Every finding on record at Cedar Creek Health Campus

Based on interview and record review, the facility failed to ensure an allegation of abuse/misappropriation was reported to the Indiana Department of Health (IDOH) and other proper authorities related to an allegation of drug diversion by facility staff for 1 of 1 misappropriation allegation reviewed. (RN 1)Finding includes:A facility investigation of an allegation of drug diversion, dated 7/12/26 and received from the Executive Director (ED), was reviewed on 8/12/26 at 10:00 a.m. The initial statement indicated RN 2 had made an allegation RN 1 was taking controlled narcotics from the facility residents. During an interview on 8/12/26 at 10 a.m., the ED indicated the allegation had not been reported to IDOH because she was unable to substantiate the allegation.A facility abuse policy, dated 11/19/25 and received from the ED as current, indicated the definition of abuse included, but was not limited to, misappropriation of property. Any person with knowledge of or suspicion of suspected violations was to report the allegation immediately. All alleged violations were to be reported to the State Survey Agency and the adult protective services.This citation relates to Intake 3072885.410 IAC (Indiana Administrative Code) 16.2-3.1-28(c)

Based on record review and interview, the facility failed to ensure care plans were implemented and in place for antibiotic medication use for 1 of 16 resident care plans reviewed. (Resident 3)Finding includes:During an interview on 5/12/26 at 11:00 a.m., Resident 3's family member indicated the resident was taking antibiotics routinely due to a history of urinary tract infections in the past.Resident 3's record was reviewed on 5/12/26 at 1:26 p.m. Diagnoses included, but were not limited to, dementia with behavioral disturbance and urinary tract infection.The Quarterly Minimum Data Set (MDS) assessment, dated 3/4/26, indicated the resident was severely cognitively impaired, she was frequently incontinent of bowel and bladder, and received antibiotic medications.A Physician's Order, dated 1/22/26, indicated Macrobid (antibiotic medication) 100 milligrams, 1 capsule daily.A Physician's Progress Note, dated 1/22/26 at 12:02 p.m., indicated the resident was seen for a follow-up per the family's request for a lump on the resident's right knee with pain and for concerns of a urinary tract infection (UTI). The resident was a candidate for prophylactic antibiotics (medication used for prevention of bacterial infection) given the history of recurrent UTIs. Macrobid 100 milligrams daily was ordered for UTI prevention.There was no care plan implemented related to the prophylactic use of antibiotic medications.During an interview on 5/18/26 at 3:15 p.m., the Director of Nursing indicated the MDS Coordinator had overlooked the antibiotic, and a care plan had not been initiated.410 IAC (Indiana Administrative Code) 16.2-3.1-35(a)

Based on observation, record review, and interview, the facility failed to ensure residents received the necessary treatment and services related to skin discolorations not assessed and or monitored for 2 of 3 residents reviewed for non-pressure related skin conditions. (Residents 4 and 35)Findings include:1. On 5/11/26 at 10:19 a.m., Resident 4 was observed sitting in a wheelchair in her room. The resident had a raised blue discoloration on her right forearm and a purple discoloration on her left shin. The resident indicated she was unsure how she received the discolorations. Record review for Resident 4 was completed on 5/12/26 at 1:29 p.m. Diagnoses included, but were not limited to, atrial fibrillation, stroke, and heart failure. A Care Plan, dated 4/30/26, indicated the resident was at risk for excessive bleeding and bruising related to medications. An intervention included to notify the physician of abnormal bruising.The admission Minimum Data Set (MDS) assessment, dated 5/4/26, indicated the resident was moderately cognitively impaired. The resident had a functional limitation in range of motion to one side of her upper and lower extremities. The resident required substantial maximal assistance with dressing and was dependent on staff for transfers. The resident received an anticoagulant (blood thinning) medication. The May 2026 Physician's Order Summary indicated the resident had received Eliquis (anticoagulant medication) 2.5 milligrams twice a day for atrial fibrillation. On 5/12/26 at 2:42 p.m., Resident 4 was observed lying in bed with a blanket over her legs. The resident had a raised blue discoloration on her right forearm.There was a lack of documentation to indicate the skin discolorations had been assessed and or monitored.During an interview on 5/12/26 at 2:44 p.m., RN 1 indicated she was unaware of the resident's discolorations. Staff should have identified the discolorations during routine care. 2. On 5/11/26 at 10:15 a.m., Resident 35 was observed sitting in a wheelchair in her room. The resident had a large dark purple discoloration on her right hand.On 5/12/26 at 9:13 a.m., Resident 35 was observed sitting in a wheelchair in the dining area. The resident had a large dark purple discoloration on her right hand.Record review for Resident 35 was completed on 5/12/26 at 3:00 p.m. Diagnoses included, but were not limited to, dementia, peripheral vascular disease, and stroke.A Care Plan, dated 10/7/20, indicated the resident was at risk for excessive bleeding and bruising. An intervention included to notify the physician of abnormal bruising and or bleeding. A Weekly Skin Assessment, dated 5/5/26, indicated the resident had no impairment.There was a lack of documentation to indicate the skin discoloration had been assessed and or monitored.During an interview on 5/12/26 at 3:05 p.m., RN 1 indicated she was unaware of the resident's discoloration. Staff should have identified the discoloration during routine care. 410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure residents received the necessary care and treatment related to a lack of a Physician's Order for oxygen use for 1 of 2 residents reviewed for respiratory care. (Resident 4)Finding includes:On 5/11/26 at 10:19 a.m., Resident 4 was observed sitting in a wheelchair in her room. The resident had a portable oxygen concentrator hooked to the back of her wheelchair. The oxygen was on the resident via a nasal canula at 2 liters. The resident indicated she had been on oxygen for a while. Record review for Resident 4 was completed on 5/12/26 at 1:29 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD) and respiratory failure. A Care Plan, dated 4/30/26, indicated the resident had potential for shortness of breath while lying flat related to COPD. An intervention included to administer oxygen per the Physician's Order.The admission Minimum Data Set (MDS) assessment, dated 5/4/26, indicated the resident was moderately cognitively impaired. The resident had a functional limitation in range of motion to one side of her upper and lower extremities. The resident required substantial maximal assistance with dressing and was dependent on staff for transfers. The resident received oxygen therapy.A Physician's Order, dated 5/12/26, indicated to administer oxygen at 2 liters per nasal canula continuously.There was no documentation indicating a Physician's Order for oxygen administration was in place prior to 5/12/26. During an interview on 5/12/26 at 2:44 p.m., RN 1 indicated the resident had been on oxygen for a while. She was unsure why there was not a Physician's Order for oxygen prior to 5/12/26. 410 IAC (Indiana Administrative Code)16.2-3.1-47(a)(6)

Based on observation, record review and interview, the facility failed to ensure infection control practices were in place and implemented related to Enhanced Barrier Precautions (EBP) and staff not wearing a gown during a peripherally inserted central catheter (PICC) medication administration observation. (Resident 22) Finding includes:During a medication administration observation on 5/14/26 at 12:54 p.m., LPN 1 was observed preparing Resident 22's medications, which included antibiotic medication to be administered intravenously through the resident's PICC line. The resident's doorway had a sign that indicated EBP was to be used. LPN 1 entered the resident's room, used hand sanitizer, and donned gloves. He had not donned a gown. He then proceeded to administer the intravenous medication through the PICC line. During an interview on 5/14/26 at 1:07 p.m., LPN 1 indicated he had not been instructed to wear a gown when administering intravenous medication through a PICC line. He was unsure if the resident had an EBP sign posted outside his door.During an interview on 5/15/26 at 8:52 a.m., the Infection Preventionist indicated a gown and gloves should be worn when administering intravenous medication through a PICC line.A facility policy, titled, Enhanced Barrier Precautions Standard Operating Procedure, received as current, indicated .1. Enhanced barrier precautions will be in place during high contact care activities for residents with the following conditions: .ii. All residents with indwelling medical devices. 1. Includes but not limited to: catheters, central lines, feeding tubes, tracheostomy tubes .2. Personal protective equipment should be used even if blood and body fluid exposure is not anticipated. a. At minimum, staff shall wear gloves and gowns during high contact care activities .410 IAC (Indiana Administrative Code) 16.2-3.1-18(b)

Based on observation, interview, and record review, the facility failed to ensure a call light was working for a dependent resident for 1 of 24 resident's call lights tested. (Resident 4)Finding includes:On 5/11/26 at 10:19 a.m., Resident 4 was observed sitting in a wheelchair in her room. The resident indicated she wanted to lie down. She had pushed the button on her call light, but no one had responded. The resident pushed the button again; there was no light that illuminated from the call system in the hallway. On 5/11/26 at 10:21 a.m., LPN 1 was notified the resident's call light was not working. She then proceeded into the resident's room and pushed the button on the call light. There was no light that illuminated from the call system in the hallway. She indicated she would inform maintenance to fix the call light and would get another staff member to help her lie down.Record review for Resident 4 was completed on 5/12/26 at 1:29 p.m. Diagnoses included, but were not limited to, stroke and hemiplegia (paralysis on one side of the body).The admission Minimum Data Set (MDS) assessment, dated 5/4/26, indicated the resident was moderately cognitively impaired. The resident had a functional limitation in range of motion to one side of her upper and lower extremities. The resident was dependent on staff for transfers. 410 IAC (Indiana Administrative Code) 16.2-3.1-19(u)

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) comprehensive assessment was accurately completed related to insulin for 1 of 16 MDS assessments reviewed. (Resident 15)Finding includes:Record review for Resident 15 was completed on 5/12/26 at 3:16 p.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus.The admission MDS assessment, dated 3/17/26, indicated the resident had received an insulin injection in the past seven days.The Medication Administration Record, dated 3/2026, lacked documentation of any insulin administration.The Physician's Order Summary, dated 5/2026, lacked any orders for insulin.During an interview on 5/13/26 at 3:05 p.m., the MDS Coordinator indicated the resident had not received any insulin and it had been marked by accident.410 IAC (Indiana Administrative Code) 16.2-3.1-31(i)

Based on observation, record review, and interview, the facility failed to ensure residents were served a therapeutic diet as ordered the physician for 2 of 3 residents reviewed for therapeutic diets. (Residents D and E) Findings include: 1. During an observation on 6/11/25 at 9:12 a.m., Resident D's breakfast meal consisted of two fried eggs, bacon, apple juice, [NAME] toast and fruit. The meal card indicated a regular diet with fortified foods was to be served. During an observation on 6/11/25 at 11:49 a.m., Resident D's lunch meal consisted of a slice of cheese pizza and a drink. At 12:17 p.m., she received a desert of cherry crisp. Resident D's record was reviewed on 6/11/25 at 4:29 p.m. The diagnoses included, but were not limited to, vascular dementia. A Quarterly Minimum Data Set (MDS) assessment, dated 3/20/25, indicated a severely impaired cognitive status, required supervision while eating, and received a therapeutic diet. A Care Plan, revised on 6/3/25, indicated the resident was at risk for malnutrition. The interventions included, the diet would be served as ordered by the physician. A Physician's Order, dated 6/9/25, indicated a diet order of a regular diet with fortified foods. 2. During an observation on 6/11/25 at 9:15 a.m., Resident E received a breakfast meal that consisted of two fried eggs, bacon, toast, water, coffee, and tangerines. The dietary card indicated a mechanical soft diet with fortified food was to be served. During an observation on 6/11/25 at 11:55 a.m., the resident received his lunch meal in his room. The lunch meal consisted of ground smoked sausage and mashed potatoes. The dietary card indicated he should have also received peas with onions, and fortified food. Resident E's record was reviewed on 6/12/25 at 9:13 a.m. The diagnoses included, but were not limited to, dementia and stroke. A Care Plan, revised on 4/14/25, indicated a risk for malnutrition. The interventions included, the diet would be served as ordered by the physician. A Significant Change MDS assessment, dated 4/21/25, indicated an intact cognitive status, required supervision with meals, and received a mechanically altered and therapeutic diet. A Physician's Order, dated 6/9/25, indicated a no added salt, mechanical soft with fortified foods diet was to be served. During an interview on 6/12/25 at 9:18 a.m., the Dietary Manager indicated at breakfast, the residents who were on a fortified foods diet were to receive either yogurt or oatmeal. On 6/11/25 at the lunch meal, the fortified food was either yogurt or the yogurt parfait. This citation relates to Complaint IN00459044. 3.1-21(b)

Based on record review and interview, the facility failed to ensure a concern related to missing clothing was documented and investigated for 1 of 1 residents reviewed for grievances. (Resident 6) Finding includes: During an interview on 3/17/25 at 1:28 p.m., Resident 6 indicated she had been missing a baseball sweatshirt for a couple of months and it had never been replaced. She also indicated she had been missing a blue and white nightgown, for approximately the past two weeks, that had not been found or replaced. The resident's record was reviewed on 3/19/25 at 1:20 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease, hypotension and muscle weakness. The Quarterly Minimum Data Set assessment for Resident 6, dated 3/14/25, indicated the resident was cognitively intact and needed substantial assistance for bed mobility and transfers. Resident grievances for the past six months were reviewed. There were no grievances from Resident 6 related to missing clothing. During an interview on 3/19/25 at 11:23 a.m., the Director of Nursing indicated she was aware of the missing items and the sweatshirt had been ordered and they were still looking for the nightgown. She indicated she did not know when the sweatshirt had been ordered or if a grievance had been completed regarding Resident 6's missing clothing. During an interview on 3/19/25 at 11:57 a.m., the Executive Director (ED) indicated the Business Office Manager had found out about the missing sweatshirt on Sunday (date not provided) and would be bringing one (a grievance form) to the resident. The ED indicated she had spoken with the resident who indicated she had reported the items as being missing, but no grievance had been completed. The policy, Resident Concern Process, indicated the following: .1. The facility will provide an open and customer friendly atmosphere for the residents and their families and representatives to voice concerns and problems with the assurance that their concerns will be heard and acted upon and, .7. Follow up from the department leader will occur within 24-48 hours with resolution entered into KeyStats (electronic charting system) 3.1-7(a)(2)

Based on record review and interview, the facility failed to ensure medications were administered and/or held per blood pressure parameters for 1 of 5 residents reviewed for unnecessary medications. (Resident 31) Finding includes: Resident 31's record was reviewed on 3/18/25 at 1:52 p.m. Diagnoses included, but were not limited to, Parkinson's disease, chronic kidney disease, and congestive heart failure. The Significant Change in Status Minimum Data Set (MDS) assessment, dated 1/20/25, indicated the resident was moderately cognitively impaired for daily decision making. The current March 2025 Physician Order Summary (POS) indicated the resident was to receive propranolol (high blood pressure treatment) 40 milligrams 1 tablet, hold if heart rate was less than 60 beats per minute and/or systolic blood pressure (top number of blood pressure reading) was less than 120 and hydrochlorothiazide (a diuretic medication) 25 milligrams 1 tablet, hold if systolic blood pressure is less than 120. The February and March 2025 Medication Administration Record (MAR) indicated the propranolol was administered outside of the set parameters on the following dates and times: - 2/5/25 6:00 p.m. to 10:00 p.m. dose: BP (blood pressure) 110/74, HR (heart rate) 60 - 2/14/25 6:00 p.m. to 10:00 p.m. dose: BP 101/46, HR 83 - 2/20/25 6:00 p.m. to 10:00 p.m. dose: BP 104/62, HR 72 - 2/24/25 6:00 p.m. to 10:00 p.m. dose: BP 112/71, HR 54 - 2/27/25 6:00 p.m. to 10:00 p.m. dose: BP 110/64, HR 67 - 3/1/25 6:00 a.m. to 10:00 a.m. dose: BP 105/58, HR 73 The February 2025 MAR indicated the hydrochlorothiazide medication was administered outside of the set parameters on 2/7/25 from 6:00 a.m. to 10:00 a.m. with a BP of 119/68. During an interview on 3/19/25 at 1:23 p.m., the Director of Nursing indicated the medications should have been held per the physician's orders. 3.1-37(a)

Based on observation, record review and interview, the facility failed to ensure safety measures were implemented related to a broken wheelchair brake and fall interventions were put into place as ordered for 2 of 4 residents reviewed for falls. (Residents 48 and 55) Findings include: 1. On 3/17/25 at 11:28 a.m., Resident 48 was observed in her room. She indicated she had fallen in the bathroom because her wheelchair was unstable and one of the locks did not work. She indicated she had reported the issue to several people. The wheelchair was present and the right brake was noted to be broken and did not work. Resident 48's record was reviewed on 3/18/25 at 11:10 a.m. Diagnoses included, but were not limited to, chronic bronchitis, heart failure, anemia and atrial fibrillation. The Admission Minimum Data Set assessment, dated 2/20/25, indicated the resident was cognitively intact and required substantial assistance for bed mobility and transfers. A Nursing Progress Note, dated 3/13/25, indicated the resident was being transferred from the toilet to the locked wheelchair when she slid from the seat onto the floor. During an interview on 3/18/25 at 11:33 a.m., CNA 1 indicated the right brake on the resident's wheelchair did not work properly and she thought a work order had been placed to have it repaired. During an interview on 3/18/25 at 11:45 a.m., the Executive Director indicated a work order had been placed that morning (3/18/25) to have the wheelchair brake repaired. He indicated the facility had been unaware the wheelchair brake was not working prior to then. 45666 2. During observations on 3/17/25 at 10:42 a.m. and 3/20/25 at 3:08 p.m. there was no sign in Resident 55's bathroom to remind the resident to call for assistance. Resident 55's record was reviewed on 3/20/25 at 3:20 p.m. The diagnoses included, but were not limited to, fracture of first lumbar vertebra, one rib on the right side, and left pubis, and Parkinson's disease. An Admission Minimum Data Set assessment, dated 3/5/25, indicated she was cognitively intact for daily decision making, required maximum assistance with transfers, was dependent for toileting, and had a fall with a fracture prior to admission into the facility and had had a fall with major injury since her admission to the facility. A Care Plan, dated 2/26/25, indicated the resident was at risk for falls related to a history of falls with lumbar and rib fractures and a recent left pubis fracture. The interventions included, but were not limited to the following: a sign in the bathroom to remind the resident to call for assistance, therapy to evaluate and treat, staff to assist the resident with transfers as needed and to keep the call light within the resident's reach. During an interview on 3/20/25 at 3:56 p.m., the Director of Nursing indicated the resident frequently removed signs placed in her room because she did not believe she needed help from the staff. A policy titled, Fall Management Program Guidelines, indicated .2. Should the resident experience a fall the attending nurse shall complete the 'Fall Event.' This includes an investigation of the circumstances surround the fall to determine the cause of the episode .interventions to reduce risk of repeat episode and a review by the IDT to evaluate thoroughness . 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure an indwelling Foley (urinary) catheter collection bag was kept off of the floor and documentation of urinary output was completed for 1 of 1 resident reviewed for urinary catheters. (Resident 3) Finding includes: On 3/20/25 at 10:42 a.m. and 12:00 p.m. Resident 3 was observed in her wheelchair. The catheter collection bag was noted to be on the floor under the chair. Record review for Resident 3 was completed on 2/21/25 at 9:46 a.m. Diagnoses included, but were not limited to, neuromuscular dysfunction of bladder, urinary retention, and personal history of urinary tract infections. The Quarterly Minimum Data Set (MDS) assessment, dated 1/29/25, indicated the resident was severely cognitively impaired and had an indwelling urinary catheter. The March 2025 Physician's Order Summary, indicated an order for the resident to have an indwelling urinary catheter and to perform catheter care every shift. The current care plans, indicated the resident used a Foley (urinary) catheter for diagnosis of neurogenic bladder. Interventions included, but were not limited to, record resident urinary output, keep leg strap in place, maintain a closed system with urinary bag below the bladder and cover. The urinary output vitals documentation reviewed from 1/20/25-3/20/25 indicated on the following dates, output was noted as small, medium, or large instead of an accurate amount of milliliters of urine: - Small: 2/19 at 10:42 a.m., 2/22 at 12:56 p.m., 2/23 at 1:52 p.m., 2/27 at 10:50 a.m., 2/27 at 1:07 p.m., 2/28 at 8:45 a.m., 2/28 at 1:07 p.m., 3/4 at 10:44 a.m., 3/6 at 1:16 p.m., 3/8 at 10:26 a.m., 3/13 at 10:32 a.m., 03/13 at 11:25 a.m., 03/14 at 11:41 a.m., and 3/18/25 at 11:13 a.m. - Medium: 1/20 at 2:53 p.m., 1/22 at 5:37 a.m., 1/22 at 1:57 p.m.,1/25 at 1:54 p.m., 1/27 at 10:23 p.m., 2/4 at 10:58 a.m., 2/4 at 1:55 p.m., 2/5 at 1:42 p.m., 2/6 at 10:51 a.m., 2/7 at 11:35 p.m., 2/8 at 11:07 a.m., and 2/11/25 at 11:24 a.m. - Large: 1/22 at 10:49 a.m., 1/23 at 10:39 a.m., 1/23 at 11:10 a.m., 1/23 at 1:44 p.m., 1/25 at 12:10 p.m., 1/26 at 11:35 a.m., 1/26 at 2:25 p.m., 1/28 at 11:33 a.m., 1/28 at 2:14 p.m., 1/30 at 11:17 a.m., 1/31 at 10:29 a.m., 2/5 at 8:13 a.m., 2/6 at 1:21 p.m., 2/8 at 1:24 p.m., 2/9 at 10:13 a.m., and 2/9/25 at 1:06 p.m. During an interview on 3/20/25 at 2:22 p.m., the Director Of Nursing (DON) indicated the facility did not have a specific policy related to documentation of urinary output for residents that have catheters and she indicated there was no further information to provide. 3.1-41(a)(2)

Based on observation, record review and interview, the facility failed to ensure a resident received the necessary care and treatment related to oxygen flow rate for 1 of 1 residents reviewed for respiratory care. (Resident 16) Finding includes: On 3/18/25 at 9:37 a.m., Resident 16 was observed seated in her room. Her portable oxygen was in use and the flow meter was set on 2 liters per minute (LPM). The resident's record was reviewed on 3/18/25 at 2:10 p.m. Diagnoses included, but were not limited to, acute respiratory failure with hypoxia and metabolic encephalopathy. The Quarterly Minimum Data Set assessment, dated 1/14/25, indicated the resident was moderately cognitively impaired, used oxygen and was dependent on staff for toileting and transfer needs. A Physician's Order, dated 9/17/24 indicated the resident was to have oxygen administered at 4 lpm by nasal cannula continuously. On 3/18/25 at 11:43 a.m., the resident was observed again in her room with the oxygen flowing at 2 lpm. LPN 1 was present and indicated it should have been set on 4 lpm. She adjusted it to the correct flow rate at that time. 3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure a pain medication was not administered prior to non-pharmacological interventions and pain monitoring completed for 1 of 5 residents reviewed for unnecessary medications. (Resident 48) Finding includes: Resident 48's record was reviewed on 3/18/25 at 11:10 a.m. Diagnoses included, but were not limited to, chronic bronchitis, heart failure, anemia and atrial fibrillation. The Admission Minimum Data Set assessment, dated 2/20/25, indicated the resident was cognitively intac and required substantial assistance for bed mobility and transfers. A Physician's Order, dated 2/13/25, indicated to give acetaminophen 650 milligrams every six hours as needed for pain. The March 2025 Medication Administration Record indicated the resident received acetaminophen 15 times between 3/1-3/18/25. There was no documentation to indicate where the pain was located, what the severity of the pain was or any non-pharmacological interventions that had been attempted prior to administering the medication. A current Pain Care Plan, dated 2/14/25, indicated the resident was at risk for pain. Interventions included, but were not limited to, attempt non-pharmacological interventions and observe for and record verbal and non-verbal signs of pain. During an interview on 3/19/25 at 10:22 a.m., the Director of Nursing indicated there should have been a pain level documented, site description of pain documented and prior interventions documented prior to administering the pain medication. 3.1-48(a)(4)

Based on record review and interview, the facility failed to ensure a prn (as needed) antianxiety medication was evaluated for continued use every 14 days for 1 of 5 residents reviewed for unnecessary medications. (Resident 48) Finding includes: Resident 48's record was reviewed on 3/18/25 at 11:10 a.m. Diagnoses included, but were not limited to, chronic bronchitis, heart failure, anemia and atrial fibrillation. The admission Minimum Data Set assessment, dated 2/20/25, indicated the resident was cognitively intact, required substantial assistance for bed mobility and transfers and took antianxiety medication. A Physician's Order, dated 2/13/25, indicated to give alprazolam (an antianxiety medication) 0.5 milligrams nightly prn. There was no stop date on the order. There was another Physician's Order, dated 3/17/25, to give alprazolam 0.5 milligrams nightly prn. During an interview on 3/19/25 at 11:23 a.m., the Director of Nursing indicated there had not been a 14-day stop date on the original order. 3.1-48(a)(2)

Based on observation, record review and interview, the facility failed to ensure infection control guidelines were in place and implemented related to Enhanced Barrier Precautions for 1 of 1 residents reviewed for isolation. (Resident 56) Finding includes: On 3/17/25 at 11:42 a.m. and 3/21/25 at 11:07 a.m., Resident 56's room was observed. There were no signs on the door or nearby indicating the resident was in Enhanced Barrier Precautions. There were no personal protective equipment (PPE) bins near the room door or inside the room. Resident 56's record was reviewed on 3/21/25 at 2:03 p.m. Diagnoses included, but were not limited to, dysphagia (difficulty swallowing) and dementia. The Admission Minimum Data Set (MDS) assessment, dated 1/22/25, indicated the resident was severely cognitively impaired and required a feeding tube. A Physician's Order, dated 1/17/25, indicated the resident was on Enhanced Barrier Precautions and the staff were to wear a gown and gloves at minimum during high-contact care activities. During an interview on 3/24/25 at 1:21 p.m., the Director of Nursing indicated the sign had just fallen down and she planned on finding another way to adhere it near the doorway. 3.1-18(b)

Based on observation, record review, and interview, the facility failed to ensure meals were served with no more than 14 hours between an evening meal and breakfast the following day for 1 of 2 meals observed. This had the potential to affect all 11 residents that ate in the VIP Dining Room. Finding includes: During a tour of the kitchen on 1/21/25 at 8:21 a.m., the Director of Food Services (DFS) indicated breakfast was served from 7:00 a.m. to 9:00 a.m. and was open dining. There were breakfast trays being served to the Main Dining Room at the time. During an observation of the breakfast meal service on 1/21/25 at 9:27 a.m., Assistant Director of Food Services (ADFS) delivered meal trays to resident's rooms. On 1/21/25 at 10:06 a.m., 11 residents were observed seated in the VIP Dining Room and were each served breakfast meals. There were three staff members observed providing assistance to residents. During an interview on 1/21/25 at 10:58 a.m., CNA 1 indicated the residents who required assistance in the VIP Dining Room were supposed to receive their breakfast meal trays around 8:30 a.m. to 9:00 a.m. The CNAs were unable to get all of the residents to the dining room, causing a delay for breakfast meal trays to be delivered. During an interview on 1/21/25 at 11:35 a.m., the DFS indicated the residents were brought down to the VIP Dining Room late and that was why breakfast was served so late. The residents were usually up and ready to eat by 9:00 a.m. The dietary staff did not take the meals to the dining room until the majority of the residents who required assistance in the VIP Dining Room were seated so they could keep the food as warm as possible. During an interview on 1/21/25 at 1:12 p.m., Dietary Aid 1 indicated he had worked the evening shift on 1/20/25. Dinner was served at 4:30 p.m. in the main dining room. The VIP Dining Room was served from 4:45 p.m. to 5:15 p.m., depending on when the kitchen staff received a call from the CNAs indicating the residents were seated and ready to eat in the VIP Dining Room. During an interview on 1/21/25 at 12:58 p.m., the Director of Nursing indicated she was unsure why the meal was served so late. When she left around 6:30 a.m. in the morning, the CNAs were already getting residents up and showered for the day. A facility policy titled, Guidelines for Meal Service, indicated . 4. Open Breakfast will be served from around 7:00 a.m. to 10:00 a.m. daily. 5. Lunch is generally served around noon. 6. Dinner is generally served around 5:00 p.m. This citation related to Complaint IN00447712 and IN00450767. 3.1-21(c)

Based on record review and interview, the facility failed to ensure a resident with a diagnosis of dementia and refusals to be bathed, received bathing at least twice a week and failed to ensure the resident's plan of care and interventions reflected the behavior of bathing refusals, for 1 of 3 residents with cognitive impairment reviewed for activities of daily living (ADL) status and behaviors. (Resident E) Finding includes: During an interview on 9/3/24 at 4:35 p.m., Resident E indicated she had not had a shower/bath since admission into the facility and was unable to remember if bathing had been offered to her. Resident E's record was reviewed on 9/4/24 at 10:54 a.m. The diagnoses included, but were not limited to, dementia. A Life Enrichment Assessment, dated 7/29/24 at 11:31 a.m., indicated it was very important for her to choose the type of bathing received and showers were preferred. A Care Plan, dated 7/29/24, indicated assistance was required for ADL's. The interventions were all dated 7/29/24 and indicated the resident was not to be rushed, encouragement was to be given to do as much as possible for herself, facial shaving was to be offered on shower days and the nurse was to be notified if refused, rest periods would be provided, nail care was to be provided on shower days, and therapy would evaluate and treat as needed. A Social Service Comprehensive Note, dated 7/31/24 at 12:00 p.m., indicated there were no behaviors, no care rejection behaviors, and no mood concerns. An Admission Minimum Data Set assessment, dated 7/31/24, indicated a moderately impaired cognitive status, no behaviors, and required moderate assistance with showers/bathing. The computer point of care (POC) documentation, indicated a shower was received on 8/13/24, 8/16/24, and 9/3/24. The shower/bathing was refused on 7/30/24, 8/2/24, 8/6/24, 8/9/24, 8/20/24, 8/23/24, 8/27/24, and 8/30/24. There was no documentation in the Progress Notes, dated 7/27/24 through 9/4/24, that indicated the shower/bathing was refused. The behavior POC, dated 7/27/24 through 9/4/24, indicated there were no behaviors, including refusal of care. A Care Plan, dated 9/4/24, indicated the resident was non-compliant with physician's orders and the plan of care related to shower refusals and refusals of hands on care. The interventions, all dated 9/4/24, indicated the physician's orders with risks and benefits of compliance would be discussed with the resident and encouraged to participate in care plan and decision making. The resident would be encouraged to participate in decision making by offering choices and discussion of advance directives. She would be monitored for the ability to give informed consent and assessed for the need for a guardian or other legal oversight as needed. During an interview on 9/4/24 at 11:20 a.m., the Director of Nursing (DON) indicated the resident refused the showers due to weakness. The refusals were a behavior associated with the dementia. There was no documentation the Social Service Director was notified of the behaviors. The refusals of showers had not been found when audited. During an interview on 9/4/24 at 11:29 a.m., the Social Service Director indicated she had not been contacted about the refusals. Behaviors were usually documented in the record and then a care plan would be initiated with interventions. She was unaware the showers were refused. During an interview on 9/4/24 at 12:05 p.m., the DON indicated she picked five residents at random each week for bathing audits. When she looked at the resident's bathing, a shower had been given on 8/13/24 and continued monitoring was not triggered. The showers were scheduled on Tuesdays and Fridays on the day shift. The DON provided documentation from the audit sheets that indicated on 7/30/24, the resident refused the shower three times, on 8/2/24 and 8/27/24 the shower was refused due to weakness, 8/20/24 the shower was refused due to awakened too early, and 8/30/24 the shower was refused with no reason documented. The DON indicated there were no behaviors documented on the POC documentation or the Progress Notes in the record. A facility policy, titled, Guideline for Mental Health Wellness Program, dated 12/31/23 and received as current from the DON, indicated behaviors were to be assessed and evaluated as part of the admission process. An attempt to determine the root cause would be assessed. Behavior interventions would be communicated to the interdisciplinary team for implementation. New behaviors were to be brought to the daily stand up meeting. The Social Service Director would review the documentation to determine if the behavior was isolated and causative factors. The Mental Health Wellness/Behavior Management Program would consist of a care plan with realistic and effective interventions. This citation relates to Complaints IN00438053 and IN00441626. 3.1-37

Based on record review and interview, the facility failed to ensure adequate supervision was provided to a cognitively impaired resident with a history of exit seeking and failed to ensure an alarmed door was effectively secured to prevent elopement for 1 of 6 residents reviewed for elopement risk. (Resident M) This deficient practice resulted in Resident M exiting the facility and being picked up by a stranger who activated 911. The immediate jeopardy began on 5/25/24 when a cognitively impaired male resident, with a history of exit seeking and a Wanderguard (door alarm bracelet used to monitor residents who wander) in place, exited the facility without staff knowledge and ambulated 0.3 miles away from the facility. The resident was absent from the facility for approximately 35 minutes, had just been medicated with an as needed anti-anxiety medication (Xanax), and was also at risk for falls. The Administrator, Assistant Director of Nursing (ADON), RN Clinical Support Nurse, and the Area Executive Director were notified of the immediate jeopardy at 3:47 p.m. on 6/3/24. The immediate jeopardy was removed, and the deficient practice corrected, on 5/26/24, prior to the start of the survey and was therefore Past Noncompliance. Finding includes: An Indiana Department of Health (IDOH) Incident Report, dated 5/26/24 at 6:29 p.m., indicated Resident M exited the facility and was returned to the facility without injury on 5/25/24 at 7:30 p.m. The five day follow-up report indicated an investigation had been completed and the root cause of the elopement was the exit door becoming lodged by a rug in the entryway. The door remained in the opened position and the resident exited through the opened door. The facility nurse had not seen the resident on the unit and had begun searching for him. Upon arrival to the front exit door, the nurse found a local police officer who had been talking to a staff member about the resident. The police officer had indicated a Good Samaritan had seen the resident and called 911, who had responded and assisted with the return of the resident. Resident M was assessed, and no injury was found. The Wanderguard bracelet was in place and functioning. The EMS (Emergency Medical Services) Run Record, dated 5/25/24, indicated the EMS Unit was notified on 5/25/24 at 7:01 p.m. and arrived on the scene at 7:07 p.m. on 5/25/24. The narrative indicated upon arrival, they found an [AGE] year-old male who was only oriented to self, sitting in the passenger seat of an SUV (sport utility vehicle). The driver of the SUV stated she noticed the male walking down the sidewalk and leaning against the fence. The resident was confused and not making sense to her. She assisted the resident into her vehicle and called 911. The resident was unable to voice where he lived or date of birth. He indicated at one time he lived at [Facility Name]. The local police department went to the facility and confirmed he currently resided at the facility. The Good Samaritan drove the resident back to the facility and the EMS Unit followed behind to ensure the facility did not want any further services from them. The resident entered the facility at 7:27 p.m. The facility Investigation Summary, dated 5/29/24, indicated Resident M exited the facility at 6:47 p.m. unattended and was found approximately 0.3 miles from the property by a Good Samaritan, who had stopped and notified 911. They stayed with the resident until the police and EMS arrived. The resident returned to the facility without injury. The timeline per the facility's camera indicated on 5/25/24 at 6:47 p.m., Resident M exited the facility through an open door. At 6:48 p.m., Environmental Services #2 arrived at the door, adjusted the rug and closed the door. She then appeared to touch the keypad. The local police officer arrived at 7:14 p.m. and left the building at 7:17 p.m. At 7:23 p.m., EMS entered the facility with Resident M. The investigation, dated and signed by the Administrator on 5/29/24, included the following staff members' statements: A typed statement, signed and dated on 5/29/24 by LPN 2 (day shift nurse on 5/25/24), indicated on 5/25/24, the resident was wanting to go outside. LPN 2 had asked CNA 3 to walk with the resident around the building and courtyard. CNA 3 walked with the resident. CNA 3's shift ended at 4 p.m. and the resident was sitting at the Nurses' Station. Resident M became restless again and LPN 2 walked him to his room and they reminisced about his past. LPN 2 finished his shift at 6:11 p.m. and the resident was sitting in his recliner in his room with his feet elevated. A typed statement, signed and dated on 5/26/24 by CNA 3, indicated at 2:00 p.m. on 5/25/24 Resident M had requested to go outside. CNA 3 escorted him to the Healthcare Courtyard and they sat in the Courtyard for 30 to 40 minutes. Resident M asked to go back to his room and then began to exhibit exit seeking behaviors and started heading near the front entrance. The door alarm sounded when Resident M approached the entrance, and CNA 3 successfully redirected him back to his room. CNA 3 provided supervision to the resident until her shift ended at 4 p.m., and reported to LPN 2 she was leaving. A typed statement, signed and dated on 5/26/24 by CNA 11, indicated on 5/25/24, she had seen the resident after dinner walking around the Healthcare Dining room about 6 p.m. CNA 11 didn't hear any alarm go off and was unaware of the resident leaving the facility. A typed statement, signed and dated on 5/26/24 by LPN 1, indicated on 5/25/24 at 6:15 p.m., Resident M was exit seeking and wandering. LPN 1 administered an as needed Xanax 0.25 mg (milligrams). Resident M was wearing a hat, red shirt, black sweatpants, and shoes. LPN 1 was then notified by a CNA and Dietary Aide the resident was outside of the building with EMS. The resident was assisted back into the facility and an assessment was completed and he was found to have no injuries or psychosocial distress. One-on-one care (one staff specifically assigned to the resident) was initiated. After the resident fell asleep, 15-minute checks were initiated. A second typed statement, signed and dated on 5/29/24 by LPN 1, indicated a follow-up interview was completed with LPN 1. LPN 1 indicated on 5/25/24 at 6:40 p.m., Resident M was sitting at the [NAME] Nurses' Station. LPN 1 had left the nursing station area to administer medications to other residents and when she returned, Resident M was no longer sitting on the couch by the Nurses' Station. LPN 1 went to the dining room to see if he was there, as he often sat there, and he was not. LPN 1 stopped and the Eagle Nurses' Station and asked RN 1 if she had seen the resident and RN 1 indicated she had not seen him. LPN 1 then went to the front door and saw two employees talking to a police officer. LPN 1 indicated this was a little bit after 7 p.m. The police officer indicated Resident M was in an ambulance and was being assessed by EMS. LPN 1 indicated she had not heard the door alarm when the resident left the building. The alarm was sounding when the resident returned to the facility. A typed statement, signed and dated on 5/26/24 by Dietary Aide (DA) 10, indicated the resident was seen at 6:15 p.m. when he was collecting room supper trays. The resident was ambulating down the [NAME] Hall. DA 10 indicated he had not heard any alarms sounding. A typed statement, signed and dated on 5/29/24 by Environmental Services (ES) 2, indicated on 5/25/24 at approximately 6 p.m., she had exited the Assisted Living Memory Care Unit after delivering clothes and observed the front door, stuck open. ES 2 moved the rug the door was stuck on and shut the door. She was unable to recall if the alarm was sounding. ES 2 looked around and had not seen a resident, so she continued with her work. A typed statement, signed and dated on 5/26/24 by DA 9, indicated on 5/25/24, she had been setting the table in the Assisted Living Dining Room when a police officer entered the front door. The police officer asked if the resident resided at the facility, and DA 9 confirmed that he did. DA 9 alerted the nurse. A wheelchair was brought to the door and the officer assisted the resident to sit in the wheelchair. A typed statement, signed and dated on 5/30/24 by CNA 8, indicated on 5/25/24 he was assigned to the Eagle Unit. CNA 8 was leaving the facility on break through the front entrance at 7 p.m. when a police officer asked if he knew Resident M. CNA 8 informed the officer he would get the nurse. LPN 1 then spoke to the officer. The facility Investigation, dated 5/29/24, indicated the timeline for the event on 5/25/24, as viewed on the facility camera, was as follows: At 6:39 p.m., a visitor was leaving the campus. The inside door was stuck wide open on the rug in the vestibule. At 6:47 p.m., Resident M exited through the open doors. At 6:48 p.m., Environmental Services 2 arrived at the door, adjusted the rug, and closed the door. She then appeared to touch the keypad. At 7:07 p.m., there were visitors who entered the door and the door closed behind them. At 7:10 p.m., there were visitors who entered the door and the door again was stuck open. At 7:17 p.m., the police officer entered through the open door. At 7:18 p.m., an Assisted Living resident fixed the rug the door was stuck on and the door closed. At 7:19 p.m., EMS entered the door and the door closed. At 7:20 p.m., employees exited the building and the door closed. At 7:22 p.m., EMS and a staff member exited with the wheelchair and the door closed. At 7:23 p.m., EMS entered the door with the resident and the door closed. Resident M's record was reviewed on 6/3/24 at 9:50 a.m. The diagnoses included, but were not limited to, dementia. An Admission Fall Risk assessment, dated 12/22/23, indicated a moderate risk for falls. An Elopement Risk assessment, dated 3/1/24, indicated a history of exit seeking, voiced statements of leaving, exit seeking alarm bracelet/device was used, monitored for placement and functioning, and the resident was an elopement risk. A Quarterly Minimum Data Set assessment, dated 3/6/24, indicated a severely impaired cognitive status, had wandering behaviors one to three days during the assessment period, no upper or lower extremity impairments, and required supervision for all activities of daily living which included ambulation. No assistive devices were required, and the resident had no falls since the past review. A Care Plan, dated 7/18/23, indicated the resident was at risk of falling. The interventions, dated 7/18/23, included therapy as needed, assist with transfers as needed, and the call light was to be kept within reach. A Care Plan, dated 7/19/23 and revised 4/30/24, indicated exit-seeking and wandering behaviors were present. The interventions included, a Wanderguard bracelet would be placed and checked for placement and functioning, encourage contact with family, diversion activities were to be offered, and he was to be directed away for the doors/exits as needed. Added on 4/4/24: the staff were to offer to take a walk with the resident throughout the facility, they were to reminisce about memorabilia and photos in his room. Added on 4/30/24: snacks of choice were to be offered. Added on 5/26/24: 15-minute checks were initiated and added on 5/30/24: the resident had pet cats in the past and enjoys talking about them. Provide distracting conversation. The current 5/2024 Physician's Order Summary included, but was not limited to: - 7/17/23: a Wanderguard bracelet was to be used and changed every month. - 5/23/24: Xanax 0.25 mg was to be given PRN (as needed) twice a day for anxiety attacks. The Medication Administration Record (MAR), dated 5/2024, indicated the exit-seeking behaviors were monitored every shift. He had exit-seeking behaviors on the evening and night shift on 5/2/24, day shift on 5/10/24, and evening shift on 5/5/24. The MAR, dated 5/2024, indicated the Wanderguard bracelet was checked for functioning every day shift and was checked for positioning every shift. A Nurse's Progress Note, dated 5/25/24 at 6:15 p.m. and signed by LPN 1, indicated the resident had been wandering and agitated. The as needed Xanax was administered. He sat at the [NAME] Unit Nurses' Station for 15 minutes and began wandering again. There was no documentation in the record to indicate the interventions of staff walking around the facility with the resident or offering a snack was implemented to assist with the exit-seeking behavior or adequate supervision was provided by staff on 5/25/24 between 6:15 p.m. and 6:47 p.m. A Nurse's Progress Note, dated 5/25/24 at 7:05 p.m. and signed by LPN 1, indicated the resident was no longer sitting at the [NAME] Unit Nurses' Station and she began searching for him. When she entered the other side of the building (Assisted Living) a police officer was talking to a CNA and Dietary Aide. The police officer informed the nurse the resident was found stumbling a few blocks from the facility and was being assessed in the ambulance and then would be brought back to the facility. A Nurse's Progress Note by LPN 1, dated 5/25/24 at 7:30 p.m., indicated the resident returned to the facility with EMS and was sitting in a wheelchair and sleeping. A full assessment was completed, and no injuries were found. There was no distress and the resident requested to go to bed. He was assisted to bed and 15-minute checks were initiated. During an interview on 6/3/24 at 9:38 a.m., the ADON indicated up until 8 p.m., the front door (Assisted Living) would only alarm if a Wanderguard went through the door. The resident had his Wanderguard bracelet on. The door was stuck on the rug, and it held the door open. Even with the door being open, the Wanderguard would have set the alarm off. The staff were all interviewed, and no one heard the alarm. The administration looked at the video and Environmental Service 2 was seen adjusting the rug and her hand did something to the keypad about a minute after the resident exited the building. When she was interviewed, she indicated there had been no alarm activated and she touched the keypad out of habit. During an interview on 6/3/24 at 10:21 a.m., the Maintenance Director indicated the Wanderguard alarm systems were checked with a bracelet every Monday, Wednesday, and Friday. The alarms were functioning on 5/24/24. During an investigation after the incident, they had found the annunciator (panel with warning lights/alarms) in the Assisted Living Nurses' Station (Nurses' Station closest to the front door) had not been wired to the front the door. The door alarm itself still worked, and could be heard in the healthcare area. He was unsure how long the annunciator piece had not been working, as the door alarm had not been wired to it. The Maintenance Director then activated the door alarm with a Wanderguard bracelet, and the alarm could be heard in the Healthcare area. LPN 4, LPN 5, and RN 6 were at the Eagle Nurses' Station, and all indicated they were able to hear the front door alarm when it was activated. During an interview on 6/3/24 at 11:23 a.m., Environmental Services 2 indicated she could not remember if the front door alarm was activated or if she just responded because the door was left open. She indicated the door had been caught on the rug. She had not gone outside to look around, though she did look out the door and had not seen anyone. She moved the rug and shut the door. She indicated if the alarm had been sounding, she would have reset the alarm on the keypad and did not remember doing that. She indicated she only remembered the door being wide open because it was caught on the rug. She indicated the alarm was activated often with residents going on the bus or out with family, and no one had educated her on what she was supposed to do if the alarm was activated. During an interview on 6/3/24 at 12:35 p.m., LPN 1 indicated she had started work at 6:00 p.m. and received in report Resident M had been wandering, agitated, and exit-seeking. He was sitting on the couch near the [NAME] Nurses' Station, which is by the back (skilled unit) entry door. LPN 1 heard the Wanderguard beeping then, because he was sitting close to the door. The PRN Xanax was administered due to his anxiety, then LPN 1 left the nursing station area to administer medications to a few other residents. When she returned, the resident was no longer sitting at the Nurses' Station. LPN 1 went to the Dining Room because Resident M did like to sit at his table there, and he was not there. LPN 1 asked RN 7 if she had seen him, and RN 7 had not seen him. When LPN 1 arrived at the front door area, she saw a police officer talking to CNA 8. The police officer informed her a citizen saw the resident stumble while he was walking and called 911. The ambulance responded and would be bringing the resident back to the facility. LPN 1 indicated she had not heard the alarm ring. During an interview on 6/3/24 at 12:52 p.m., RN 7 indicated she worked 2 p.m. to 10 p.m. on 5/25/24 on the Eagle and [NAME] Units. She last saw the resident around 4 p.m. She had not heard the Wanderguard alarm ringing. The Wanderguard was in place and was functional when he was brought back to the facility. During an interview on 6/3/24 at 12:57 p.m., CNA 8 indicated 5/25/24 was his first day of orientation and he was assigned to the Eagle Unit. He was exiting the front door to go on break when the police officer came in and asked him if the resident resided at the facility. CNA 8 indicated he was just learning the residents and was unsure, then LPN 1 arrived and spoke with the officer. During an interview on 6/4/24 at 8:57 a.m., the Administrator indicated the observation of the video from the facility camera indicated the alarm had been sounding. They were able to see Environmental Services 2 putting the code in on the keyboard. She had thought the alarm was activated by the door being held open by the rug. The employee was observed looking out the door, but not going outside to look around. A facility policy for elopement/missing resident, dated 12/31/23 and identified as current by the ADON, indicated when a door alarm was sounding, the staff were to respond promptly to the sounding door alarm. The charge nurse, facility supervisor or Executive Director should call staff to a central area and designate staff to perform a head count, have two staff exit the alarming door and go in opposite directions around the building perimeter, one staff was to review the sign out log and 24 hours nurse report, one or more staff were to search the facility, and if necessary, one or more staff were to expand the search to the facility premises. If the resident was not found on the property, the local police department, physician and responsible party was to be notified. A facility policy titled, Alarm Checks, dated 12/31/23 and received from the Area Executive Director as current, indicated the door alarms were to be checked by the Director of Plan Operations or designee daily during the typical business days. The Administrator was to be notified immediately if the alarms were non-functioning. The individual alarms were to be checked daily for functioning and every shift for placement. The past noncompliance immediate jeopardy began on 5/25/24. The immediate jeopardy was removed, and the deficient practice corrected by 5/26/24 after the facility implemented a systemic plan that included the following actions: - The rug in the vestibule was removed. - All residents in the facility were reviewed for elopement risk. - The residents who were assessed as an elopement risk have Wanderguard bracelets initiated. - All Physician's Orders for the bracelets and checking for functioning and placement were reviewed and were up to date. - All exit doors have been evaluated to ensure the Wanderguard is functioning. - Elopement binders have been updated - As of 5/26/24, 93 of 122 employees have been educated on the elopement/missing resident policy and all remaining staff will be educated upon their return to work. - An elopement drill was completed without concerns. This citation relates to Complaint IN00435373. 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure residents received the necessary care for activities of daily living care (ADL) related to long unkempt fingernails and the lack of offering residents shaving per the plan of care for 2 of 3 residents reviewed for ADL care. (Residents 21 and 26) Findings include: 1. On 4/29/24 at 11:19 a.m., Resident 21 was observed lying in bed in her room. Her fingernails were long, thickened and discolored. The resident indicated she would like them trimmed and no one had offered to trim them. On 5/1/24 at 11:07 a.m., and again on 5/2/24 at 9:07 a.m., Resident 21 was observed in her room. Her fingernails were still long, thickened and discolored. Record review for Resident 21 was completed on 5/1/24 at 2:33 p.m. Diagnoses included, but were not limited to diabetes mellitus, dementia, stroke, and Parkinson's disease. The Quarterly Minimum Data Set (MDS) assessment, dated 2/21/24, indicated the resident was moderately cognitively impaired. The resident had an impairment on one side of the upper and lower extremities for a functional limitation in range of motion. The resident required a substantial assistance with personal hygiene. A Care Plan, dated 1/5/21 and revised 2/22/24, indicated the resident had a diagnosis of cerebrovascular accident (stroke) with right hemiparesis/hemiplegia (weakness, paralysis) requiring assistance with ADL care. During an interview on 5/2/24 at 9:42 a.m., CNA 1 indicated residents' nails were offered to be cut when they receive bathing. This was her first shift back from being off for 5 days and she had noticed Resident 21's fingernails needed to be cut. During an interview on 5/2/24 at 11:45 a.m., the Director of Nursing (DON) indicated the nurse was able to soak the resident's fingernails, cut them a little and then clean underneath of them. The resident had a fungus on her nails and had an antifungal ointment applied to them daily. She acknowledged the staff should have attempted to soak and cut her fingernails before today. 45666 2. On 4/29/24 at 10:00 a.m., Resident 26 was noted in bed. He had grown out facial hair and his hair was disheveled. On 4/30/24 at 2:43 p.m., Resident 26 was noted in his room in bed. He had facial hair and his hair was disheveled. Resident 26's record was reviewed on 4/30/24 at 2:58 p.m. Diagnoses included, but were not limited to, dementia without behavioral disturbance, cognitive communication deficit, and Parkinson's disease. A Care Plan, dated 4/5/23, indicated the resident required staff assistance to complete ADL tasks completely and safely. Interventions included, but were not limited to, offer facial shaving on shower days, as needed, or as requested. Notify nursing of refusals. There was no documentation available in the record related to the resident receiving assistance with shaving. During an interview on 5/1/24 at 10:55 a.m., the DON indicated the resident had an electric razor that had broken. They were trying to get it replaced, but the staff were unable to get in touch with the resident's son. The DON was unable to provide any further documentation. During a follow-up interview on 5/1/24 at 1:45 p.m., the DON indicated shaving was considered basic care and they do not have to document it in the record. 3.1-38(a)(3)(D) 3.1-38(a)(3)(E)

Based on observation, record review, and interview, the facility failed to ensure proper supervision and assistance was provided with bed mobility for a resident, resulting in a resident falling and obtaining a humerus fracture for 1 of 3 residents reviewed for accidents of the 5 who met the criteria for accidents. (Resident #112) Finding includes: On 4/23/15 at 9:44 a.m. Resident #112 was observed sitting in her wheelchair in the Main Dining Room. The resident had an immobilizer in place to her left upper extremity. The resident was unable to indicate why she had the immobilizer in place. The record for Resident #112 was reviewed on 4/23/15 at 9:36 a.m. The resident's [DIAGNOSES REDACTED]. Review of 3/5/15 Admission Minimum Data Set (MDS) assessment indicated the resident was cognitively impaired and had a fall in the last 2 to 6 months prior to admission. The resident was an extensive assist with a 2 person physical assist for bed mobility. Review of a Fall Circumstance Assessment and Intervention form dated 4/18/15 7:30 a.m., indicated a CNA had reported assisting Resident #112 with turning in bed and the resident had rolled out of bed. It was further indicated the resident had been sent to the emergency room and later returned to the facility with a fracture of the left proximal humerus. A hospital imaging result, CR (conventional radiology, x-ray) of the left shoulder, dated 4/18/15 at 9:20 a.m., indicated " Impression: 1. There is an acute, comminuted, mildly displaced fracture of the proximal humerus surgical neck and greater tuberosity..." Resident #112 had a care plan for ADLS (activities of daily living). The nursing interventions included "...I need 2 assist with all task extesive (sic) -dependent assist with all care..." The resident also had a care plan for risk for falls related to decreased safety awareness, weakness, impaired balance, and need for assistance with transfers/toilet use. Review of the PT (physical therapy) - Therapist Progress & Discharge Summary, dated 4/10/15, indicated the resident was able to safely roll from side to side requiring dependent (100% assist). Review of the Fall Investigation Follow Up, dated 4/23/15, indicated, "Resident was being rendered care. CNA turned resident on right side to renderend (sic) incontinent care. CNA went to cabinet approx 5 feet away to get wipes. Resident who is obese started to roll forward (sic). Due to her weight she continued to fall forward off the bed on to the floor. Resident has no safety awareness..." An Employee Counseling Record Form included in the fall follow up, dated 4/20/15, indicated, "....Employee did not follow care plan for resident. Resident fell out of bed and injured herself..." Interview with CNA #3 on 4/24/15 at 11:44 a.m. indicated the resident required assist of 2 with bed mobility and was dependent on staff for all ADLs. Interview with the DHS (Director of Health Services) on 4/24/15 at 2:10 p.m. indicated the resident should have been assisted by 2 CNAs with bed mobility at the time of the fall. 3.1-45(a)(2)