mg) one tablet by mouth every 8 hours as needed for anxiety. During an observation of the medication cart on 9/19/25 at 10:42 a.m., Licensed Practical Nurse (LPN) 11 indicated Resident 2's hydroxyzine had come in from the pharmacy. He removed the medication card containing Resident 2's hydroxyzine and indicated there were six pills missing from the card. The September 2025 MAR did not contain information that the hydroxyzine had been administered since it was ordered. During an interview on 9/22/25 at 11:25 a.m., the Assistant Director of Nursing (ADON) indicated the doses of hydroxyzine 25 mg should have been documented on the MAR when given and documented the effectiveness of the dose given. 2. The clinical record for Resident S was reviewed on 9/18/25 at 10:30 a.m. The resident's diagnoses included, but were not limited to, dysphasia (inability to swallow) and pain in left shoulder. A Quarterly Minimum Data Set (MDS) assessment, completed 6/19/25, indicated she was cognitively intact and received scheduled and as needed pain medications. She received narcotic medications. A physician's order, dated 7/31/25, indicated she was to receive oxycodone-acetaminophen (narcotic pain medication) 5-325 mg one tablet via gastric tube every six hours as needed for pain. A progress note, dated 8/20/25, indicated Resident S had experienced a medication error. Her son and the physician were notified, and a Complete Blood Count (CBC) and Basic Metabolic Panel (BMP) had been ordered for the next day. Resident S was alert and oriented to situation, no acute distress was noted on the assessment. On 9/23/25 at 9:30 a.m., the CNC provided an incident report, dated 8/20/25 at 2:23 p.m., that indicated Resident S had received Norco (narcotic pain medication) 5-325 mg instead of her ordered oxycodone 5-325 mg. Resident S was stable and had no adverse side effects noted. Her vital signs were stable. There were no injuries noted at the time of the incident. The nurse who administered the wrong medication was educated on the five rights of administering medications. During an interview on 9/23/25 at 9:30 a.m., the CNC indicated Resident S should have received her pain medication as ordered by the physician. 3. The clinical record for Resident V was reviewed on 9/18/25 at 9:30 a.m. The diagnoses for Resident V included, but were not limited to, kidney disease. A physician's order, dated 7/17/25, indicated Resident V was to receive 150 milligrams of bupropion (antidepressant) in the evenings. The medication was changed on 8/6/25. A physician's order, dated 8/6/25, indicated Resident V was to receive 1.5 tablets for a total dosage of 225 milligrams of bupropion daily. A physician's order, dated 8/25/25, indicated Resident V was to receive 300 milligrams of bupropion daily. The August 2025 Medication Administration Record (MAR) indicated the following days Resident V did not receive 1.5 tablets that equaled 225 milligrams of bupropion: 8/7/25, 8/8/25, 8/9/25, 8/11/25, 8/14/25, 8/16/25, 8/17/25, 8/18/25, 8/20/25, 8/21/25, 8/22/25 and 8/25/25. An interview was conducted with the Executive Director (ED), the Nurse Consultant (NC), and the Director of Nursing (DON) on 9/23/25 at 9:21 a.m. They indicated Resident V was taking 150 milligrams of bupropion as of 7/17/25. The medical provider had increased the resident's dosage to 1.5 tablets totaling 225 milligrams of bupropion daily on 8/6/25. The pharmacy had not notified the facility until 8/11/25; the medication was unable to come in as half tablets. They could not supply the 1.5 tablets. The provider was notified on 8/11/25. The order was changed on 8/26/25 to 300 milligrams of bupropion by the medical provider. An interview was conducted with Nurse Practitioner 8 on 9/23/25 at 9:56 a.m. He indicated he was notified the pharmacy was unable to provide the 1.5 tablets of bupropion a few days prior to the 20th of August. He had seen the resident, and she had reported feeling down. Since the pharmacy was unable to provide 225 milligrams of bupropion due to the inability to supply half tablets, he increased the dosage to 300 milligrams as of 8/25/25. He would have liked to have been notified sooner that the 225 milligrams of bupropion was not available. 4. The clinical record for Resident 64 was reviewed on 9/18/25 at 11:00 a.m. Her diagnoses included, but were not limited to, infected ocular socket lesion and injury of conjunctiva and corneal abrasion. The impaired visual function care plan, revised 10/19/24, indicated she had a detached retina in her right eye and was only able to see out of her left eye. The goal was for her to have no indications of acute eye problems. An interview was conducted with Family Member 4 on 9/18/25 at 11:07 a.m. He indicated he visited Resident 64 on a daily basis. He was present in the facility all day on 9/13/25 and 9/14/25, from 9:00 a.m. to 5:00 p.m. both days. He was unsure whether Resident 64 received her ordered eye drops either day, because he never saw nursing staff administer them. The physician's orders indicated to administer one drop of Refresh Celluvisc Ophthalmic Gel 1 % in both eyes four times a day for dryness from 1/13/25 to 4/21/25. This order was on hold from 3/24/25 to 3/27/25. The same order began again on 5/1/25 and was ongoing for eye health. There were hold dates from 5/9/25 to 5/10/25 and 7/29/25 to 7/31/25. The January 2025 through September 2025 MARs (medication administration records) indicated the eye drops were administered four times daily, as ordered. An observation of the medication cart contents was conducted with QMA (Qualified Medication Aide) 5 and the DON (Director of Nursing) on 9/19/25 at 12:10 p.m. There were two boxes of Refresh Celluvisc Ophthalmic Gel 1% in the cart. Each box originally contained a total of 30 individually packaged administrations. One box, with an open date of 8/20/25, had 23 administrations left. The other box, dated 3/3/25, had 15 administrations left. The DON indicated they needed to confirm the number of boxes sent from the pharmacy and provided the pharmacy's telephone number. A telephone interview was conducted with the Pharmacist on 9/19/25 at 1:29 p.m. She indicated, since 1/15/25, they delivered three boxes of Refresh Gel, each with 30 administrations per box, for a total of 90 administrations. They were delivered on 1/15/25, 3/4/25, and 8/20/25. One box of Refresh would run out in seven and a half days, if administered four times per day, as ordered, which was 3 weeks worth basically. She stated, There is definitely a long lapse in refilling the Refresh. The 9/13/25 nurse's note indicated she continued on antibiotic therapy related to an eye infection. 3.1-37(a)

Based on interview and record review, the facility failed to ensure residents were respected and their dignity was maintained for 15 of 71 residents reviewed for resident rights (Residents' B, C, D, E, F, G, H, J, K, N, Q, T, V, FF, and ZZ).Findings include: 1. The clinical record for Resident V was reviewed on 9/18/25 at 9:30 a.m. The diagnoses for Resident V included, but were not limited to, kidney disease. An Annual 7/18/25 Minimum Data Set (MDS) assessment indicated Resident V was cognitively intact. An interview was conducted with Resident V on 9/18/25 at 9:47 a.m. She indicated first shift (day shift) Certified Nurse Aides (CNAs) were rude, sarcastic and frequently on their cell phones during care. She had been in the mechanical lift transferring to her wheelchair, and the CNA put her phone on speaker to speak to someone. 2. The clinical record for Resident ZZ was reviewed on 9/18/25 at 9:30 a.m. The diagnoses for Resident ZZ included, but were not limited to, anxiety disorder. A Quarterly MDS assessment, dated 8/20/25, indicated Resident ZZ was cognitively intact. During an interview with Resident ZZ on 9/18/25 at 1:18 p.m., he indicated the CNA staff were rude, disrespectful, and had bad attitudes. 3. The clinical record for Resident T was reviewed on 9/18/25 at 9:30 a.m. The diagnoses for Resident T included, but were not limited to, obstructive and reflux uropathy (any condition that affects urinary tract, kidneys and bladder). A Quarterly MDS assessment, dated 8/20/25, indicated Resident T was cognitively intact. An interview was conducted with Resident T on 9/18/25 at 9:25 a.m. She indicated Licensed Practical Nurse (LPN) 20 was rude and argumentative. LPN 20 will slam doors when she gets mad. 4. A resident council meeting was conducted on 9/18/25 at 10:30 a.m. The attendees were the following: Residents' B, C, D, E, F, G, H, J, K, Q, and V. During the council meeting, the council indicated the staff were “rude, arrogant, and dismissive” toward the residents. The staff often times were on their cell phones during care. The council felt like they were treated like children. The staff speak in a tone as “do what we say and do it on our time not the residents' time. The residents were pushed to their rooms and forgotten. There were long delays in responding to call lights. Staff don't answer them. There were times, the residents would go to sleep with their call lights on and wake up to the call light still on. The council complained, but do not see any change in the mannerisms of the staff. 5. The clinical record for Resident FF was reviewed on 9/17/25 at 11:56 a.m. The resident's diagnosis included, but were not limited to, diabetes and delusional disorder. A Quarterly MDS assessment, completed 8/15/25, indicated he was cognitively intact. He rejected care four to six times during the look back period and displayed behaviors not directed at others. During an interview on 9/17/25 at 11:56 a.m., Resident FF indicated some of the CNAs were rude and loud mouthed and would call him out of his name at times. Some of the staff refused to heat up food items for him. 6. The clinical record for Resident Q was reviewed on 9/18/25 at 10:00 a.m. His diagnoses included, but were not limited to, Parkinson's disease. The 8/10/25 Quarterly MDS assessment indicated he was moderately cognitively impaired. An interview and observation were conducted with Resident Q on 9/18/25 at 10:05 a.m. He indicated the staff in the facility did not treat him with respect and dignity. He could be in the hallway and say Hey nurse, to the staff, and they just ignored you and acted like you didn't say anything. It took 45 minutes for his call light to be answered. It's embarrassing to have to have someone wipe me. He'd always been independent. Now he just went to the restroom by himself. Perhaps he wasn't supposed to, but that's what happened, because they don't come. Staff left him in a soiled brief all morning about three weeks ago. He and the bed were soaked. The staff said they had other patients, but they're just in the hallway bull sh***** and laughing. An interview was conducted with Resident Q on 9/18/25 at 10:03 a.m. He indicated the staff limited him to two cups of coffee a day. An anonymous interview was conducted with a staff member. They indicated if a resident asked for coffee on the evening shift, They ain't gonna get nothin' in the evening time. They don't give 'em (expletive.) 7. The clinical record for Resident N was reviewed on 9/17/25 at 12:30 p.m. Her diagnoses included, but were not limited to, chronic obstructive pulmonary disease, chronic kidney disease, heart failure, and arthritis. The 8/29/25 Quarterly MDS assessment indicated she was moderately cognitively impaired. An interview was conducted with Resident N on 9/17/25 at 12:18 p.m. She indicated staff were rough during care at times. She had arthritis in her legs and you can't just move me too quickly. It hurt and sometimes she complained. Staff would say they were getting it done. They acted like they were in a rush. It hurt her physically and mentally. She stated, I don't feel like they have to be that rough. An interview was conducted with the Executive Director (ED), Director of Nursing (DON), and the Nurse Consultant (NC) on 9/23/25 at 2:53 p.m. The ED indicated she expected the residents to be treated respectfully. A Resident Rights Quality of Life policy was provided by the ED on 9/22/25 at 2:46 p.m. It indicated, “Purpose. To ensure that all residents are treated with the level of dignity they are entitled to while residing at the Facility. Policy. Each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect and individuality…VII. Facility Staff speaks respectfully to residents at all times, including addressing the resident by his or her name of choice…XII. Demeaning practices and standards of care that compromise dignity are prohibited…” A resident rights policy was provided by the ED on 9/22/25 at 2:46 p.m. It indicated, “…Employees are to treat all residents with kindness, respect, and dignity and honor the exercise of resident's rights…” This citation relates to Intakes 2605799 and 2613777. 3.1-3(t)

Based on interview and record review, the facility failed to timely complete a Significant Change of Status Minimum Data Set (MDS) assessment for a resident who discontinued dialysis services for 1 of 2 residents reviewed for dialysis (Resident 2). Findings include: The clinical record for Resident 2 was reviewed on 9/18/25 at 10:15 a.m. The resident's diagnosis included, but were not limited to, diabetes, anxiety disorder, chronic kidney disease, and acute and chronic respiratory failure. A Quarterly MDS assessment, completed 7/26/25, indicated Resident C was cognitively intact and had received dialysis. A physician's order, dated 7/28/25, indicated she was to receive hemodialysis on Monday, Wednesday, and Friday weekly. During an interview on 9/19/25 at 10:32 a.m., Resident 2 indicated she did not receive dialysis anymore. The doctor stopped her dialysis a couple of months ago. During an interview on 9/19/25 at 11:05 a.m., the Transportation Director indicated she had not taken Resident 2 to or from dialysis since she started working at the facility. The Transportation Director began working at the facility in July of 2025. During an interview on 9/19/25 at 2:26 p.m., the Assistant Director of Nursing (ADON) indicated Resident 2's dialysis had officially been discontinued on 7/3/25. Resident 2 had not received dialysis for a week and a half prior to it being officially discontinued. During an interview on 9/19/25 at 2:55 p.m., the Corporate Minimum Data Set Coordinator indicated a Significant Change of Status MDS Assessment should have been completed for Resident 2 after her dialysis was discontinued. The facility used the Resident Assessment Instrument (RAI) manual as the policy for completing MDS assessments. 3.1-31(d)(1)

Based on interview and record review, the facility failed to ensure a resident was able to receive personal funds when requested for 1 of 2 residents reviewed for personal funds. (Resident Z)Findings include: The clinical record for Resident Z was reviewed on 9/17/25 at 11:00 a.m. The diagnoses for Resident Z included, but were not limited to, anxiety. The 8/4/25 Quarterly Minimum Data Set (MDS) assessment indicated Resident Z was cognitively intact. An interview was conducted with Resident Z on 9/17/25 at 11:48 a.m. He indicated he was unable to receive his personal funds from the Business Office when he requested $50.00 a couple of weeks ago. The Business Office Manager (BOM) had indicated she was unable to give him any money. An interview was conducted with the BOM on 9/22/25 at 3:07 p.m. She indicated there was a week, or two, the residents were unable to receive their personal funds. The former Executive Director (ED) had abruptly left employment at the facility. The ED was the signer to the checks for the residents' personal funds. Resident Z requested $50.00 a week or two ago, and the BOM was unable to provide the money to him. There was a delay due to the new ED had to receive the approval from the home office to have the ability to become the new signer of the checks for the residents' personal funds. The resident trust fund policy was provided by the ED on 9/22/25 at 3:40 p.m. It indicated, .The Administrator [ED] is responsible for ensuring the establishment and accurate maintenance of the Resident Trust Fund and the related Resident Trust Fund Petty Cash account, including the handling of the funds according to facility policy as well as state and federal regulations.Resident Trust Fund Petty Cash.4. This fund must be available to the resident according to state and federal guidelines, but not less than Monday-Friday during regular office hours.3.1-6(f)(1)

Based on interview and record review, the facility failed to ensure the residents' preferences were honored for 2 of 2 residents reviewed for choices. (Resident T and Resident V) Findings include: 1. The clinical record for Resident V was reviewed on 9/18/25 at 9:30 a.m. The diagnoses for Resident V included, but were not limited to, kidney disease. An Annual 7/18/25 Minimum Data Set (MDS) assessment indicated Resident V was cognitively intact. An interview was conducted with Resident V on 9/18/25 at 10:03 a.m. She indicated the staff have poor communication with the residents. The staff does not know anything about the residents' preferences with care. Resident V had to tell staff how she prefers to be bathed, and how to transfer her in her wheelchair. She reminds them to remove the dirty clothes from her hamper. They just throw wet linen and trash in the hamper with her clothes. Since they do not remove the dirty clothes from the hamper it delays her clothing to be sent to the laundry to be cleaned. She has signage on the bathroom door and verbalizes to the staff her preferences. Resident V's clinical record did not include a completed initial activities/preference assessment. An interview was conducted with the Executive Director on 9/22/25 at 2:50 p.m. She indicated she was unable to locate an activity/preference assessment that had been completed for Resident V. 2. The clinical record for Resident T was reviewed on 9/18/25 at 9:30 a.m. The diagnoses for Resident T included, but were not limited to, obstructive and reflux uropathy (any condition that affects urinary tract, kidneys and bladder). Resident T was admitted to the facility on [DATE]. A Quarterly 8/20/25 MDS assessment indicated Resident T was cognitively intact. The resident's care plan did not include preferences on bathing type and frequency nor getting up or going to bed timeframes. An Activity Initial Assessment for Resident T, dated 1/24/25, indicated it was very important for the resident to choose her bathing type and bedtime. It did not indicate if she preferred showers or bed baths. It was documented as whenever with her preference to get up in the morning and go to bed. An interview was conducted with Resident T on 9/18/25 at 9:18 a.m. She indicated she does have some preferences, but they were not honored by the staff. She would prefer to be showered twice a week. She was unsure how many showers she was supposed to receive. She currently only received one a week; all other bathing was bed baths. Resident T would also prefer to be woken up for the day, at 11:30 a.m., and then put back to bed at 2:30 p.m. She had been told by Certified Nurse Aides (CNAs) that she was not able to be placed back in bed at 2:30 p.m. They were not going to get her up and put her back down on the same shift. She would have to wait to be put back down until second (evening) shift arrived, which would be around 3:00 p.m. to 3:30 p.m. She currently got up, between 12:00 p.m. to 12:30 p.m., and was laid back down around 3:00 p.m. to 3:30 p.m. She agreed to get up later, so she could be laid back down on second shift. That was the timeframe the staff were willing to do for her. She was unable to stay up for long periods of time due to pain. If she can't be laid down by 2:30 p.m., then she will have to get up later to accommodate the staff. The weekends were the worst about getting up and being put back to bed. Sometimes, the staff were unable to get her up at all. She cannot recall being asked by staff what her preferences were with getting up and/or laying down timeframes nor bathing preferences. An activities initial assessment for Resident T, dated 4/27/25, was in the resident's medical record, but it was blank. An interview was conducted with the Assistant Director of Nursing (ADON) on 9/19/25 at 10:29 a.m. She indicated upon admission; the residents' preferences were filled out by the Activities Department. An interview was conducted with the Activities Director (AD) on 9/19/25 at 10:14 a.m. She indicated on a resident's admission she has five days from a resident's admission to speak with the resident about their preferences. Resident V and Resident T were both admitted to the facility prior to her start date in July 2025. August and September 2025 Shower Sheets were provided for Resident T by the ADON on 9/22/25 at 2:00 p.m. It indicated the following days the resident received a bed bath instead of a shower: 8/1/25, 8/15/25, 8/22/25, 8/29/25, 9/3/25, 9/4/25, 9/6/25, 9/10/25, 9/13/25, and 9/18/25.An interview was conducted with CNA 3 on 9/22/25 at 10:40 a.m. She indicated Resident T gets up at around noon and was placed back down by the second shift staff after 3:00 p.m. A Quality-of-life resident rights policy was provided by the Executive Director on 9/22/25 at 2:46 p.m. It indicated, To ensure that all residents are treated with the level of dignity they are entitled to while residing at the facility.Each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect and individuality. 3.1-3(u)(3)

Based on observation, interview, and record review, the facility failed to ensure a resident's call light was within reach for 1 of 2 residents reviewed for call devices in reach. (Resident N)Findings include:The clinical record for Resident N was reviewed on 9/17/25 at 12:30 p.m. Her diagnoses included, but were not limited to, chronic obstructive pulmonary disease, chronic kidney disease, heart failure, and arthritis. The ADL (activities of daily living) care plan, revised 8/18/25, indicated he had an ADL self-care performance deficit related to impaired balance, limited mobility, pain, and shortness of breath, and she would refuse to get out of bed. An intervention was to encourage her to use bell to call for assistance. The 8/29/25 Quarterly MDS (Minimum Data Set) assessment indicated she was moderately cognitively impaired. An observation and interview were conducted with Resident N in her room on 9/17/25 at 12:18 p.m. She was lying in bed. Her call light cord was tied around the right side rail, hanging down the right side of her bed, eight inches from the floor. Resident N had a wooden stick, one inch wide, one and half feet long on her bedside table in front of her. She used it to attempt to reach her call light, but she was unsuccessful. She indicated staff were in the room about an hour and a half earlier, but they didn't adjust her call light to be within reach. She stated, Most of the time I can't reach my call light. I don't suffer too much [sic] not being able to reach it. I take my stick and start beating on the table, and they can hear me, and then they come. She indicated she couldn't get her hand around to reach the call light cord, and she couldn't turn over to reach the light. Resident N again tried to reach her call light cord, but she couldn't. She stated, I can't get it in my hand and do anything. When she soiled her brief, she hit the bedside table or side rail with her wooden stick to get staff's attention. Resident N demonstrated this at this time. An observation and interview with Resident N were conducted on 9/17/25 at 1:55 p.m. She was lying in bed, eating her lunch. No one else was in the room at this time. Her call light remained in the same position, wrapped around the right side rail of her bed, hanging down, eight inches from the floor. Resident N indicated she wasn't sure who brought her lunch tray to her, but they did not ensure her call light was in reach. An observation of Resident N and interview with UM (Unit Manager) 6 was conducted on 9/17/25 at 1:57 p.m. UM 6 untangled her call light from the side rail and placed it within reach of Resident N. UM 6 indicated her call light should always be within her reach, and they may need to get a clip for the call light or a different type of call light. The Use of Call Light policy was provided by NC (Nurse Consultant) 1 on 9/19/25 at 10:54 a.m. It indicated, It is the policy of this home to ensure residents have a call light within reach that they are physically able to access and that they have been instructed on its use .All nursing personnel must always be aware of call lights. Ensure call light is within reach of resident prior to leaving the residents room .Be sure call lights are placed near the resident, never on the floor or bedside stand.This citation relates to Intakes 2605799 and 2613777. 3.1-3(v)(1)

Based on observation, interview and record review, the facility failed to ensure staff remained at bedside while administration of a narcotic medication to a resident as ordered for 1 of 1 random observation of a resident receiving his medications. (Resident X) Findings include: The clinical record for Resident X was reviewed on 9/19/25 at 3:20 p.m. The diagnoses included, but were not limited to, heart failure. The 9/5/25 Quarterly Minimum Data Set assessment indicated Resident X was cognitively intact. A behavior care plan, dated 4/5/24, indicated Resident X had been witnessed holding pain medication in his hand after observation of placing pill in his mouth and drinking water. The interventions included but were not limited to, nurse to observe resident swallowing medication and not pocketing. A physician's order, dated 4/4/24, indicated the staff were to observe the resident swallowing medication due to pocketing. A physician's order, dated 5/19/25, indicated the resident was to receive 10-325 milligrams of Percocet every six hours. The staff were to crush the medication and administer in applesauce. An observation was conducted of Resident X in his bed on 9/17/25 at 11:57 a.m. During an interview with the resident, Registered Nurse (RN) 10 entered the resident's room. RN 10 handed Resident X a medication cup with a yellow crushed pill in applesauce. He then immediately left the resident's room. The resident had reported at that time; the crushed medication was his Percocet medication. He had been accused of selling his narcotic medication, which was untrue, but now he received the narcotic medication crushed. RN 10 should have stayed in the room while he ate it. He then spooned the medication from the cup into his mouth. Resident X's clinical record did not include a self-medication assessment and care plan that indicated the resident was able to safely administer his medications without the presence of the staff. An interview was conducted with the Assistant Director of Nursing (ADON) on 9/19/25 at 11:25 a.m. She indicated Resident X had been caught selling his Percocet medication on the street, so now he received the narcotic medication crushed in applesauce. RN 10 should have remained in the room until the resident had swallowed the medication. A self-administration of medications policy was provided by the Nurse Consultant on 9/22/25 at 8:50 a.m. It indicated, .Any resident who desires to self-administer medication is permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the residents and other residents in the facility 3.1-11(a)

Based on observation, interview, and record review, the facility failed to ensure a homelike environment for 2 of 4 residents reviewed for homelike environment. (Resident BB and Resident 44)Findings include: 1. An observation was conducted of Resident 44's room on 9/18/25 at 9:25 a.m. There was brown splatter along both closet doors. On 9/19/25 at 10:55 a.m., there continued to be brown splatter along both of Resident 44's closet doors. On 9/22/25 at 3:30 p.m., there continued to be brown splatter along both of Resident 44's closet doors. On 9/22/25 at 3:35 p.m., the Assistant Director of Nursing (ADON) went into Resident 44's room and acknowledged the splatter on Resident 44's closet doors. 2. An observation and interview were conducted with Resident BB in his room on 9/22/25 at 10:50 a.m. He indicated his television doesn't work. He could turn the television on but there was no volume. Resident BB took the remote and demonstrated he was able to turn the television on and off and attempted to increase the volume, but the television remained with no sound. Resident BB indicated he liked watching television and the volume hasn't been working for approximately four to five weeks. An observation and interview were conducted of Resident BB's room with Corporate Nurse 25 on 9/22/25 at 2:10 p.m. Corporate Nurse 25 attempted to take the remote and see if she could get the volume to work on the television, but it was unsuccessful. Corporate Nurse 25 indicated she would have to get the Maintenance Director to see if he could fix the television. Resident BB indicated the Maintenance Director had been in a couple of times and he indicated Resident BB needed a new television. Resident BB indicated if he wanted to watch television and be able to hear it, he would go to one of the common areas and watch the television since he cannot watch the television in his room. The clinical record for Resident BB was reviewed on 9/19/25 at 2:10 p.m. The diagnoses included, but were not limited to, femur fracture, congestive heart failure, diabetes mellitus, and muscle weakness. An admission Minimum Data Set assessment, dated 8/15/25, indicated Resident BB was cognitively intact, had impairment to one side of lower extremities, and indicated it was very important for him to keep up with the news. A policy entitled Policy for a Safe, Homelike Environment, approved date of 4/2025, was provided by the Executive Director on 9/22/25 at 2:28 p.m. The policy indicated to create a comfy, pleasant environment personalized to residents' preferences and needs, allowing them to use their personal belongings where possible. Maintain the building infrastructure (ceilings, walls, floors) in good repair. Provide regular housekeeping and maintenance to maintain cleanliness and orderliness throughout resident and staff areas. 3.1-19(f)(5)

Based on observation, interview, and record review, the facility failed: to provide routine suprapubic catheter care and to provide routine nephrostomy tube care to a resident, resulting in a hospitalization for sepsis, acute kidney injury, and UTI (urinary tract infection) associated with his nephrostomy catheter for 1 of 3 residents reviewed for urinary catheter care (Resident 36); and ensure the residents' medications were administered as ordered for 2 of 6 residents reviewed for unnecessary medications (Resident 23 and Resident 32). Findings include: 1. The clinical record for Resident 36 was reviewed on 9/26/23 at 2:00 p.m. His diagnoses included, but were not limited to: metastatic prostate cancer, bladder cancer, deep vein thrombosis, type 2 diabetes, and hypertension. He was readmitted to the facility from the hospital on 8/13/23. The 8/13/23 hospital discharge paperwork read, admitted : 8/2/2023. discharge date : 8/13/2023 .I need my outpatient team to followup on the following issues: 1. Confusion caused by UTI - You had an infection which was making you confused when you came in. You were treated for UTI with ampicillin and ceftriaxone, and then a change of your suprapubic catheter was carried out. 2. Acute kidney injury - You had an acute injury to your kidney when you came in. You were treated with fluids and we held medications that could worsen your kidney function. 3. Metastatic Prostate Cancer - We held your cancer medication while you were in patient. We would like you to follow up with your hematologist to restart your medication. You were still taking your prednisone while in patient, and this should be carried on after your discharge. 4. Excess fluid in your kidney - You were found to have an increased amount of fluid in both your kidneys due to a back up of urine. Two tubes were placed close to your kidneys to help them drain this increased fluid. Fluid collected should be drained regularly. You will need to have these tubes checked in 4 weeks time. The facility physician's orders indicated to provide urinary catheter care every shift and as needed, to include emptying of the drain bag, peri-care, ensuring positioning of the catheter bag and tubing was below the level of the bladder, to ensure tubing was free of kinks and securement device was in place, and to notify the physician of any abnormalities, starting 8/14/23. The August, 2023 TAR (treatment administration record) indicated this order was carried out every shift from 8/14/23 through 8/31/23. The 8/13/23, 5:11 p.m. nurse's note read, resident came back from the hospital, vital sign is within the normal range. resident has has [sic] a nephrostomy tube Right and left that need to be change every shift. There were no care plans to address Resident 36's nephrostomy tubes. The 8/15/23, NP (Nurse Practitioner) note, written by NP 12, read, .Pt [Patient] was admitted to hospital 8/2 during hematology/oncology appointment. Pt with AMS [altered mental status] and confusion. With E.Coli and E. Faecalis UTI. Treated with ampicillin and ceftriaxone. SPT [suprapubic catheter] exchanged. AKI [acute kidney injury] with hydronephrosis. Bilateral nephrostomy tubes placed 8/8. Pt did require one unit PRBC [packed red blood cell] and 1g IV iron. Pt with metastatic prostate cancer; secondary sites include bone and bladder. Goals of care were discussed and pt was changed to DNR [do not resucitat.] hospitalization complicated by pt testing Covid +. Medications adjusted: metoprolol increased, glargine decreased to 10U qhs [every evening], mirtazapine added. Today, pt seen resting in bed. VSS [vital signs stable.] Patient denies any complaints at the time of visit. Denies c/o [complaints of] pain. Pt would not sign POST [physician orders for scope of treatment] form when reviewed with this provider. Nursing aware. Nursing reports no acute concerns. A change in condition is likely at any time and without 24-hour care there is a reasonable likelihood that untoward outcomes may occur. Faxes, Laboratory studies, and imaging studies reviewed. Nursing notes, orders, medications noted. Chart reviewed. Labs ordered .Genitourinary: Suprapubic Cath [catheter,] Bilateral nephrostomy tubes .Genitourinary: SPT draining clear urine; SPT site with out erythema or drainage, Bilateral nephrostomy tubes - draining clear, yellow urine, scant blood noted .GeriCare Assessment/Treatment Plan Diagnosis .Breakdown (mechanical) of nephrostomy catheter The physician's orders indicated to empty his nephrostomy catheter every shift to drain urine, starting 8/14/23. The August TAR indicated this order was carried out every shift from 8/14/23 through 8/31/23. There were no physician's orders to ensure his left and right nephrostomy catheters were in place; to provide left and right nephrostomy catheter care; or to monitor and record output of his left and right nephrostomy catheters after his 8/13/23 readmission with nephrostomy tubes until 8/31/23. The physician's orders read, Nephrostomy Left side : Indwelling Catheter in place. Catheter Care Q [every] shift and PRN [as needed] every shift for Catheter Care related to MALIGNANT NEOPLASM OF OVERLAPPING SITES OF URINARY ORGANS (C68.8) Empty drain bag & provide peri-care. Position catheter bag & tubing below level of the bladder, check tubing is free of kinks & securement device in place. Notify MD of abnormalities (unusual urine appearance, burning, pain, feeling of full bladder), with a start date of 8/31/23. The physician's orders indicated the same for his right side nephrostomy tube, starting 8/31/23. The 8/18/23 NP note read, .Genitourinary: SPT draining clear urine; SPT site with out erythema or drainage, Bilateral nephrostomy tubes - draining clear, yellow urine. scant blood noted. The 8/21/23, 3:33 p.m. nursing note read, Resident resting in bed at this time. Bilateral nephrostomy tubes remain intact and patent. Suprapubic catheter intact and patent. Resident continues to deny any pain. Assisted with all adls [activities of daily living] as needed. Call light within reach. Will continue to monitor. The 9/1/23 NP note read, .seen today for a federally mandated visit for management of chronic diseases. Resident is alert and oriented, requires assist with transfers, medication management, and ADLs [activities of daily living.] PMH [past medical history] of DM [diabetes mellitus,] prostate cancer with mets [metastisis] to bladder, bone, and lung, anemia, HTN [hypertension], depression. All are reviewed and stable. No acute concerns reported by resident at this time. Labs reviewed and stable. Full Code status. VSS. Weight stable. Regular Diet. Pt with significant overall decline due to cancer. Continues to defer DNR or hospice services. Today, nursing stating bilateral nephrostomy tubes were clamped. Upon opening, urine malodorous and thick in appearance. DON [Director of Nursing] aware. Order to flush bilateral nephrostomy tubes and SPT. Ordered UA, C+S [urinalysis, culture and sensitivity,] PICC [peripherally inserted central catheter] placement, IVF [intravenous fluids] and rocephin via PICC until C+S results. CrCl [Creatinine clearance] 32.87. Pt alert and oriented. VSS. Denies c/o pain or nausea. Afebrile. NAD [no abnormality detected.] Pt. seen at this time for scheduled ECF regulatory visit. This is a complex patient with complex co-morbidities. As a result, Pt. continues to reside in ECF. A change in condition is likely at any time and without 24hr care there is a reasonable likelihood that untoward outcomes may occur. Faxes, laboratory studies, and imaging studies reviewed. Nurses notes, orders, meds noted. Chart reviewed. The 9/1/23, 10:34 p.m. nurse's note read, Resident was sent to the hospital at 20:50 Pm. Resident appears lethargy. Bp [blood pressure:] 71/35, pulse: 136 and was having difficulty following direction . Family, Doctor and DON were notified. The 9/1/23 hospital admission note read, Patient presents with Fatigue BIBA [brought in by ambulance] from ECF [extended care facility.] Per medics, patient has been sick for the past week. Increased weakness over the past 24 hrs [hours.] Patient is typically verbal + can hold conversations, but is currently not answering questions. Hx [History] kidney cancer, has nephrostomy and suprapubic in place Assessment and Plan 1. Urosepsis: Febrile, tachycardic, initially hypertensive. No leukocytosis. UA shows [greater than sign] 100 WBCs [white blood cells,] large leuks. CT shows distended urinary bladder. Last Ucx [urine culture] on 7/11 negative for growth. Resume broad-spectrum Vanc [Vancomyocin,] Zosyn monitor renal function closely. BP still low normal s/p 3 L IVF. Consider pressors if necessary 2. Bilateral nephrostomy tubes: Previously had chronic indwelling Foley. S/p [Status post] bilateral nephrostomy tubes at VA [Veterans Affairs] last month, per daughter. Urology consulted for management History of Present Illness .presenting to [name of hospital] with a chief complaint of shortness of breath. Brought in by EMS [emergency medical services] from skilled nursing facility. Per EMS, is normally responsive however has not been responsive in the ED [emergency department.] Staff reported increased weakness for the past 24 hours. Was febrile on arrival at 102. Was additionally hypotensive however responded well to IV fluids The 9/6/23 hospital note read, presents for routine bilateral nephrostomy exchange. 1. Sepsis, due to unspecified organism .2. AKI (acute kidney injury) .3. Urinary tract infection associated with nephrostomy catheter .4. Abnormal EKG [electro cardiogram.] The 9/10/23 hospital discharge summary read, Caring for your nephrostomy tube. Your care team will instruct you on how to care for your nephrostomy tube. You'll have to inspect your tube on a daily basis as well as empty any urine that has collected in the drainage bag. Inspection of your nephrostomy tube. When you inspect your nephrostomy tube, you should check the following: Verify that your dressing is dry, clean, and secure. If it's wet, dirty, or loose, it will need to be changed. Check your skin around the dressing to make sure there's no redness or rash. Look at the urine that has collected in your drainage bag. It shouldn't have changed in color. Be sure there are no kinks or twists in the tubing that leads from your dressing to the drainage bag. The 9/10/23 hospital discharge Medication List indicated to start taking IV Zosyn 4.5 gram/100 mL, inject into the vein every 6 hours for 8 doses. The 9/10/23, 11:55 p.m. facility nurse's note read, Resident returned to facility per [name of ambulance company.] The facility physician's orders did not include orders for urinary catheter care or nephrostomy tube care after his 9/10/23 return from the hospital. An interview and observation was conducted with Resident 36 on 9/26/23 at 2:15 p.m. He was lying in bed in his room. His catheter tubing was draining dark, sedimentary looking urine into the bag. Resident 36 indicated staff did not regularly come in to provide him catheter care. An interview was conducted with LPN (Licensed Practical Nurse) 5 on 9/28/23 at 3:15 p.m. She indicated she provided catheter care to Resident 36 when she worked, but she hadn't worked in a while. She reviewed Resident 36's orders and indicated he went out to the hospital, and the catheter and nephrostomy care orders were not put back into the computer upon his return. He used to have orders for care of both every shift. She indicated there was no way to verify the care was being done. She was going to inform the DON and unit manager now, so that orders could be placed. An interview was conducted with the NC (Nurse Consultant) on 9/29/23 at 2:08 p.m. She indicated she did not see any nephrostomy tube care orders after Resident 36's 8/13/23 readmission with nephrostomy tubes until 8/31/23 and there was no care plan referencing the nephrostomy tubes. The September, 2023 MAR (medication administration record) indicated Resident 36 only received 7 of the 8 ordered doses of Zosyn. An interview was conducted with LPN 1 on 9/29/23 at 2:40 p.m. She indicated she administered the noon dose of Zosyn on 9/12/23, to equal a total of 8 doses administered, but was unable to sign off on it, because a QMA (Qualified Medication Aide) already signed it off as medication on order. An interview was conducted with NP 12 on 9/29/23 at 12:47 p.m. She indicated Resident 36 should have had orders for his nephrostomy tube care upon his 8/13/23 hospital return and his 9/10/23 hospital return, including to flush as needed, routine dressing changes, monitoring of the site, and recording of output every shift. On 9/1/23, one of the nurses came to get her to look at one of the outputs from the tube and one of the tubes was clamped. After opening, the urine output was thick and white in color. The tubes should always be open. She had no idea how they got clamped, maybe during care. She saw him this morning to look at one of his nephrostomy tubes, because there were concerns one of the sutures came out of one side, but the tube was still in place, with output flowing freely. An observation of Resident 36's right side nephrostomy tube care was made on 9/29/29 at 11:49 a.m. The care was performed by LPN 1. There was no redness at the site and no kinks in the tubing. The urine draining from the tubing was dark yellow. Betadine was used to clean the surrounding skin and tubing. The tubing was irrigated with 3 ml of saline. Gauze/drain sponges were placeed on the site and tegiderm dressing was placed on top. The Care of Nephrostomy Tube policy was provided by the DON on 9/29/23 at 9:15 a.m. It read, 1. Verify that there is a physician's order for this procedure. 2. Review the resident's care plan to assess for any special need of the resident .Check placement of the tubing and integrity of the tape during assessments .Empty drainage bag once per shift and as needed Measure output as follows: a. Initially every hour x [times] 4 hours; then b. Every 4 hours x 24 hours; then c. Every 8 hours Measure output from the right and left kidneys separately. (Record urinary and nephrostomy output separately ) Change dressings every 1-3 days, or as ordered 34850 2. The clinical record for Resident 23 was reviewed on 9/27/23 at 10:00 a.m. The resident's diagnosis included, but was not limited to, anxiety disorder. A Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated Resident 26 was cognitively intact. A physician order dated 8/30/23 indicated Resident 23 was to receive 1 drop in each eye of carboxymethylcellulose sodium ophthalmic solution for dry eyes. The September 2023 Medication/Treatment Administration Record (MAR/TAR) indicated the following days the resident did not receive her eye drops due to medication was not available: 9/2/23 - day shift, 9/4/23 - day shift, 9/5/23 - day and evening shift, 9/6/23 - day shift, 9/7/23 - day shift, 9/11/23 - day and evening shift, 9/12/23 - day and evening shift, 9/13/23 - day shift, and 9/14/23 - day shift An interview was conducted with Resident 23 on 9/28/23 at 1:34 p.m. She indicated she does not routinely receive her eye drops. An interview was conducted with the Director of Nursing on 9/29/23 at 9:02 p.m. She indicated Resident 23 was running out of her eye drops prior to her insurance covering the cost for more. She was unaware of the resident not receiving her eye drops. She would address. 3. The clinical record for Resident 32 was reviewed on 9/27/23 at 1:00 p.m. The resident's diagnosis included, but was not limited to, depression. A physician order dated 6/14/23 indicated Resident 32 was to receive 25 milligrams of zoloft daily. The September 2023 Medication Administration Record indicated the following days the resident had not received the 25 milligrams of zoloft due to unavailable medication: 9/11/23, 9/12/23, 9/13/23 An interview was conducted with the Director of Nursing on 9/29/23 at 9:02 a.m. She indicated Resident 32 had missed the 25 milligrams zoloft for 3 days due to unavailable. A Medication Ordering and Receiving From Pharmacy policy was provided by Director of Nursing on 9/27/23 at 10:29 a.m Policy: Medications and related products are received from the dispensing pharmacy on a timely basis. The facility maintains accurate records of medication and receipt .2. If not automatically refilled by the pharmacy, repeat medications (refills) are written on a medication order form/ordered by utilizing the pharmacy provided reorder sticker and placing it in the appropriate area on the order form provided by the pharmacy for that purpose and or ordered electronically order as follows: .c. Reorder medication five days in advance of need, as directed by the pharmacy order and delivery schedule, to assure an adequate supply is on hand . This Federal tag relates to complaint IN00418378. 3.1-37 3.1-37(a)

Based on observation, interview, and record review, the facility failed to coordinate care to address a resident's continued use of a Foley catheter resulting in the resident developing a urinary tract infection for 1 of 1 residents reviewed for catheter care. (Resident 25) Findings include: The clinical record for Resident 25 was reviewed on 4/20/22 at 11:51 a.m. Resident 25's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 25 was admitted to the facility on [DATE]. At the time of admission, Resident 25 had a Foley catheter in place. An observation of Resident 25 occurred on 4/19/22 at 11:17 a.m. Resident 25 had a Foley catheter and the drainage bag was hanging on the side of his bed. An interview with Resident 25 was conducted on 4/19/22 at 11:17 a.m. Resident 25 indicated, he was not sure why he had a Foley catheter. He stated, prior to his admission to the facility, he lived at an Assisted Living and did not have a urinary catheter. A Discharge Summary dated 2/4/22 from [local hospital's name] was received on 4/21/22 from NC (Nurse Consultant). It indicated, Resident 25's discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Under the section Hospital course, it indicated, Urology was consulted for hematuria [sic, blood in urine] s/p [sic, status post [MEDICAL RECORD OR PHYSICIAN ORDER] .Will need eventual cystoscopy [sic, endoscopy of the urinary bladder via the urethra] and stent removal versus exchange . Post discharge instructions indicated, Resident 25 had a follow up appointment with Urology physician on 2/9/22 at 9:10 a.m. Resident 25 was unable to attend the Urology appointment on 2/9/22 because he was readmitted to the hospital on 2/8/22. An interview with NC was conducted on 4/21/22 at 2:01 p.m. When asked what the clinical indication for Resident 25's Foley catheter was, she was unable to identify why he still had a Foley catheter. She then indicated, she remembered having a conversation with the Nurse Practitioner regarding the indication for the continued use of a Foley catheter for Resident 25. NC indicated, the Nurse Practitioner wanted to keep the Foley catheter in until Resident 25 was seen by Urology and they would determine when and if to remove the Foley catheter. A physician's progress note dated, 3/15/2022 at 3:55 p.m. indicated, He does have Urology appt today for f/u [sic, follow up] on Foley catheter/possible voiding trial. A Urology visit note dated 3/15/22 was provided on 4/21/22 by SCH (scheduler) 51. It did not indicate the reason for continued use of Resident 25's Foley catheter. It did indicate, with his chronic Foley, he will need a urine culture at least 10-14 days preoperatively and be placed on culture specific antibiotics. The visit note did not address when or if the Foley should be removed or a voiding trial. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 25's urinalysis report dated 3/19/22 indicated, Resident 25's urine was orange, cloudy, contained large amount of blood and a large amount of white blood cells. The results were abnormal. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A copy of Resident 25's urine culture result dated 3/23/22 at 4:30 p.m. was received from NC on 4/21/22 at 3:45 p.m. The urine culture result indicated, the culture could not be performed as the specimen quality was inadequate .Test not performed. The specimen exceeds stability for the test requested. Resident 25's clinical record did not contain a progress note indicating the results of the urine culture from 3/23/22 were communicated to the physician. An interview with NP was conducted on 04/21/22 at 3:31 p.m. NC indicated, the nurse should have notified the physician of the result of the urine culture and ask if they wanted to repeat the order and get it sent out. On 4/5/22, a physician to facility message was sent. A copy of the message was received on 4/21/22 at 3:45 p.m. from NC. The message indicated, Resident 25's urine was yellow but a little cloudy and to order a urinalysis for the next lab day. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview with Resident 25's Urologist was conducted on 4/21/22 at 3:49 p.m. Urology indicated, when a new patient comes in with a urinary catheter already in place, they usually do not inquire about the indication for its use. They were not given any information from the facility which indicated they wanted Urology to address the indication for continued use or determine when/if it could be removed nor had Urology ordered the Foley. As of 4/21/22, Resident 25 still had a Foley catheter. Resident 25's care plan dated 3/30/22 indicated, he was at risk for a urinary tract infection related to Foley catheter use and [MEDICATION(S)] (inflammation of bladder). The interventions included, but not limited to: encourage fluids, monitor for signs/symptoms of urinary tract infection, and to monitor labs as ordered. 3.1-41(a)

Based on interview and record review, the facility failed to adequately address a resident's pain after a fall with [CONDITION(S)] resulting in continued extreme pain for 1 of 1 residents reviewed for death. (Resident 36) Findings include: The clinical record for Resident 36 was reviewed on 4/20/22 at 10:53 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was admitted to the facility on [DATE]. The 1/16/22 progress note read, Resident tested positive for covid 19, resident moved immediately with N95 into red zone precautions, MD and family notified. The 1/21/22, 10:02 p.m. nurse's note, written by the NC (Nurse Consultant) read, Resident alert to self with moderate to severe confusion. Severe tremors in all extremities. Unable to hold drink or use eating utensils. respirations 21 BP [blood pressure] =118/94 HR [heart rate] =100. Resident appears fearful. She doesn't know where she is and does not answer direct questions such as her DOB [date of birth.] Needs reassurance and coaching to help slow her breathing and calm her. Periods of calm are brief and she begins to panic again. Called on-call provider who ordered STAT [immediately, without delay] CBC [complete blood count,] BMP [basic metabolic panel,] and UA [urinalysis.] Daughter of resident notified and states the she has noticed a decline in the resident's status. She also states her mother does have a history of anxiety. DON [Director of Nursing] also notified of resident's current status. The 1/22/22, 5:41 a.m. nurse's note, written by LPN (Licensed Practical Nurse) 19, read, Resident resting in bed at this time. Frequently wakes up due to a productive cough. No SOB [shortness of breath] noted. Resident has significant weakness in her lower extremities. Requires assistance with sitting up in bed, transfers, and ADLs [activities of daily living.] The 1/22/22, 2:25 p.m. nurse's note, written by LPN 19, read, Res [Resident] was heard yelling out in room. Upon entering room, res had gotten out of bed by self and fallen to floor. Res was asked where she was going, and res stated she was getting ready for her first day of school. Increased anxiety and confusion continues. Res was assessed for injuries and a skin tear to R elbow was noted. Res was transferred back to bed and vitals were taken., BP 139/78, P [Pulse] 96, R [Respirations] 20, 02 95% 1 L 02, T. [Temperature] 98.4. Pain noted to R [right] side. Skin tear to R elbow was cleaned and bandaged. Res repositioned to L [left] side in bed and bed is in lowest position. Family notified and is at bedside, and NP [Nurse Practitioner] aware. Neuros [Neurological checks] will be started and will continue to monitor. The 1/22/22, 2:54 p.m. nurse's note, written by LPN 19, read, NP was made aware of the pain res is having to R hip, writer asked if a R hip xray was able to be obtained and NP agreed. Writer ordered STAT xray from [name of lab company. The 1/22/22, 6:29 p.m. nurse's note, written by LPN 19, read, Res is resting in room at this time. Neuros continues and family continues to be at bedside. Awaiting Lab to obtain test. Vitals WNL [within normal limits.] Pain continues to R side. Lying on L to alleviate pain. Continues with ATB [antibiotic.] No a/r d/t ATB. T. 9.78. Fluids encouraged. Cough and congestion continues. Will continue to monitor. The 1/22/22, 6:45 p.m. nurse's note, written by LPN 19, read, Res had a fall this afternoon and had an order to obtain a xray to R hip, unable to obtain xray until tomorrow and res is having increased pain to R side. Family in agreeance to send to ER [emergency room ] for further eval [evaluation] and tx [treatment.] 911 called and EMT [emergency medical technicians] on way to transport. Family at bedside. The 1/22/22, 7:05 p.m. nurse's note, written by LPN 19, read, Resident transported to the hospital by EMS [emergency medical services.] The 1/22/22 evening shift pain level was a 5 on a scale of 1 to 10, and that nonpharmacological interventions were not applicable. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The January, 2022 MAR (medication administration record) indicated Resident 36 did not receive any as needed Acetaminophen or any other pain medication to address her continued pain after her fall. The last pain medication given, prior to going to the hospital, was 650 mg of regularly scheduled Tylenol at 8:00 a.m., before her fall. An interview was conducted with the NC on 4/20/22 at 1:35 p.m. in the presence of the ADON (Assistant Director of Nursing). She indicated, if she were the nurse on duty during Resident 36's fall, she would normally have given pain medication afterwards to address her pain. An interview was conducted with the NC on 4/20/22 at 3:45 p.m. She indicated she couldn't find any verification that pain medication was given to address Resident 36's continued pain after her fall. An interview was conducted with LPN 19 on 4/22/22 at 10:08 a.m. She indicated she found Resident 36 on the floor. She was complaining of hip pain, so she called the physician and got an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 36 she was very confused prior to the fall, agitated, antsy, and not understanding what was going on. LPN 19 was working the Covid-19 unit at the time and only caring for a total of 3 residents, including Resident 36. The fall occurred while she was caring for another resident. It was the weekend, and she got the order for the x-ray, but the lab was unable to come. She made sure Resident 36 left to go to the hospital, before she ended her shift. She stated, I felt really bad for her, because we waited for so long. If you had to move her, she let me know she hurt. When you moved her, she was guarding the area and would say ouch. I don't know if she had any scheduled pain medications. Tylenol was able to be given, but she couldn't remember if she gave any, and she didn't think she had any as needed pain medications that were available to be given. She couldn't recall exactly what she told the on call physician/NP, but she'd been a nurse for a while and she didn't feel right leaving the without her being sent out. Her shift was over at 6:00 p.mm. and she didn't leave until Resident 36 actually left in the ambulance. She had a feeling something was wrong. Either her hip was really, really bruised, if not broken. An interview was conducted with NP 18 on 4/22/22 at 9:39 a.m. She suggesting reviewing the facility's paging system records to find out whether the on call provider was notified of the pain. She stated, I can't tell you why they wouldn't administer pain meds [medicatins] in that time frame. I would have been off that day, so it would have been the on call NP who would have responded. The 1/22/22 paging system records were provided by the ADON on 4/22/22 at 10:47 a.m. They indicated the thread between LPN 19 and the NP began on 1/22/22 at 2:11 p.m. There was a total of 5 communications as follows: LPN 19 - Res had a fall this afternoon.Vitals WNL. Confusion and anxiety is increasing. Stated she was going to get ready for first day of school. Skin tear to R elbow measuring 2 cm X 1 cm. Found on R side and is complaining of pain. Can we obtain xray of R hip? NP - Yes LPN 19 - Thank you LPN 19 - [Name of x-ray company] won't be able to be here until tomorrow, can we go ahead and send to ER. Res is in extreme pain? NP - Yes!! The 1/23/22, 5:56 a.m. progress note read, Resident admitted to [name of hospital] with [CONDITION(S)]. The 1/22/22 hospital notes indicated, Assessment/Plan: Principal Problem: Closed fracture of right hip, initial encounter .1. Right Closed fracture right hip: 2/2 [secondary to] Unwitnessed fall. [CONDITION(S)] with debility likely contributing. X-ray right hip shows acute mildly displaced right femur transcervical neck fracture Ortho consulted with no surgical plans at this time. Trend troponins. Echo in the morning. NPO [nothing by mouth.] Pain control 4. Hypertensive emergency: Blood pressure 200 systolic. Does have AKI [acute kidney injury,] likely pain contributing On arrival she is alert but not oriented. Not following commands or answering questions. She is moaning in pain .moving all extremities except right hip due to pain The 1/25/22 Palliative Care Consult Note from the hospital read, Plan: 1) acute pain/closed R [CONDITION(S)] - continues comfort care. 2) Palliative care - placed hospice consult - will continues support pt [patient] and family as able. The Pain - Clinical Protocol was provided by the ED (Executive Director) on 4/20/22 at 4:05 p.m. It read, 2. The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. 3.1-37(a)

Based on interview and record review, the facility failed to determine motor ability, fully conduct neurological check assessments, and identify pain after a fall that resulted in a femur fracture for 1 of 3 residents reviewed for falls. (Resident C) Finding include: The clinical record for Resident C was reviewed on 1/26/2022 at 11:22 a.m. The clinical diagnoses included, but were not limited to, dementia without behavioral disturbances, cachexia, [CONDITION(S)], and muscle weakness. A Quarterly Minimum Data Set, dated dated [DATE], indicated that Resident C was cognitively impaired, needed staff assistance with activities of daily living, and had multiple falls without injury. A fall care plan for Resident C, dated 8/7/2021, included interventions of anticipating resident's needs and assuring her call light was within reach. A progress note, dated 1/9/2022 at 8:44 p.m., indicated that Resident C was found on the floor next to her wheelchair by Licensed Practical Nurse (LPN) 3. The fall assessment for the fall on 1/9/2022 was entered by the Director of Nursing (DON) on 1/10/2022 and signed by the DON on 1/14/2022. It did not indicate a level of injury or if Resident C sustained an injury from the fall. A progress note, entered as a late entry was completed by LPN 3 on 1/14/2022 and dated for 1/9/2022 at 8:45 p.m. The note stated, .CNA then came over to the Rehab where residents nurse was and said resident was on the floor next to her wheel chair [sic]. Nurse had not been out of the room but 15 minutes before fall was reported. Resident was assessed and had no complaint of paint and or discomfort and stated I don't know how I fell Neuro sheet filled out pupils were equal and round bilateral extremities were equal in length call light was within reach. Risk management was completed [sic]. No indication of range of motion (ROM) or transfer status noted during progress note or fall assessment. A physical therapy summary of the evaluation on 1/10/2022, indicated that Resident C was having 10/10 pain to the right hip with any movement that was sharp. The note indicated PT recommended x-rays and would continue evaluation, specifically gait, post results. An occupation therapy treatment note, dated 1/10/2022 at 4:36 p.m., indicated that Resident C was having 10/10 pain to the right hip. The first Neurological Assessment sheet was provided by Administrator on 1/26/2022 at 2:35 p.m. This sheet contained assessment information for Resident C from 1/9/2022 to 1/10/2022. Resident C had pain level documented as 0/10 during all assessments until 1/10/2022 on 2nd shift (2-10:30 p.m.). Extremities were not assessed on the neurological assessment until 1/10/2022 on 2nd shift (2-10:30 p.m.) During the 2nd shift assessment on 1/10/2022, Resident C showed weakness in lower extremities and an increase of pain to 9/10. A second Neurological Assessment sheet was provided by Administrator on 1/26/2022 at 2:35 p.m. This sheet stated on 1/10/2022 at 1:45 a.m. and continued until 3rd shift on 1/10/2022. Pain was noted as 0/10 on all assessment on this sheet. Extremities were not assessed until 1/10/2022 at times of 1st, 2nd, and 3rd shift. At those times, Resident C was noted to have strong lower extremities. The 3rd shift had information marked out and HOSP HOSP written over the data. The medication administration record for Resident C indicated she had received as needed [MEDICATION(S)] two times on 1/10/2022 during the second shift for pain of 9/10 and 10/10. An x-ray result for Resident C, dated 1/10/2022 at 9:46 p.m., indicated a possible right femur fracture. A progress note, dated 1/10/2022 at 10:31 p.m., indicated that Resident C was transferred to the hospital for evaluation and treatment. An emergency room note from 1/10/2022, indicated that Resident C was seen for post fall evaluation. Resident C was complaining of a painful right hip that appeared to be shortened, an x-ray was obtained that disclosed a closed fracture at the neck of the right femur. An interview with Therapy Staff 9 on 1/26/2022 at 3:30 p.m., indicated she and a Physical Therapist (PT) 10 had attempted treatment with Resident C around 2:00 p.m., on 1/10/2022. PT 10 was there to evaluate Resident C for physical therapy but could not entirely complete the evaluation due to Resident C complaining of pain to her right hip. PT 10 then informed Registered Nurse (RN) 11 of the complaints of pain and weakness. An interview with RN 11 on 1/26/2022 at 3:35 p.m., indicated he had taken care of Resident C on 1/10/2022. PT 10 had come to RN 11 to report Resident C's increased pain and weakness. RN 11 went down to assess Resident C and then reported concerns to the physician. Resident C was then ordered [MEDICATION(S)] for pain control and an x-ray to rule out fracture. Towards the end of his shift, Resident C was noted to have a fracture to her femur and sent to the hospital for evaluation and treatment. Stated he only documented one set of neurological checks on her that shift but had been checking on her often due to her pain. RN 11 verified his signature as that on the first Neurological Assessment provided which indicated weakness and pain. An interview with Certified Nursing Assistant (CNA) 5 on 1/26/2022 at 4:15 p.m., indicated they had assisted LPN 3 and CNA 6 with getting Resident C off the floor after her fall on 1/9/2022. When transferring the resident from the floor, Resident C was complaining of pain to her hip. CNA 5 did not have any further interaction with Resident C that evening. An interview with CNA 7 on 1/27/2022 at 6:32 p.m., indicated CNA 7 provided care for Resident C on 1/10/2022 in the morning. Resident C was having pain and weakness to her legs, especially when transferring. Resident C also had complications with her feeding tube that day and the nurse was in to see Resident C a couple of times. CNA 7 indicated the nurse stated Resident C was probably just sore from her fall when she reported Resident C's pain. A policy entitled, Falls-Clinical Protocol, was provided by the Administrator on 1/27/2022 at 10:35 a.m. The policy indicated, .the nurse shall assess and document/report the following: .Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc . A policy entitled, Neurological Assessment, was provided by the Administrator on 1/27/2022 at 10:25 a.m. The policy indicated neurological assessments should be completed following an unwitnessed fall and part of the neurological assessment is to .Determine motor ability. This Federal tag related to complaint IN 620. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure adequate supervision and training were in place to prevent a staff member from inflicting injury on a resident (Resident B). 1 of 3 residents reviewed for injury in a sample of 3. Findings include: The record of Resident B was reviewed on 9/28/15 at 10:00 A.M. Diagnoses, obtained from the current [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment indicated Resident B was significantly cognitively impaired, required staff assistance for all activities of daily living, ambulated infrequently with staff assistance, could not balance without stabilization of staff, and was incontinent of bowel and bladder. A Skin Assessment for Resident B documented on 8/18/15 at 4:15 P.M., indicated no areas of bruising or discoloration, and noted Resident B's skin was CDI (clean, dry, and intact). A facility Reported Incident, filed with the Department on 8/21/15 at 3:57 P.M., included, but was not limited to: Incident date: 08/21/2015, Incident time: 12:15 P.M., Residents Involved: (Resident B), Staff Involved: (CNA #1), Brief description of incident: Resident noted to have discoloration to left upper extremities. Type of Injury: Left thumb discoloration 3.0 x 3.0 CM (centimeters); Left medial thumb 2.0 x 2.0 CM; Left knuckle 1.5 x 2.5 CM; Left wrist 0.1 x 0.1 CM all discolorations. Immediate action taken: CNA was suspended pending investigation. Follow up: Investigation completed along with staff education .employee involved in investigation was terminated. A nurse's progress note entered by the Director of Nursing on 8/21/15 at 2:30 P.M., indicated Resident with multiple discolorations to lue (left upper extremity) left thumb, 3.0 x 3.0cm, left knuckle area 1.5 x 2.5cm, left medial aspect of the thumb 2.0 x 2.4cm. No [MEDICAL CONDITION] note to areas bright red in color .M.D. notified .resident's son notified as well . An Investigation report completed by the Director of Nursing and dated 08/21/15 included, but was not limited to: On 08/21/15 (CNA #4) reported .a housekeeper observed (CNA #1) hitting on (Resident B) .Upon assessment of (Resident B) was found (sic) with multiple discolorations to left upper extremity of unknown origins. One of the areas of discolorations had tiny abrasions consistent with fingernail injuries . Writer then went to (CNA #1) to notify her that there was an allegation of abuse against her and she was suspended pending further investigation . .(Dietary Aide #3) .stated she did not witness the incident but knows who the eyewitness is .she declined to speak any further . (CNA #1) was contacted via telephone .(she) stated to writer that she really doesn't want to come up to the facility at all .writer then notified (CNA #1) the allegations had been substantiated and the decision was made to terminate. (CNA #1) then stated okay and hung up the phone. During an interview on 9/28/15 at 3:15 P.M. the Director of Nursing indicated CNA #1 had been terminated for a substantiated instance of resident abuse against Resident B, and that Dietary Aide #3 was terminated for failure to report abuse and refusing to cooperate with an abuse investigation. An undated facility policy titled Abuse Protection and Response Policy received from the Director of Nursing on 9/28/15 at 11:00 A.M. Indicated: Policy: Abuse, as hereafter defined, will not be tolerated by anyone, including staff, patients, consultants and volunteers, family members or legal guardians, friends or any other individual Castleton Health Care Center (sic). Definitions: Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain or mental anguish. Physical Abuse: includes hitting, slapping, punching and kicking . This Federal tag relates to Complaint IN 848. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to provide catheter care to a resident resulting in a hospitalization for urosepsis and a UTI (urinary tract infection) for 1 of 2 residents reviewed of 2 who met the criteria for urinary catheter use. (Resident #65) Findings include: The clinical record for Resident #65 was reviewed on 9/11/14 at 10:00 a.m. The [DIAGNOSES REDACTED]. He was admitted to the facility on [DATE]. An interview was conducted with LPN #5, the nurse for the unit on which Resident #65 resided, on 9/8/14 at 1:30 p.m. LPN #5 indicated Resident #65 did not use an indwelling Foley catheter. An observation of Resident #65 was made on 9/10/14 at 2:10 p.m. His catheter tubing was visible underneath his wheel chair. The 6/20/14 hospital discharge records indicated a catheter insertion date of 6/17/14 and to "leave Foley until seen by urology." The hospital discharge orders did not include orders for catheter care. The 6/20/14 Admission Physician's Orders, obtained by LPN #11, did not include orders for catheter care. The June, 2014 MAR (medication administration record) for Resident #65 indicated an order to "monitor and record urine output from Foley Q (every) shift." The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]." The July, 2014 Physician's Order Sheet for Resident #65, printed on 6/23/14, did not include orders for catheter care. The July, 2014 MAR for Resident #65, printed on 6/23/14, did not indicate any orders for catheter care, nor did they indicate catheter care was provided. No physician order for [REDACTED]. The 7/4/14 hospital records for Resident #65 indicated he was admitted to the hospital on [DATE]. It indicated, "Assessment/Plan: 1. Urosepsis, UTI: likely source for AMS (altered mental status), likely secondary to catheter in place. [MEDICAL CONDITION], Febrile Tm 103.8, BP (blood pressure) stable....UA (urinalysis) positive for Mod (moderate) leukocytes, packed wbc (white blood cell), [MEDICATION NAME] positive. Urine and blood cultures sent. Starting on [MEDICATION NAME] (antibiotic). Tylenol prn fever. Hydrate gently tonight IVF (intravenous fluid) but reevaluate for continuation tomorrow due to [MEDICAL CONDITIONS].....History of Presenting Illness: ....presenting to (name of hospital) emergency department with complaint of AMS. History obtained from ER staff and niece due to pt's (patient's) condition. Pt reported to have been at nursing home "shutting down" as pt's family understood with altered mental status, started today, constant, no relieving factors, associated complaint of "pain" but couldn't express where, and stated "yes" to some SOB (shortness of breath) and feeling hot/chills. Pt with additional [MEDICAL CONDITION] for approximately 2 weeks, associated possible weakness to R (right) side....Pt recently hospitalized ....urology saw pt for bladder outlet obstruction of unknown cause to be worked up outpatient late July, sent to nursing home as instructed with Foley in place until scheduled visit." The 7/4/14 lab values indicated in the records were as follows: "WBC - 6.7 HGB - 12.0 HCT - 40.1 PLT - 281 NA - 142 K - 4.1 CL - 105 CO2 - 22 BUN - 44 CREATININE - 2.22 CALCIUM - 9.9" An interview was conducted with Unit Manager (UM) #1 on 9/11/14 at 11:39 a.m., regarding catheter care orders for Resident #65's 6/20/14 admission to the facility. She indicated, "When they (nursing) called the doctor on 6/20 (6/20/14), they would normally have catheter orders on the admission orders [REDACTED]. I also don't see the original 6/20/14 hospital discharge orders (for catheter care)." Regarding the expectation for catheter care, if there were no orders, she indicated, "We would follow our standard policy for catheter care." Regarding whether catheter care was provided to Resident #65 in July, 2014, prior to his 7/4/14 hospital admission with a UTI, she indicated, "I don't see verification that catheter care was provided, or what the order was." An interview was conducted with UM #1 on 9/11/14 at 1:28 p.m. She indicated, "(Name of LPN #11) got the admission orders [REDACTED]. It was our responsibility to get the orders. I'm not sure how the catheter care treatments got on the MAR. Someone must have realized it, and put them on the MAR, but an order was never received." The Urinary Catheter Care policy was provided by the ADON (Assistant Director of Nursing) on 9/12/14 at 9:30 a.m. It indicated the purpose was, "To prevent infection of the resident's urinary tract." 3.1-41(a)(2)

Based on record review and interview, the facility failed to ensure staff followed policy and procedure in the appropriate and safe use of a mechanical lift, resulting in a resident being dropped to the floor with subsequent injury (a fractured left humerus; upper arm bone) and subsequent disability and pain. 1 resident of 3 (Resident #B) reviewed for mechanical lift use. Findings include: The record of Resident #B was reviewed on 6/30/14 at 1:00 P.M. [DIAGNOSES REDACTED].) Resident #B's record indicated she was her own responsible person. A Quarterly Minimum Data Set (M.D.S.) assessment dated [DATE] indicated Resident #B was totally dependent on staff for assistance with bed mobility, transfers, and bathing, did not ambulate, and had impaired mobility on one side in both upper and lower extremities. A physical therapy "Plan of Treatment" dated 4/09/14 indicated "Transfers: Pt (patient) is (brand name of mechanical lift) transfer." A CNA assignment sheet received from the Director of Nursing (D.O.N.) on 6/30/14 at 2:45 p.m., and indicated to have been current on 6/01/14 indicated Resident #B was to be transferred using a mechanical lift. Progress notes for Resident #B indicated: 6/01/14 2:20 P.M., "CNA came to nurses station notified Resident (Resident #B) was on floor. Two CNA were trying transfer (sic) Resident from chair to bed (symbol for "with") (brand name of mechanical lift)...sling came off. Resident slid to floor. Resident landed on floor on her left side of body...Resident stated 'Denied hit the head to floor (sic) but (symbol for "left") side face, arm, leg hurting.' Called 911 for transportation. Resident fell 11:30 call 911 11:35 pm. Called Dr...received order for send hospital (sic) for fall evolve (sic). 911 transportation arrived to building 11:40 transported to (acute care hospital)..." 6/01/14 4:30 P.M. "Returned from ER (emergency room ) via ambulance...(symbol for "left") arm was in a sling (symbol for "secondary to") (symbol for "left") humerus fx (fracture)..." 6/01/14 4:45 P.M. "Given 10/325 (milligrams) (brand name, combination [MEDICATION NAME] and [MEDICATION NAME]; pain reliever), [MEDICATION NAME] 600 mg (milligrams)...to relieve pain 10/10." (Pain rated as a "ten" on a scale of one to ten, with ten being the highest possible pain rating). 6/01/14 9:00 P.M. "Given (brand name; combination [MEDICATION NAME] and [MEDICATION NAME]; pain reliever), for pain 7/10..." 6/02/14 1:30 A.M. "Resident given (name brand, combination [MEDICATION NAME] and [MEDICATION NAME]; pain reliever), for pain to left arm...Resident stated pain at 6/10..." 6/03/14 10:30 A.M. "Res (resident) C/O (complains of) that pain regamin (sic) not working...new orders for (brand name, combination [MEDICATION NAME] and [MEDICATION NAME]; pain reliever), noted..." 6/06/14 4:35 P.M. "...Resident C/O (symbol for "left") shoulder pain and that it's severe..." 6/09/14 5:00 A.M. "Resident C/O left shoulder pain, states that her pain is severe..." 6/18/14 (no time noted) "Resident requested 2 (brand name, combination [MEDICATION NAME] and [MEDICATION NAME]; pain reliever)..." A hospital X-Ray report for Resident #B dated 6/01/14 indicated "[MEDICATION NAME] neck of the proximal humerus." (A fracture across the bone of the upper arm, closest to the shoulder.) Resident #B was interviewed on 6/30/14 at 11:30 A.M. She was alert, oriented, and cooperative. She indicated that during a transfer from a chair to her bed, using a mechanical lift, "They dropped me. It wasn't hooked up right. I landed on my arm and it broke. It was very painful then and it still hurts now." During an interview with the Administrator on 6/30/14 at 11:20 A.M., he indicated that the facility had investigated Resident #B's accident and injuries of 6/01/14, and that the 2 CNAs involved in the incident did not follow facility policy and procedure to ensure safe use of the mechanical lift, resulting in Resident #B being dropped to the floor and suffering a fractured left upper arm. During an interview with the Administrator on 6/30/14 at 2:30 P.M., he indicated facility security video identified CNA #1 and CNA #2 entering Resident #B's room together just before the incident of 6/01/14. The Administrator indicated during the above interview that he had interviewed CNA #1 on 6/02/14, and she had refused to accept any responsibility for the incident involving Resident #B, and that she was no longer employed by the facility. A "Disciplinary Warning Notice" for CNA #1 dated 6/04/14 indicated: "Warning For: Failure to obey safety rules. Offenses: Final warning. Disposition: Report to supervisor's office for conference. Remarks: Failure to properly place (brand name of mechanical lift) pad straps-resulting in a fall with a fracture." The "Disciplinary Warning Notice" indicated that CNA #1 had declined to sign it. The Administrator indicated during the above interview that he had interviewed CNA #2 on 6/03/14, and she had accepted responsibility for the incident involving Resident #B, and that she stated "I didn't do my job. I should have checked the sling to make sure it was on right." The Administrator indicated CNA #2 had been counseled, received retraining in mechanical lift use, and continued to work in the facility. A "Disciplinary Warning Notice" for CNA #2 dated 6/06/14 indicated: "Warning For: Failure to obey safety rules. Offenses: Final warning. Disposition: Report to supervisor's office for conference. Remarks: Failure to properly place (brand name of mechanical lift) pad straps-resulting in a fall with a fracture." CNA #2 signed the "Disciplinary Warning Notice" without comment. An undated facility policy received from the Administrator on 6/30/14 at 10:00 A.M., and titled with the brand name of the mechanical lift in use in the facility indicated: "Purpose: A (brand name of mechanical lift) enables nursing personnel to lift and transfer a Resident to and from bed as safely and as easily as possible. Policy: A (name brand of mechanical lift) is to be used for Residents who are too heavy to move by yourself or who are seriously disabled. A (name brand of mechanical lift) is never to be used without two (2) staff members present." This federal tag relates to Complaint IN 247. 3.1-37(a)

Based on observation, record review and interview the facility failed to ensure integrity of resident's skin, in that when resident's had [MEDICAL CONDITION]'s, the nursing staff failed to ensure the resident's skin was not exposed to fecal matter which resulted in extensive excoriation to one resident's abdomen and leg. This deficient practice effected 2 of 2 resident's reviewed with [MEDICAL CONDITION]'s in a sample of 6. (Resident "B" and "E") Findings include: 1. The record for Resident "B" was reviewed on 12-30-13 at 11:00 a.m. [DIAGNOSES REDACTED]. The resident also had an abdominal surgical wound and the resident had an [MEDICAL CONDITION]. These [DIAGNOSES REDACTED]. A review of the hospital Discharge Summary Notes, dated 11-27-13 indicated the resident had "short gut syndrome with chronic protein [MEDICAL CONDITION]" and physician orders for [MEDICATION NAME] e tabs four times a day as needed for diarrhea." A review of the "Admission Nursing Assessment," dated 11-27-13 indicated the resident site/skin surrounding the stoma of the [MEDICAL CONDITION] was without excoriation. The notation indicated the [MEDICAL CONDITION] was "functioning." The "interim" plan of care, dated 11-27-13, indicated the resident had an [MEDICAL CONDITION]. The "goal" indicated the resident "will receive assistance to be kept clean, dry and comfortable on an ongoing basis." The "approach" to the plan of care included "check resident every 2 - 3 hours and PRN (as needed) for incontinent episodes, [MEDICAL CONDITION] care per order." A subsequent plan of care, dated 12-09-13 instructed the nursing staff to "monitor for s/s (signs and symptoms) complications and report to nurse: abdomen for s/s distention, resident complaints of pain, changes in output: color, consistency, amount. Report signs or symptoms of complications to physician." A review of the nurses notes indicated that on the day of admission, 11-27-13 the "[MEDICAL CONDITION] drained 150 ml (milliliters) of stool." "11-29-13 [MEDICAL CONDITION] intact output 700 - no s/s of infection at [MEDICAL CONDITION] site." "12-01-13 [MEDICAL CONDITION] draining with no difficulties." The resident was transported to the local area hospital on 12-02-13 and returned to the facility on [DATE]. The Re-assessment dated [DATE], indicated the resident did not have excoriation adjacent to the [MEDICAL CONDITION] site. "12-11-13 at 3:40 p.m. [MEDICAL CONDITION] patent draining loose stool. Bag changed." "12-12-13 [MEDICAL CONDITION] non intact, [MEDICAL CONDITION] drainage bag replaced. [MEDICAL CONDITION] drainage bag CDI (clean,dry, intact)." "12-14-13 at 2:00 p.m. [MEDICAL CONDITION] patient/draining freely. Area around stoma redness noted. Barrier cream put on as a nurses measure." The resident was transported to the local area hospital on 12-14-13 at 9:00 p.m., per resident "request - indication skin excoriation." "12-15-13 at 3:00 a.m. Arrived to the facility. Excoriation noted around [MEDICAL CONDITION] site. Hospital applied [MEDICATION NAME] drainage bag at [MEDICAL CONDITION] site for better functioning. [MEDICAL CONDITION] drainage is yellow and liquid. Excoriation noted in perineal area... " "12-15-13 2:00 p.m. [MEDICAL CONDITION] intact patent. Draining loose stool large amount." A subsequent entry also dated 12-15-13 and noted as a "late entry" at 1:00 a.m., indicated "Pt. (patient) was evaluated by hospital because of complications with [MEDICAL CONDITION]. [MEDICAL CONDITION] changed at the hospital and a [MEDICATION NAME] drainage bag was attach because of loose consistency of stool, excoriation around [MEDICAL CONDITION] site, excoriation noted around perineal areas excoriation noted on coccyx." The resident had a physician order dated 12-16-13 to "Send to ER for excoriation to ostomy site et c/o pain per resident's request." "12-16-13 4:40 p.m. Resident transported to hospital per resident's request et (and) orders received. Resident with excoriation et redness at ostomy site. When changing ostomy bag resident c/o (complained of) pain et burning. Area very reddened et moist." "12-16-13 at 11:45 p.m. Resident arrived back at facility. Ostomy changed and orders for [MEDICATION NAME] powder two times daily. Resident was given pain medication at ER (emergency room ) 2 [MEDICATION NAME] (a narcotic [MEDICATION NAME]) and 1 - 6 mg (milligrams) [MEDICATION NAME] (a narcotic pain medication) injection." "12-20-13 at 3:20 a.m. Changed [MEDICAL CONDITION] times 2 due to leakage." The record indicated the resident requested to be transported to the local area hospital on 12-20-13 at 10:00 a.m. A review of the physician progress notes [REDACTED]. The hospital record review on 01-02-14 at 8:00 a.m., dated 11-25-13, indicated the resident's, [MEDICAL CONDITION] assessment "assisted with complete pouch change - thin high pouch. Placed in high output pouch to Foley bag - will need to change to standard opening pouch if output thickens." The resident was again transported to the local area hospital on 12-02-13. The discharge summary, dated 12-09-13 included a [DIAGNOSES REDACTED]. This is likely due to short-gut syndrome." Upon return to the facility, the resident had a physician order for [REDACTED]. In addition the record lacked documentation the resident received the medication to treat the diarrhea stool. The resident was transported to the local area hospital once again on 12-16-13. The hospital notation titled "Physical Exam," indicated, "ostomy to RLQ (right lower quadrant) of abd. (abdomen) not attached, with surrounding [DIAGNOSES REDACTED] and warmth." In addition the ER (emergency room ) nurses notes indicated, the resident was "from Castleton Care, pt. (patient) with foley cath. (catheter) in place, states has been in place for a few wks. (weeks). Stoma to right side draining yellowish colored stool. Area around stoma and on leg excoriated and red. New ostomy barrier device placed with bag. Ostomy is filling up quickly and busting, skin is red and irritated around stoma." The record indicated the patient was sent to the Emergency Department from ECF (extended care facility) due to ostomy leaking. She has a large amount of skin irritation at the area that the ostomy is leaking. This most likely represents irritation rather than [MEDICAL CONDITION] given the fact that the ostomy has been leaking onto this area. We repaired the ostomy in the Emergency Department. Plan will be for her to go home with barrier cream as well as some [MEDICATION NAME] as it could represent early yeast infection with inflammation at this area." The hospital [DIAGNOSES REDACTED]." The resident returned to the facility with physician orders to apply "[MEDICATION NAME] combination no. 69 ([MEDICATION NAME] Skin Calming) cream two times daily and [MEDICATION NAME] ([MEDICATION NAME] powder) two times daily." During a subsequent admission to the local area hospital on 12-20-13, the Hospital "Physical Exam," indicated the "ostomy site without a bag and significant skin breakdown with irritation and drainage, tenderness surround the area as well - large area of [DIAGNOSES REDACTED] surrounding ostomy with powder - [DIAGNOSES REDACTED] in perineal and sacral area." The hospital nurses notes indicated "...large areas of excoriation below ostomy and into peri area and sacrum." A review of the "Treatment Record" for December 2013 indicated the resident also had a physician order, dated 12-13-13 for "mastisol glue - apply to outer edge of ostomy bag to increase adhesiveness. Apply, blot dry with gauze." The treatment record indicated the nurses initials with a circle around each initial on 12-14-13, 12-15-13, 12-16-13 and 12-18-13. The 12-19-13 nurse practitioner progress note indicated the resident had a "history of very loose stools with dark green color" but lacked an assessment or knowledge the resident had extensive excoriation from the leaking of the ostomy of fecal matter onto her skin. During an interview on 01-03-14 at 1:00 p.m., the Director of Nurses indicated the facility was unable to purchase the "glue." The record lacked documentation the of the full extent of the excoriation of the resident's skin from fecal matter or the physician had been notified for intervention. During an interview on 01-02-14 at 12:30 p.m., licensed nurse # 7 indicated "When we would put the paste on (the resident) would just cry - it hurt so bad. Yes it was excoriated. We sent (resident) out a few times for that problem. One time (resident) came back with a [MEDICATION NAME] bag on it. It seemed to get better but we didn't have very many of those bags so we went back to using the [MEDICAL CONDITION] bag. Sometimes if we couldn't get the [MEDICAL CONDITION] bag on we just put the Chux under her and it (in regard to feces) would just flow out." During an interview on 01-02-14 at 2:10 p.m., licensed nurse #8 indicated, "I think the nurse practitioner looked at it - I know she looked at an abdominal wound the resident had. The one time I saw it, it was an irritation. I think that was around the first part of December." 2. The record for Resident "E" was reviewed on 01-02-14 at 12:20 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. A review of the nurses notes indicated episodes of the [MEDICAL CONDITION] bag leaking/busted which exposed the resident's skin to fecal matter: "12-07-13 at 5:40 p.m. [MEDICAL CONDITION] bag was leaking so I replaced it." "12-08-13 at 8:00 p.m. [MEDICAL CONDITION] was leaking again and had to be changed." "12-09-13 at 6:00 a.m. [MEDICAL CONDITION] bag busted again and changed at 11:00 p.m." "12-09-13 at 12:30 p.m. [MEDICAL CONDITION] was changed 3 times on noc (night) shift is intact." "12-17-13 at 2:55 a.m. Resident resting until ostomy bag started leaking. Changed ostomy bag and resident requested PRN (as needed) pain medication." "12-18-13 at 5:50 a.m. [MEDICAL CONDITION] changed since it had busted open. Seems to be draining OK now." "12-29-13 at 11:00 a.m. [MEDICAL CONDITION] bag changed d/t (due to) leakage. Patent draining loose stool." During an observation on 01-03-14 at 10:40 a.m., the resident was positioned in bed slightly leaning to the left side. The Director of Nurses indicated the resident was going to be transported to the local area hospital for the evaluation of a wound on his leg. With permission of the resident, the [MEDICAL CONDITION] site was observed. The ostomy stoma was without redness or excoriation to the surrounding skin, however the ostomy bag was full of brown stool. The area adjacent to the stoma/fecal bag dried fecal matter was observed. The dried matted extended approximately 2 inches down the mid sternal area. During this observation, the resident indicated, "It's (in reference to the dried fecal matter), from being turned and it (in regard to the drainage bag) needs to be emptied." 3. A review of the facility policy on 01-02-14 at 1:15 p.m., titled "[MEDICAL CONDITION] Care," and dated 08-14-2008, indicated the following: "Purpose (bold type) The purpose of this procedure is to provide guidelines that will aid in preventing exposure of the resident's skin to fecal mater. When evaluating the condition of the residents skin, note the following - breaks in the skin, excoriation, signs of infection (heat, swelling, pain, redness, purulent exudate, etc.)." 4. A review of the facility policy on 01-03-14 at 10:00 a.m., titled "Change in a Resident's Condition (bold type)," and dated 10-24-2011, indicated the following:"Policy (bold type) The facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, residents rights, etc.)." "Protocol for Notification - Notification of Attending Physician (bold type) - The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been: a significant change in the resident's physical/emotional/mental condition; a need to alter the resident's medical treatment significantly ...." This Federal tag relates to Complaint IN 689 and IN 749. 3.1-47(a)(3)

Based on observation, interview, and record review, the facility failed to provide necessary services and treatment to prevent the development of pressure sores (stage ll to the left buttock, stage lll to the right buttock) for 1 resident who was admitted without pressure sores of 3 residents reviewed for pressure sores in a sample of 5. (Resident B) Findings include: 1. The record of Resident B was reviewed on 10/22/12 at 1:00 p.m. [DIAGNOSES REDACTED]. An initial Minimum Data Set assessment, dated 9/29/12, indicated Resident B was cognitively impaired, had trouble concentrating, had physical and verbal behaviors directed toward others, did not ambulate, was totally dependent on staff for bed mobility, was frequently incontinent of bowel and bladder, and required extensive staff assistance for activities of daily living. An "Admission Nursing Assessment," dated 9/10/12 the date of Resident B's admission to the facility, indicated surgical incisions to the right hip. No pressure sores or other skin concerns were documented on admission. A "Bowel and Bladder Assessment," dated 9/10/12, indicated "Condition of Skin: No redness." Resident B's admission orders Pressure Relieving Mattress." Per interview wit the Director of Nursing (D.O.N.) on 10/23/12 at 11:45 a.m., this is the standard foam mattress used for all residents in the facility. Resident B was sent to the hospital on [DATE] with symptoms of respiratory distress, and returned to the facility on [DATE]. A hospital "Transfer/Referral Form," dated 9/22/12, indicated "Skin: redness around coccyx." An "Admission Nursing Assessment," dated 9/22/12 the date of Resident B's readmission to the facility, indicated "Ext (extensive) Discoloration Buttock Excoriation." A physician's orders [REDACTED]." The record indicated no other treatment or intervention for risk for pressure sores at that time. Nurse's notes for Resident B on 9/30/12 at 10:30 p.m., indicated "An area of about 3.4 x (times) 3 cm (centimeters) was noted on his lower buttock..." Resident B's nurse's notes contain no other reference to skin condition, including assessment and/or treatment. A "Skin Assessment Verification" form, dated 9/30/12, indicated Resident B had a Stage ll pressure sore to her sacral area measuring 3.4 by 3.0 centimeters. Treatment was indicated to be "Calmo q shift" ([MEDICATION NAME] ointment every shift). No other treatment or intervention was noted. A "Wound Progress Note," dated 10/03/12, completed by Advanced Practice Nurse/Wound Care Specialist indicated: "Wound Location: Sacrum. Measurements: 8.0 by 9.0 by 0.1 centimeters. Etiology (Type): Pressure Stage: Unstageable/DTI (Deep Tissue Injury) Type of Tissue: Red...Fragile Diagnosis/Plan: Unstageable-DTI- sacrum...DC briefs in bed. Upgrade mattress.." During an interview with the Director of Nursing (D.O.N.) on 10/24/12 at 2:30 p.m., she indicated that care staff were encouraged to not use briefs on residents in bed, but that there was no documentation of specific instructions to not use briefs for Resident B while in bed, and no documentation of whether this had been done. She also indicated that Resident B's mattress had not been upgraded from the facility's standard foam mattress. Resident B was sent back to the emergency roiagnom on [DATE] secondary to diarrhea and coffee grounds emesis. Hospital records, which include Forensic Nursing evaluation with documentation and photos, indicated that on presentation to the emergency room , Resident B had a Stage lll pressure sore on the right buttock measuring 2.5 by 2.5 centimeters with surrounding redness of 7 by 5 centimeters. The left buttock was noted to have "3 small" Stage ll pressure sores with surrounding redness of 5 by 10 centimeters. The resident was admitted to the hospital and wound care treatment was begun. Resident B returned to the facility on [DATE]. A "Skin Assessment Verification" form on that date indicated the presence of a Stage l pressure sore to the coccyx measuring 2.5 by 2.0 centimeters and a Stage ll pressure sore to the left buttock measuring 1.5 by 0.7 centimeters. Resident B's pressure sores were observed on 10/23/12 at 9:15 a.m. The wounds were noted to be consistent with the documentation on the 10/22/12 Skin Assessment Verification. The resident remained on the facility's standard foam mattress. Records indicated a low air loss mattress was ordered on that date. Resident B's record contained no reference to a turning or repositioning schedule. During an interview on 10/23/12 at 3:45 p.m., the D.O.N. indicated that the facility did not document the need for turning schedules for residents at risk for pressure sores, either as a physician's orders [REDACTED]. She indicated there was no place in the resident's record designated to document turning or repositioning as performed. She indicated CNA assignment sheets noted "Turn Q 2 hr" (Turn every 2 hours) and it was "assumed" that staff would know to turn residents who were at risk for pressure sores. 2. A facility policy dated 10/24/2011 received from the D.O.N. on 10/23/12 at 8:45 a.m., indicated: "Purpose: To provide identification of pressure ulcer risk factors and interventions for the risk factors...Once a pressure ulcer develops, it can be extremely difficult to heal. The facility should have a system to assure timely and appropriate evaluation... Interventions and Preventive Measures...Place resident on a minimum of a q (every) hour turning and repositioning program." This federal tag relates to Complaint IN 917. 3.1-40(a)(1)

Based on record review and interview, the facility failed to ensure a resident with a gastrostomy feeding tube was assessed to accurately reflect the resident's status and condition and to ensure the resident received appropriate care and services to prevent injury to the gastrostomy tube insertion site, resulting in the resident (Resident K) being sent to a hospital emergency room for treatment with a resultant [DIAGNOSES REDACTED]. 1 resident of 4 reviewed for gastrostomy tube care in a sample of 11. Findings include: 1. The record of Resident K was reviewed on 6/05/12 at 95 a.m. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (M.D.S.) assessment dated [DATE] indicated Resident K had significant cognitive deficits, required total staff assistance for all activities of daily living, was incontinent of bowel and bladder, and received all nutrition through his gastrostomy tube. Records indicate Resident K has had a gastrostomy feeding tube since his admission to the facility in January of 1990. A nurse's note for 5/16/12 at 2:45 p.m. indicated: "C.N.A. in resident's room...noted dislodged g/t (gastrostomy tube)...attempted to reinsert x 2 (times 2)...unable to replace g/t..." A nurse's note dated 5/16/12 at 3:30 p.m. indicated "(name of treating physician) called...may send out to (acute care hospital emergency room )...replace g/t." A hospital physician's dictated "emergency room Report" dated 5/23/12 included, referring to the emergency room visit of 5/16/12, "He (Resident K) was seen here a week ago, had the [DEVICE] replaced and at that point, it was felt that there was essentially no [DEVICE] care ongoing..." A nurse's note dated 5/23/12 at 2:30 p.m. indicated "pt (patient) has an open area under GT site. Area around site looks swollen (symbol for "and") irritated. Called (treating physician) to inform rec. (received) order to send to ER for evaluation (symbol for "and") tx (treatment). Pt did agree that pt did want to go to the hospital..." An Emergency Department Triage Report dated 5/23/2012 at 3:38 p.m. indicated: "Chief Complaint: [DEVICE] infection. Data: Pt (patient) presents from ECF (Extended Care Facility) with infection to [DEVICE]. [DEVICE] is purulent with foul smelling discharge..." A physician's dictated "emergency room Report" dated 5/23/12 indicated: "History of present illness:..The patient is a [AGE] year old male, chronically handicapped...presents to the Emergency Department for possible [DEVICE] infection...there is some purulent drainage... Abdomen: Soft. He has a [DEVICE] in place. There has been what appears to be essentially no care of the [DEVICE]. There is significant granulation tissue with [DIAGNOSES REDACTED] (enlarged or overgrown) skin. There is some drainage which is probably [MEDICAL CONDITION] contents. There is an [DIAGNOSES REDACTED]tous (reddened; a sign of inflammation or infection) patch primarily around the [DEVICE] site and progressing to the lateral (to the side) aspect... The patient does need [DEVICE] care. It is felt at this point that he is not getting this at the facility. I have involved nursing supervisor, forensic nurse to take pictures of the wound and somehow to arrange [DEVICE] care for this gentleman. We were able to cleanse the [DEVICE] site. There was significant invasion of the soft tissue with the [DEVICE] cuff. This was removed from the soft tissue. Photographs were obtained..." A hospital document titled "Flow Sheet" dated 5/23/12 indicated at these times: 5:00 p.m. "...entered room to assess pt...[DEVICE] site oozing brownish purulent drainage around site, reddened around site/swollen also..." 7:25 p.m. "...assumed care of pt. [DEVICE] insertion site red with puss like drainage noted site has strong odor swelling noted pt. has dried crusted drainage that is dark red in color around site cleaned site with tech holding pts arm, pt appeared to be in extreme pain when site touched..." 7:35 p.m. (Forensic Nurse) at bedside taking pictures of [DEVICE]. The plastic disk at insertion site sitting at a 90 degree angle straight up it appears that half of disk is embedded into pts (patient's) skin the top of disk rubs the pts abd (abdomen) when pt is sitting up which has caused a sore...doctor at bedside the disk pulled out of skin and area that is open where disk was embedded cleaned with saline and dressed with 4 x 4's (dressings) that are y-ed and layered around tube to keep disk from embedding again." 7:57 p.m. "APS (Adult Protective Services) to be filed on phone for PT (patient)." 8:02 p.m. "(Name of facility) called...report given to (name of facility R.N.) R.N. aware that aps will be contacted about [DEVICE]." 2. An undated facility policy titled "[DEVICE] Site Care" received from the Director of Nursing On 6/06/12 at 2:40 p.m. and indicated to be a current facility policy indicated: "Purpose: To keep [DEVICE] site clean and free of infection Policy: [DEVICE] care should be done daily unless complications or infection exist. It should then be done as per physician's orders [REDACTED]. Procedure: 5. You should assess the [DEVICE] site daily for signs of infection and report: a. Redness b. Drainage, or c. Temperature 8. Document any pertinent observations in the medical record." During a meeting on 6/05/12 at 12:35 with the Director of Nursing (D.O.N.) and the Assistant Director of Nursing (A.D.O.N.), Resident K's record was reviewed, including the following nurse's notes: 5/19/12 6:30 a.m. "...(symbol for "no") s/s (signs or symptoms) of infection at the site..." 5/20/12 11:15 a.m. "...Site (symbol for "without") s/s of infection..." 5/21/12 10:30 p.m. "...Site (symbol for "without") redness or drainage..." 5/22/12 7:45 a.m. "...(symbol for "no") s/s of infection..." 5/23/12 6:00 a.m. "...(symbol for "no") sign of infection..." The Assistant Director of Nursing indicated she had written the nurse's note of 5/23/12 at 2:30 documenting the condition of Resident K's [DEVICE] site and sending him to the emergency room for treatment. The A.D.O.N. also indicated she had interviewed the nurses who had done Resident K's [DEVICE] care on the evening of 5/22/12 and the morning of 5/23/12 and both indicated they had not noted any concerns with the [DEVICE] site. The hospital Forensic Nurse's photographs of Resident K's [DEVICE] site obtained at the emergency room and documenting the condition of his [DEVICE] site on admission were reviewed. Both the D.O.N. and the A.D.O.N. indicated they could offer no explanation as to the apparent conflict between the facility's documentation of Resident K's [DEVICE] site condition and that documented in hospital records and photographs, or how this condition could have developed in the time between the nurse's note of 5/23/12 at 6:00 a.m. and his discharge to the hospital for treatment at 2:30 p.m. 3.1-44(a)(2)