Every finding on record at Cedars the

Based on interview and record review, the facility failed to ensure resident specific accident prevention interventions were implemented for 2 of 12 residents reviewed (Resident 7 and Resident 21).Findings include: Resident 7's record was reviewed on 8/29/25 at 12:29 PM. Diagnoses included dementia and right upper arm fracture. Resident 7's Comprehensive Minimum Data Set, (MDS), dated [DATE], indicated their Brief Interview for Mental Status (BIMS) score was 9 (moderate cognitive impairment). The MDS indicated Resident 7 had no impairment of their arms or legs. The MDS indicated Resident 7 required staff supervision or touching assistance with walking. The MDS indicated Resident 7 had experienced 2 falls. A clinical assessment log indicated Resident 7 had experienced falls on the following dates: 1/18, 1/20, 1/21, 3/28, 7/30, 7/31, 8/6, 8/9, 8/12, 8/15, 8/17, 8/20, 8/22, and 8/26/25. Resident 7's care plan, dated 2/6/25, indicated they had a behavior of not waiting for staff assistance. The target goal was to have fewer episodes by 10/24/25. Interventions included anticipating, meeting the residents' needs and medications as ordered. Resident 7's care plan, dated 2/3/25, indicated they had a risk for falls due to confusion, deconditioning, poor balance and unawareness of safety needs. The target goal was for Resident 7 to be free from falls through 10/24/25. Fall interventions initiated on 1/24/25 included a touch pad call light and removal of wheelchair foot pedals. Fall interventions initiated on 2/3/25 included call light in reach, physical activities, and appropriate footwear. Therapy evaluation was initiated as a fall prevention intervention on the following dates 1/24, 2/3, 4/1, 7/31, and 8/22/25. Resident 7's care plan for fall prevention did not include any alternative fall prevention interventions or therapy recommendations for fall prevention on the following dates 8/6, 8/9, 8/12, 8/15, and 8/17/25. Resident 7's care plan for fall prevention did not include any alternative fall prevention interventions or therapy recommendations for fall prevention until 8/20/22. In an interview, on 9/2/2025 at 10:04 AM, the Administrator indicated each fall should have been reviewed. The Administrator indicated alternative interventions should have been considered after each fall. The Administrator indicated any new therapy recommendations should have been implemented after each therapy evaluation. 2. During an observation, on 8/29/2025 at 1:48 PM, Resident 21's room had anti-slip tape strips on the floor at the bedside and in front of the recliner. Anti slip tape was not in the resident's bathroom. Resident 21's record was reviewed on 08/26/2025 at 11:00 AM. Diagnoses included moderate dementia, Parkinson's Disease, and muscle weakness. A review of Resident 21's current quarterly MDS, dated [DATE], indicated their BIMS (Basic Interview for Mental Status) score was 5 (cognitively impaired). A review of an initial fall assessment, dated 8/20/25 at 7:30 AM indicated, Resident 21 was found lying on the bathroom floor. 3 skin tears were observed to the resident's left elbow area. Poor balance was indicated as normal for Resident 21. A list of all interventions in place at the time of fall was for 3rd shift staff to toilet resident between 5-530am per wife request. Documentation failed to include if Resident 21's call light was in reach or if a motion detector was in use in at the time of the fall. A review of Toilet Use tasks documented on 8/20/25 indicated staff had documented assisting Resident 21 to the toilet at 1:50 AM, and next at 8:21 PM. A review of tasks documented on 8/20/25 indicated staff had documented toileting for Resident 21 at 4:30 AM. AM Toileting was not documented between 5:00 AM- 8:00 AM on 8/24/25, 8/25/25, 8/26/25, 8/27/25, 8/28/25, 8/29/25, 8/30/25, 9/1/25, 9/2/25. In an interview, on 8/29/2025 at 2:02 PM, CNA 6 indicated resident refusals were charted in tasks. Some residents had a paper log posted on a wall to indicate when toileting occurred. Resident 21 didn't have a paper log in his room. In an interview, on 8/29/2025 at 2:53 PM, the Director of Nursing indicated AM Care would be between 5:00-8:00 AM. Anti-slip tape in the bathroom would be a potential intervention that was not in place. A review of Resident 21's current Care plan, titled At Risk for Falls, indicated the resident had problems of confusion, deconditioning, gait and balance problems, and incontinence. Interventions included staff to offer routine toileting prior to AM care and anticipate and meet the resident's needs, assure the resident's call light was within reach. Resident 21 needed prompt response to all requests for assistance. A motion sensor was placed in Resident 21's room, assure nonskid strips were in front of the bed and recliner to allow for better footing when attempting to ambulate. Staff was to remind Resident 21 to wait for assistance if he was feeling weak. In an interview, on 09/02/2025 at 9:56 AM, the DON indicated Resident 21 was no longer supposed to be routinely toileted before 6:00 AM. Staff was aware of the 5AM Toileting schedule. A current policy, undated, provided by the Administrator on 9/2/25 at 11:00 AM, indicated each resident will receive care and services in accordance with their individualized risk for falls. Fall risk interventions included the call light being within reach, implementing a routine rounding schedule, unsure adequate lighting in the resident environment, increase the frequency of rounding by staff, and scheduling ambulation or toileting assistance. The Care Plan will be revised as needed. 3.1-45(a)

Based on observation, interview and record review, the facility failed to ensure medications were disposed when expired and labeled when opened for 3 of 6 residents reviewed. (Resident 35, Resident 24, and Resident 39) On [DATE] at 9:40 AM, Registered Nurse (RN) 5 was observed preparing medications for Resident 35. An opened vial of Resident 35's insulin was observed to have a handwritten open date of [DATE]. RN 5 indicated the inulin should have been disposed of 30 days after the open date.On [DATE] at 9:47 AM, RN 5 was observed examining open medications in the medication cart. RN 5 indicated Resident 24's eye lubricant had been opened and had not been labeled with an open date. RN 5 indicated Resident 39's inhaler had been opened and had not been labeled with an open date. RN 5 indicated all medications should be labeled with the date the medication had been opened.Resident 35's record was reviewed on [DATE] at 10:55 AM. Resident 35 had been diagnosed with diabetes.A physician order indicated Resident 35 was to be administered insulin on a sliding scale 4 times a day.2. Resident 24's record was reviewed on [DATE] at 11:30 AM. Resident 24 had been diagnosed with dry eye syndrome.Resident 24's eye lubricant label indicated the medication could be administered 1 or 2 drops to the affected eye as needed.3. Resident 39's record was reviewed on [DATE] at 11:24 AM. Resident 35 had been diagnosed with a cough.A physician order, dated [DATE], indicated Resident 39 could be administered 2 puffs of albuterol inhalant every 6 hours as needed for wheezing, cough or shortness of breath.A current facility policy, titled Medication Administration, dated [DATE], indicated medication expirations dates should be identified and the nurse manager should be notified.A current facility policy, titled Medication Storage, dated [DATE], indicated medication storage areas should be inspected routinely for outdated and discontinued medications.3.1-25(j)(m) and (n)

Based on observation, interview and record review, the facility failed to ensure physician orders were followed for 3 of 12 residents reviewed (Resident 7, Resident 18 and Resident 20).Findings include: Resident 7's record was reviewed on 8/29/25 at 12:29 PM. Diagnoses included atrial fibrillation (irregular heartbeat that leads to blood clots) and anemia. Resident 7's Comprehensive Minimum Data Set (MDS), dated [DATE], indicated their Brief Interview for Mental Status (BIMS) score was 9 (moderate cognitive impairment). A physician order, dated 7/1/25, indicated Resident 7 was to be administered warfarin sodium (warfarin) 4 milligrams (mg) every Monday, Tuesday, Wednesday, Thursday and Friday for prevention of blood clots. A physician order, dated 7/5/25, indicated Resident 7 was to be administered warfarin 5 mg every Saturday and Sunday. The physician order indicated warfarin was not to be administered on Monday 8/11/25 and Tuesday 8/12/25. A lab report, dated 8/11/25, indicated Resident 7's blood clotting time (INR) was critically high at 5.1 (normal target range is 2-3.5). A review of progress notes, dated 8/11/25 through 8/18/25 did not indicate the physician had been notified of the lab. Resident 7's Medication Administration Record, (MAR), dated 8/1/25 through 8/31/25, indicated the resident had been administered warfarin 5 mg on Monday 8/12/25. A lab report, dated 8/18/25, indicated Resident 7's INR was 4.6. A progress note, dated 8/19/25 at 2:31 PM, indicated the Nurse Practitioner (NP) had ordered Resident 7 to be administered vitamin K (helps blood to clot) 2.5 mg STAT (immediately). The NP ordered warfarin to be held for the next 2 days and INR to be tested on the next lab day. In an interview, on 9/2/2025 at 10:04 AM, the Administrator indicated they had not been aware of Resident 7 receiving warfarin after a physician ordered warfarin to be on hold. A current facility policy, titled Medication Administration, dated 1/1/25, indicated medications would be administered according to physician orders. The policy indicated medications outside of physician parameters should be held. The policy indicated the MAR should be reviewed to identify medications to be administered. 2. Resident 18's record was reviewed on 08/29/25 at 9:17 AM. Diagnoses included hypertension, kidney and ureter disorder, and dementia. A review of Resident 18's current quarterly MDS indicated their BIMS (Basic Interview for Mental Status) score was 12 (moderate cognitive impairment). A review of Resident 18's current care plan indicated there were no care plans for daily weights. A review of physician orders, dated 05/29/25 at 06:00 AM, indicated Resident 18 would be weighed daily each morning to monitor for increased edema and weight gain. A review of progress notes, dated 5/30.25 through 9/2/25 indicated there were no documented refusals for Resident 18 missing 26 daily weights between the dates of 05/30/25 and 08/22/25. In an interview, on 08/29/25 at 10:30 AM, Employee 9 indicated Resident 18 had daily weights ordered for fluid shifting and edema in lower extremities. Resident 18 refused weights, routine care, and diet orders often. When refusals occurred, the refusals should be charted in progress notes, and the resident would be reapproached by the DON (Director of Nursing). In an interview, on 08/29/25 at 10:45 AM, the DON indicated she was unsure of why Resident 18 was started on daily weights and has not been told of refusals were occurring. She was not aware Resident 18 had missed 26 weights. When a resident refused, the DON's expectation was to be informed so she could attempt to reapproach them. Employee 9 indicated refusal of care should be documented in the progress notes. In an interview, on 08/29/25 at 11:15 AM, the Administrator indicated she was not aware of Resident 18's refusal of weights. Employees were expected to report refusals to the DON so another attempt could be made, and refusals were to be documents in progress notes. A current policy, dated 01/01/25, provided by the DON, indicated residents who were clinically indicated would have their weight monitored daily. 3. Resident 20's record was reviewed on 08/27/2025 at 11:27 AM. Diagnoses included primary hypertension and hyperlipidemia. A review of Resident 20's current quarterly MDS indicated their BIMS (Basic Interview for Mental Status) score was 15 (cognitively intact). A review of physician orders, dated 5/15/2025 at 2:12 PM ,indicated Metoprolol Succinate ER 25 MG was to be given one time a day related to hypertension. The order indicated to not give Metoprolol for systolic blood pressure less than 110 and/or diastolic blood pressure less than 60 or pulse less than 60. A review of physician orders, dated 5/15/2025 at 2:12 PM, indicated Isosorbide Mononitrate 60 mg was to be given one time a day related to hypertension. the order indicated to not give Isosorbide for systolic blood pressure less than 110 and/or diastolic blood pressure less than 60 or pulse less than 60. A review of physician orders, dated 5/15/2025 at 2:12 PM, indicated Losartan Potassium 25 mg was to be given one time a day related to hypertension. The order indicated to not give Losartan for systolic blood pressure less than 110 and/or diastolic blood pressure less than 60 or pulse less than 60. A review of the August 2025 Medication Administration Record (MAR) indicated missing blood pressure and heart rate measurements for [DATE], 3, 8, 9,10, and 15th for 3 of 3 medications with an order to hold if blood pressure is less than 110 and/or diastolic blood pressure less than 60 hold medication or pulse less than 60. One resident refusal was documented on August 7, 2025, at 8:00 AM. A review of Vital Signs measurements dated August 2025 indicated missing blood pressure and heart rate measurements for the mornings of August 1, 2, 3, 8, 9,10, and 15th, 2025 between 7:00 AM and 9:00 AM. In an interview, on 8/28/2025 at 9:17 AM, LPN 4 indicated blood pressure and heart rate should be measured before giving Metoprolol to make sure measurements were not below the hold parameters. A current policy dated 1/1/25, provided by the Administrator indicated blood pressure and heart rate measurements were required when giving antihypertensives (Metoprolol, Isosorbide Mononitrate, Losartan). When applicable, hold medication for blood pressure and/or heart rate outside the physician's prescribed parameters. Sign MAR after administration and record vital signs onto the MAR and document any refusals. 3.1-37

Based on interview and record review the facility failed to ensure residents were treated with dignity and respect for 1 of 4 residents reviewed (Resident B). Findings include: Resident B's record was reviewed on 6/30/25 at 11:30 AM. Diagnosis included major depressive disorder, anxiety disorder and nontraumatic intracerebral hemorrhage. A report, dated 6/18/25, was provided by the Administrator on 6/30/25 at 12:33 PM. The report indicated on 6/19/25, Resident B's family reported they had observed staff talking about Resident B on their camera while care was provided to Resident B on 6/18/25. The family reported staff had indicated Resident B did not like them. An investigation timeline, dated 6/18/25 - 6/19/25, was provided by the Director of Nursing (DON) on 6/30/25 at 11:30 AM. The timeline indicated the following: On 6/18/25, the DON and Administrator met with Certified Nurse Aide (CNA) 2 for discussion of Resident B's care concerns per the family observation on Resident B's room camera. CNA 2 indicated he and CNA 3 had a discussion during Resident B's care regarding Resident B not liking CNA 2. CNA 2 indicated he was not mad or angry but was stating the facts during the conversation in front of Resident B with CNA 3. On 6/19/25, the DON and Administrator spoke with Resident B's family. Resident B's family indicated they had overheard via Resident B's room camera of CNA 2's discussion with CNA 3. The discussion was in regards to Resident B not liking CNA 2. CNA 2 indicated he didn't understand why as Resident B used to be a monk. CNA 2 indicated he thought [NAME] were supposed to show peace and love. CNA 2 nor CNA 3 acknowledged the resident nor attempted to end the conversation. CNA 2's statement, dated 6/19/25, indicated he had asked CNA 3 to help with Resident B's care. During care CNA 2 indicated he confirmed Resident B did not like CNA 2 as he was resistant to care earlier in the day for CNA 2 but not CNA 4 who were in the room together at the time. CNA 2 indicated he was not upset or frustrated with Resident B not liking him. CNA 2 indicated he did acknowledge the camera in Resident B's room to show he was aware of the camera. CNA 2 discussed Resident B with CNA 3 in front of Resident B without acknowledging Resident B. CNA 3's statement, dated 6/19/25, indicated CNA 3 had assisted CNA 2 with Resident B's care per request. CNA 3 indicated when CNA 2 and CNA 3 entered the room, CNA 2 acknowledged the camera with Hi Camera. CNA 3 indicated CNA 2 proceeded to explain Resident B did not like him. CNA 3 indicated she had told CNA 2 she had also had moments where she felt Resident B did not like her but it could be due to cognition and those feelings could be inaccurate. CNA 3 indicated CNA 2 had commented on Resident B's history of being a monk and thought [NAME] were peace and loving. CNA 3 indicated she was trying to help CNA 2 understand feelings may not be intentional and related to CNA 2. CNA 3 did not try to stop the conversation in front of Resident B. During an interview, on 6/30/25 at 10:26 AM, the DON indicated Resident B's family reported concerns regarding care provided by CNA 2 and CNA 3 based on their observations via a camera in Resident B's room. The DON indicated the camera observed CNA 2 discussing with CNA 3 about how Resident B did not like CNA 2 in front of Resident B. Resident B was not acknowledged during the conversation. The DON indicated CNA 3 did not attempt to stop the conversation. During an interview, on 6/30/25 at 12 PM, the Administrator indicated Resident B's family reported concerns regarding CNA 2 and CNA 3 with Resident B's care. The Administrator indicated the family reported concerns via observation on a camera in Resident B's room. The Administrator indicated she reviewed the camera and observed CNA 2 acknowledged the camera and indicated Resident B does not like him upon entering Resident B's room. CNA 2 then had a conversation with CNA 3 in front of Resident B and the camera about how Resident B did not like CNA 2. The Administrator indicated CNA 2 was unprofessional to discuss feelings about Resident B to another staff in front of the resident. The Administrator indicated Resident B was not acknowledged and CNA 3 did not attempt to stop the conversation. During an interview, on 6/30/25 at 12:41 PM, CNA 5 indicated staff should not discuss feelings or resident information in front of residents. CNA 5 indicated conversations in front of residents outside of care are disrespectful to the resident. CNA 5 indicated when she worked with other staff who discussed residents inappropriately in front of resident are told to discuss elsewhere During an interview, on 6/30/25 at 12:30 PM, CNA 6 indicated residents are treated with respect, kindness, spoken to with visible face and privacy is provided. CNA 6 indicated staff should not discuss residents in front of residents. CNA 6 indicated when staff were observed discussing residents in front of residents staff are told to stop the conversation and respect the resident. A policy, dated 2025, titled Resident Rights, was provided by Administrator on 6/30/25 at 12:33 PM. The policy indicated the resident had the right to be treated with dignity and respect. This finding relates to Complaint IN00461891. 3.1-9(a)

Based on interview and record review the facility failed to ensure fall interventions were followed for 1 of 3 residents reviewed (Resident B). Findings include: A facility reported incident, dated 2/15/25, was provided by the Administrator on 2/17/25 at 10:58 AM. The report indicated Resident B had a fall with resultant fracture involving the distal fibula with no displacement. Resident B's record was reviewed on 2/17/25 at 11:25 AM, diagnosis included: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and dementia. A nursing note, dated 2/15/25, indicated Resident B was found in the bathroom at 9:40 AM alone on the floor due to a self transfer. The note indicated Qualified Medication Aide (QMA) 3 assisted Resident B onto the toilet, exited the room, then found Resident B on the bathroom floor around 10 AM. A nursing note, dated 2/15/25, timed 3:11 PM, indicated Certified Nurse Aide (CNA) 4 noticed swelling and bruising at Resident B's ankle. An X-ray was ordered and indicated a fracture involved the distal fibula with no displacement. A care plan note, dated 2/12/25, indicated a new fall intervention was added to the CNA sheet to not leave Resident B in the bathroom alone/unattended. Resident B's current care plan indicated she was at risk for falls related to confusion, gait/balance problems, incontinence and was unaware of safety needs. During an interview, on 2/17/25 at 11:28 AM, the Administrator indicated on 2/15/25 Resident B was found on the bathroom floor around 9:40 AM due to attempt to self transfer onto the toilet. The Administrator indicated Resident B was assessed and then assisted onto the toilet by QMA 3. The Administrator indicated QMA 3 left Resident B on the toilet alone, exited the room and returned to find Resident B on the floor around 10 AM. The Administrator indicated staff should not have left Resident B on the toilet alone. During an interview, on 2/17/25 at 12:01 PM, CNA 2 indicated fall interventions for resident's at risk for falls are posted in the resident room and/or on the certified nurse aide sheet. CNA 2 indicated a CNA sheet was obtained at the beginning of each shift and as needed. CNA 2 indicated the sheet included resident information regarding assistance needed and special notes, including fall risk/interventions in place for the resident. A current CNA sheet was provided by the Administrator on 2/17/25 at 12:37 PM, the CNA sheet indicated Resident B was a high fall risk and was not to be left in the bathroom unattended/alone. A policy, dated 2024, titled Fall Prevention Program, was provided by the Administrator on 2/17/25 at 12:37 PM. The policy indicated the nurse will indicate on the CNA sheet the resident's fall risk and interventions. 3.1-45(a)

Based on observation, interview, and record review the facility failed to ensure food items were laebled and stored to prevent contamination and hand hygiene was performed consistently. 39 of 39 residents residing in the facility were served food prepared in the kitchen. Findings include: During an observation and interview on [DATE] at 9:16 AM, a container of chopped lettuce was observed in an assembly area with no date on the container. The lettuce was observed to have brown and yellow edges. [NAME] 2 indicated the lettuce appeared old and should not be used. A container of grape tomatoes was observed in the assembly area with no date on the container. A package of polish sausage was wrapped in foil in the freezer with no date found on the package. Bags containing corn, peas and potatoes were also found open with the packaging twisted and tied with a twist-tie in the walk-in freezer with no open dates. [NAME] 2 indicated items should be labeled and dated when opened. A package was observed in the walk-in cooler labeled turkey ,d+[DATE]-,d+[DATE]. [NAME] 2 indicated the turkey was expired and should have been thrown away 2 days ago. In the reach in freezer, a large container of Denali caribou ice cream did not have an open date. In the reach in cooler, a bag of shredded cheddar cheese, a bag of parmesan cheese and a bag of whipped topping were open, with the packaging twisted and closed with a twist tie. No dates were found on the packages. In the reach in drink cooler, an open container of iced tea concentrate had an open date of ,d+[DATE]. [NAME] 2 indicated he did not know if he should use it or not. During an observation, on [DATE] at 9:24 AM, Dietary aide 4 was observed returning to the kitchen from the dining area and preparing to perform dishwashing duties. She washed her hands for 7 seconds, then went to the dishwashing station to perform her duties. During an observation, on [DATE] at 11:45 AM, [NAME] 2 began the process of pureeing meat for the lunch meal. [NAME] 2 indicated he needed to obtain water to complete the process, exited the kitchen and went to the dining area to obtain the water. No hand hygiene was performed. During an interview, on [DATE] at 10:54 AM, the Dietary Manager indicated hands should be washed with soap and good friction for at least 20 seconds and hands should be washed when changing tasks and work areas and after touching a resident. She indicated the cook should have washed his hands before returning to his workstation to finish the puree process. She indicated hand hygiene should be performed when changing workstations and after touching a resident or their belongings. She indicated all food should be labeled and dated when opened. In an interview on [DATE] at 12:03 PM the Administrator indicated all residents in the facility were served food consumed in the kitchen. A current policy, dated [DATE], titled Safe Food Storage Guidelines provided by the Administrator on [DATE] at 8:25 AM indicated all products should be used by expiration date or discarded. A current policy, dated [DATE], titled Infection Control Handwashing provided by the Administrator on [DATE] at 8:25 AM indicated hand hygiene should be performed before and after handling food, after contact with the resident environment, and before and after assisting a resident with meals. A current policy, undated, titled Handwashing/Handrub indicated staff should rub hands together vigorously for at least 20 seconds during handwashing. 3XXX,d+[DATE](i)3

Based on interview and record review, the facility failed to ensure the resident was provided with required transfer information for a hospital transfer for 1 of 2 residents reviewed (Resident 37). Findings include: Resident 37's record was reviewed on 9/11/24 at 2:28 PM. Diagnoses included dementia, cognitive communication deficit, gastrointestinal hemorrhage and anemia. Resident 37's Quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident's Brief Interview for Mental Status (BIMS) was 6 (severe cognitive impairment). The MDS indicated Resident 37 was being administered anticoagulants (blood thinners). A Health Status Note, dated 5/31/24 at 12:10 AM, indicated Resident 37 had been transferred to the hospital by an ambulance due to critical laboratory results. An Admission Summary, dated 6/3/24 at 11:33 PM, indicated Resident 37 had returned from the hospital at 3:00 PM. A hopsital transfer form was unable to be located in the resident's record for the date of 5/31/24. In an interview, on 9/13/24 at 10:10 AM, Licensed Practical Nurse (LPN) 27 indicated a transfer form should be used each time a resident was sent to the hospital. LPN 27 indicated a copy of the transfer form should be sent with the resident to the hospital. LPN 27 indicated the original transfer form should be placed in the resident's medical record. In an interview, on 9/13/24 at 1:39 PM, the Administrator indicated a hospital transfer form for Resident 37 should have been included in the resident's record but had not been completed by the nursing staff. In an interview, on 9/13/24 at 11:40 AM, the Director of Nursing indicated they were unable to locate a facility hospital transfer policy. 3.1-12(a)(6)(A)

Based on interview and record review, the facility failed to ensure physician orders related to a high-risk medication were clarified and followed for 1 of 2 residents reviewed (Resident 37). Findings include: Resident 37's record was reviewed on 9/11/24 at 2:28 PM. Diagnoses included dementia, cognitive communication deficit, gastrointestinal hemorrhage and anemia. Resident 37's Quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident's Brief Interview for Mental Status (BIMS) was 6 (severe cognitive impairment). The MDS indicated Resident 37 was being administered Eliquis (blood thinner). An Order Note, dated 5/21/24 at 12:13 PM, indicated Resident 37 had a moderate amount of rectal bleeding. New orders were obtained from the Nurse Practitioner (NP). The new orders and labs were noted into the facility laboratory (lab) system and Resident 37's medical record. A physician order, dated 5/21/24, indicated Resident 37 was to have blood tests drawn for a complete blood count (counts the different blood cells and hemoglobin (iron) also known as a CBC) and a comprehensive metabolic panel (measures kidney and liver function also known as a CMP) on the next lab day. The physician order indicated a CBC and CMP were to be collected on the next lab day 1 time a day for a positive stool blood test until 5/23/24 at 11:59 PM. A physician order, dated 5/23/24, indicated Resident 37 was to have blood tests drawn for a CBC and a basic metabolic panel (measures kidney function also known as a BMP) on 5/26/24 for gastrointestinal bleeding (GI bleed) for 1 day. A lab report, dated 5/23/24, indicated Resident 37's red blood cell count was 2.68 (normal range is 3.9 to 5.4) and their hemoglobin level was 7.5 (normal range is 12 to 16). A physician order dated 5/24/24 indicated Resident 37's Eliquis was to be held until 5/28/24 and the resident was to be referred for an outpatient blood transfusion. An Order Note, dated 5/24/24 at 9:24 AM, indicated Resident 37's lab results were reviewed by the NP. New orders were received and noted. An Order Note, dated 5/25/24 at 9:49 PM, indicated Resident 37 fell from their wheelchair and had bleeding from their head. Resident 37 was sent to the emergency department due to the resident's high risk for bleeding. An Order Note, dated 5/27/24 at 3:25 AM, indicated a lab technician was at the facility to draw Resident 37's blood for a CMP and a BMP. An Order Note, dated 5/27/24 at 1:07 PM, indicated Resident 37 had a bowel movement that was positive for blood. A lab report, dated 5/27/24, indicated Resident 37's CMP levels were in normal range for the resident. The lab report did not included the CBC results ordered fo 5/26/24. An Order Note, dated 5/28/24 at 12:03 PM indicated the NP was notified of Resident 37's lab results. An Order Note, dated 5/30/24 at 6:38 AM, indicated the physician ordered a CBC in 2 weeks on 6/13/24. A NP Medical Visit note, dated 5/30/24, at 11:51 AM indicated Resident 37's previous blood tests had not been completed as ordered. The NP indicated a STAT (immediate) CBC was to be collected. The NP indicated the STAT CBC order had been discussed with the nursing staff. An Order Note, dated 5/30/24 at 12:46 PM, indicated the NP reviewed Resident 37's CBC results from 5/27/24. An Order Note, dated 5/30/24 at 6:57 PM, indicated the NP ordered outpatient infusion services for Resident 37. Resident 37's Medication Administration Record, dated 5/1/24 through 5/31/24, indicated the resident was to be administered a Eliquis 2 times a day. The MAR indicated the Eliquis had not been administered from 5/24/24 at 4:30 PM through 5/27/24. The Eliquis was resumed on 5/28/24. Resident 37 was administered the Eliquis 2 times a day on 5/28/24, 5/29/24 and 5/30/24. A Health Status Note, dated 5/30/24 at 11:45 PM, indicated Resident 37 had a critical hemoglobin level of 4.6. A Health Status Note, dated 5/31/24 at 12:10 AM, indicated Resident 37 had been transferred to the hospital by an ambulance due to critical laboratory results. An Admission Summary, dated 6/3/24 at 11:33 PM, indicated Resident 37 had returned from the hospital at 3:00 PM. A hospital discharge summary, dated 6/3/24, indicated Resident 37 was admitted to the hospital on 5/31/24 with a hemoglobin level of 4.6. Resident 37's hemoglobin level of 5.4 was labeled as a panic result on 5/31/24 at 1:37 AM. In an interview on 9/13/24 at 10:10 AM, Licensed Practical Nurse (LPN) 27 indicated blood thinners should not be given if a GI bleed was suspected or known. LPN 27 indicated a blood thinner that was ordered to be held should not have been resumed until repeat CBC results were known. LPN 27 indicated in the event of a missed CBC; the physician should have been made aware of the missed blood test and to clarify when the blood thinner was to be resumed. In an interview on 9/13/24 at 11:40 AM, the Director of Nursing indicated they were unable to locate a facility policy related to care for a GI bleed. The Facility Assessment, dated 9/4/24, indicated the facility could care for residents who were diagnosed with anemia, residents diagnosed with gastroesophageal reflux (GERD) and residents who were at risk for bleeding. The National Institute of Health (NIH.gov, 2022) indicated a hemoglobin level below 7 requires a blood transfusion 3.1-37

Based on observation, interview, and record review the facility failed to ensure hand hygiene was performed during wound care for 1 of 2 residents reviewed (Resident 12). Findings include: During wound care observation, on 9/11/24 at 10:29 AM, Licensed Practical Nurse (LPN) 5 entered Resident 12's room where a tray of supplies was prepared on the bedside table containing a pair of scissors, dressing supplies, wound cleanser, and Dakins solution. LPN 5 opened the Dakins solution and poured about 10 ml in a plastic cup. She then opened a jar of wound packing, pulled out about 1 inch of packing, cut it with the scissors, and placed the packing in the cup of solution. She poured wound cleanser in another cup and placed a piece of gauze in the cup. LPN 5 removed the dressing and packing for Resident 12's right hip wound and then picked up a prepared plastic cup containing the wound cleanser and cleaned the wound with the gauze, then patted it dry with a dry piece of gauze. No hand hygiene or glove change was observed. LPN 5 picked up the cup of Dakin's solution and had the soaked packing in her hand, beginning to turn her body toward Resident 12 when the activity was stopped. During an interview on 9/11/24 at 10:35 AM, LPN 5 indicated she should have washed her hands and changed gloves before handling the clean dressing materials. She indicated she was not sure about how often hand hygiene and glove changes should be performed in the wound care process. She also indicated she did not know she should clean the scissors prior to use with wound care products. Resident 12's record was reviewed on 9/11/24 at 12:16 PM. Diagnoses included multiple sclerosis, type 2 diabetes without complications, and dermatitis, unspecified. Resident 12's current quarterly Minimum Data Set (MDS) indicated their Basic Interview for Mental Status (BIMS) score was 14 (cognitively intact). The MDS indicated the resident had a stage 4 pressure ulcer. Resident 12's current care plan titled Wound, I have developed an actual pressure injury, indicated the resident had a problem of a stage 4 pressure ulcer on her right buttock, with a goal date of 10/30/24. Interventions included Dakins solution treatment should be administered as ordered. Physician orders dated 8/29/24 indicated Resident 12's right buttock should be washed with baby soap and water and patted dry. A Dakin's solution saturated, one inch packing strip should be packed tightly to the wound, covered with an abdominal pad, kerlix and tape, two times daily. In an interview on 9/11/24 at 12:10 PM, the Director of Nursing indicated LPN 5 should have washed her hands and applied her gloves prior to the procedure, after removing the old dressing, after cleaning the wound and any other time her gloved hands contacted contaminated items. A current policy, dated 2017, titled Dressing a Wound, indicated hand hygiene and applying new gloves should be performed before and after removing a dressing, before and after cleansing the wound, before applying the new dressing, and after the completion of the procedure. 3.1-40

Based on observation, interview, and record review the facility failed to ensure respiratory care was provided according to physician's orders for 1 of 2 residents reviewed (Resident 29). Findings include: During an observation and interview, on 9/9/24 at 10:41 AM, Resident 29 was observed lying in bed with an oxygen concentrator positioned near the bed with tubing and a nasal cannula lying on top of the concentrator. The nasal cannula was not contained in a bag. The Director of Nursing (DON) indicated oxygen tubing not in use should be bagged to prevent contamination. During an observation, on 9/10/24 at 10:17 AM, Resident 19's oxygen concentrator was observed positioned near the bed with tubing and a nasal cannula lying on top of the concentrator. The nasal cannula was not contained in a bag. Resident 29's record was reviewed on 9/9/24 at 1:30 PM. Diagnoses included Alzheimer's disease with early onset, dyspnea, unspecified and heart failure unspecified. Resident 29's current significant change Minimum Data Set (MDS) dated [DATE] indicated a Basic Interview for Mental Status (BIMS) should not be done because the resident was rarely or never able to make herself understood. The MDS indicated Resident 29 used supplemental oxygen and did not have recorded occurrences of care refusal. Resident 29's current care plan titled, has shortness of breath, indicated Resident 29 had a problem of dyspnea, with a goal date of 10/10/24. Interventions included to administer oxygen as ordered. Physician orders dated 5/24/23 indicated oxygen should be administered at a rate of 2 liters per minute while lying in bed every shift. Progress notes dated 9/9/24 and 9/10/24 did not indicate any care refusals had occurred. In an interview on 9/11/24 at 9:41 AM, LPN 5 indicated oxygen should be in place at 2 liters per minute for Resident 29 when lying in bed, at bedtime, and for naps. She indicated the tubing should be contained in a plastic bag when not in use. A current policy titled Oxygen Administration dated 9/10/24 provided by the Administrator indicated oxygen should be administered according to physician's orders. 3.1-47(a)(6)

Based on interview and record review, the facility failed to develop and implement person-centered interventions to promote healing of pressure ulcers for 1 of 3 residents reviewed for pressure ulcers (Resident N). Findings include: On 8/16/24 at 1:28 P.M., Resident N's record was reviewed. Diagnoses included paraplegia (paralysis of legs and lower body) due to a progressive neurological disease, diabetes, and weakness. A significant change MDS (Minimum Data Set) assessment, dated 5/1/24, indicated the resident had no cognitive impairment, no moods, behaviors or rejection of care. She had impaired range of motion (ROM) to both her upper and lower extremities and was dependent on staff for toileting, bathing, bed mobility, transfers, and lower body dressing. She required maximal assistance with upper body dressing and personal hygiene. She had a new unstageable pressure ulcer (previous MDS assessment, dated 3/13/24, indicated the resident had no pressure ulcers). A Care Area Assessment (CAA), dated 5/14/24, indicated Resident N had an unstageable pressure ulcer to her right buttock which was being monitored and treated. She required assistance with activities of daily living, bed mobility, and care. She had a pressure relieving mattress in place on bed and preventative measures in place to help keep skin intact. Staff assisted her to change positions frequently, treatments done as ordered, and skin assessments completed as ordered. The CAA lacked indication the resident refused treatments or turning/repositioning recommendations. She had no specific written repositioning program. Current care plans were as follows: Dated 1/29/19: The resident preferred to sleep in her recliner and chose not to use the bed. Dated 4/10/24: The resident had developed a stage 4 (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcer to her right buttock due to neurological disease, decreased mobility, weakness, and incontinence. The goal was for the pressure ulcer to heal without complications. Interventions included: administer treatment as ordered; nurse to measure and assess the wound weekly and notify MD as needed; pressure relieving mattress to bed and chair; turn and reposition a minimum of every 2 hours. Dated 5/4/18 and revised 5/14/24: The resident had behaviors which included; being resistant to care; refusing treatments, medication, and care; and making poor self care choices. The goal was to remain safe. Interventions were: care in pairs; document behaviors which were discussed in morning meetings; if more than 2 episodes/month, a behavior management note was to be written; and staff behavior interventions. The care plan lacked indication the resident refused wound treatments and turning/repositioning and lacked interventions to assess reasons for refusals such as pain or time preferences. A health status note, dated 4/10/24 at 11:05 a.m., indicated the resident was observed with an area to her right buttock, which had changed in appearance. The facility wound nurse and NP (Nurse Practitioner) were notified and treatment orders obtained. A Wound Clinic progress note, dated 5/31/24 at 12:30 p.m., indicated the resident's right buttock wound was debrided (mechanically removed dead tissue) and classified as a stage 3 pressure ulcer (Full thickness tissue loss-Subcutaneous fat may be visible but bone, tendon or muscle is not exposed-Slough may be present but does not obscure the depth of tissue loss-May include undermining or tunneling). The facility was to obtain a wound vacuum to be applied to the wound and changed 3 times per week. The resident was to be encouraged to sleep in a bed with a specialty mattress and ROHO cushion obtained for her wheelchair and recliner chair. A Wound Clinic progress note, dated 6/10/24 at 12:45 p.m., indicated the resident had a new wound to her left buttock and continued with the wound vac to her right buttock wound. The resident indicated to the wound clinic facility staff were able to tip her side to side, but felt it could be done more often. Wound clinic recommendations and orders were to add a different adhesive to the base of the right buttock wound and continue with the wound vacuum. A dressing was ordered for a new left buttock wound. The resident was counseled to get her blood sugars below 200, at all times, increase the number of times her blood sugar was checked, continue with protein in her diet and protein shot supplement, and she must offload her ulcers and any other bony prominences every 2 hours. There were no changes made to Resident N's care plan for increased monitoring of blood sugars, turning/repositioning plan, or need for bed with a specialty mattress. A Wound Clinic progress note, dated 6/17/24 at 10:00 a.m., indicated the resident had a new pressure ulcer to her sacrum which measured 0.9 cm length x 0.5 cm width x 0.1 cm depth. Orders were to continue with the wound vacuum to the right buttock pressure ulcer, continue the same treatment to the left buttock wound, and cleanse the pressure ulcer to the sacrum with Kaltostat followed by dressing 3 times per week. She was to continue with eating high protein and her turning program. The TAR (Treatment Administration Record), dated April 2024, May 2024, June 2024, July 2024, and August 2024, indicated the resident refused wound treatments on 5/19/24 and 6/19/24. The TAR, dated June 2024, lacked an order to cleanse the pressure ulcer to the sacrum with Kaltostat followed by a dressing 3 times per week and there was no treatment completed to the sacral wound. A Wound Clinic progress note, dated 6/24/24 at 1:45 p.m., indicated the residents right buttock pressure ulcer measured larger/deeper and was tender to touch. Her left buttock pressure ulcer was unchanged and the sacral pressure ulcer was healed. The wound vacuum was to continue to the right buttock wound and current treatment continued for the left buttock wound. A Wound Clinic progress note, dated 7/19/24 at 1:45 p.m., indicated the resident was seen for continued treatment to her right and left buttock wounds. The wound vac was to continue to the right buttock wound and mepilex dressing applied to the left buttock. Progress notes indicated Resident N refused care/turning/repositioning on the following days: 5/3/24; resident indicated she hadn't needed any care at the time. Staff were to reapproach at a later time. There was no follow up note. 5/9/24; the resident hadn't wanted her wounds measured and dressing changed until after her shower. The wounds were not assessed or dressing changed. 6/19/24; resident refused wound vac treatment because she hadn't wanted to be in pain all night. 6/26/24; the resident refused to get up and go to lunch in activity room because the battery in my wound vac is low and I can't leave my chair. 6/28/24; resident refused left buttock wound change because she hadn't wanted to roll so many times due to the pain. 7/9/24; refused attempts to assist with repositioning and indicated she was ok. 7/10/24; refused to be turned at 8:30 a.m. because she was comfortable in the current position; refused wound care to left buttock due to not wanting to roll so many times. 7/15/24; resident refused to be repositioned at a time staff were wanting her to reposition. 7/22/24; resident refused wound care due to her pain medication worn off and having had a procedure done during the day. On 8/13/24 at 10:55 A.M., Resident N was interviewed. She was observed seated in her oversized recliner chair in her room. A bed with a pressure reducing mattress sat on the other side of the room without linens and personal items strewn across. The resident indicated she slept in her reclining chair which could be sat straight up or laid down completely. She was observed with her right buttock elevated and she indicated there was a pillow below it. She indicated she had a sore on her bottom present since October 2023. She'd had a wound vacuum on it but it had been taken off until her next appointment with the wound clinic on 8/15/24. On 8/14/24 at 1:15 P.M., the Administrator, Director of Nursing (DON) and facility wound nurse were interviewed. All present indicated weekly wound assessments had not been completed per the facility policy. The care plan had not been updated with interventions regarding refusals of wound care and education on consequences of refusals. There had been no specific turning/repositioning program put in place nor further assessments completed when the resident refused to turn/reposition. The resident's new sacral wound identified by the wound clinic and orders given to treat on 6/17/24, should have been implemented, but had been missed. The wound had healed without treatment on 6/24/24. A policy titled Wound Care Guidelines, amended 8/14/24 and provided at 1:13 P.M. by the DON indicated wounds were to be assessed and documented on weekly including measurements and treatments. This Citation relates to Complaints IN00439941, IN00440684, and IN00440721. 3.1-40(a)(1) 3.1-40(a)(2)

Based on interview and record review, the facility failed to conduct a thorough investigation of an allegation of physical abuse for 1 of 3 residents reviewed for abuse (Resident N). Findings include: An incident reported to the Indiana Department of Health, dated 7/30/24, indicated Resident N had complained of severe lower back pain while being provided care by 2 staff members. The resident alleged she had been moved forcefully by the staff and had heard a snap in her back followed by severe pain. She was hospitalized on [DATE] due to the pain. A CAT (a radiology exam) scan completed at the hospital indicated she had an acute compression fracture of her lumbar vertebrae (L3/L4), which required treatment. On 8/16/24 at 1:28 P.M., Resident N's record was reviewed. Diagnoses included paraplegia (paralysis of legs and lower body) due to a progressive neurological disease, diabetes, and weakness. A significant change MDS (Minimum Data Set) assessment, dated 5/1/24, indicated the resident had no cognitive impairment, no moods, behaviors or rejection of care. She had impaired range of motion (ROM) to both her upper and lower extremities and was dependent on staff for toileting, bathing, bed mobility, transfers, and lower body dressing. She required maximal assistance with upper body dressing and personal hygiene. A hospital note, dated 7/30/24, indicated the resident had been hospitalized for increased pain following allegation of staff forcefully transferring her into a wheelchair. She had a mild L3/L4 compression fracture which was treated with vertebroplasty (injection of cement into the fractured vertebrae). A grievance for complaint of care, dated 7/31/24 at 1:00 p.m., indicated Resident N had returned from the hospital and had concerns about her care. She indicated she'd been hospitalized due to a fracture in her back which she alleged occurred due to 2 CNA's (Certified Nurse Aid) moving her back too quickly and hurting her while positioning her in the wheelchair. When asked, the resident indicated she believed it occurred within 24 hours of having the back x-ray ordered. When it occurred, she'd heard her spine crack and had yelled out in pain loudly. She indicated she had reported the incident and increased pain to her nurse within 24 hours and had informed the DON, face to face on 7/26/24. On 8/13/24 at 10:55 A.M., Resident N was interviewed. She was observed seated in her oversized recliner chair in her room. When asked, she indicated she couldn't remember who the staff were who provided care when she hurt her back. She wasn't sure if it was agency staff or facility staff, but she fractured her back when the 2 CNA's moved her too hard and fast. On 8/13/24 at 1:30 P.M., the facility investigation into the allegation of abuse by Resident N was reviewed. The investigation lacked information about staff who had cared for the resident, nor were these staff interviewed. There were no resident interviews completed regarding potential care concerns. On 8/14/24 at 1:13 P.M., the Administrator was interviewed and provided the current facility policy on Abuse Prohibition with steps to be taken if allegations made. The Administrator indicated she had been on an extended leave of absence and not present during the investigation of Resident N's allegation of abuse. Upon receiving an allegation of abuse, an immediate and thorough investigation should be completed. She indicated the investigation of Resident N's allegations had not been conducted thoroughly, according to facility policy, which indicated the following: .Upon the allegation of identification of abuse .it is the policy to assure safety of the resident involved during and after such allegation and to prevent further potential abuse .while the investigation is in progress .3. The Administrator and Director of Nursing will ensure investigation, including interviews, with all residents having the same potential to be affected by the accused person .All staff members on duty at the time of the alleged incident will also be interviewed regarding the witnessing of the alleged abuse. A list of such employees will be provided in the report so no one will be missed in the investigative process This citation relates to Complaint IN00439941, IN00440684, and IN00440721. 3.1-28(d)

Based on observation, record review, and interview the facility failed to ensure there was an assessment and documentation of resident's dislodged PICC (peripherally inserted central catheter) line (thin, soft tube inserted into a vein in the arm, leg or neck for long-term intravenous antibiotics, nutrition, medications, and blood draws) and PICC line site in 1 of 1 resident reviewed (Resident C). Findings include: An Indiana report form, dated 7/17/24 at 7:01 AM, indicated during morning care Certified Nursing Aide (CNA) 2 noticed Resident C's Peripherally Inserted Central Catheter (PICC) line was out of her arm. The resident indicated she was not sure how it came out. Resident C's record was reviewed on 7/17/24 at 9:42 AM. Diagnoses included sepsis, metabolic encephalopathy, and diverticulitis of the large intestine with perforation and abscess with bleeding. Resident C's current Comprehensive Minimum Data Set (MDS), dated [DATE], indicated her Basic Interview for Mental Status (BIMS) score was 14 (cognitive intact). The MDS indicated she had recent open or laparoscopic (including creation or removal of ostomies or percutaneous feeding tubes, or hernia repair) surgery involving the gastrointestinal tract and required wound care. The MDS indicated the resident was on antibiotics, diuretics, opioids, was on IV medication and had IV access. Resident C's current Care plan, revised 7/11/24, indicated the resident had IV (intravenous) medications related to her infection in the colostomy stoma with a goal she would be free from complications related to her IV therapy with a target date of 10/2/24. Interventions included: 1) If IV infiltrated antidote for vesicant/irritant medication may be infused into the IV catheter prior to removal. 2) If IV infiltrated stop infusion and thoroughly examine the site .remove the cannula, elevate the arm, notify the physician. 3) Change dressing as ordered and observe every shift. 4) Monitor/document/report signs and symptoms of infection as needed. 5) Monitor/document/report signs and symptoms of IV fluid leakage at the insertion site. Physician orders dated 6/25/24 at 22:00 indicated Resident C's PICC line was to be maintained, could be used for law draws, and to apply biopatch to the PICC line. The order was discontinued on 7/17/24. Resident C's Treatment Administration Record (TAR), dated 7/1/24 through 7/16/24 indicated the facility staff documented the resident's PICC line was to be maintained, could be used for lab draws, and to apply biopatch to PICC line days, evenings, and nights except on the following dates: 7/6/24, 7/13/24 on days and 7/5/24, 7/11/24, and 7/16/24 on evenings. A witness statement by CNA 2 indicated she was doing morning care when she noticed Resident C's PICC line was out. She indicated she asked her what happened, and the resident indicated she was not sure, it must had been pulled out. CNA 2 indicated she took the PICC line to Licensed Practical Nurse (LPN) 4 and reported what Resident C told her. In an interview on 7/22/24 at 8:35 AM LPN 4 indicated on 7/17/24 around 6:10 AM CNA 2 brought Resident C's PICC line to her. She indicated CNA 2 indicated the resident had just handed it to her. LPN 4 indicated there was a small amount of dried bright red blood on the tip of the PICC line. LPN 4 indicated she went in the resident's room and checked the site. She indicated the dressing was still intact at the PICC line site on the resident's left upper arm and there was no blood on the dressing. She indicated she did not remove the dressing. She indicated she did not measure the length of the PICC line after it came out of Resident C's arm or document, however she did report the PICC line being out to the physician. No orders were given. In an interview on 7/22/24 at 8:31 AM LPN 3 indicated she observed CNA 2 bring Resident C's PICC line to the nurses' station area and hand it to LPN 4. She indicated she did not observe the resident's PICC line. No progress note could be located relating to the 7/17/24 dislodgement assessment and documentation of Resident C's PICC line and/or left upper mid anterior PICC line site. No information was provided related to the 7/17/24 dislodgement assessment and documentation of Resident C's PICC line and/or left upper mid anterior PICC line site. In an Interview on 7/22/24 at 12:06 PM the Director of Nursing indicated the dislodged PICC Line and the PICC line site should had been assessed and documented and it was not . A current policy, dated 6/24/24, titled, Central Lines Policy/Procedures, provided by the DON on 7/22/24 at 1:43 PM, indicated when a PICC line was discontinued the length of the PICC line, the intactness of the catheter tip, the site appearance, and dressing applied needed to be documented. 3.1-37

Based on observation, interview, and record review the facility failed to ensure kitchen sanitation was maintained. 33 of 33 residents currently residing in the facility consumed food prepared in the facility kitchen. Findings include: During an observation on 9/5/23 at 6:00 AM a container of buttermilk was observed in the walk-in cooler. The container was about half full and a thick white substance was observed on top of the liquid that was a yellowish white. The date stamped on the container was 8/15/23. A container labeled lemon pudding indicated the expiration date was 9/3/23. A container labeled cherry pie filling indicated the expiration date was 8/22/23. A container labeled marshmallow sauce indicated the expiration date was 9/1/23. A container labeled western dressing was dated 7/13/23- 7/19/23. A container labeled ranch dressing did not have a date. A container stored with the other dressing bottles containing a white liquid did not have a label or date. An open package of salami was dated 8/16/23. 5 containers of salad were dated 9/1/23. In an interview on 9/5/23 at 6:22 AM, Cook 2 indicated leftover items should not be stored for more than 3 days. She indicated items should be used or discarded by the expiration date. A shelf underneath a counter in the kitchen area were 9 skillets. The shelf contained multiple brown and tan specks, too many to count, and 2 pieces of dried macaroni. Drip pans underneath the flat top grill were more than half covered in a dried, dark brown substance with multicolored specks and debris from pinpoint to dime sized, too many to count. In an interview on 9/5/23 at 6:25 AM, Cook 2 indicated the shelves are normally cleaned at least once a week and as needed. She indicated the shelf should have been cleaned. She indicated she did not know how often the drip pans should be cleaned because she had never done it before. During a record review beginning 9/5/23 at 7:30 AM, Daily Freezer/Refrigerator Temperature Logs were reviewed. On the log labeled Back Cooler, temperatures were not filled out for September 2, 3 and 4. On the log labeled Back Freezer, temperatures were not filled out for September 2, 3 and 4. On the log labeled Walk-in Cooler, temperatures were not filled out for September 2, 3 and 4. On the log labeled Line Cooler, temperatures were not filled out for September 2, 3 and 4. On the log labeled Front Cooler, temperatures were not filled out for September 2, 3 and 4. On the log labeled Front Freezer, temperatures were not filled out for September 2, 3 and 4. During an interview on 9/5/23 at 6:25 AM, Cook 2 indicated refrigerator and freezer temperatures should be obtained and logged twice daily with any variances reported immediately to the Dietary Manager. In an interview on 9/5/23 at 6:42 AM, Registered Nurse 4 indicated all residents residing in the facility consumed food prepared in the kitchen. A current policy, undated, titled Shelves and Other Surfaces provided by the Administrator on 9/6/23 at 3:00 PM indicated splashes and spills should be wiped off as they occur. A current policy, undated, titled Daily Cleaning Schedule provided by the Administrator on 9/6/23 at 3:00 PM indicated the range catch pan should be cleaned daily. A current policy, dated 2/22/21, titled Safe Food Storage Guidelines provided by the Administrator on 9/6/23 at 3:00 PM indicated all products should be used by expiration date or discarded. During an interview, on 9/08/23 12:18 PM the administrator indicated the instructions at the top of the Daily Freezer/Refrigerator Temperature Log Received from Cook 2 on 9/5/23 at 7:30 AM served as the facility policy for temperature monitoring. The form indicated temperatures should be checked and recorded twice daily. 3.1-21(i)(3)

Based on record review and interview, the facility failed to ensure a Registered Nurse (RN) worked 8 consecutive hours in the facility 11 days of 60 reviewed. Finding includes: On 9/6/23 at 11:24 AM staff schedules for the nursing department were reviewed from 8/1/23 to 9/1/23. The staffing schedule for 8/6/23 indicated 2 agency License Practical Nurses (LPN) worked during the 24 hours. No Registered Nurse (RN) worked on 8/6/23 for 8 consecutive hours. The staffing schedule for 8/13/23 indicated 2 agency LPNs worked during the 24 hours. No RN worked on 8/13/23 for 8 consecutive hours. The staffing schedule for 8/20/23 indicated 2 agency LPNs worked during the 24 hours. A RN worked on 8/13/23 for 1.25 hours, not for 8 consecutive hours. The staffing schedule for 8/27/23 indicated 2 agency LPNs worked during the 24 hours. No RN worked on 8/27/23 for 8 consecutive hours. A review of the facility's Payroll Based Journal Report dated 1/1/23 -3/31/23, indicated the facility failed to have an RN working 8 consecutive hours per day during the fiscal quarter on the following days: 2/4/23, 2/07/23, 2/11/23 2/17/23, 2/26/23, 2/27/23 and 2/28/23. In an interview on 9/7/23 at 11:45 AM, the Administrator indicated the facility failed to have a RN on staff every Sunday in August for 8 hours and there should have been. The facility did not have a policy regarding RN staffing hour requirements. No policy was provided by the survey exit. 3.1-17(b)(3)

Based on observation, interview, and record review the facility failed to ensure privacy was maintained for 1 of 6 residents reviewed (Resident 23). Findings include: During an observation on 9/5/23 at 7:54 AM an Indiana Physician's Orders for Scope of Treatment (POST) form was observed taped to the wall above the head of Resident 23's bed. The form contained Resident 23's name, date of birth, a medical record number and orders pertaining to cardiopulmonary resuscitation, medical interventions, antibiotics, and artificially administered nutrition. Resident 23's record was reviewed on 9/6/23 at 11:38 AM. Diagnoses included nontraumatic intracerebral hemorrhage in hemisphere, cortical, expressive language disorder, idiopathic normal pressure hydrocephalus. A review of Resident 23's current annual Minimum Data Set (MDS) dated [DATE] indicated his Basic Interview for Mental Status (BIMS) score was 2 (severely cognitively impaired) and unable to be interviewed. During an interview on 9/6/23 at 11:35 AM, Resident 23's sister who was his Power of Attorney indicated she did not know what the form was or why it was posted in the room. In an interview on 9/6/23 at 11:47 AM, The Social Services Director indicated a prior member of management, no longer employed by the facility had directed staff to hang the POST form above Resident 23's bed. A current policy titled HIPPA Privacy Compliance Summary, undated, provided by the Administer on 9/6/23 at 1:40 PM indicated private health information should be protected and only accessed by authorized personnel. 3.1-3(o)

Based on record review and interview the facility failed to provide the resident with a written explanation of the Notice of Transfer or Discharge and Bed Hold Policy within 24 hours of a hospital transfer for 1 of 2 residents reviewed for hospitalization . (Resident 25). Findings include: Resident 25's record was reviewed on 9/05/23 at 9:04 AM. Diagnoses included hypo-osmolality, hyponatremia, type 2 diabetes mellitus, and hypertension. A review of Resident 25's current quarterly Minimum Data Set (MDS) dated [DATE] assessment indicated her Basic Interview for Mental Status (BIMS) assessment score was 13 (cognitively intact). A review of Resident 25's census record indicated she was hospitalized [DATE] to 5/20/23. A progress note, dated 5/16/23 at 7:51 PM, indicated Resident 25 had a witnessed fall and was being transported to the hospital. A progress note dated 5/20/23 at 111:27 AM indicated Resident 25 returned to the facility. A review of Resident 25's chart lacked documentation to show a Notice of Transfer or Discharge and Bed Hold Policy Notice was initialed and supplied to the family or resident's representative within 24 hours of discharge of her 5/16/23 hospitalization . A review of Resident 25's census record indicated she was hospitalized [DATE] to 6/19/23. A progress note, dated 6/15/23 at 7:51 PM, indicated Resident 25 was being sent to the hospital due to low sodium. A progress note dated 6/19/23 at 7:18 PM indicated Resident 25 returned to the facility. A review of Resident 25's chart lacked documentation to show a Notice of Transfer or Discharge and Bed Hold Policy Notice was initialed and supplied to the family or resident's representative within 24 hours of discharge of her 6/15/23 hospitalization . In an Interview on 9/07/23 at 1:23 PM, the Administrator indicated the facility failed to provide Resident 25 or her representative with a written explanation of the Notice of Transfer or Discharge and Bed Hold Policy within 24 hours of her 6/15/23 and 5/16/23 hospitalization transfers. A current policy titled Bed Hold Policy, undated, provided by the Administrator on 9/8/23 at 11:40 AM did not refer to providing the resident or her representative with a written explanation of the Notice of Transfer or Discharge and Bed Hold Policy within 24 hours of hospital transfer. No further policies were provided by time of survey exit. 3.1-12(a)(25)(26)

Based on interview and record review, the facility failed to ensure the provision of a discharge summary for 1 of 7 residents reviewed. (Resident 30). Findings include: Resident 30's record was reviewed on 9/7/23 at 10:00 AM. Diagnoses included partial left foot amputation, osteomyelitis (infection in the bone) of the left ankle and foot, diabetes, irregular heartbeat, heart failure and peripheral vascular disease. A review of Resident 30's current discharge Minimum Data Set (MDS) dated [DATE] indicated their Basic Interview for Mental Status (BIMS) score was 15 (cognitively intact). The MDS indicated the resident had a surgical wound and had been prescribed blood thinners. A review of a physician order dated 7/7/23 indicated the resident required wound care to the left foot weekly and PRN for soiling and/or dislodgement. A review of a physician order dated 6/24/23 indicated the resident had been prescribed Plavix (blood thinner). A review of a physician order dated 6/23/23 indicated the resident was to be monitored for adverse effects of blood thinners such as bruising and excessive bleeding. A review of a social service progress note dated 7/5/23 at 3:17 PM indicated Resident 30's discharge papers had been started. A review of a social service progress note dated 7/7/23 at 8:28 AM indicated Resident 30 was to be discharged to home with home health for wound care, physical therapy (PT) and occupational therapy (OT). The note indicated PT had informed the Director of Nursing of Resident 30's discharge plan. A review of a discharge instruction sheet dated 7/5/23 indicated the social service director had completed a discharge summary. The discharge instruction sheet sections for medications and the nursing discharge summary were blank. In an interview on 9/8/23 at 10:53 AM, the Administrator indicated the nursing department should have provided the resident with discharge instructions for wound care and medications. A current undated policy provided by the Administrator indicated discharge planning concerns would be identified by all disciplines. 3.1-36(a) 3.1-36(a)(1) 3.1-36(a)(2)

Based on interview and record review the facility failed to ensure the provision of scheduled showers at resident preferance for 1 of 7 residents reviewed. (Resident 10). Findings include: During an interview on 6/6/23 at 9:45 AM Resident 10 indicated they had not been provided with routine showers as scheduled. Resident 10 indicated they signed each shower sheet upon completion of each shower. Resident 10 indicated they signed each shower sheet due to past episodes of the staff lying about skipping the resident's showers and then marking they had refused showers. Resident 10's record was reviewed on 9/6/23 at 10:05 AM. Diagnoses included multiple sclerosis and generalized muscle weakness. Resident 10's current comprehensive Minimum Data Set (MDS) dated [DATE] indicated their Basic Interview for Mental Status (BIMS) score was 15 (cognitively intact). The MDS indicated the resident was totally dependent on the staff for bathing. Resident 10's current care plan indicated the resident had a problem of a self-care deficit due to muscular dystrophy and the inability to bear weight with a goal date of 12/14/23. Interventions included extensive assistance by 2 staff members with showers each Monday and Friday and whirlpools each Wednesday and Saturday. Progress notes dated 7/16/23 at 6:19 PM indicated Resident 10 was to have a shower every Sunday and Thursday evening at 9:00 PM. Resident 10 was to sign a shower sheet when the shower was completed or if the shower was refused. The progress note indicated the resident had refused their shower and signed and dated the shower sheet. Progress notes dated 8/6/23 at 8:54 PM indicated Resident 10 was to have a shower every Sunday and Thursday evening at 9:00 PM. Resident 10 was to sign a shower sheet when the shower was completed or if the shower was refused. The progress note indicated the resident had refused their shower. Progress notes dated 9/3/23 at 8:10 PM indicated Resident 10 was to have a shower every Sunday and Thursday evening at 9:00 PM. Resident 10 was to sign a shower sheet when the shower was completed or if the shower was refused. The progress note indicated the resident had refused their shower. Resident 10's shower review sheets dated July 2023 indicated the resident had signed shower sheets on 7/2/23, 7/6/23, 7/20/23 and 7/30/23. Shower review sheets dated 7/23/23 and 7/27/23 did not portray Resident 10's signature. Resident 10's shower review sheets dated August 2023 indicated the resident had signed shower sheets on 8/6/23, 8/13/23, and 8/27/23. Shower review sheets dated 8/3/23, 8/17/23, 8/24/23 and 8/31/23 did not portray Resident 10's signature. Resident 10's shower review sheet dated 9/3/23 indicated the resident had signed the shower sheet. Resident 10's task sheet indicated the resident was to have a shower every Tuesday, Thursday and Saturday at 5:00 AM. The task sheet indicated the resident was totally dependent with showers on 8/9/23, 8/11/23, 8/25/23 and 9/1/23. The task sheet indicated the resident was independent with a shower on 9/3/23. The task sheet indicated showers were not applicable on 8/13/23, 8/16/23, 8/18/23, 8/20/23, 8/23/23, 8/27/23 and 9/6/23. In an interview on 9/7/23 at 1:18 PM, the Administrator indicated they were unaware of Resident 10's report of not receiving scheduled showers. The Administrator indicated residents were to receive all scheduled showers and refusals of showers should be reported to the nurse and documented. A current undated policy provided by the Administrator indicated residents would receive all scheduled showers. The policy indicated the nurse would be notified if a resident refused their shower. 3.1-38(a)(3)

Based on interview and record review the facility failed to ensure pharmacy recommendations were addressed timely for 1 of 5 residents reviewed. (Resident 12). Findings include: Resident 12's record was reviewed on 9/26/23 at 9:29 AM. Diagnoses included generalized anxiety disorder, unspecified dementia, moderate without behavioral disturbance, psychotic mood disturbance and anxiety, and heart failure, unspecified. Resident 12's current annual, Minimum Data Set (MDS) dated [DATE] indicated her Basic Interview for Mental Status (BIMS) score was 3 (severely cognitively impaired). The MDS indicated Resident 3 received antianxiety medication daily. Resident 12's current Care plan titled Uses Psychotropic Medication indicated the Resident 12 had a problem of risk of adverse effects, with a goal date of 11/30/23. Interventions included pharmacy consultations. Pharmacy Consultation Report dated 6/19/23 provided by the Administrator on 9/7/23 at 3:20 PM indicated a new order to increase Buspar to 5 mg three times daily from 5 mg twice daily had been written on 5/15/23 and had not yet been initiated. A Medical Visit Note dated 5/15/23 indicated the order for Buspar 5 mg twice daily should be discontinued and an order for Buspar 5 mg three times daily should be initiated. Physician orders dated 2/5/23 indicated Buspar 5 mg was ordered to be given twice daily. This order was discontinued 7/18/23. Physician orders dated 7/18/23 indicated Buspar 5 mg was ordered to be given three times daily. In an interview on 9/8/23 at 10:10 AM, Registered Nurse 4 indicated pharmacy recommendations are normally given to the physician or nurse practitioner the next business day and carried out within a few days. He was not sure why the order to change the frequency of Buspar had not been carried out in a timely manner. RN 4 indicated the order should have been carried out within a few days of receiving the pharmacy recommendation. During an interview on 9/08/23 12:25 PM, the Administrator indicated she did not have a policy pertaining to responding to pharmacy recommendations or receiving and transcribing physician's orders. 3.1-25(i)

Based on observation, interview, and record review, the facility failed to ensure interventions to prevent development of a pressure ulcer were in place for 1 of 3 residents reviewed with pressure ulcers (Resident B). This resulted in teh development of a stage II pressure ulcer (Partial-thickness skin loss with exposed dermis-may present as an intact blister). Finding include: On 3/28/18 at 3:59 P.M., Resident B's record was reviewed. [DIAGNOSES REDACTED]. An Interdisciplinary Progress Note, dated 3/16/18 at 3:52 P.M., indicated Resident B arrived to the facility at 11:00 a.m. accompanied by family. The note indicated the resident was polite, talkative and alert and oriented to time, person, and place. The resident was able to ambulate with the walker and 1 assist for short distances. Resident uses w/c for out of room transfers. A SS (Social Service) Admission Note, dated 3/16/18 at 4:10 P.M., indicated the resident came from another facility. Family notes history of (Resident B) present illness as that on (date) he was admitted to (hospital) for an infection which caused him to need therapies at (facility). While at (facility), the resident developed a heel blister and had to stay off his left heel for three weeks so he was discharged from therapies on 3/15/18. There was no indication a pressure area was present on Residnet B's right heel. A Discharge Order Summary Report from the transferring facility, dated 3/16/18, indicated the resident had an unstageable pressure ulcer to the left heel, Resident to wear off-loading boot to left foot at all times and Prostat twice daily to increase protein. Admission Physician Orders, dated 3/16/18, included, but were not limited to, Every HS (bedtime) cleanse area to L heel, paint with [MEDICATION NAME], apply ABD (dressing), and wrap with kerlix for wound care. There were no orders for protein supplements to assist with wound healing and no orders for preventative measures to prevent development of new pressure ulcers. On 3/28/18 at 2:31 P.M., the resident was observed sitting in his bedside recliner chair with his feet elevated. His heel were resting on the chair which had no pillows or pressure relieving devices. On 3/28/18 at 4:24 P.M., Resident B was interviewed. He indicated that his right heel had started to feel funny one day, and he told the nurse who looked at his foot and found the blister on his right heel. The resident indicated he tries to keep his feet elevated. A family member, who was present during the interview, indicated the resident had some thin blue heel protectors that he wore in bed but they were not pressure relieving devices. The family member indicated at the previous facility, the resident wore an off-loading boot to his left heel. The family member indicated the resident propelled himself in the wheelchair using his heels to move himself along. On 3/28/18 at 5:02 P.M., CNA (Certified Nurse Assistant) 3 and LPN 5 were interviewed. During the interview, CNA 3 indicated she was caring for Resident B. She indicated she was not aware of skin issues with the resident. LPN 5 reminded CNA 3 about keeping the resident's feet elevated. LPN 5 provided a copy of the CNA worksheets, updated 3/27/18. The CNA worksheet did not indicate Resident B had any skin issues or that his heels should be elevated. On 3/29/18 at 10:22 A.M., the DON (Director of Nursing) was interviewed. During the interview, she indicated she did not know why a baseline plan of care had not been put into place, upon admission to the facility, to prevent the resident from acquiring another pressure ulcer. Review of Interdisciplinary Progress Notes indicated the following: 3/17/18 at 2:33 A.M., resident is alert/ oriented but suffers from bouts of confusion. The resident is 1-2 assist with adls (Activities of Daily living) and transfers. Resident came from another facility where he had been recovering from a bladder infection and had also suffered a blister to his L (left) heel during his stay there. 3/17/18 at 1:31 P.M., Dressing intact to the L heel. 3/18/18 at 1:23 A.M., The resident is 1-2 assist with adls (Activities of Daily living) and transfers. Resident is recovering from a bladder infection and had also suffered a blister to his L heel during his stay at another facility. 3/19/18 at 1:22 A.M., Resident is recovering from a bladder infection and had also suffered a blister to his L heel during his stay at another facility and no new skin issues since admission. 3/20/18 and 3/21/18, no documentation of left heel found. 3/22/18 at 5:00 P.M., Resident was found to have a blister to the R (right) heel and was treated per protocol. Resident states the blister came from walking in therapy and the pressure of the foot caused the blister. Resident encouraged to elevate BLE (bilateral lower extremities) as much as possible. A Physician Order, dated 3/21/18 (no time), was for Therapy to evaluate and treat as indicated for PT (Physical therapy), OT (Occupational therapy), ST (Speech therapy). A Physician Order, dated 3/22/18 (no time), was to every HS, apply ABD and kerlix to R heel for Wound care. On 3/29/18 at 11:39 A.M., the DON provided a current copy of the facility's policy, titled Prevention of Pressure Ulcers which stated the following: Procedure: 1. The unit nurse will perform a head to toe skin assessment within the first (4) hours upon admission or readmission to the facility to assess for skin breakdown .5. It is the responsibility of the unit nurse to implement skin breakdown prevention interventions to the resident Care Plan when admission takes place; such as, repositioning at a minimum of Q (every) 2 hours, not positioning the resident on any bony prominence that appears red .9. Any resident that is bedridden or chairbound will have their heel floated at all times and turning and repositioning Q 1-2 hours; or as specified in care plan .12. Ensure that the care plan accurately reflects the skin/wound assessment findings with clear, objective and measurable goals included for pressure areas, skin tears, stasis ulcers and surgical incisions. Care Plans are to be updated and kept current This Federal tag relates to Complaint IN 766 3.1-40(a)(1)