Every finding on record at Century Villa Health Care

Based on interview and record review, the facility failed to ensure residents were treated with respect and dignity for 3 of 3 residents reviewed for respect and dignity. (Resident C, D and E)Findings include: During an interview, on 6/15/26 at 1:30 p.m., the Executive Director (ED) indicated CNA 1 was terminated for poor verbal customer service. There were three (3) alert and oriented residents who indicated CNA 1 was rude and loud when she talked to them.During an interview, on 6/15/24 at 2:40 p.m., Resident E indicated CNA 1 spoke very loud, rude, and in a harsh tone whenever she provided care for her. CNA 1 would talk in a loud and harsh tone to her roommate. Resident E's daughter indicated CNA 1 did not talk to Resident E's roommate with respect and dignity. During an interview, on 6/15/26 at 3:09 p.m., Resident C indicated CNA 1 was very rude to her. She used her position to let you know she was the person in charge. She indicated CNA 1 treated her with disrespect. During an interview, on 6/15/26 at 3:15 p.m., Resident D indicated CNA 1 was very rude and spoke to her with a harsh tone. She indicated CNA 1 did not treat her with respect and dignity. A facility document, titled Status Change Notice, dated 6/12/26 and provided by the ED on 6/16/26 at 10:55 a.m., indicated CNA 1 was terminated, on 6/12/26, for poor unacceptable verbal customer service. She was not eligible to rehire.During an interview, on 6/16/26 at 11:08 a.m., CNA 1 indicated she asked a resident in the hallway to please not speak to her like that. CNA 1 indicated the resident spoke to her in a harsh and loud tone. The ED had talked with CNA 1 regarding the way she spoke to the resident. Then, she sat a resident at a table where three other residents were sitting. One of the residents complained about her sitting the resident at the table. CNA 1 tried to explain to the residents why she sat the resident at their table. After breakfast, she was called into the ED's office and told she was suspended pending an investigation for the way she spoke to the residents in the dining room and a nurse in the hallway.During an interview, on 6/16/26 at 12:12 p.m., RN 3 indicated CNA 1 brought a resident to breakfast and sat her at a different table than normal. Another resident had told CNA 1 the resident did not sit at that table. CNA 1 raised her voice and told the residents she was allowed to sit there. CNA 1 had told RN 3 to stop being rude to other people. RN 3 told CNA 1 the hallway was not the place to talk this. As RN 3 was walking back from the dining room, CNA 1 raised her voice in a harsh tone told RN 3 that she did not help the CNA's, she needed to stop being rude to other people and needed to help the CNAs at mealtimes. A current facility policy, titled Resident Right Policy, dated 8/1/25 and provided by the Director of Nursing on 6/15/26 at 2:21 p.m., indicated .Respect and dignity-The resident has a right to be treated with respect and dignity 410 IAC (Indiana Administrative Code) 16.2-3.1-3(t)

Based on interview and record review, the facility failed to ensure a resident's representative received notification in writing of the facility's bed hold policy, the Ombudsman was notified when a resident's was transferred and discharged to the hospital, and discharge paperwork provided to a resident's caregiver did not contain another resident's information for 2 of 3 residents reviewed for discharge. (Resident 37 and C)Findings include:1. The clinical record for Resident 37 was reviewed on 12/12/25 at 2:38 p.m. The diagnoses included, but were not limited to, muscle weakness, Alzheimer's disease, major depressive disorder, hypertension, osteoporosis, chronic kidney disease, and pain. A facility reported incident, dated 11/23/25 at 5:01 p.m., indicated Resident 37 had a fall, was sent to the hospital, and was hospitalized . The clinical record did not include documentation to indicate the bed hold policy was provided to the resident's representative in writing or the Ombudsman was notified of the transfer to the hospital. During an interview, on 12/16/25 at 10:30 a.m., the Clinical Support Nurse indicated the resident was not on the Ombudsman notification list and the Ombudsman should have been notified. During an interview, on 12/16/25 at 10:45 a.m., the Director of Nursing (DON) indicated there was no documentation the bed hold policy was provided to the resident's representative in writing or the Ombudsman was notified of the transfer to the hospital. 2. The clinical record for Resident C was reviewed on 12/16/25 at 2:09 p.m. The diagnoses included, but were not limited to, muscle weakness, diabetes mellitus, anemia, chronic kidney disease, and hypertension. Resident C was discharged from the facility to home on 8/30/25. During an interview, on 12/17/25 at 10:35 a.m., Resident C's caregiver indicated she received another resident's paperwork with personal health information on it, along with Resident C's discharge paperwork. During an interview, on 12/17/25 at 2:31 p.m., Registered Nurse 7 indicated when a resident was close to discharge, social services would print and prepare the discharge paperwork in a folder. During the discharge, an RN would go over the paperwork with the resident and/or a family member before sending them home. During an interview, on 12/17/25 at 2:55 p.m., the DON indicated when a resident was discharged , the nurse would go over paperwork with the resident and family or caregiver. The paperwork went into a folder and went with the resident. If someone else's paperwork was mixed in, it should be noticed and caught before discharge. A current facility policy, titled Protected Health Information (PHI), Management and Protection of, undated and received from Clinical Support on 12/17/25 at 3:43 p.m., indicated .it is the responsibility of all personnel who have access to resident and facility information to ensure that such information is managed and protected to prevent unauthorized release or disclosure A current facility policy, titled Bed Hold and Return to Center Policy, revised on 4/20/18 and received from the Clinical Support Nurse on 12/16/25 at 11:26 p.m., indicated .A copy of the facility Bed Hold Policy Review and Notice will be provided to the resident and/or resident representative upon admission by the Admissions Coordinator or designee .A copy of the facility Bed Hold Policy Review and Notice will be provided to the resident and/or resident representative at the time of transfer or in cases of emergency transfer, within 24 hours. Multiple attempts to notify the resident representative will be documented in the progress notes in cases where the facility was unable to notify the representative A current facility policy, titled Transfer or Discharge, Facility-Initiated, revised on 10/2022 and received from the Clinical Support Nurse on 12/16/25 at 11:26 p.m., indicated .Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require/representative notification and orientation, and documentation as specified in this policy .The facility will send a copy of the discharge notice to a representative of the Office of the State LTC Ombudsman .Notice to the Office of the State LTC Ombudsman will occur at the same time the notice of discharge is provided to the resident and resident representative .When a resident is transferred or discharged from the facility, the following information is documented in the medical record .A summary of the resident's overall medical, physical, and mental condition .Disposition of personal effects .Disposition of medication .The signature of the person recording the data in the medical record This citation relates to Intake 2617173. 3.1-12(a)(6)(A)(i) 3.1-12(a)(6)(A)(ii) 3.1-12(a)(6)(A)(iii)

Based on interview and record review, the facility failed to ensure Abnormal Involuntary Movement Scale (AIMS) assessments were completed and daily weights were obtained for 2 of 2 residents reviewed for quality of care. (Resident 21 and 46)Findings include: 1. The clinical record for Resident 21 was reviewed on 12/15/25 at 11:39 a.m. The diagnoses included, but were not limited to, bipolar disorder, anxiety disorder, delusional disorder, persistent mood disorder, and dementia without behavioral disturbances. A care plan, dated 8/8/23, indicated Resident 21 was at risk for adverse side effects related to the use of antipsychotic and antidepressant medication. A physician's order, dated 11/14/24, indicated to administer Invega (an atypical antipsychotic medication) extended release 1.5 milligram (mg) tablet once a day at bedtime. A physician's order, dated 10/16/25, indicated to administer Pristiq (an antidepressant medication) extended release 25 mg tablet once a day. An Abnormal Involuntary Movement Scale (AIMS) assessment, dated 2/21/24 at 12:16 p.m., indicated the involuntary movement score was zero (0). An Abnormal Involuntary Movement Scale (AIMS) assessment, dated 1/21/25 at 8:44 p.m., indicated the assessment was completed by error with no involuntary movement score. During an interview, on 12/15/25 at 2:24 p.m., the Director of Nursing (DON) indicated the AIMS assessments were to be completed every 3-6 months. During an interview, on 12/17/25 at 11:55 a.m., the DON indicated Resident 21's last AIMS assessment was performed on 1/21/25 and had been struck out in error. AIMS assessments were to be completed every six months for residents who were receiving psychotropic medications. During an interview, on 12/18/25 at 9:29 a.m., LPN 6 indicated AIMS assessments were to be completed for residents who received psychotropic medications upon admission and then quarterly. During an interview, on 12/18/25 at 9:36 a.m., LPN 5 indicated AIMS assessments were to be completed for residents who received psychotropic medications every three months. During an interview, on 12/18/25 at 12:25 p.m., the DON indicated the nursing staff were responsible for the completion of the AIMS assessments. 2. The clinical record for Resident 46 was reviewed on 12/17/25 at 9:04 a.m. The diagnoses included, but were not limited to, diabetes mellitus, congestive heart failure, and anxiety disorder. A care plan, dated 3/6/24, indicated Resident 46 had a diagnosis of congestive heart failure. The interventions included, but were not limited to, monitor weight gain unrelated to intake, obtain weights as ordered, and notify the physician of significant weight loss or gain. A physician's order, dated 8/23/24, indicated to obtain a daily weight and notify the Nurse Practitioner (NP) if the resident had a 3-pound weight gain in 24 hours. The Medication Administration Record, dated 5/1/25 to 5/31/25, indicated documentation a daily weight was obtained was missing on 5/5/25, 5/8/25, 5/11/25, 5/12/25, 5/15/25, 5/16/25, 5/17/25, 5/18/25 and 5/19/25. The Medication Administration Record, dated 6/1/25 to 6/30/25, indicated documentation a daily weight was obtained was missing on 6/3/25, 6/4/25, 6/6/25, 6/10/25, 6/14/25, 6/18/25 and 6/21/25. The Medication Administration Record, dated 7/1/25 to 7/31/25, indicated documentation a daily weight was obtained was missing on 7/20/25, 7/25/25, 7/26/25 and 7/31/25. The Medication Administration Record, dated 8/1/25 to 8/31/25, indicated documentation a daily weight was obtained was missing on 8/10/25, 8/11/25, 8/12/25, 8/19/25, 8/20/25, 8/23/25 and 8/24/25. During an interview, on 12/17/25 at 9:36 a.m., the Director of Nursing (DON) indicated if the resident was supposed to be weighed daily then the nurse was expected to obtain a weight. During an interview, on 12/17/25 at 1:35 p.m., Licensed Practical Nurse (LPN) 5 indicated when a resident had an order for a daily weight, he would provide a list of the residents for the Certified Nursing Assistant (CNA) to obtain. Once the weight was obtained, it would be documented in the resident's record. During an interview, on 12/17/25 at 1:45 p.m., CNA 6 indicated any staff could obtain a resident's weight. The weight list came from the nurse, the weight would be obtained, and the nurse would chart the weight in the resident's record. A current facility policy, titled Psychotropic Medication Use, dated as revised 7/2022 and received from the Clinical Support Nurse on 12/16/25 at 11:55 a.m., indicated .Residents receiving psychotropic medications are monitored for adverse consequences. A current facility policy, titled Heart Failure - Clinical Protocol, dated as revised 11/2018 and received from the Clinical Support Nurse on 12/17/25 at 1:30 p.m., indicated .The physician will help identify or clarify causes of congestive heart failure .The physician will review and make recommendations for relevant aspects of the nursing care plans; for example .weights .to monitor, when to report the findings to the physician 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure a medication cart was locked when not in direct observation of staff for 1 of 4 medication carts randomly observed for medication storage. (300 hall medication cart) Findings include:During an observation, on 12/12/25 at 10:30 a.m., the 300-hall medication cart was unlocked and unattended.During an observation, on 12/12/25 at 10:32 a.m., LPN 4 came out of room [ROOM NUMBER] and went to the medication cart.During an interview, on 12/12/25 at 10:32 a.m., LPN 4 indicated the medication should not have been left unlocked when she went into room [ROOM NUMBER].During an interview, on 12/17/25 at 11:57 a.m., the Director of Nursing (DON) indicated medication carts should be locked all times when not in direct supervision of nursing staff.During an interview, on 12/18/25 at 9:21 a.m., QMA 7 indicated medication carts should be kept locked when not in direct observation of the staff member responsible for the cart.During an interview, on 12/18/25 at 9:26 a.m., LPN 6 indicated medication carts should be kept locked when not in direct observation of the staff member responsible for the cart.During an interview, on 12/18/25 at 9:37 a.m., LPN 5 indicated medication carts should be kept locked when not in direct observation of the staff member responsible for the cart.A current facility policy, titled Medication Labeling and Storage, revised on 2/2023 and received from the DON on 12/17/25 at 12:12 p.m., indicated .Compartments.containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open A current facility policy, titled Exceptional Living Centers Job Description Licensed Practical Nurse-605014, with no date and received from the DON on 12/17/25 at 12:12 p.m., indicated .Carries out responsibilities in compliance with federal, state, local laws and regulations, and with facility philosophy, policies and procedures 3.1-25(m)

Based on observation, interview and record review, the facility failed to ensure staff wore personal protective equipment (PPE) into an enhanced barrier precaution (EBP) room while providing care for 1 of 5 residents reviewed for enhanced barrier precautions. (Resident 46)Findings include:During an observation, on 12/16/25 at 3:59 p.m., RN 2 entered Resident 46's room to administer medication and a bolus feed. The resident had a gastrostomy tube (a tube surgically inserted into the stomach to provide medication and nutrition) and was in isolation for enhanced barrier precautions. RN 2 did not put on an isolation gown to administer the medication and bolus feed through the gastrostomy tube.The clinical record for Resident 46 was reviewed on 12/17/25 at 9:28 a.m. The diagnosesincluded, but were not limited to, gastrointestinal hemorrhage, vascular disorder ofthe intestine, gastrostomy status, and [NAME]-Danlos syndrome.A physician's order, dated 7/25/25, indicated Resident 46 was in enhanced barrier precautions due to the gastrostomy tube.During an interview, on 12/17/25 at 9:13 a.m., the Director of Nursing (DON) indicatedwhen a resident was in enhanced barrier precautions the staff were supposed to a wear a gown and gloves.During an interview, on 12/17/25 at 12:11 p.m., LPN 3 indicated she would wear a gownand gloves while administering medication or bolus tube feeds through a gastrostomy tube.A current facility policy, titled Enteral Tube Feeding via Syringe (Bolus), dated November 2018 and provided by the DON on 12/17/25 at 9:13 a.m., indicated .The following equipment and supplies will be necessary when performing this procedure.Personal protective equipment e.g., gowns, gloves, mask.A current facility policy, titled Enhanced Barrier Precautions, dated March 2024 and provided by the DON on 12/17/25 at 9:13 a.m., indicated .Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include.device care or use.feeding tube.3.1-18(b)(2)

Based on observation, interview and record review, the facility failed to ensure the correct personal protective equipment (PPE) for contact precautions was used, to perform hand hygiene after resident contact, to utilize enhanced barrier precautions (EBP) when required, to protect clean laundry from contamination, to perform hand hygiene and change gloves while performing wound care, and to keep the indwelling catheter tubing from touching the floor for 7 of 7 residents reviewed for infection control. (Resident 19, 33, 47, 18, 20, 38 and 48) Findings include: 1. During an observation, on 9/27/24 at 8:54 a.m., QMA 5 was giving medications to Resident 28. After finishing with Resident 28, she walked over to Resident 19 and touched the resident's blanket without wearing a gown or gloves as she asked if the resident needed anything. Resident 19 had an order for contact precautions with a sign on the door. QMA 5 exited the room and walked directly to her medication cart outside the dining room. No hand hygiene was observed while she was in the room, walking down the hall, or at the medication cart. She then wrote on her resident information paper, accessed her computer screen, and prepared Resident 18's morning medications. During an observation, on 9/30/24 at 9:23 a.m., LPN 4 was giving medications to Resident 19 who remained on contact precautions with no gown or gloves on while she was in the room. The clinical record for Resident 19 was reviewed on 9/27/24 at 9:32 a.m. The diagnoses included, but were not limited to, chronic kidney disease stage 3, personal history of malignant neoplasm of bronchus and lung, personal history of malignant neoplasm of brain, and history of Escherichia coli extended-spectrum beta-lactamases producing organism (ESBL) with current infection. A physician's order, dated 9/25/24, indicated contact isolation precautions for ESBL in urine culture every shift until 10/1/24. A care plan intervention, initiated 9/25/24, indicated contact isolation precautions for ESBL for Resident 19. A nurse's note, dated 9/25/24 at 12:57 p.m., indicated the Nurse Practitioner (NP) ordered contact precautions. During an interview, on 9/30/24 at 1:35 p.m., LPN 4 indicated for enhanced barrier precautions, staff should wear a gown and gloves when giving direct care or touching a resident, and contact isolation was basically the same thing. She indicated they had to wear gowns and gloves when they were going to be in contact with an area where the infection was but not every time you went into the room. During an interview, on 10/01/24 at 2:26 p.m., the Assistant Director of Nursing (ADON) indicated that all staff had been educated on hand hygiene and the correct use of PPE, including requirements for wearing gowns and gloves every time they enter a room under contact precautions. 2. During random observations, on 9/25/24, 9/26/24, 9/27/24, 9/30/24, 10/1/24 and 10/2/24, Resident 33 was not on enhanced barrier precautions and there was no sign on her door. The clinical record for Resident 33 was reviewed on 9/27/24 at 10:44 a.m. The diagnoses included, but were not limited to, frequent history of extended spectrum beta lactamase (ESBL) resistance infections, stage 3 chronic kidney disease, overactive bladder, type 2 diabetes mellitus, spondylosis cervical region, and systemic lupus erythematosus. The resident was considered colonized (organism was frequently present in stool and urine) with ESBL. A urinalysis culture report, dated 4/14/24 at 2:32 p.m., indicated the resident's urine had ESBL present. A Minimum Data Set (MDS) quarterly assessment, dated 7/3/24, indicated the resident had a multi-drug-resistant organism (MDRO): ESBL. A urinalysis culture report, dated 7/9/24 at 1:36 p.m., indicated the resident's urine had proteus mirabilis ESBL present. A urinalysis culture report, dated 8/1/24 at 12:34 p.m., indicated the resident's urine had proteus mirabilis ESBL present. A MDS quarterly assessment, dated 9/30/24, indicated the resident was occasionally incontinent of urine and frequently incontinent of bowel. The clinical record did not include an order for enhanced barrier precautions. During an interview, on 9/26/24 at 11:35 a.m., CNA 6 indicated Resident 33 was not on enhanced barrier precautions. During an interview, on 10/01/24 at 2:26 p.m., the ADON indicated the resident was not on enhanced barrier precautions. During an interview, on 10/01/24 at 2:35 p.m., the NP indicated the resident had frequent urinary tract infection cultures which showed ESBL. A Centers for Medicare and Medicaid Services (CMS) memorandum QSO-24-08-NH, titled Enhanced Barrier Precautions in Nursing Homes, dated 3/20/24, indicated EBP are indicated for residents with any of the following: Infection or colonization with a CDC-targeted MDRO . Centers for Disease Control and Prevention (CDC) website, https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html, titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), accessed on 9/26/24 at 11:00 a.m., indicated ESBL was a CDC-targeted MDRO. 3. During random observations, on 9/25/24, 9/26/24, 9/27/24, 9/30/24, 10/1/24 and 10/2/24, Resident 47 was not on enhanced barrier precautions (EBP) and there was no sign on her door. The clinical record for Resident 47 was reviewed on 9/30/24 at 9:25 a.m. The diagnoses included, but were not limited to, disorder of kidney and bladder and neuromuscular dysfunction of the bladder. A physician's order, dated 7/26/24, indicated foley catheter (indwelling urethral catheter) care every shift. A nurse's note, dated 9/12/24 at 11:59 a.m., indicated the resident's indwelling urethral catheter was draining clear yellow urine. A MDS quarterly assessment, dated 9/6/24, indicated the resident had an indwelling urethral catheter. A care plan, initiated 7/25/24, indicated the resident had a foley catheter related to neurogenic bladder. The clinical record did not include an order for enhanced barrier precautions. During an interview, on 10/01/24 at 3:25 p.m., the Director of Nursing (DON) indicated the resident had an indwelling urethral catheter present and should be on EBP. She did not know why there was no signage on the door or an order. A Centers for Medicare and Medicaid Services (CMS) memorandum QSO-24-08-NH, titled Enhanced Barrier Precautions in Nursing Homes, dated 3/20/24, indicated EBP are indicated for residents with any of the following .indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO .Indwelling medical device examples include .urinary catheters 4. During an observation, on 10/01/24 at 11:02 a.m., there were three pairs of pants and one shirt hanging on the handrail outside of room [ROOM NUMBER]. Resident 18 and Resident 20 were in room [ROOM NUMBER] with contact droplet isolation for Covid. During an interview, on 10/01/24 at 11:04 a.m., CNA 7 indicated the clothes were not supposed to be hanging on the hand railing outside. During an interview, on 10/01/24 at 11:32 a.m., the Housekeeping Manager indicated she told the staff to hang the clothes on the outside of the door so the nursing staff would take it in. Clothes should not be hung on the rails outside the rooms. 49891 5. During a wound care observation, on 10/2/24 at 9:58 a.m., LPN 2 did not change her gloves and did not perform hand hygiene after removing Resident 38's shoe and dirty dressing before cleansing the wound with saline and gauze. She did not change gloves and perform hand hygiene after putting Resident 38's shoe back on and before re-capping the Santyl ointment. The clinical record for Resident 38 was reviewed on 9/26/24 at 3:25 p.m. The diagnoses included, but were not limited to, Parkinson's disease, dementia, muscle weakness, and abnormalities of gait and mobility. A care plan, dated 8/14/24, indicated the resident had an arterial wound on her left ankle. Interventions included, but were not limited to, administering treatments as ordered. A physician's order, dated 9/3/24, indicated the resident's left ankle wound was to be cleansed with normal saline, skin prep was to be applied around the wound, Santyl ointment was to be applied to the wound bed, and the area was to be covered with an island dressing once daily. 6. During an observation, on 9/27/24 at 11:31 a.m., Resident 48 was sitting in his wheelchair and the catheter tubing was on the floor. The clinical record for Resident 48 was reviewed on 9/27/24 at 10:52 a.m. The diagnoses included, but were not limited to, chronic kidney disease, congestive heart failure, hypertension, and major depressive disorder. A care plan, dated 4/9/24, indicated the resident had a foley catheter. Interventions included, but were not limited to, barrier precautions and checking the tubing for kinks each shift. A physician's order, dated 4/9/24, indicated the indwelling catheter tubing was to be secured using an anchoring device to prevent movement every shift. During an interview, on 9/27/24 at 11:34 a.m., the DON indicated the catheter tubing should not be on the floor. A current facility policy, titled Catheter Care, Urinary, dated as revised 8/22 and received from the DON on 9/30/24 at 9:00 a.m., indicated .The purpose of this procedure is to ensure bags are kept off the floor .Check the resident frequently A current facility policy, titled Wound Care, dated as revised October 2010 and received from the Director of Nursing (DON) on 10/2/24 at 11:39 a.m., indicated .Steps in the Procedure .Put on exam glove. Loosen tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. 6. Put on gloves A current facility policy, titled Isolation- Categories of Transmission-Based Precautions, dated 4/2/24 and received from Clinical Support on 9/27/24 at 1:50 p.m., indicated .When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door .so that personnel and visitors are aware of the need for and the type of precaution .(enhanced barrier precautions) .used for residents who .are infected or colonized with MDROs (or have risk factors for MDRO acquisition) A current facility policy, titled Handwashing/ Hand Hygiene, dated 8/19 and received from the Administrator on 10/1/24 at 9:25 a.m., indicated .Use an alcohol-based hand rub .or soap .and water for the following situations .Before and after direct contact with residents c. Before preparing or handling medications .After contact with objects .in the immediate vicinity of the resident .Before and after entering isolation precaution settings A current facility policy, titled Isolation- Categories of Transmission-Based Precautions, dated 4/2/24 and received from Clinical Support on 9/27/24 at 1:50 p.m., indicated .Contact precautions are implemented for residents .infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces .Staff .wear gloves .when entering the room .Gloves are removed, and hand hygiene performed before leaving the room .Staff .wear a disposable gown upon entering the room 3.1-18(b) 3.1-18(l)

Based on record review and interview, the facility failed to ensure the physician was notified timely of a choking episode for 1 of 1 resident reviewed for respiratory infection. (Resident 12) Finding includes: The clinical record for Resident 12 was reviewed on 9/26/24 at 3:59 p.m. The diagnoses included, but were not limited to, chronic kidney disease stage 3, psychotic and mood disturbance, anxiety, and vascular dementia with psychotic behavior. A progress note, dated 9/20/24 at 11:07 p.m., indicated the resident choked on hamburger meat during dinner. The resident was breathing but coughing. The resident was unable to bring the food up. The resident was suctioned to remove phlegm and mucus. The resident continued to cough and when she spoke, she made a gurgling sound. The resident's daughter was notified. A triage form, dated 9/20/24 at 7:00 p.m., indicated the resident had a possible aspiration and requested the nurse practitioner (NP) to assess the resident's lung sounds on Monday (9/23/24). A nurse practitioner's progress note, dated 9/23/24, indicated the resident was seen for an acute visit for a recent coughing episode. The resident experienced an episode over the weekend, during which she required suctioning. The nursing staff reported changes in breath sounds following the episode. During the examination, wheezing was noted throughout the resident's lungs. The choking episode and wheezing raised concern for a possible respiratory issue. The plan was to obtain a 2-view chest x-ray to evaluate for potential pneumonia. Oxygen saturation (percentage of oxygen in the blood) and changes in respiratory exam would be continuously monitored. Follow-up would be scheduled when results were returned or sooner if necessary. A progress note, dated 9/24/24 at 3:04 p.m., indicated the NP reviewed the chest x-ray results. New orders were received for Augmentin (an antibiotic) 800/125 milligrams (mg) for 5 days and to monitor oxygen saturation twice daily for a cough. A physician's order, dated 9/24/24, indicated Ipratropium-Albuterol solution (a medication used to treat lung conditions) 0.5-2.5 mg /3 milliliters (ml) 1 vial inhale orally twice daily for shortness of breath for 10 days. A care plan, dated 9/24/24, indicated the resident had pneumonia. The approaches included, but were not limited to, auscultate lung sounds, listen for crackle and breath sounds due to atelectasis (in aspiration pneumonia rhonchi and wheezing are also present), and monitor and document for mental changes, in the elderly, pneumonia may initially present as mental changes and cough only. During an interview, on 10/01/24 at 2:40 p.m., the Nurse Practitioner indicated she was notified of the episode by the triage note on Monday (9/23/24). A current policy, titled Acute Condition Changes, dated as revised 2017 and received from the Assistant Director of Nursing (ADON) on 10/1/24 at 2:08 p.m., indicated .the facility shall use defined protocol to evaluate and report changes in condition of its residents/patients .physicians shall help identify and manage causes of acute changes of condition (ACOC) .acute changes of condition will be identified and managed properly .residents/patients with acute changes of condition will not experience preventable decline in condition while being treated in the facility .the nursing staff will contact the physician based on the urgency of the situation .for emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour or less) 3.1-5(a)(1) 3.1-5(a)(2) 3.1-5(a)(3)

Based on observation, interview and record review, the facility failed to ensure the correct amount of oxygen was administered as ordered by the physician for 1 of 1 resident reviewed for respiratory care. (Resident 54) Finding includes: During an observation, on 9/25/24 at 2:23 p.m., Resident 54's oxygen concentrator (a device used to provide supplemental oxygen therapy) was set on 2.5 liters per minute (L). During an observation, on 9/26/24 at 12:20 p.m., the resident was sitting in the common area and his portable oxygen tank was set on 4L. The clinical record for Resident 54 was reviewed on 9/27/24 at 10:22 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, hypertension, and chronic kidney disease. A care plan, dated 6/18/24, indicated the resident was on oxygen therapy. Interventions included, but were not limited to, monitor oxygen saturation, monitor for signs and symptoms of respiratory distress, and administer oxygen by nasal cannula as ordered. A physician's order, dated 7/12/24, indicated the resident was to receive 2L of oxygen continuously. During an interview, on 9/25/24 at 12:24 a.m., LPN 4 indicated the resident's oxygen concentrator was on 2.5L. The resident's order was for 2 to 4L depending on the resident. During an interview, on 9/26/24 at 12:25 p.m., the Director of Nursing (DON) indicated the resident oxygen was set on 4L and she was not sure of the resident's order. During an interview, on 9/26/24 at 1:17 p.m., the DON indicated the resident's order was for 2L and the resident was on 4L. The staff should follow the physician's order. A current policy, titled Oxygen Administration, revised 10/2010 and received from the DON on 9/26/24 at 10:40 a.m., indicated .The purpose of this procedure is to provide guidelines for safe oxygen administration .Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration 3.1-47(a)(6)

Based on interview and record review, the facility failed to ensure a staff member treated residents with respect and dignity while providing Activities of Daily Living (ADL) care for 3 of 5 residents being reviewed for ADL care. (Resident B, G and H) The deficient practice was corrected on 12/28/23, prior to the start of the survey, and was therefore past noncompliance. Finding includes: A document, titled Indiana State Department of Health Survey Report System, dated 12/22/23 at 7:30 a.m., indicated CNA 1 was being very abrupt and trying to hurry Resident B during ADL care, to the point, she was in tears. CNA 1 acted as if she had no patience for her. The incident was witnessed by the resident's daughter and other staff members. After the incident investigation was completed, it was determined CNA 1 acted abruptly and, in a haste, to do Resident B's ADL care. The resident felt tearful, since she was hurried to do her morning tasks. After interviews with other residents on the date in question and careful consideration, CNA 1 was relieved of her employment at the facility. A facility document, titled Status Change Notice, dated 12/22/23, indicated CNA 1 was involuntarily terminated from the facility, on 12/22/24, for providing abrupt care with a resident, which was witnessed by a family and staff member. A handwritten statement from CNA 2, dated 12/22/23, indicated the day started out bad. She witnessed CNA 1 being very rushed + [and] abrupt and she came off as she was agitated with a resident. The clinical record for Resident B was reviewed on 7/11/24 at 12:10 p.m. Diagnoses included, but were not limited to, dementia, anxiety, acute respiratory failure with hypoxia, and chronic kidney disease stage 5. A quarterly Minimum Data Set (MDS) assessment, completed on 12/14/23, indicated Resident B had a moderate cognitive impairment. She was totally dependent on the facility staff for mobility. A care plan, dated as initiated on 12/15/23, with a revised date of 6/20/24, addressed the problem the resident required assistance with ADL's related to debility, self-care deficit, respiratory failure, chronic obstructive pulmonary disease, congestive heart failure, and diabetes mellitus. Interventions included, but were not limited to, 12/15/23, monitor for fatigue and provide rest periods as needed. 12/15/23, provide adaptive equipment: wheelchair. 12/15/23, total dependence with two assist using sit to stand lift. 12/15/23, use mechanical sit to stand lift with two staff member's assistance for transfers. A Social Service Director (SSD) progress note, dated 12/22/23 at 9:08 a.m., indicated Resident B's daughter came to the Social Service Director and indicated her mother's aide had been verbally mean to her that morning and physically rough. This same CNA had treated her mother like this before, but she had let it go. She was not going to let it happen anymore. The SSD spoke to the resident, who was crying, and she confirmed with the resident the same aide had been mean to her before and the resident pleaded she did not want that CNA to care for her any longer. A SSD progress note, dated 12/22/23 at 9:14 a.m., Resident G indicated he got along with CNA 1, but she could be a bit rough around the edges when she was in a bad mood. When the resident was asked when the last time CNA 1 was in a bad mood, he indicated that morning. The resident indicated CNA 1 was not mean, but she was rough while getting him out of the bed. A SSD progress note, dated 12/22/23 at 9:21 a.m., the SSD spoke with Resident H to see how his morning had been, and he indicated it could have been better. When asked what happened, he indicated CNA 1 was very grouchy and was not nice while providing care that morning. The resident indicated CNA 1 got a little rough sometimes, which was normal for that CNA to act that way. During a phone interview, on 7/11/24 at 12:30 p.m., Resident B's daughter indicated her mother called her on 12/22/23 and was crying because CNA 1 had gotten her up for lunch, abruptly and quickly with the stand-up lift, while yelling at her. She was afraid she was going to fall out of the stand-up lift because she was shaking as she stood in the stand-up lift, due to the fast pace which CNA 1 was pushing the stand-up lift. When she arrived at the facility, her mother was in the dining room, crying because she did not believe someone would treat her like that. Her daughter indicated her mother deserved to be treated with respect and dignity. Resident B was still upset about the incident with the stand up lift a few days later. She did not want CNA 1 to care for her anymore and she relayed that information to the management staff. During an interview, on 7/11/24 at 11:30 a.m., the Director of Nursing (DON) indicated CNA 1 was terminated for poor customer service due to providing abrupt care with Resident B. A facility document, titled Resident Rights, dated 12/2016 and provided by the DON on 7/12/24 at 3:06 p.m., indicated .Employees shall treat all residents with kindness, respect and dignity. Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to .be treated with respect, kindness, and dignity . The deficient practice was corrected by 12/28/23, after the facility implemented a systemic plan that included the following actions: all the residents on the hallway with Resident B were interviewed, all facility staff were re-educated regarding abuse and neglect, Resident B's care plan was updated, SSD monitored the residents' psychosocial status, and CNA 1 was terminated. 3.1-3(t)

Based on observation, interview and record review, the facility failed to ensure a resident with a diagnosis of Alzheimer's disease who was a known risk for an elopement was kept safe from eloping from the facility property for 1 of 1 resident being reviewed for elopement. (Resident B) The deficient practice was corrected on 9/30/23, prior to the start of the survey, and was therefore past noncompliance. Finding includes: An incident report to the Indiana Department of Health (IDOH), dated 10/2/23, indicated an elopement event involving a resident occurred on 9/29/23 at 5:55 p.m. A staff member returning to the facility, on 9/29/23 at 5:55 p.m., observed Resident B at the edge of the property by a mailbox of the neighboring property. She stopped and brought the resident back into the facility, then reported the incident. The root cause of the elopement was while a visiting family member came in and out of the facility, the resident followed the family member out of the facility. The resident thought she was going home. The temperature that day was 73 degrees Fahrenheit, and it was sunny outside. The resident was fully clothed at the time of the incident. On 10/11/23 at 11:23 a.m., Physical Therapist 1 was observed using a rolling measuring wheel (used to measure steps or feet while walking) from the middle of the main dining room and walking to the mailbox at the house across the street from the facility. The resident propelled herself 537 feet from the main dining room to the mailbox. The Executive Director (ED) indicated the elopement incident occurred at dinnertime, approximately at 5:45 p.m. She had been in the dining room eating and left the dining room, but a staff member had redirected her to her room and the staff member thought she went back to her room. She was an elopement risk prior to eloping. The facility did not have a wanderguard door system to prevent residents who were diagnosed with Alzheimer's from leaving the facility. They thought the resident got out of the facility because a 12-[AGE] year-old girl was running in and out of the facility. The girl would go out to her car, then run back into the facility to visit her grandma, then go back out the front doors. She did this at least three times. The thought was when the girl ran back inside, the resident was sitting in the lobby, waited for the door to open, then propelled herself out the front door and down the road towards town. The ED indicated Resident M can propel herself at a fast pace in her wheelchair, as if she was walking with her feet, in the wheelchair. The record for Resident M was reviewed on 10/11/23 at 2:15 p.m. Diagnoses included, but were not limited to, cerebral infarction, Alzheimer's disease, and chronic obstructive pulmonary disease. The resident's admission Minimum Data Set (MDS) assessment, dated 8/18/23, indicated her Brief Interview for Mental Status was a three, which indicated she was severely cognitively impaired. Her functional status indicated her locomotion on and off the unit was a setup help only with the assistance of one person. A progress note, dated 9/29/23 at 6:00 p.m., indicated the resident was found by QMA 4 outside in front of the facility right by the road at 5:55 p.m. The resident was looking for her kids and she decided if they were not coming to the facility, then she would go home. Two CNAs observed her leaving the dining room indicating she was looking for her children. Both CNAs suggested for her to go to the 100 or 400 hallways. She started to go down the 400-hallway, so both CNAs went back to the dining room. The only way the resident got out without setting off an alarm was if she turned around and headed to the front of the facility as the two CNAs went to the dining room to finish meal prep. The young girl with the family repeatedly went in and out the sliding glass front door. Most likely, she followed the young girl out the front door. The resident had a care plan, dated 8/15/23, which addressed the problem she had impaired cognitive function/dementia or impaired thought processes related to dementia. Approaches included, but were not limited to, 8/15/23, cue, reorient and supervise as needed. During an interview, on 10/11/23 at 12:00 p.m., QMA (Qualified Medication Aide) 4 indicated she was on her way back to the facility to work on an art project when she saw Resident M propelling herself down the side of the road, across the street from the facility in the gravel part of the side of the road. She knew who the resident was because she had taken care of her before. When QMA 4 asked her what she was doing, she indicated she was looking for her kids. She got the resident to get into her vehicle, then brought her back to the facility. The resident did have dementia. During an interview, on 10/11/23 at 1:51 p.m., RN 5 indicated, on 9/23/22, she had tried to get the resident to go to the dining room, but she did not want to go in there. Approximately 10 minutes after RN 5 was in the dining room, QMA 4 brought the resident in from her vehicle. A current policy, titled Emergency Procedure-Missing Resident, dated August 2018 and provided by the Director of Nursing on 10/11/23 at 11:40 a.m., indicated Resident elopement resulting in a missing resident is considered a facility emergency. Policy Interpretation and implementation: 1. Residents at risk for wandering and/or elopement will be monitored, and staff will take necessary precautions to ensure their safety. 2. Staff will implement the protocol for missing resident immediately upon discovering that a resident cannot be located The deficient practice was corrected by 9/30/23, after the facility implemented a systemic plan that included the following actions: The facility investigated the incident involving Resident M. The Executive Director notified the required state agencies. The Maintenance Director checked the function of all exit doors. Current residents in the facility were assessed for elopement risk and care plans for residents identified as being at risk for were reviewed and updated. Elopement books were reviewed. An elopement drill was completed. Education was initiated for staff and an AD Hoc Quality Assurance Performance Improvement meeting was held with the Medical Director by phone. This Federal tag relates to Complaint IN00418739. 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure a resident had a physician's order for a dressing and to address a wound found on admission for 2 of 2 residents reviewed for non-pressure skin conditions. (Resident E and 362) Findings include: 1. During an observation, on 8/7/23 at 1:44 p.m., Certified Nursing Assistant (CNA) 5 and CNA 6 were providing incontinence care for Resident E. When CNA 6 removed the resident's pants, a dressing was noticed on the resident's left lower leg. The leg had a stretchy wrap from approximately four inches from the knee to the ankle. There was approximately one inch of a white pad sticking out of the top of the stretchy wrap. The record for Resident E was reviewed on 8/4/23 at 3:44 p.m. Diagnoses included, but were not limited to, dementia, macular degeneration, pain in thoracic spine, and repeated falls. During an interview, on 8/7/23 at 1:45 p.m., CNA 5 indicated she worked on 8/4/23 and did not remember the dressing on the resident's leg. During an interview, on 8/7/23 at 1:46 p.m., CNA 6 indicated she had no idea why she had the dressing and thought maybe it was from a fall over the weekend. During an interview, on 8/7/23 at 1:50 p.m., the Director of Nursing (DON) indicated she did not know why the resident had the wrap and the resident needed to have an order for the dressing. During an interview, on 8/7/23 at 4:00 p.m., the DON had talked to the hospice agency and her nursing staff, and no one knew why the dressing was on the resident's leg. The CNAs working indicated the dressing was not there on 8/4/23 and there should have been an order on the Medication Administration Record (MAR) for any dressings. 48525 2. During an observation, on 8/1/23 at 1:55 p.m., Resident 362 was sitting up in a chair and had a red open area on her right shin without a dressing. During an observation, on 8/3/23 at 10:42 a.m., the resident was sitting up in a chair with a dressing to her right shin covering up the open area. The record for Resident 362 was reviewed on 8/3/23 at 10:30 a.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease, dementia, and congestive heart failure. An admission nursing assessment, dated 7/25/23 at 2:30 p.m., indicated the nurse noted multiple wounds on the resident's legs and feet. The nurse who completed the assessment had put the wound notes in the comment section instead of the wounds section. A physician's order, dated 8/3/23, indicated the facility was to do wound care to both feet and legs every day and as needed. The resident went eight (8) days with no wound treatments to the open areas on the right shin. During an interview, on 8/3/23 at 12:04 p.m., RN 4 indicated the resident admitted to the facility with wounds to her legs and feet. During an interview, on 8/7/23 at 11:18 a.m., the Wound Charge Nurse indicated the resident came into the facility with the wounds. The wound care was not triggered since the staff nurse put the admission wound information in the comment section and not the wound section. The facility should have notified the doctor when the initial skin assessment was completed to obtain orders for the wound treatment. A current policy, titled Dressing Changes, dated 11/21/14 and received from the Clinical Support Nurse on 8/7/23 at 3:39 p.m., indicated .Infection control practices regarding dressing changes is followed to assist in prevention of exposure to infectious situations by reducing the number of instances of individual exposure to harmful substances .the following general guidelines will be followed: Review the physicians order regarding dressing changes .Administer treatment as ordered by the physician A current policy for resident assessment was requested but was not provided by exit conference. 3.1-37(a)

Based on record review and interview, the facility failed to notify the physician of a significant weight loss and to ensure the resident received nutritional interventions in a timely manner for 1 of 5 residents reviewed for nutrition. (Resident 45) Finding includes: The record for Resident 45 was reviewed on 8/3/23 at 12:06 p.m. Diagnoses included, but were not limited to malignant neoplasm of the left breast and mild cognitive impairment of an unknown cause. The resident had the following weights: 1. On 4/24/23, the weight was 95.2 pounds. 2. On 5/5/23, the weight was 89.5 pounds which was a significant weight loss of 5.99% in 9 days. A physician order, dated 5/13/23, indicated Remeron (an appetite stimulant) was ordered. The intervention was implemented 8 days after the significant weight loss occurred. A physician notification of the significant weight loss was not noted in the Electronic Record from 4/24/23 to 5/13/23. During an interview, on 8/3/23 at 3:19 p.m., the Assistant Director of Nursing indicated the physician should be notified of a significant weight loss. The Nurse Practitioner (NP) was notified on 5/13/23 when the order for Remeron was received. The notification to the NP occurred 8 days after the significant weight loss occurred. A current policy, titled Change in a Resident's Condition or Status, dated as revised February 2021 and received from the Director of Nursing on 87/23 at 3:43 p.m., indicated .Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status .The nurse will notify the resident's attending physician or physician on call when there has been a .significant change in the resident's physical/emotional/mental condition .A 'significant change' of condition is a major decline or improvement in the resident's status that .will not normally resolve itself without intervention by staff or implementing stand disease-related clinical interventions .impacts more than one area of the resident's health status A current policy, titled Significant Weight Loss, dated as revised 4/2021 and received from the Executive Director on 8/8/23 at 12:03 p.m., indicated .The goal of medical nutrition therapy [MNT] is to identify underlying causes or factors contributing to the significant unplanned weight loss, and intervene as appropriate to resolve the problem and stabilize the weight .Appropriate members of the interdisciplinary team will .Identify individuals with significant weight losses .Weight loss .5% weight loss in 1 month .Assess whether or not the weight loss was desirable [avoidable or unavoidable], and document accordingly .Request/implement nutrition interventions based on the individual case 3.1-46(a)(1)

Based on observation, interview and record review, the facility failed to assess and document the post dialysis and daily observation for 1 of 1 resident reviewed for dialysis. (Resident 22) Findings include: The record for Resident 22 was reviewed on 08/03/23 at 10:02 a.m. Diagnoses included, but were not limited to, dependence on renal dialysis, and stage 4 chronic kidney disease. A care plan, dated 7/15/23, indicated the resident needed hemodialysis related to ESRD (end stage renal disease). The interventions included, but were not limited to, emergency care of shunt: apply pressure and call 911, monitor vital signs (blood pressure, pulse, etc.), notify physician of significant abnormalities, monitor signs and symptoms of infection, monitor, document, and report symptoms of renal insufficiency (poor kidney function), bleeding, or worsening peripheral edema. A progress note, dated 6/19/23 at 11:15 a.m., indicated the resident was at dialysis. The resident left at 9:45 a.m. for dialysis appointment with Quality Care Transport. A progress note, dated 6/23/23 at 9:46 a.m., indicated the resident was transported to dialysis per Quality Care ambulance. A progress note, dated 8/2/23 at 9:45 a.m., indicated the resident was on leave of absence to dialysis. There were no post dialysis notes in the electronic medical record. During an interview, on 8/7/23 at 11:12 a.m., the Assistant Director of Nursing indicated the resident went to dialysis on Monday, Wednesday, and Friday. During an interview, on 8/7/23 at 1:31 p.m., the Director of Nursing indicated the resident did not have a shunt/graft, as indicated in the care plan, but had a line in the subclavian area. During an interview, on 8/7/23 at 2:50 p.m., the Director of Nursing indicated there was a sign off form in the dialysis binder when the resident was returned from dialysis, it was signed and verified by facility staff and remained in the binder. The form contained information sent to the dialysis unit and returned with information from dialysis. She did not have a post dialysis assessment. A current policy, titled Hemodialysis Access Care, with a revision date of 9/2010 and received from the Director of Nursing on 8/7/23 at 1:30 p.m., indicated .the general medical nurse should document in the resident's medical record every shift as follows .location of catheter, condition of dressing (interventions if needed) .if dialysis was done during the shift .any part of report from dialysis nurse post-dialysis being given .observations post - dialysis 3.1-37(a)

Based on record review and interview, the facility failed to ensure the mandatory submission of staffing information, Payroll Based Journal (PBJ), was electronically submitted to the Centers for Medicare and Medicaid Services (CMS) in a timely manner for the 2nd Quarter of 2023. (1/1/2023-3/31/2023) Finding includes: Staffing information was reviewed on 8/1/23 at 1:40 p.m. During an interview with the Administrator, on 8/1/23 at 1:40 p.m., the Certification and Survey Provider Enhanced Reports 3 (CASPER 3) was given to the Administrator. He indicated he was checking on why all areas were triggered in the Payroll Based Journal (PBJ), he knew they turned it in so he will call Corporate. During an interview with the Administrator, on 8/1/23 at 4:40 p.m., he indicated he spoke with Corporate about the PBJ information. Corporate indicated they received the information on time from the facility but unfortunately it was not turned in on time. Corporate office staff had it on their desk and it was not turned in timely.

Based on observation, interview and record review, the facility failed to ensure staff wore gloves when performing a blood glucose check for 1 of 5 residents reviewed for medication administration. (Resident 29) Finding includes: During an observation, on 8/2/23 at 12:12 p.m., RN 2 entered the dining room holding an accu check machine (to test blood sugar levels), an alcohol swab and a lancet. She approached the resident and bent down holding the accu check machine under the table. She began talking to the resident and cleaned the resident's finger with an alcohol swab. The nurse did not have gloves on and took the lancet and stuck the resident's finger. She obtained the blood and finished the accu check. The record for Resident 29 was reviewed on 8/4/23 at 4:03 p.m. Diagnoses included, but were not limited to, type 2 diabetes, chronic kidney disease, atrial fibrillation, dementia, and anxiety disorder. During an interview, on 8/2/23 at 12:15 p.m., RN 2 indicated she did not know what the facility policy said about accu checks and she should not have done a blood sugar check in the dining room without gloves. During an interview, on 8/2/23 at 12:30 p.m., the Director of Nursing (DON) indicated the facility policy was to wear gloves when doing an accu check and not to do one in the dining room. A current policy, titled Blood Glucose Monitoring, dated 5/17/16 and received from the Director of Nursing on 8/2/23 at 12:30 p.m., indicated .The nurse will assist the resident with blood glucose monitoring to obtain a quantitative measure of blood glucose as ordered by the physician .Assemble equipment and take to bedside/resident. Explain procedure and provide privacy. Wash hands & apply gloves .Remove gloves and wash hands A current policy, titled Medication Administration, dated as revised on 4/2019 and received from the Director of Nursing on 8/7/23 at 3:40 p.m., indicated .Medications are administered in a safe and timely manner .Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable 3.1-18(b) 3.1-18(l)

Based on interview and record review, the facility failed to ensure a resident received the pneumococcal immunization and/or notified the physician when the resident or resident's representative had questions or concerns for 1 of 5 residents reviewed for immunizations. (Resident 6) Finding includes: The record for Resident 6 was reviewed on 8/7/23 at 9:59 a.m. The immunization record indicated the resident did not have a pneumococcal immunization. During an interview, on 8/7/23 at 3:36 p.m., the DON (Director of Nursing) indicated the family was concerned with getting the vaccination. The MD (Medical Doctor) had been notified of the situation and was waiting to hear back about a decision. During an interview, on 8/7/23 at 3:42 p.m., the ADON (Assistant Director of Nursing) provided a note, dated 8/7/23 at 8:36 a.m., which indicated the facility contacted the MD and was waiting for a call back about getting the health clearance for the vaccination. There was no documentation to support the facility contacted the MD in a timely manner about the family's concern since the resident was admitted on [DATE]. A current policy, titled Pneumococcal Vaccine, dated as revised in October 2019 and received from the DON at 1:00 p.m., indicated .Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated 3.1-13(a)(1)

Based on observation, interview and record review, the facility failed to assess, monitor and document a bruise from an unknown origin throughout the healing process for 1 of 1 resident reviewed for non-pressure skin areas. (Resident C) Finding includes: A report, titled Indiana State Department Health Survey Report System, undated, indicated on 11/08/22 at 10:01 a.m., a bruise was observed on Resident C's left arm with an unknown origin. After further investigation, the resident indicated CNA 1 grabbed her left arm during a bed change, but the facility did not substantiate allegations of abuse against CNA 1. A written statement by the Director of Nursing (DON), dated 11/8/22, indicated there were no visible handprints on Resident C's left arm. The record for Resident C was reviewed on 12/7/22 at 3:30 p.m. Diagnoses included, but were not limited to, encephalopathy, chronic obstructive pulmonary disease, depression, pain, and generalized muscle weakness. Resident C's quarterly MDS (Minimum Data Set) assessment, dated 10/5/22, indicated she had a BIMS (Brief Interview Mental Status) assessment score of 14, which indicated she was cognitively intact. She required extensive two-person physical assist for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use and personal hygiene. Bathing required extensive assist with one person. The resident's record lacked progress notes, a skin observation tool assessment, and an observation/event monitoring documentation to indicate the bruise on the resident's left arm observed, on 11/8/22, had been assessed and was being monitored throughout the healing process. The last completed Skin Observation Tool, dated 11/4/22 at 10:27 a.m., indicated the resident had no red, open or bruise areas noted at the time. During an interview, on 12/7/22 at 3:33 p.m., the Assistant Director of Nursing (ADON) indicated she observed a bruise on Resident C's left arm. The bruise was a purple and the size of a dime when she found it on 11/8/22. She did not document an assessment of the bruise in her records, but she was sure the nurse caring for her assessed and documented it. The facility did not typically follow through with monitoring, such as measuring small bruises like the one she found on the resident. The nurses would document whether the bruise was still present or not. On 12/8/22 at 2:38 p.m., Resident C was observed lying, in her bed, with her right arm propped up on two pillows. She had a faintly yellow bruise noted just above her wrist area. When asked if she knew how she got the bruise, she indicated an unidentified CNA grabbed her arm and she demonstrated how she grabbed her arm. During an interview, on 12/8/22 at 3:00 p.m., the DON indicated the bruise on Resident C's left forearm was a small yellow bruise when the ADON observed it on 11/8/22. She would check for the assessment, monitoring and documentation of the bruise. During an interview, on 12/8/22 at 5:25 p.m., the Executive Director (ED), DON and ADON was in attendance. The ED indicated they did not have the measurements for resident's bruise to her left arm. The ADON indicated she thought the dayshift nurse on 11/8/22, was going to assess and document the bruise and the dayshift nurse thought she was going to assess and document the bruise. Neither of them assessed or documented it. The DON indicated there was no documentation of an assessment or monitoring of the bruise through the healing process. A current facility policy, titled Facility Responsibilities for Reporting Allegations, dated as revised September 2022 and provided by the DON on 12/7/22 at 12:53 p.m., indicated The following addresses facility responsibilities for .injuries of unknown source .Injuries on Unknown Source NOT Required to Report .NOTE: Even if the injury is not one that requires a report, the facility should adequately assess and monitor the resident, notify the physician/resident representative as appropriate, and document the injury and investigation as a part of the resident's medical record 3.1-37(a)

Based on record review and interview the facility failed to submit an updated Preadmission Screening and Resident Review (PASARR) after a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident 2) Finding includes: Resident 2's clinical record was reviewed on 9/14/22 at 1:02 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A level one PASARR was completed on 2/25/22 with no mental illness diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nursing Progress Note, dated 5/16/22 at 3:55 p.m., indicated the resident was transported to a psychiatric hospital. A Nursing Progress Note, dated 5/31/22 at 11:00 a.m., indicated the resident returned from the psychiatric hospital. A Nursing Progress Note, dated 5/31/22 at 3:27 p.m., indicated the Psychiatric Nurse Practitioner (NP) evaluated the resident and added the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview, on 9/15/22 at 9:58 a.m., the Social Services Director (SSD) indicated the Minimum Data Set (MDS) assessment coordinator typically completed the PASARR. She indicated the PASARR should have been submitted with the identification of the delusional disorders and would check with the MDS coordinator. During an interview, on 9/15/22 at 10:00 a.m., the SSD indicated an updated PASARR with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A current facility policy with an effective date of 6/25/17, titled PASARR (Preadmission Screening and Resident Review) and provided by the Director of Nursing (DON) on 9/16/22 at 2:51 p.m., indicated .It is the policy of the facility to coordinate the assessment process with the preadmission screening and annual resident review (PASARR) program under Medicaid in Subpart C to the extent practicable to avoid duplicative testing and effort. This includes incorporating the recommendations from the PASARR level ll determination and evaluation in the residents' assessment, care plan, and transition of care; and referring all level ll residents and all residents with new or evident conditions related to Level ll review upon significant change in status assessment . 3.1-16(d)

Based on interview and record review, the facility failed to ensure a resident, who had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident 31). Finding includes: Resident 31's clinical record was reviewed on 9/16/22 at 9:40 a.m. Current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a current 4/26/22 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a current care plan problem/need regarding The resident has [CONDITION(S)] [CHF]. This problem originated, 9/9/2021. Approaches to this problem included, but were not limited to, Monitor/document/report PRN [as needed] any s/sx [signs and symptoms] of [CONDITION(S)]: dependent [CONDITION(S)] of legs and feet, periorbital [CONDITION(S)], SOB [shortness of breath] upon exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles and wheezes upon auscultation of the lungs, Orthopnea, weakness and/or fatigue, increased heart rate ([CONDITION(S)]) lethargy and disorientation. A 9/4/22, hospital discharge summary indicated the resident was admitted to the hospital on 9/3/22. The discharge summary included but was not limited to the following: Problem focused hospital course: . chest radiograph showing cardiomegaly, and pulmonary venous congestion Chronic diastolic CHF .The heart is enlarged and there is pulmonary venous congestion . Review of the resident's weight record for July 1 2022 to September 12, 2022 (a 74 day period of time) indicated the following: The resident did not have documented refusal or documented weights for 31 of 74 days 7/1/22, 7/4/22, 7/5/22, 7/7/22, 7/13/22, 7/14/22, 7/15/22, 7/17/22, 7/18/22, 7/19/22, 7/21/22, 7/23/22, 7/25/22, 7/26/22, 7/28/22, 7/29/22, 7/31/22, 8/2/22, 8/4/22, 8/8/22, 8/9/22, 8/11/22, 8/14/22, 8/15/22, 8/18/22, 8/19/22, 8/20/22, 8/21/22, 8/23/22, 8/7/22, and 9/12/22. During an interview on 9/16/22 at 3:33 p.m., the Director of Nursing (DON) indicated the resident often refused to be weighed because she found getting out on bed to be painful. The staff had been lax in documenting the resident's refusals. The facility had informed the physician of the resident's refusal on this day. The physician had discontinued the daily weights on this date (9/16/22). She indicated the facility had not evaluated and identified other alternative methods to assess the resident for [CONDITION(S)]. 3.1-37

Based on interview and record review, the facility failed to provide ordered medications for 1 of 10 residents reviewed for medication use. (Resident 65) Finding includes: During an observation, on 9/12/22 at 2:05 p.m., Resident 65 was sitting in his recliner in his room with his eyes closed. He did not respond to his name. In an interview at the time of the observation, the resident's wife indicated he had times when he was so tired, he barely opened his eyes. The resident's clinical record was reviewed on 9/13/22 at 1:18 p.m. Diagnoses included, but were not limited to, somnolence. A Nursing Progress Note, dated 9/2/22 at 6:36 p.m., indicated the physician saw the resident on rounds and ordered [MEDICATION(S)] (stimulant) 5 milligrams (mg) daily. A Nursing Progress Note, dated 9/3/22 at 11:56 a.m., indicated [MEDICATION(S)] was not given because of waiting on delivery. A Nursing Progress Note, dated 9/5/22 at 8:10 a.m., indicated [MEDICATION(S)] was not given because the medication was not available. A Nursing Progress Note, dated 9/7/22 at 10:20 a.m., indicated [MEDICATION(S)] was not given because the medication was not available A Nursing Progress Note, dated 9/8/22 at 9:07 a.m., indicated [MEDICATION(S)] was not given because it was not in the facility or in the emergency drug kit (EDK). A Nursing Progress Note, dated 9/9/22 at 8:39 a.m., indicated [MEDICATION(S)] was not given because the medication was not available. The Nursing Progress Notes lacked documentation of notification of the physician or pharmacy of the unavailability of [MEDICATION(S)]. During an interview, on 9/13/22 at 3:35 p.m., the Director of Nursing (DON) indicated she would investigate why [MEDICATION(S)] was unavailable to be administered to the resident until 9/10/22. During an interview, on 9/13/22 at 3:53 p.m., the DON indicated the administration of the [MEDICATION(S)] was delayed because a written script for the medication was not given to the pharmacy by the physician. The Nurse Practitioner (NP) wrote the script for the [MEDICATION(S)]. The pharmacy sent the medication once the script was received. During an interview, on 9/15/22 at 2:39 p.m., Licensed Practical Nurse (LPN) 2 indicated when a resident's medication was unavailable, she would look through the resident's back up medications. Next, she would check the EDK. Then, she would notify the pharmacy and the physician. During an interview, on 9/16/22 at 12:07 p.m., Registered Nurse (RN) 3 indicated when a medication was unavailable in the medication cart, she checked the EDK. Next, she would notify the pharmacy to get an emergency delivery if the medication was needed emergently. Then, she would notify the physician or NP. A current facility policy with an effective date of 6/21/17, titled Medication Administration and provided by the DON on 9/16/22 at 11:54 a.m., indicated . If a medication is unavailable, contact the pharmacy and document accordingly . 3.1-25(a)

Based on observation, interview and record review, the facility failed to ensure a resident was free from accident hazards when the facility failed to complete an assessment prior to the use of a stand up lift for 2 of 3 residents reviewed for falls (Residents B and D) and failed to identify the root cause of a fall for 1 of 3 residents reviewed for falls (Resident B). Resident B was transported to the ER after a fall which resulted in a fractured humerus (the arm bone between the shoulder and elbow). Findings include: 1. During an observation, on 8/25/21 at 1:03 p.m., Resident B was sitting up in a wheelchair in the dining room. She had a sling on her right arm and her right foot was elevated on the wheelchair footrest. The record for Resident B was reviewed on 8/25/2021 at 12:45 p.m. Diagnoses included, but were not limited to, generalized muscle weakness, [CONDITION(S)] (paralysis of one side of the body) and [CONDITION(S)] (weakness or the inability to move one side of the body) following a cerebral infarction affecting the right dominant side and a history of falling. A care plan, dated 7/20/21, indicated the resident had a risk for falls related to a new environment, a history of falls and weakness. The interventions included, but were not limited to, refer to PT(physical therapy), OT (occupational therapy) and ST (speech therapy) as needed. A care plan, dated 8/2/21, indicated the resident had an ADL (activities of daily living) self-care deficit related to [CONDITION(S)]/[CONDITION(S)] to her right arm from an old [CONDITION(S)] ([CONDITION(S)] accident). The interventions included, but were not limited to, on 8/2/21 the resident required a stand up lift for transfers. An Occupational Therapy (OT) Evaluation and Plan of Treatment, dated 7/22/21, indicated the resident had impaired left and right upper arm strength and had poor standing balance during ADLs. The resident presented with impairments in balance, dexterity, fine motor coordination, mobility, strength, planning and problem solving resulting in limitations and/or participation restrictions in the areas of mobility and self-care. The OT Evaluation and Plan of Treatment, dated 7/22/21, did not include the use of a stand up lift or Hoyer lift for transfers. A Physical Therapy (PT) Evaluation and Plan of Treatment, dated 7/22/21, indicated the resident had poor static standing and had impaired right and left lower leg strength. The Clinical Impressions included the resident presented with significant limitations to functional mobility. The PT Evaluation and Plan of Treatment, dated 7/22/21, did not include the use of a stand up lift or Hoyer lift for transfers. A progress note, dated 8/9/21 at 10:55 a.m., indicated the CNA was getting the resident out of the bathroom and the resident started sliding out of the stand-up lift. The CNA lowered her to the floor. When the nurse arrived to the room, the stand-up lift arms were fully extended and the resident was sitting on the floor in front of the lift. The resident had pain in her right arm and shoulder. The right arm was more relaxed than usual and the wrist area was turned in. A progress note, dated 8/9/21 at 11:05 a.m., indicated the ambulance was on the way to get the resident. A progress note, dated 8/10/21 at 1:14 p.m., indicated the fall follow up included an injury and the resident had a fractured right humerus. A Facility Fall report, dated 8/9/2020 at 10:40 a.m., indicated the resident slid out of the stand-up lift and was lowered to the floor. The resident was sent to the ER for evaluation. She had a bruise in her right upper inner arm. The predisposing factors indicated the resident had a gait imbalance, used a wheeled walker and used a stand up lift for transfers. The Facility Fall report did not include a root cause of the fall. An Emergency Medicine note, dated 8/9/21 at 11:56 a.m., indicated the resident presented to the emergency room (ER) for an evaluation of right shoulder pain. The diagnoses management comments indicated the resident slipped out of a harness and onto the floor and landed mostly on her right side. She had extensive bruising of her right upper arm, the right wrist and an abrasion in her right antecubital fossa (a depression on the anterior of the elbow joint). A Radiology Report, dated 8/9/21 at 1:02 p.m., indicated the resident had a fall during a Hoyer lift transfer and zero mobility with her right arm. The impression indicated the resident had a humeral neck fracture of the right arm. During an interview, on 8/25/21 at 3:36 p.m., the Physical Therapist (PT) 2 indicated the resident had a contracted right hand from an old stroke. She needed maximum assist for transfers and her right lower extremity strength was a 3 minus which indicated she can't move against gravity with full range of motion. Her static standing was poor with both of her legs and she was not able to move through a full range of motion partly due to weakness and partly due to her having large swollen legs. The definition of poor static standing was maximum assistance and upper extremity support to maintain standing and being unable to shift weight. The resident would not need to shift weight to use the stand-up lift and she was able to hold on to the lift with her left hand. She could not hold the lift with her right hand due to the contracture. During an interview, on 8/25/21 at 4:11 p.m., the Director of Nursing (DON) indicated there was no assessment in the electronic record for the use of the stand-up lift. The facility policy did not include assessing a resident's weight bearing status prior to the use of the stand-up lift. During an interview, on 8/25/21 at 4:32 p.m., the PT 2 indicated he would make verbal recommendations about the use of a lift, however this verbal recommendation would not be documented. During an interview, on 8/26/21 at 11:36 a.m., the DON indicated the facility would talk with physical therapy about the use of a lift but would not document what the therapist recommended. There was no documentation of the root cause of the fall for Resident B. During an interview, on 8/26/21 at 12:08 p.m., CNA 3 indicated she got Resident B up like normal with the stand-up lift and assisted her to the restroom. All of a sudden the resident's legs went straight out and she went down. CNA 3 held the resident by her pants, unclasped the sling and eased the resident to the floor. The sling and the buckle had to be removed and the resident's arm might have been bumped while removing the sling. The resident's right arm was contracted and she could not extend it. She could grab the lift handle with her left hand. The resident's right arm would be put under the sling during the transport. During an interview, on 8/26/21 at 12:35 p.m., the [name of company] stand-up lift representative indicated the stand-up lift had two types of attachments. The first one was the belt and it went around the lower back. The resident must be at a 20% weight bearing at a minimum although this could vary based on the physical therapist recommendations. If the resident was more flaccid on top and could bear more weight this type of belt would not work as well. If the resident's shoulders were shrugging during the stand-up lift while using the belt then the transport attachment should be used. The muscle tone and how flaccid a resident was would determine if the belt could be kept straight on the lower back. He indicated there was no requirement the resident would have to hold onto the lift. If the resident locked their legs during the transport, they would be fully supported and could not fall out. The resident's arms needed to be on the outside of the belt. The representative indicated he had [AGE] years' experience with this type of lift. During an interview, on 8/26/2021 at 12:45 p.m., the DON indicated the facility did not have the transport attachment and only used the belts for the stand-up lift. 2. During an observation, on 8/25/21 at 1:17 p.m., Resident D was assisted to the toilet from her wheelchair by CNA 4 and a stand-up lift. The record for Resident D was reviewed on 8/26/21 at 12:30 p.m. Diagnoses included, but were not limited to, cerebral infarction, type 2 diabetes mellitus, dementia without behavioral disturbance and chronic pain. A care plan, dated 3/23/21, indicated the resident had a risk for falls related to a new environment, weakness and a balance problem. The interventions included, dycem in chair on 7/20/21, OT/PT evaluate for transfers on 8/5/21, keep frequently used items within reach on 3/23/21, ensure appropriate footwear when out of bed on 3/23/21, and educate and remind resident of safety awareness such as locking brakes on wheelchair, asking for assistance before transferring and call light use on 3/23/21. The care plan did not include the use of a stand up lift. A care plan, revised on 4/5/21, indicated the resident had an ADL self-care deficit related to dementia. The interventions indicated the resident required extensive assistance with transfers. The care plan did not include the use of a stand up lift. During an interview, on 8/26/21 at 2:15 p.m., the DON indicated the resident did not have a care plan for the use of the stand lift and did not have an assessment for the use of the stand lift. A current policy, titled Fall Management, dated 6/25/17 and received from the DON on 8/25/21 at 12:51 p.m., indicated .A fall risk observation is used to identify individuals who are a high risk for falls, as well as those individuals who have any risk factors for falls .Communicate residents risk status and interventions to care givers .Fall prevention is achieved through an interdisciplinary approach of managing risk factors implementing appropriate interventions to reduce risk for falls .Develop a plan of care which can include general and specific interventions to reduce falls risk .Response to a resident fall .Begin fact finding and complete a post-fall huddle to explore contributing factors .Complete a fall risk observation to identify any causes that may have contributed to the fall .Complete a root cause analysis .and determine an intervention based on the root cause .Implement intervention [immediate] after the fall. As the investigation continues the root cause analysis may trigger additional interventions to resident plan of care A current policy, titled Hoyer Lift, revised on 02/24/15 and received from the DON on 8/25/21 at 12:51 p.m., indicated .Total Hoyer lift should be used for residents who are immobile or who are non-weight bear .Standup Hoyer lift should be used for residents with limited mobility .STANDUP HOYER [requires assist of one] .Positioning belt around resident in seated position .The belt offers comfortable support for residents capable of standing upright and grasping lift bar .The standard belt is used for residents that have consistent and reliable motor functions .Position the belt around the resident's lower back, just above the belt line .Fasten safety strap around resident to secure .Attaching belt to stand-have the resident place their feet on the foot support plate, [assist if necessary] with their shins against the shin support pad. For added stability, fasten strap around calves .Position the resident's arms on the outside of the harness and place their hands on the padded handles A [Name of Company] Operation Manual for Care Lifts and Care Stands dated as revised on 2/08 and received from the DON on 8/25/2021 at 4:37 p.m., indicated .IMPORTANT: Read this manual before operating [Name of Company] Lift and Stand equipment .The [name of company] Stand was designed specifically for assisting your residents/patients to a standing position. Once in a standing position, you or your staff can safely perform a number of resident/patient care tasks .Because the Stand is an assistive device, it should only be used with residents/patients that can bear the requisite amount of weight as determined by your facility. It also requires that resident/patients possess more advanced motor skills than for the [Name of Company] Lift. It is important to first determine the appropriateness of this piece of equipment for a particular resident/patient .If you need help in assessing a resident's/patient's weight-bearing ability, please ask your therapy department for assistance .Care Belt .This belt offers comfortable support for residents/patients capable of standing upright and grasping lift bar .The standard belt .is used for residents/patients that have consistent and reliable motor functions .Position the top of the belt around the upper body of the resident/patient, just below the shoulder blades and under the arms .TIP: an assessment of each resident's/patient's ability to bear weight should be performed prior to using the Care Stand .Transport Attachment .The Transport Attachment slides over the Care Belt and provides full seat support for those residents/patients less able to assist the lifting process This Federal Tag relates to Complaint IN 425. 3.1-45(a)(1)

Based on observation, record review and interview the facility failed to completely assess a resident receiving anticouagulant therapy resulting in a hospitalization after a fall and failed to recognize and evaluate for a foreign body obstruction in a resident care planned for placing foreign objects in her mouth resulting in hospitalization and surgery for [REDACTED]. (Resident B and Resident C). Findings include: The record for Resident B was reviewed on 2/2/17 at 10:00 a.m. [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. Care Plans for 7/26/16 identified the resident as a fall risk, approaches included, but were not limited to, encourage to move legs, call light in reach, anticipate needs, encourage to ask for assistance, and monitor for changes in level of consciousness. Revision of the care plan dated 12/18/16 at 10:49 a.m., included a sensor pad in bed. A 4/29/16 care plan identified the resident as having alteration in though processes, safety awareness, manifested by difficulty with decision making. Approaches included, but were not limited to, encourage participation in activities, reorient as necessary, allow to vent, and involve family. A fall assessment completed on 10/6/16 indicated Resident B had a score of 15. This score indicated a high risk for falling. A review of an incident report received on 2/3/17 at 1:26 p.m., from the Assistant Director of Nursing (ADON) indicated on 12/18/16 the nurse on duty reported at 4:57 a.m., she heard something thud and the resident was observed laying on the floor with her head against the edge of the room door. The nurse reported the bed alarm and bathroom call light were not flashing. The nurse on duty noted redness to the back of the head and treatment included ice applied to head. Physician and family were notified at end of the shift. Progress notes indicated: 12/19/16 at 9:14 a.m., the nurse on duty indicated resident complained of nausea. The nurse received an order to send the resident to the emergency room . The resident then stated she felt better and didn't need to go to the hospital. A review of emails to the physician received from the ADON on 2/3/17 at 1:26 p.m., indicated on 12/18/16 at 6:27 a.m., the resident was observed on the floor at 3:30 a.m., after getting out of bed without assistance. She hit the back of her head on the edge of the door, ice was applied. Range of motion (ROM) unchanged. Neuros (Neurochecks) and vs (vital signs) were within normal limits. Resident stated she was on her way to the fridge to get a coke and a salad. She was given her coke and salad and the alarm put back on the bed. At 11:11 a.m., the email continued from the nurse on duty, resident fell this morning has hematoma on back of her head. Denied any pain. Did have bleeding in brief since fall. Can't tell if it is vaginal or not. Some clots when she was wiped after urinating. Is on Cipro, ([MEDICATION NAME], an antibiotic) for chronic UTI. Temp (temperature) was 99.8 and PRN (as needed) Tylenol ([MEDICATION NAME]) was given. The resident was now vomiting. PERRL (pupils equal, round and reactive to light). Any new orders indicated? 12/18/16 at 12:22 p.m., nurse response: resident now denies any nausea. Do you still want her sent? Physician response: 12/18/16 at 12:24 p.m., No monitor. Does she have nausea medications or she just feels better? 12/18/16 at 12:26 p.m., nurse on duty writes: says she feels better and just wants to rest. What about bleeding? Monitor? Thank you Physician response at 12:58 p.m. Yes. Nurses Notes on 12/19/16 at 11:22 a.m., indicated the Nurse Practitioner 2 examined resident and new orders to obtain an urinanaylsis were obtained. Vitals Signs recorded: 12/20/16: 10:44 a.m. Blood Pressure (BP)134/66 pulse 76 temperature: 96.8 degrees Fahrenheit A review of Laboratory results from [MEDICATION NAME] (PT) (test to see how long it takes blood to clot, a prolonged PT means the blood is taking too long to clot) and International Normal Ratio (INR) (test to see how long it takes blood to clot, the higher, the greater risk for bleeding) with dosage orders indicated: 12/20/16: PT 46.0 (average normal 12-13) INR: 3.98 (2.0-3.0 is therapeutic normal), current dose: [MEDICATION NAME] 5 mg daily, hold x 2 days then 4 mg daily, INR next week. Vital signs on: 12/23/16 at 10:11 a.m. BP 123/72 pulse: 90 temperature 100.3 degrees Fahrenheit respiratory rate: 16 oxygen rate: 94% room air A nurses note dated 12/23/16 at 12:16 p.m., indicated resident would not talk to staff, would not comply with staff either. Would not stand up with staff and would not answer questions when asked. Resident did have a very small amount of emesis. Eyes were open, vital signs were within normal limits. Resident was on an antibiotic for UTI. Resident was in the bed with the head of the bed elevated, and the call light was in reach. At 1:01 p.m., the notes indicated the resident refused to get up for meal, would not stand with staff or even talk to any staff, just sits and stares. Vital signs on: 12/24/16 at 6:15 a.m. BP: 144/84 pulse: 145 temperature: 100.0 degrees Fahrenheit respirations: 22 oxygen rate: 92% on room air comments: .suctioned resident several times, helped with her breathing, she seemed congested at back of throat, she was not very responsive, had cold cloths on resident's armpits and forehead to help with fever. communication with family and physician. Nursing notes on 12/24/16 at 5:30 a.m., indicated the family was contacted regarding resident condition. .Family requested resident be sent to (name of hospital). Vital signs are: BP 144/84, pulse 145, respirations 22, temperature 100 degrees Fahrenheit. Resident is extremely congested, we have suctioned several times, she is non responsive, biting on tongue and just extremely lethargic . sending to ER .5 :59 a.m., Resident transferred to (name hospital) by ambulance. CT (Computerized Tomography) scan of the head completed on 12/24/16 at (Name of Hospital) indicated there were bilateral acute on chronic subdural hematoma collections. There was a significant component of high density hemorrhage bilaterally. A small amount of high density acute subarachnoid hemorrhage was seen at the right posterior frontal lobe. Discharge Summary, dated 12/24/16 at 3:53 p.m., from (name of local hospital to tertiary care center) indicated, . this patient has been accepted and is being transferred, but just before transfer had focal [MEDICAL CONDITION], and a rapid response was called , most likely secondary to bleed .this patient was seen on admission to the emergency room with worsening lethargy for the last few days and more altered mental status since last night and found to have [MEDICAL CONDITION] . UTI and encephopathy .Impression: most likely had this hemorrhage from fall 6 days ago in the setting of [MEDICATION NAME] Laboratory studies from hospital admission indicated PT/INR: collected 12/24/16 at 12:23 : PT: 14.2 and the INR was 1.29. During an interview with the Director of Nursing (DON) on 02/03/2017 at 10:09 a.m., she indicated the Treatment Administration Record indicated no checks for bed alarm were completed prior to the fall. During an interview with the Nurse Practitioner 2 on 2/6/16 at 9:00 a.m., she examined the resident on 12/19/16 the day after the fall. She indicated she did not examine the resident's head injury, her focus was the hematuria and treatment of [REDACTED]. On examination, the resident wakened easily, had no specific complaints, and no distress was noted. an order for [REDACTED]. A current policy titled Fall Prevention dated 9/10/15 received from the DON on 2/3/17 at 1:25 p.m., indicated .staff is continuously reminded and inserviced on the importance of bed/chair alarms and ensuring residents are toileted every two hours. Licensed nursing staff are required to document on the MAR indicated [REDACTED] An Internet cite titled Subdural Hematoma by WebMD retrieved on 2/6/17, indicated a subdural hematoma is a collection of blood outside the brain. Subdural hematomas are usually caused by severe head injuries The symptoms included, but were not limited to, .nausea and vomiting, lethargy, and excessive drowsiness, weakness, apathy and [MEDICAL CONDITION] .People who take blood thinners are more likely to develop a subdural hematoma. A relatively minor head injury can cause subdural hematoma in people with bleeding tendency 2. Resident C's record was reviewed on 2/01/17 at 2:12 p.m. [DIAGNOSES REDACTED]. Resident C's Care Plan dated 09/04/2012, addressed the problem of self care deficit related to weakness and dementia. Approaches dated 12/07/2016 included, but were not limited to, .dentures in AM out HS (at bedtime) Resident C's Care plan dated 12/05/2016 addressed the problem of alteration in thought processes including the resident doesn't talk. Approaches dated 11/13/2013 included, but were not limited to, .res(resident) is eating heris(sic) putting necklaces in her mouth, staff is not to put necklaces on res A twenty four hour report entry received from the DON (Director of Nursing) on 2/3/17 at 9:00 a.m., indicated the resident's partial denture was missing on 1/15/17. An email communication sent to the physician on 1/18/17 at 6:18 p.m., indicated,Resident chocked(sic) at dinner just now, expelled some mucous, but remains gurggly (sic), resident suctioned and helpful, no audible wheezes heard, VS (vital signs):B/P (blood pressure) 78/48 P (pulse)-80 R (respirations)-22 T(temperature) 99.5, Oxygen level between 89-90% on RA (room air). Do you want to go ahead and do CXR (chest x-ray). Mobile X here now if so Thanks. The email communication did not include the resident's partial denture was missing. A physician order [REDACTED]. A physician order [REDACTED]. The Electronic Medication Administration Record [REDACTED]. A nursing progress note dated 1/20/2017 at 9:43 p.m., indicated .Resident up in geri-chari this shift, attempted to feed resident and resident not swallowing, neither food or medicine today, oral care provided A nursing progress note dated 1/21/2017 at 5:45 p.m. indicated, .Resident is not swallowing food or liquids. She is holding everything in her mouth An email communication sent to the physician on 1/21/2017 at 9:40 a.m. indicated, We did chest x-ray on her this week also, you ordered [MEDICATION NAME] (sic) (generic guaifenisin- [MEDICATION NAME]) and breathing tx (treatment) prn (as needed). We aren't able to give the cough syrup too thin and unable to thicken I tried. she is on honey thick liquids. We haven't been able to give meds last two days or feed d/t (due to) every time we put something in her mouth she gets choked and starts producing thick frothy mucous. This morning she was the same way before breakfast even started. I took res (resident) out and suctioned her, got moderate amount of thick phlegm blood and gave br (breathing) tx. It just rolls out of mouth. We need to d/c (discontinue) [MEDICATION NAME] (sic). Any other orders? I will cont (continue) with br tx and see if that helps. The email communication did not include the resident's partial denture was missing. A physician order [REDACTED]. An Office/Clinic Note dated 1/23/2017 at 10:15 EST (eastern standard time) indicated .Was asked to see resident today. Started with cough last week-CXR (chest x-ray) done on 1/18/17 showed 'mild cardiomegaly with [MEDICAL CONDITION] vascular congestion in lower lobes.' Pt (patient) was given [MEDICATION NAME] over the weekend for continue (sic) cough and congestion. Has been suctioned orally many times over the weekend. No fever .Pt is normally non-verbal and is not responding today to verbal stimuli .Nurse reports that she noted that patient partial denture is missing for an unknown period of time .Will obtain X-ray of soft tissue of neck to check for foreign body. NPO (nothing by mouth) per recommendation A Radiology Report dated 01/23/2017 indicated, .NECK, SOFT TISSUE .Conclusion: Denture in hypopharynx just above esophagus The Emergency Documentation from (Name of Hospital) dated 1/23/2017, indicated .Patient was sent to surgery. Has foreign body stuck in throat The Surgical Documentation from (Name of Hospital) dated 1/23/2017, indicated .Indication: New onset of dysphagia, partial denture lodging in the pharyngeal area. Procedure: .The scope was advanced to the pharyngeal area, where the partial was lodged in the pharyngeal and upper [MEDICAL CONDITION] sphincter area, There was diffuse [MEDICAL CONDITION] in the pharyngeal area. Attempt to remove the partial with biopsy forcep failed due to extreme high risks for perforation. Findings: Severe pharyngeal [MEDICAL CONDITION] and partial impaction in the upper [MEDICAL CONDITION] sphincter and pharyngeal area. Recommendation: Will transfer to tertiary center for FB (foreign body) removal The Final Report from (Name of Hospital) dated 1/23/2017, indicated .who was found to have swallowed her partial denture. She was taken to regional hospital and intubated for airway protection. EGD (upper endoscopy) performed at (Name of Hospital) and dentures were unable to be removed .Impression and Plan: .Intubated, sedated .May attempt to restart home pureed diet regimen upon extubation tomorrow During an interview on 02/02/17 at 3:20 p.m., the DON indicated a CNA (certified nursing aide) reported the resident's partial denture was not in her mouth when she put her to bed and it was several days later before the nursing staff thought the resident's difficulties could be related to the missing partial denture. During an interview on 02/03/17 at 10:09 a.m., the DON indicated the date the partial was missing was 01/15/17. During an interview on 02/03/17 at 1:09 p.m., the Speech Therapist 3 indicated she was off work the week of January 19th and was not aware of the resident's issues with swallowing until she came back to work on 1/23/17 and received an email about the resident. She was not notified of the missing partial denture in the email. The Speech Therapist indicated she was the Program Manager for the Department and was always on call for any problems or concerns. During an interview on 02/05/17 at 3:00 p.m., NP 2 ( Nurse Practitioner) indicated she was not aware the resident had a missing partial denture until 1/23/17. This Federal Tag relates to complaint IN 352. 3.1-37(a)

Based on interview and record review, the facility failed to implement interventions for a known weight loss for 1 of 4 residents reviewed for nutrition (Resident C). The resident had a weight loss of 9% in 29 days. Finding includes: Resident C's record was reviewed on 2/01/17 at 2:12 p.m. [DIAGNOSES REDACTED]. Resident C's Care Plan dated 04/01/2011, indicated the resident had a potential for weight loss and interventions included, but were not limited to, monitor weights and monitor food intake. The weight log indicated the following weights for Resident C: 12/06/16 149.5 pounds, 01/02/17 145.8 pounds, 01/28/17 137.4 pounds, 01/29/17 134.3 pounds and 02/01/17 133 pounds. A nourishment progress note dated 01/27/17 at 9:26 a.m., indicated weight: 1/03/17 145.8 pounds, awaiting re-admission weight and care plan problems remain appropriate/current. A physician order [REDACTED]. A physician order [REDACTED]. An annual nutrition note dated 09/21/16 indicated weight was 150 pounds, no significant weight change for resident with diet of pureed, honey thickened liquids and no RD (registered dietician) recommendations at this time and will monitor as warranted. During an interview on 02/01/17 at 3:36 p.m.,the RD indicated the need to look at daily, weekly and monthly weights. She indicated she made routine visits every 2 weeks and the facility had meetings every Tuesday to review the residents needs and add residents with nutrition and weight issues to her list for Wednesdays. The RD indicated she was not aware of any issues with Resident C. The RD indicated she had not entered any notes on Resident C since 09/21/16. During an interview on 02/01/17 at 3:47 p.m., the Director of Dietary Services indicated Resident C did not have a significant weight loss and did not have changes in her intake. She indicated the resident was not placed on her worksheet. During an interview on 02/03/17 at 1:09 p.m., the Speech Therapist #3 indicated she received an email on 1/23/17 about Resident C having increased mucous and difficulty swallowing. During an interview on 02/03/17 at 1:24 p.m., the Director of Dietary Services indicated Resident C was not on any type of nourishment or supplement. A current policy titled Weight Policy and Procedure dated 12/01/15, received from the ADON (assistant director of nursing) on 2/06/17 at 11:55 am, indicated .Those residents identified as nutritionally at risk will be weighed on a weekly basis .Resident are considered to be at nutritional risk if they .have documented evidence of poor intake/appetite, or weight changes as follows: 5% in one month, 7% in three months, 10% in six months .An individual nutritional intervention program will be implemented for each resident who has had a significant weight loss within the above time frames .the resident's nutritional needs .will be evaluated by the certified dietary manager or registered dietitian .The resident will be placed on the appropriate nutritional program. The individualized program will include any of the following: snacks of choice, shakes, whole milk, ice cream, pudding .nutritional supplements 3.1-46(a)(1)

Based on record review, observation and interview, the facility failed to prevent the development of pressure ulcers for 1 of 2 residents reviewed for pressure ulcers in a sample of 9. (Resident # 28) This deficit practice resulted in Resident # 28 developing two unstageable pressure areas to the bilateral antecubital area of the arms. Findings include: The record for Resident # 28 was reviewed on 10/11/11 at 12:30 p.m. Current [DIAGNOSES REDACTED]. An annual 8/23/11 Minimum Data Set Assessment indicated the resident had a limitation in range of motion in the upper extremity on one side. A plan of care, dated 5/30/11, indicated a problem of "Potential for Tissue integrity impairment, hx (history) for pressure ulcer....keep skin clean and dry,...inspect skin q. (every) shift, report changes...." A plan of care, dated 8/30/11, indicated the resident was to receive active assist range of motion upper extremities and to monitor for redness or open areas. The record lacked documentation of the active assist range of motion to the upper extremities for the month of October 2011. Current physician orders [REDACTED]. The original date of the order was 8/9/11. Current CNA assignment sheet for October 2011 indicated the resident should wear geri gloves at all times and to remove to bathe. The September 2011 Treatment Administration Record (TAR) indicated the resident had a skin tear on 9/6/11 on the left antecubital that was treated and healed on 9/12/11. The TAR also indicated the resident had a pressure ulcer on her coccyx that was healed on 9/21/11. The resident's weight record indicated her weights were stable at 81 pounds on 8/15/11 and 86.8 pounds on 10/4/11. A shower sheet, dated 10/3/11, indicated the resident had open area to the right and left antecubital area. LPN # 1 signed the shower sheet. A nursing note, dated 10/3/11 at 11:51 a.m., indicated a 1 centimeter (cm) by 0.5 cm unstageable open area on right antecubital and a 3 cm by 1.5 cm unstageable open area 0.5 cm deep on the left antecubital. The left arm was red and swollen. The physician was notified and an order, dated 10/3/11, was obtained for [MEDICATION NAME] (antibiotic) 1 gram intramuscularly daily for 7 days and to cleanse the bilateral antecubital areas with saline then apply 50/50 mixture of Santyl and [MEDICATION NAME] and cover with a 2 by 2 gauze daily for 14 days. A nursing note, dated 10/4/11 at 2:32 p.m., indicated "Weekly measurements to unstageable areas to bilateral anticubical's (SIC) is left anticubical (SIC) is 3.0 X (by) 1.5 X 0.5 cm area is covered with yellow slough with surrounding skin on elbow deep red in color and slightly warm to touch. Right anticubical (SIC) measures 1.0 X 0.5 cm area is covered with eschar and red in color surrounding area to elbow...." A 10/9/11 nursing note timed 12:23 p.m., indicated "...pressure ulcers continue to bilateral anticubitals. (SIC) Yellow slough noted on the inner surfaces; periphery noted to be deep red in color. Slight warmth noted...remains on antibiotic for skin infection...." During a care observation with CNA # 4 on 10/11/11 at 10:20 a.m., Resident # 28 was in bed. Her left arm was contracted at the elbow and positioned with her arm bent and her hand next to her face, with her right arm bent at the elbow and tucked under the left arm. There were no geri-gloves on the resident. There was a dressing to the left antecubital and the area surrounding the dressing was red in color and no dressing was in place to the right antecubital. The right antecubital had a small dark area in the antecubital area. During interview on 10/11/11 at 2:50 p.m., LPN # 1 indicated she had completed the assessment and measurements on 10/3/11 when she was notified of the areas. She indicated she was unsure if the areas had been documented on prior to 10/3/11. During interview on 10/11/11 at 3:50 p.m., CNA # 2 indicated Resident # 28 should receive a bath every morning which included taking off the geri-gloves, washing and lotioning the arms. During interview on 10/11/11 at 4 p.m., LPN # 3 indicated she observed the open areas on 10/3/11 and was not aware the areas had been assessed prior to that date. A 9/02 policy titled "Prevention of Decubitus Ulcers-Pressure Areas" was provided by the Assistant Director of Nursing on 10/11/11 at 2:30 p.m., and deemed as current. The policy indicated: "...Early recognition is of extreme importance. Frequently observe the resident's skin, especially over bony and pressure point areas for redness and/or soreness. Remember-bedsores are much easier to prevent than to cure! Small scratches and bruised may be the beginning of decubitus ulcers...Special Notes...4. Use padding between bony prominences...Stage III 1. Broken skin...infection or [MEDICAL CONDITION] may be present. 4. Eschar may be present...Stage IV...3. Extent of destruction may not be visible; decayed area may be larger than apparent wound...." A 10/07 policy titled "Pressure Area Protocol" was provided by the Assistant Director of Nursing on 10/11/11 at 2:30 p.m., and deemed as current. The policy indicated: "....Procedure: 1. Each resident will have a Pressure Ulcer Risk Assessment performed as follows:...b. quarterly c. with any significant change in condition...3. Skin observations are made daily during the performance of bathing and dressing the resident. 4. CNAs are responsible for promptly notifying the hall nurse of all observations including: a. redness...j. skin discoloration k. open areas...." 3.1-40(a)(1)