Every finding on record at Chalet Rehabilitation and Healthcare Center

Based on observation, interview, and record review, the facility failed to ensure foods were served in a sanitary and safe manner for 1 of 3 kitchen observations. Staff hair was not covered while in the kitchen food preparation area and while serving the meal. (Cook 4) Finding includes: During a follow-up kitchen observation on 6/1/26 from 12:20 p.m. to 12:40 p.m., [NAME] 4 was observed working at the food preparation table located on the opposite side of the steam table that held the noon foods. [NAME] 4 was observed preparing the resident's food trays. [NAME] 4 was observed to have facial hair, approximately one-half inch in length, located above the upper lips and sideburns located in front of both ears. The facial hair above the lips and the sideburns were observed to not be covered. During an interview on 6/1/26 at 1:20 p.m., the Dietary Manager indicated staff hair, including facial hair, was to be kept covered while in the kitchen. On 6/1/26 at 1:46 p.m., the Dietary Manager provided an undated copy of the Personal Hygiene and Health Reporting policy and indicated it was the current policy in use by the facility. A review of the document indicated, .hair restraints must be worn around exposed foods .beards and mustaches .must be restrained using beard covers . On 6/1/26 at 3:45 p.m., a review of the Indiana Food Establishment Sanitation Requirements, Title 410 IAC (Indiana Administrative Code) 7-26, effective April 15, 2025, indicated, .food employees shall wear hair restraints, such as hats, hair coverings or nets .that are designed and worn to effectively keep their hair from contacting .exposed food . 410 IAC (Indiana Administrative Code) 16.2-3.1-21(i)(2)410 IAC (Indiana Administrative Code) 16.2-3.1-21(i)(3)

Based on observation, record review, and interview, the facility failed to ensure infection control practices were implemented for residents requiring Enhanced Barrier Precautions (EBP) for 1 of 5 residents reviewed for EBP. Gowns were not worn during direct resident care. (Resident 74, CNA 2, and CNA 3)Finding includes: On 6/1/26 at 10:10 a.m., a sign was observed on Resident 74's door indicating EBP (gown and gloves) were required for direct resident care. CNA 2 and CNA 3 were observed to be providing care to Resident 74. CNA 2 and CNA 3 were observed to be wearing only gloves. CNA 2 was observed cleansing Resident 74's groin area with a washcloth. At that time, CNA 3 had begun to don a gown. CNA 2 stopped providing direct care to Resident 74 donned a gown. During an interview at that time CNA 2 and CNA 3 indicated that a gown should have been donned prior to providing direct care to Resident 74. During an interview on 6/1/26 at 12:03 p.m., the Director of Nursing indicated that staff should wear EBP (gowns and gloves) when providing direct care to a resident that required EBP. On 6/2/26 at 9:00 a.m., Resident 74's clinical record was reviewed. The diagnoses included, but were not limited to, chronic kidney disease and benign prostatic hyperplasia. An admission Minimum Data Set assessment, dated 5/18/26, indicated Resident 74 had no cognitive impairment.A Physician Order, dated 5/12/26, indicated Resident 74 had an indwelling urinary catheter and to follow EBP when providing direct care. On 6/1/26 at 12:16 p.m., the Director of Nursing provided a copy of policy titled, Enhanced Barrier Precautions - 880, Infection Control, Enhanced Barrier Precautions (EBP), revised 12/2024 and indicated it was the current policy in use by the facility. A review of the policy indicated, Enhanced Barrier Precautions apply when: .Indwelling medical devices including central lines, urinary catheters, tube feeding tubes, and tracheotomies. 410 IAC (Indiana Administrative Code) 16.2-3.1-18(b)(1)

Based on interview and record review, the facility failed to protect a resident's rights to be free from verbal and mental abuse by the Administrator for 1 of 3 residents reviewed for abuse. (Administrator, Resident B)Finding includes:On 3/5/26 at 9:15 a.m., the clinical record for Resident B was reviewed. The diagnoses included, but were not limited to, bipolar disorder (a chronic mental health condition characterized by intense mood swings to extreme highs to severe lows) and PTSD (Post-traumatic stress disorder; a chronic mental health condition triggered by experiencing or witnessing terrifying events, causing symptoms such as nightmare, flashback, severe anxiety, and avoidance of triggers lasting over a month).The admission Minimum Data Set (MDS) assessment, dated 1/15/26, indicated Resident B was cognitively intact.On 3/5/26 at 9:00 a.m., a facility reportable incident report was reviewed. The report was submitted to the Indiana Department of Health on 2/26/26 and a follow-up report was submitted on 2/27/26. The report indicated that on 2/19/26 the facility Administrator was involved in verbal altercations against Resident B. The report indicated the Administrator's behaviors displayed against Resident B on 2/19/26 .violated the resident's rights and met the definition of abuse. As a result of the facility's investigation, the Administrator was suspended on 2/27/26 at which time the Administrator resigned her position. During an interview on 3/5/26 at 10:30 a.m., the Regional Director of Operations (RDO) and the Chief Nursing Officer (CNO) indicated on 2/27/26 at 1:30 p.m. Resident B reported that on 2/19/26 the Administrator was in and out of Resident B's room as other staff were directed to pack up the resident's belongings. The verbal altercations between the Administrator and Resident B were described as continually escalating, with the Administrator speaking to Resident B in disrespectful, mocking, and intimidating tones. The CNO and the RDO had witnessed video clips from Resident B's phone. The RDO and CNO stated the clips showing portions of the negative interactions of the Administrator towards Resident B confirmed that the statements and tone of the Administrator towards Resident B violated policy and expectations. The actions of the Administrator were noted as both verbally and mentally abusive towards Resident B. The RDO and the CNO noted that the interactions were described as and appeared as escalating in nature, with the Administrator having plenty of opportunities to either attempt deescalation or walk away and cool down rather than continue.On 3/5/26 at 1:13 p.m., the RDO provided an undated copy of a document titled Video Evidence Summary, and indicated the document was a narrative and transcript of Resident B's phone recorded video clips from the events occurring on 2/19/26. A review of the contents of the video indicated that the Administrator was degrading, mocking, and intimidating towards Resident B, including but not limited to the following:- Video 1: Administrator stated, Let's record each other.' This was noted as a response to Resident B recording the Administrator. It was determined the Administrator was only pretending to record Resident B but was done in a mocking manner. Administrator stated, You are an unpaid customer and I can't keep you here.- Video 2: Administrator stated, You are handicapped. Aren't you handicapped? Resident B stated, Shame, shame. I haven't done anything to you. Administrator then responded, You're right. You haven't paid your bill, and then stated, You have to pay your bill.- Video 3: Administrator's voice was heard partway through the video clip and stated Resident B needs to exit immediately. When Resident B responded to this asking where they should go, Administrator responded, Not my problem, and then stated, Leave my building. I need you to leave.- Video 5: Administrator referred to the resident as handicapped, another individual responded, Unfortunately, yes I am. Resident B stated they had done nothing to the Administrator, Administrator responded saying resident had not paid their bill.- Video 6: Administrator was standing near doorway and tells Resident B they needed to exit the room. Resident B stated they are handicapped and asked where they should go. Administrator responded Resident B needed to leave the room and that they would determine the next steps once resident left the room. Administrator said again the resident is an unpaid customer and cannot remain in the facility. Resident B stated their insurance confirmed the bill would be handled. Administrator stated they are not continuing that discussion.During an interview on 3/5/26 at 2:10 p.m., the RDO, CNO, and Regional Nursing Consultant stated the Administrator's statements and tone qualified for verbal and mental abuse against Resident B.On 3/5/26 at 10:28 a.m., the CNO provided a policy titled Abuse Prevention and Prohibition, dated 12/1/23, and indicated it was the policy currently in use by the facility. A review of the policy indicated that the facility was to .ensure that all residents are free from abuse, neglect, misappropriation of their property, and exploitation. This includes, but is not limited to freedom from.verbal, mental, sexual, or physical abuse.This deficient practice was corrected on 3/2/26 after the facility implemented a systemic plan of correction that included the following actions: all staff were educated on abuse prevention and reporting, with ongoing monitoring and audits.This citation relates to Intakes 2785050 and 2794931.410 IAC (Indiana Administrative Code) 16.2-3.1-27(a)(1)410 IAC (Indiana Administrative Code) 16.2-3.1-27(b)

Based on interview and record review, the facility failed to ensure an incident of alleged staff to resident verbal and mental abuse was immediately reported to facility management, as indicated by facility policy, for 1 of 3 residents reviewed for reporting resident abuse. (Resident B, Administrator, Director of Nursing, Assistant Director of Nursing, Staffing Coordinator, and Housekeeping Supervisor) Finding includes: On 3/5/26 at 9:00 a.m., facility reportable incident report was reviewed. The report was submitted to the Indiana Department of Health on 2/26/26, a follow-up report was submitted on 2/27/26, and a new update was submitted on 3/4/26. The report indicated that on 2/19/26 the facility Administrator was involved in verbal altercations against Resident B. The report indicated the Administrator's behaviors displayed against Resident B on 2/19/26 .violated the resident's rights and met the definition of abuse. Additionally, the Director of Nursing (DON), Assistant Director of Nursing (ADON), Staffing Coordinator, and Housekeeping Supervisor witnessed the Administrator's verbal altercations against Resident B. The identified staff failed to intervene and failed to report the abuse allegation to the facility's compliance hotline. As a result of the facility's investigation, the Administrator was suspended on 2/27/26 at which time the Administrator resigned her position and the other staff members were terminated. During an interview on 3/5/26 at 10:11 a.m., Licensed Practical Nurse (LPN) 3 indicated alleged abuse situations were to be immediately reported to management or to the facility's compliance hotline if it was related to the Administrator. During an interview on 3/5/26 at 10:15 a.m., LPN 4 indicated all alleged abuse was to be immediately reported to management or to the facility's compliance hotline if it was related to the Administrator. During an interview on 3/5/26 at 10:20 a.m., the local Ombudsman indicated Resident B reported on 2/27/26 at 12:05 p.m., that in mid-February, the Administrator was in Resident B's room. The Administrator had spoken to Resident B in a mocking, undignified and intimidating tone, and was disrespectful and unprofessional. Resident B indicated there were multiple staff members who witnessed the Administrator's verbal and mental abuse. The Ombudsman immediately notified the Chief Nursing Officer (CNO) of Resident B's abuse allegation. During an interview on 3/5/26 at 10:30 a.m., the CNO indicated on 2/27/26 at 1:00 p.m., the Ombudsman informed her of the abuse allegations involving the Administrator and Resident B. The CNO immediately interviewed Resident B who reported that on 2/19/26 the Administrator was in Resident B's room. The Administrator spoke with the resident in a mocking, undignified, and intimidating tone, and was disrespectful and unprofessional. Resident B indicated there were multiple staff members, who were in and out of her room, and witnessed the Administrator's verbal and mental abuse. Resident B identified the following staff members who witnessed the alleged verbal abuse: DON, ADON, Staffing Coordinator, and Housekeeping Supervisor. The CNO indicated that the verbal and mental abuse allegation had not been reported to the facility management or to the facility compliance hotline. During an interview on 3/5/26 at 3:10 p.m., the CNO indicated the staff who witnessed the verbal and mental abuse allegation should have immediately reported the allegation to the facility administration or to the facility compliance hotline. The DON, ADON, Staffing Coordinator, and Housekeeping Supervisor were terminated for failure to intervene and failed to report the alleged abuse. On 3/5/26 at 1:13 p.m., the Regional Director of Operations (RDO) provided an undated copy of the Video Evidence Summary and indicated the document was a narrative of Resident B's 2/19/26 phone video recordings that Resident B had provided to the CNO and RDO. A review of the document included, but was not limited to, .When the resident asks where she should go, [Administrator] responds, 'Not my problem.' The document indicated the Administrator's tone was degrading, mocking, and intimidating toward Resident B. On 3/5/26 at 10:28 a.m., the CNO provided a copy of the Abuse and Incident Reporting Policy, dated 4/8/24, and indicated it was the current policy in use by the facility. A review of the document indicated, .The facility will ensure all alleged violations involving mistreatment.verbal abuse may be considered a type of mental abuse.are reported immediately to the administrator or other officials.abuse also includes.verbal abuse.may be considered a type of mental abuse.if staff are aware of or witness any abuse that occurs, it must be reported. This deficient practice was corrected on 3/2/26 after the facility implemented a systemic plan of correction that included the following actions: all staff were educated on abuse prevention and reporting, with ongoing monitoring and audits. This citation relates to Intakes 2785050 and 2794931. 410 IAC (Indiana Administrative Code) 16.2-3.1-28(c)

Based on interview and record review, the facility failed to ensure a resident's person-centered fall prevention care plan interventions were implemented for 1 of 3 residents reviewed for falls. This deficient practice resulted in a resident sustaining a fracture to her left tibia and fibula. (Resident B) Findings include:During an interview on 2/13/26 at 9:52 a.m., Resident B indicated she had a fall from bed when CNA 1 stood on the left side of the bed and rolled Resident B to her right side. Resident B's left leg slid forward, and she fell from the bed. Resident B fractured her left tibia and fibula. There was only one staff member in her room when she fell.The clinical record for Resident B was reviewed on 2/8/26 at 1:53 p.m. The diagnoses included, but were not limited to, cerebral infarct and hemiplegia affecting left nondominant side.A care plan, dated 10/1/25, indicated Resident B had a self-care deficit related to weakness, limited mobility, and impaired balance. The interventions included, but were not limited to, two staff assist with bed mobility.A Quarterly Minimum Data Set (MDS) assessment, dated 12/31/25, indicated Resident B was cognitively intact.A Progress Note, dated 2/8/26 at 6:24 a.m., indicated Resident B had a witnessed fall from her bed while CNA 1 provided care.A Progress Note, dated 2/8/26 at 6:50 p.m., indicated Resident B complained of pain in her left leg. An x-ray had been completed.A Progress Note, dated 2/8/26 at 11:08 p.m., indicated Resident B had a left tibia and fibula fracture and was being sent to the hospital. An X-ray result, dated 2/8/26 at 7:35 p.m., indicated Resident B had a fracture involving the proximal tibia and fibula with no displacement.During an interview on 2/13/26 at 2:33 p.m., Licensed Practical Nurse (LPN) 1 indicated she was the nurse that cared for Resident B when she fell from her bed and fractured her left tibia and fibula. CNA 1 reported to LPN 1 that Resident B rolled out of bed on her right side when CNA 1 was providing care. LPN 1 was not aware that Resident B needed two staff members to assist with bed mobility.During an interview on 2/13/26 at 2:40 p.m., CNA 1 indicated on 2/8/26 at approximately 6:30 a.m., she was providing care to Resident B when Resident B fell from her bed. CNA 1 stood at the left side of Resident B's bed and rolled Resident B to her right side. While Resident B was lying on her right side, CNA 1 attempted to fix the sheet under Resident B and Resident B rolled off the right side of the bed and fell on the floor. CNA 1 had not been made aware that Resident B needed two staff to assist with bed mobility.On 2/13/26 at 8:46 a.m., the Director of Nursing provided a copy of a facility policy, titled Fall Management and Fall Risk, dated 10/20/23, and indicated this was the current policy used by the facility. A review of the policy indicated person-centered fall related interventions to address fall prevention would be implemented.This deficient practice was corrected on 2/11/26 after the facility implemented a systemic plan of correction that included the following actions: staff were educated on bed mobility and following the plan of care, with ongoing monitoring and audits. This citation related to Intake 2742859.3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident's tube gastrostomy tube feeding was labelled for 1 of 2 residents reviewed for tube feeding. (Resident C) Findings include:On 2/13/26 at 12:21 p.m., Resident C was observed lying in bed. There was a tab-colored tube running from under Resident C's sheet up to a tube feeding pump at the side of the bed. The feeding pump was set to administer 60 milliliters (ml) of feeding per hour with a 40 ml water flush every hour. The feeding bag lacked a label that indicated the type of feeding, the rate of the feeding, the date and time the feeding was hung/administered, and the nurse's initials. At that time, LPN 2 indicated the feeding bag should have been labeled when the nurse hung it. The clinical record for Resident C was reviewed on 2/16/26 at 8:39 a.m. The diagnoses included, but were not limited to, traumatic brain injury, aphasia, dysphagia, and gastrotomy.A current physician's order, initiated 12/29/25, indicated Glucerna 1.5 at 60 ml per hour with 40 ml free water flush every hour.On 2/16/26 at 9:00 a.m., the Director of Nursing provided a copy of an undated facility policy, titled Enteral Tube Feeding via Continuous Pump, and indicated this was the current policy used by the facility. A review of the policy indicated on the formula label document staff initials, date and time the formula was hung/administered, and initial that the label was checked against the physician's order.3.1-47(a)(2)

Based on observation, interview and record review, the facility failed to ensure a comprehensive care plan was developed for a resident with an indwelling urinary catheter for 1 of 2 residents reviewed for urinary catheters. (Resident C) Finding includes:On 1/6/26 at 11:20 a.m., observed Resident C to have an indwelling urinary catheter. At that time, Resident C indicated the staff had taken good care of his urinary catheter since it had been placed. The clinical record for Resident C was reviewed on 1/7/26 at 9:43 a.m. The diagnoses included, but were not limited to, obstructive uropathy and benign prostatic hyperplasia. A current physician's order, initiated on 8/7/25, indicated Resident C had an indwelling urinary catheter. The Quarterly Minimum Data Set (MDS) assessment, dated 11/15/25, indicated Resident C was moderately cognitively impaired and had an indwelling urinary catheter. The clinical record for Resident C lacked a comprehensive care plan for Resident C's indwelling urinary catheter. On 1/7/26 at 11:58 a.m., the Director of Nursing provided a copy of a facility policy, titled Comprehensive Care Plans, dated 2/22/21, and indicated this was the current policy used by the facility. A review of the policy indicated the person centered comprehensive care plan was developed within seven days of the completion of the required MDS assessment and no later than 21 days after admission. This citation is related to Intake 2705290. 3.1-35(a)

Based on observation, interview, and record review, the facility failed to ensure a resident's with a peripherally inserted central line (PICC) (a small tube inserted into a vein in the upper arm that extends to the top of the heart used to administer intravenous fluid/medications) was dated and initialed for 1 of 2 residents reviewed for quality of intravenous (IV) care. (Resident D) Finding includes:On 1/6/26 at 10:28 a.m., observed Resident D to have an IV (a small catheter inserted into the vein) in the right upper arm. The IV dressing was not dated or initialed. At that time, Resident D indicated he had been receiving antibiotics through his PICC (peripherally inserted central catheter) line. The clinical record for Resident D was reviewed on 1/6/26 at 2:08 p.m. The diagnoses included, but were not limited to, acute hematogenous osteomyelitis, peripheral vascular disease, and diabetes. A current physician's order, initiated on 1/3/26, indicated to change PICC line dressing every seven days and as needed. An admission Minimum Data Set (MDS) assessment, dated 12/31/25, indicated Resident D was cognitively intact. The Treatment Administration Record (TAR), dated 1/1/26 through 1/6/26, indicated Resident D's PICC line dressing was placed/changed on 1/3/26. On 1/7/26 at 9:47 a.m., observed Resident D's PICC line dressing to not be dated or initialed. At that time, Resident D indicated he didn't think it had been changed in over a week at least. On 1/7/26 at 12:00 p.m., the Director of Nursing provided an undated copy of a facility policy, titled PICC/Midline/CVAD Dressing Change, and indicated this was the current policy used by the facility. A review of the policy indicated it was the policy of the facility to change PICC line dressing every week or if soiled. 3.1-47(a)(2)

Based on interview and record review, the facility failed to ensure documentation was complete for 2 of 3 residents reviewed. The Treatment Administration Record was incomplete. (Resident B, Resident C) Finding includes:1. On 1/6/26 at 11:20 a.m., observed Resident C to have an indwelling urinary catheter. At that time, Resident C indicated the staff had taken good care of his urinary catheter since it had been placed.The clinical record for Resident C was reviewed on 1/7/26 at 9:43 a.m. The diagnoses included, but were not limited to, obstructive uropathy and benign prostatic hyperplasia.A quarterly Minimum Data Set (MDS) assessment, dated 11/15/25, indicated Resident C was moderately cognitively impaired and had an indwelling urinary catheter.The physician's orders included, but were not limited to: - Ensure catheter bag is covered, maintain urinary drainage bag below the bladder, keep tubing and bag from touching the floor, and empty bag every shift, initiated on 8/7/25. - Provide catheter care every shift, initiated on 8/7/25. The December 2025 TAR, dated 12/1/25 at 12:00 a.m., through 12/31/25 at 11:59 p.m., indicated the facility failed to ensure documentation was completed for the following treatments on the following days:- Ensure catheter bag is covered, maintain urinary drainage bag below the bladder, keep tubing and bag from touching the floor, and empty bag every shift. The TAR was left blank on 11/15/25 evening shift, 11/16/25 night shift, 11/19/25 evening and night shifts, 11/20/25 night shift, and 11/21/25 night shift. - Provide catheter care every shift. The TAR was left blank on 11/15/25 evening shift, 11/16/25 night shift, 11/19/25 evening and night shifts, 11/20/25 night shift, and 11/21/25 night shift. 2. The clinical record for Resident B was reviewed on 1/6/26 at 9:30 a.m. The diagnoses included, but were not limited to, heart failure, diabetes, cellulitis of right lower leg, and acquired absence of right leg above knee. A quarterly MDS assessment, dated 9/9/25, indicated Resident B was moderately cognitively impaired. The physician's orders included, but were not limited to:- Apply zinc oxide 20% ointment to coccyx every shift, initiated 11/10/25, and discontinued on 12/7/25.- Provide catheter care every shift, initiated 11/11/25, and discontinued on 12/7/25.- Monitor for new onset of frequency, urgency, malaise, dysuria, fever, persistent nausea and vomiting, flank pain, suprapubic pain, hematuria, increased urinary sediment, and new onset of altered mental status every shift for neurogenic bladder, initiated 11/11/25, and discontinued on 12/7/25.- Cleanse lower back skin tears with soap and water and pat dry. Apply a thick layer of sensi care cream (barrier cream), cover with Mepilex bordered sacrum dressing once daily on Mondays, Wednesday, and Fridays, initiated 11/12/25, and discontinued on 12/7/25.- Cleanse area to left distal medial thigh with normal saline and pat dry. Paint wound bed with betadine each shift, initiated 11/14/25, and discontinued on 11/22/25.- Cleanse left proximal medial thigh with wound cleanser and pat dry. Apply Medihoney to wound bed and cover with bordered gauze daily on Mondays, Wednesdays, and Fridays, initiated 11/17/15, and discontinued on 11/28/25.- Cleanse left lateral foot with wound cleanser and pat dry. Apply skin prep to peri-wound, apply collagen to wound bed then hydrocolloid daily on Mondays, Wednesdays, and Fridays, initiated 11/17/25, and discontinued on 12/7/25.- Cleanse left ischium with wound cleanser and pat dry. Apply hydrocolloid daily on Mondays, Wednesdays, and Fridays, initiated 11/19/25, and discontinued on 11/28/25. - Cleanse coccyx with wound cleanser and pat dry. Apply hydrocolloid daily on Mondays, Wednesdays, and Fridays, initiated 11/24/25, and discontinued on 11/28/25 at 12:20 p.m.- Cleanse area to left distal medial thigh with wound cleanser and pat dry. Apply Medihoney to wound bed, cover with bordered gauze daily on Mondays, Wednesdays, and Fridays, initiated 11/24/25, and discontinued on 11/28/25.- Cleanse left distal hip surgical wound with normal saline and pat dry. Apply skin prep to peri wound (may use Duoderm as added barrier). Apply white foam lightly packed into the incision and bridge area with dressing tape. Cut a piece of black wound vac foam dressing and connect with white foam. Then, secure with dressing drape. Place the track pad over the black foam and connect to low continuous suction at 100 mmHg (milimeters of Mercury). Pad the wound vac tubing with an ABD pad and secure with tape daily on Mondays, Wednesdays, and Fridays, initiated 11/24/25, and discontinued on 12/7/25.- Cleanse left proximal hip with normal saline and pat dry. Apply skin prep to per-wound (may use Duoderm as added barrier). Apply white foam lightly packed into the incision. Bridge area with dressing tape and cut a piece of black wound vac foam and connect with the white foam. Secure with dressing drape and place the track over the black foam. Then connect to low continuous suction at 100 mmHg. Pad the wound vac tubing with an ABD pad and secure with tape daily on Mondays, Wednesdays, and Fridays, initiated on 11/24/25, and discontinued on 12/7/25. The November 2026 TAR, dated 11/1/25 at 12:00 a.m. until 11/30/25 at 11:59 p.m., indicated the facility failed to ensure documentation was completed for the following treatments on the following days:- Apply zinc oxide 20% ointment to coccyx every shift. The TAR was left blank on 11/16/25 evening shift, 11/17/25 evening shift, 11/23/25 evening shift, 11/26/25 day shift, and 11/28/25 day shift.- Provide catheter care every shift. The TAR was left blank on 11/28/25 day shift.- Monitor for new onset of frequency, urgency, malaise, dysuria, fever, persistent nausea and vomiting, flank pain, suprapubic pain, hematuria, increased urinary sediment, and new onset of altered mental status every shift for neurogenic bladder. The TAR was left blank on 11/16/25 evening shift, 11/17/25 evening shift, 11/23/25 evening shift, 11/26/25 day shift, and 11/28/25 day and evening shifts.- Cleanse lower back skin tears with soap and water and pat dry. Apply a thick layer of sensi care cream (barrier cream), cover with Mepilex bordered sacrum dressing once daily on Mondays, Wednesday, and Fridays. The TAR was left blank on 11/26/25 (Wednesday) day shift and 11/28/25 (Friday) day shift.- Cleanse area to left distal medial thigh with normal saline and pat dry. Paint wound bed with betadine each shift. The TAR was left blank on 11/16/25 day and evening shifts and 11/17/25 evening shift. - Cleanse left proximal medial thigh with wound cleanser and pat dry. Apply Medihoney to wound bed and cover with bordered gauze daily on Mondays, Wednesdays, and Fridays. The TAR was left blank on 11/26/25 (Wednesday) day shift and 11/28/25 (Friday) day shift.- Cleanse left lateral foot with wound cleanser and pat dry. Apply skin prep to peri-wound, apply collagen to wound bed then hydrocolloid daily on Mondays, Wednesdays, and Fridays. The TAR was left blank on 11/26/25 (Wednesday) day shift and 11/28/25 (Friday) day shift.- cleanse left ischium with wound cleanser and pat dry. Apply hydrocolloid daily on Mondays, Wednesdays, and Fridays. The TAR was left blank on 11/19/25 (Wednesday) day shift, 11/21/25 (Friday) day shift, 11/26/25 (Wednesday) day shift, and 11/28/25 (Friday) day shift.- Cleanse coccyx with wound cleanser and pat dry. Apply hydrocolloid daily on Mondays, Wednesdays, and Fridays. The TAR was left blank on 11/26/25 (Wednesday) day shift and 11/28/25 (Friday) day shift.- Cleanse area to left distal medial thigh with wound cleanser and pat dry. Apply Medihoney to wound bed, cover with bordered gauze daily on Mondays, Wednesdays, and Fridays. The TAR was left blank on 11/26/25 (Wednesday) day shift and 11/28/25 (Friday) day shift.- Cleanse left distal hip surgical wound with normal saline and pat dry. Apply skin prep to peri wound (may use Duoderm as added barrier). Apply white foam lightly packed into the incision and bridge area with dressing tape. Cut a piece of black wound vac foam dressing and connect with white foam. Then, secure with dressing drape. Place the track pad over the black foam and connect to low continuous suction at 100 mmHg. Pad the wound vac tubing with an ABD pad and secure with tape daily on Mondays, Wednesdays, and Fridays. The TAR was left blank on 11/26/25 (Wednesday) day shift and 11/28/25 (Friday) day shift.- Cleanse left proximal hip with normal saline and pat dry. Apply skin prep to per-wound (may use Duoderm as added barrier). Apply white foam lightly packed into the incision. Bridge area with dressing tape and cut a piece of black wound vac foam and connect with the white foam. Secure with dressing drape and place the track over the black foam. Then connect to low continuous suction at 100mmHg. Pad the wound vac tubing with an ABD pad and secure with tape daily on Mondays, Wednesdays, and Fridays. The TAR was left blank on 11/26/25 (Wednesday) day shift and 11/28/25 (Friday) day shift.During an interview on 1/7/15 at 10:10 a.m., the Director of Nursing (DON) indicated the documentation on the TARs should have been completed. On 1/7/26 at 11:58 a.m., the DON provided a copy of an undated facility policy, titled Charting and Documentation, and indicated this was the current policy used by the facility. A review of the policy indicated all services provided to the residents shall be documented in the resident's medical record. This citation relates to Intake 2705290. 3.1-50(a)

Based on observation, record review, and interview, the facility failed to ensure reasonable accommodation of needs for 1 of 18 residents observed for call light access. (Resident 52) Finding includes: On 3/30/25 at 8:36 a.m., Resident 52 was observed sitting up in his wheelchair in his room. The touch pad call light was observed to be wrapped around and clipped to the plug in cord at the foot of the bed between Resident 52's bed and the wall, out of reach of Resident 52. On 3/31/25 at 9:12 a.m., Resident 52 was observed in bed with the touch pad call light wrapped up and attached with a clip to the plug in cord at the foot of bed between the bed and the wall, out of reach of Resident 52. During an interview at that time, Resident 52 indicated he was unable to reach the call light. During an interview on 3/31/25 at 9:20 a.m., RN 2 indicated that the call light was not in within Resident 52's reach. During an interview on 3/31/25 at 9:23 a.m., the Director of Nursing (DON) indicated that Resident 52 could not reach his call light. During an observation on 4/2/25 at 9:02 a.m., Resident 52 was observed in bed with his eyes closed. The touch pad call light was observed to be lying on the floor. During an interview on 4/2/25 at 9:12 a.m., RN 2 indicated that Resident 52's call light was not accessible to the resident. The clinical record for Resident 52 was reviewed on 3/31/25 at 10:30 a.m., the diagnoses included, but were not limited to, severe protein calorie malnutrition and heart valve replacement. On 3/31/25 at 10:11 a.m., the Regional Support provided an undated Call Light Policy and indicated it was the current policy in use by the facility. The policy indicated call lights would be accessible when in the room. 3.1-3(v)(1)

Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessment was correctly coded to reflect the hospice election status for 1 of 2 residents reviewed for hospice. (Resident 44) Finding includes: On 4/2/25 at 11:41 a.m., the clinical record of Resident 44 was reviewed. The diagnosis included, but was not limited to, acute kidney failure. A physician's order, dated 8/8/24, indicated Resident 44 was admitted hospice. An annual MDS assessment, dated 1/16/25, indicated Resident 44 was not receiving hospice services. During an interview on 4/2/25 at 10:57 a.m., the MDS Coordinator indicated Resident 44 had been receiving hospice services for a long time and indicated MDS assessment should have been updated. During an interview on 4/2/25 at 11:02 a.m., the Executive Director indicated the facility followed the RAI (Resident Assessment Instrument) manual regarding MDS assessment accuracy. On 4/2/25 at 12:01 p.m., the Executive Director provided a copy of the CMS RAI Version 3.0 Manual (Center for Medicare and Medicaid Services Resident Assessment Instrument), dated October 2019, and indicated it was the current manual in use by the facility. A review of the manual indicated, if a nursing home resident elects the hospice benefit, the nursing home is required to complete an MDS . 3.1-31(d)

Based on observation and interview, the facility failed to ensure a person-centered comprehensive care plan was accurately developed or implemented for residents' advanced directives, for 3 of 18 residents reviewed for advanced directive preferences. (Resident 23, Resident 29, Resident 281) Finding includes: 1. On [DATE] at 10:45 a.m., Resident 23's clinical record was reviewed. Resident 23's diagnoses included, but were not limited to, chronic obstructive pulmonary disorder and chronic pancreatitis. A physician's order, dated [DATE] and with no end date, indicated that Resident 23 had an advanced directive, or code status, of do not resuscitate or DNR (a medical order that instructs medical professionals not to attempt CPR if a patient's heart stops beating or breathing; this allows the patient to die naturally). A POST (Indiana Physician Orders for Scope of Treatment) form, prepared [DATE], indicated Resident 23 had selected do not attempt resuscitation/DNR. The form was signed by the resident. The care plan for Resident 23 lacked a section reflecting the resident's advanced directive preferences. 2. On [DATE] at 11:00 a.m., Resident 29's clinical record was reviewed. Resident 29's diagnoses included, but were not limited to, chronic respiratory failure, congestive heart failure, and type 2 diabetes mellitus. A physician's order, dated [DATE] and with no end date, indicated Resident 29 had an advanced directive, or code status, of CPR (cardiopulmonary resuscitation, also called a full code status, where the medical order indicates to attempt CPR if resident is without pulse and breath). A POST form, prepared [DATE], indicated Resident 29 had selected to attempt resuscitation/CPR if found without pulse and breath. The form was signed by the resident. The care plan for Resident 29 lacked a section reflecting resident's advanced directive preferences. 3. On [DATE] at 11:30 a.m., Resident 281's clinical record was reviewed. Resident 281's diagnoses included, but were not limited to, COPD, congestive heart failure, and chronic kidney disease. A physician's order, dated [DATE] and with no end date, indicated Resident 281 had an advanced directive, or code status, of DNR. A POST form, prepared [DATE], indicated Resident 281 had selected do not attempt resuscitation/DNR. The form was signed by the resident. The care plan for Resident 281 lacked a section reflecting resident's advanced directive preferences. During an interview on [DATE] at 10:30 a.m., the DON (Director of Nursing) indicated that advanced directive preferences should be included on residents' care plans. On [DATE] at 1:35 p.m., the DON provided an undated policy titled Care Plans Protocol, and indicated that it was the policy currently in use by the facility. A review of the policy indicated that the care plan must include measurable goals and resident specific interventions based on resident needs and preferences to promote the resident's highest level of functioning including medical, nursing, mental, and psychosocial well-being and care plans should be completed or modified timely. 3XXX,d+[DATE](a)

Based on interview and record review, the facility failed to ensure an advanced directive care plan was updated when the resident's code status preference was changed for 1 of 18 residents reviewed. (Resident 7) Finding includes: On [DATE] at 9:55 a.m., Resident 7's clinical record was reviewed. The diagnosis included, but was not limited to, chronic obstructive pulmonary disease. Current Physician orders, dated [DATE], included, but was not limited to, Code Status: CPR (cardiopulmonary resuscitation), start date [DATE] with no end date noted. The annual Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident 7 was cognitively intact. Resident 7's care plan included, but was not limited to, .[Resident 7] has an established advanced directive of POST [Indiana Physician Orders for Scope of Treatment] form indicating DNR [do not attempt resuscitation/do not resuscitate] code status. The care plan was initiated on [DATE] and was considered current through [DATE]. On [DATE] at 12:55 p.m., the Executive Director provided a copy of Resident 7's hospital discharge summary document. A review of the document, dated [DATE], indicated Resident 7's code status preference was attempt resuscitation/CPR [full code status]. The POST form, signed by Resident 7 on [DATE], indicated Resident 7 had chosen Attempt Resuscitation/CPR. The clinical record lacked a revised code status care plan for Resident 7 whose code status preference, dated [DATE], was changed from DNR to full code status. During an interview on [DATE] at 10:51 a.m., Resident 7 indicated she had changed her code status preference from DNR to full code at the end of January. During an interview, on [DATE] at 10:00 a.m., the Director of Nursing (DON) indicated Resident 7's care plan should have been updated at the time the resident's code status preference was changed from DNR to full code. On [DATE] at 1:35 p.m., the DON provided an undated copy of the Care Plans Protocol and indicated that it was the current policy in use by the facility. A review of the document indicated, .the care plan should be revised on an on-going basis to reflect changes in the resident, and the care the resident is receiving . 3XXX,d+[DATE](d)(1) 3XXX,d+[DATE](d)(2)(B)

Based on interview and record review the facility failed to ensure staff reported an allegation of physical abuse immediately for 1 of 3 residents reviewed for abuse. (Resident B) Finding includes: During an interview on 1/3/24 at 1:27 p.m., the Administrator indicated on 12/30/23, an allegation was made that LPN 1 (Licensed Practical Nurse) witnessed LPN 2 and QMA 1 (Qualified Medication Aide) abruptly put Resident B in bed. Once Resident B was in bed, he sat up and LPN 2 kicked Resident B. It was alleged this took place a couple weeks ago but unfortunately it was not reported until 12/30/23. During an interview on 1/4/24 at 9:50 a.m., LPN 1 indicated approximately 2 to 3 weeks ago, on evening shift after 7:00 p.m., Resident B was on the floor, on his knees, at the foot of his bed. He had a small can in his hand that LPN 1 thought was shaving cream. LPN 1 asked LPN 2 and QMA 1 to help get Resident B off the floor and into his bed. LPN 1, LPN 2, and QMA 1 entered Resident B's room to get him up and LPN 2 indicated that Resident B's legs needed to be straightened first. After Resident B's legs were straightened, QMA 1 put an arm under Resident B's left armpit and LPN 2 put an arm under Resident B's right armpit and each of them grabbed the back of Resident B's pants. Then LPN 2 and QMA 1 flung Resident B's upper body into his bed with Resident B's legs still hanging off the bed. LPN 1 described flung as rough. When LPN 2 and QMA 1 flung Resident B into bed, Resident B hit his head on the right siderail. Once Resident B hit his head, Resident B sat up and threw the can he had been holding. The can grazed QMA 1, so QMA 1 immediately left the room. Then Resident B and LPN 2 had a back and forth. LPN 1 described the back and forth as talking at each other instead of to each other. LPN 2 was speaking English at Resident B and Resident B was speaking Spanish at LPN 2. LPN 2 was telling Resident B to be quiet. LPN 2 seemed frustrated. Then, LPN 2 extended her left leg out and kicked Resident B in the lower right shin as they were still going back and forth. LPN 1 indicated the kick didn't seem forceful, but it seemed purposeful. At that time, there was no reason for LPN 2 to extend her leg and make any contact with Resident B's leg. LPN 1 put Resident B's legs in bed, made sure Resident B was comfortable, and LPN 1 and LPN 2 left the room and went to the nurse's station. LPN 1 should have reported that she witnessed LPN 2 kick Resident B immediately but was afraid of retaliation. The clinical record for Resident B was reviewed on 1/4/24 at 1:57 p.m. The diagnoses included, but were not limited to, dementia, cerebral infarct, and cognitive communication deficit. An Admission MDS (Minimum Data Set) assessment, dated 9/6/23, indicated Resident B was severely cognitively impaired. On 1/3/24 at 10:36 a.m., the DON (Director of Nursing) provided a copy of a facility policy, titled Abuse and Incident Reporting to IDOH (Indiana Department of Health), dated 5/12/23, and indicated this was the current policy used by the facility. A review of the policy indicated physical abuse included kicking. The facility will ensure that all alleged violations of abuse are reported immediately to the administrator and to other officials according to state and federal regulations. 3.1-28(c)

Based on observation, interview, and record review the facility failed to ensure food was stored in a sanitary manner for 1 of 1 kitchen observations. Food was not dated. Finding includes: During the initial tour of the kitchen on 9/13/23 from 9:01 a.m. until 9:40 a.m., the freezer and refrigerator were observed. Inside the freezer the following was observed: - A large clear plastic opened bag, undated, that contained 1 chicken breast that was observed to be covered with small ice crystals. - A large clear plastic opened bag, undated, that contained green vegetables that was observed to have small ice crystals throughout the bag. Inside the refrigerator the following was observed: - An opened, undated, glass 32 ounce container. The glass container was half full of great value pickles with a use by date of 6/18/23. - An opened, undated, clear plastic 30 ounce container. The plastic container was half full of mayonnaise. - An opened, undated, clear plastic gallon container. The gallon container was 3/4 full of unsweet tea with a best by date of 2/18/23. - An opened, undated, clear plastic 74 ounce container. The plastic container was 3/4 full of maraschino cherries. - An opened, undated, glass 16 ounce jar. The glass jar was 1/2 full of pickle relish. - An opened, undated, plastic 128 ounce container. The plastic container was 1/4 full of mayonnaise. The Dietary Manager was unable to locate a use by or expiration date printed on the plastic container. - An opened, undated, clear plastic 32 ounce container. The container was 1/2 full of crushed garlic. - An opened, undated, plastic 128 ounce container. The container was 1/2 full of ranch salad dressing. The Dietary Manager was unable to locate a use by or expiration date printed on the plastic container. During an interview on 9/13/23 at 9:04 a.m., the Dietary Manager indicated any food items that were opened should have been dated for the date they were opened. The Dietary Manager was not sure what the expiration dates were for the 128 ounce container of ranch dressing or the 128 ounce container of mayonnaise. The Dietary Manager needed to call the company. On 9/13/23 at 11:48 a.m., the Regional Nurse provided a copy of a facility policy, titled Safe Food Handling, dated 9/1/21, and indicated this was the current policy used by the facility. A review of the policy indicated all foods will be covered and dated. This Federal tag relates to Complaint IN00412623. 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to provide a clean homelike environment for 4 of 24 rooms observed. Liquid was on the floor and commodes were dirty. (Resident 24, Resident 182, room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]) Findings include: 1. On 6/28/23 from 10:30 a.m. until 10:40 a.m., a thick clear, slick liquid was observed on the floor in front of Resident 24's bathroom. No staff were present. At 10:45 a.m., Housekeeper 2 was observed to clean the area. Housekeeper 2 indicated that Resident 24 spits on the floor. On 6/29/23 from 11:06 a.m. until 11:10 a.m., a thick clear, slick liquid was observed on the floor in the hall next to the beauty shop. 2. During an interview 6/29/23 at 10:30 a.m., Resident 182 indicated his commode had been nasty since he had been admitted to the facility. On 6/30/23 at 9:45 a.m., observed the commode in room [ROOM NUMBER] to have a dark brown area approximately 1/4 inch in width, on the floor surrounding the commode. On 6/30/23 at 10:00 a.m., observed the commode in room [ROOM NUMBER] to have a dark brown area approximately 1/4 inch in width, on the floor surrounding the commode. On 6/30/23 at 10:10 a.m., observed the commode in room [ROOM NUMBER] to have a dark brown area approximately 1/4 inch in width, on the floor surrounding the commode. During an interview on 6/30/23 at 10:11 a.m., Housekeeper 2 indicated she was not sure what the substance on the floor surrounding the commode was or how to remove it. During an interview on 6/30/23 at 10:12 a.m., Housekeeper 3 indicated several commodes had the same dark brown area surrounding the commode. Staff were supposed to put a work order in when they see it. During in interview on 6/30/23 at 10:15 a.m., the Housekeeping Supervisor indicted she tried to use a tool (putty knife) to remove the stained area. She indicated, It's the caulking it needed to be replaced. Maintenance would be who needed to replace the caulking. We would have normally put in a work order. During an interview at 10:30 a.m., the Maintenance Director indicated he did not have any current work orders and was unaware of the areas around the commodes. On 6/30/23 at 11:40 a.m., the current work orders were reviewed. The current work orders lacked any orders to fix the commodes. On 6/30/23 at 11:14 a.m., the Director of Nursing provided a policy titled Safe/Clean Environment, dated 11/2020, and indicated it was the current policy being used by the facility. A review of the policy indicated .5. The facility will provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. 3.1-19(f)

Based on observation and interview, the facility failed to provide a reasonable accommodation of needs for 1 of 24 residents reviewed. A call light was out of reach. (Resident 25) Findings include: On 6/26/23 from 9:30 a.m. until 9:45 a.m., Resident 25 was observed in her room sitting in a broda chair with both eyes closed. The chair was facing the door to the resident's room. The chair was next to the resident's bed. The residents call light was observed to be out of the reach of the resident. On 6/26/23 from 10:30 a.m. until 10:45 a.m., observed Resident 25 in her room. The resident's call light was out of the reach of the resident. On 6/27/23 from 11:22 a.m. until 11:45 a.m., observed the same. On 6/28/23 from 9:30 a.m. until 9:45 a.m., observed the same. On 6/29/23 from 8:20 a.m. until 8:40 a.m., observed the same. During an interview on 6/26/23 at 9:45 a.m., LPN 1 indicated due to impaired cognition Resident 25 never used her call light. During an interview on 6/27/23 at 11:25 a.m., Resident 25's room mate indicated Resident 25 did not always have her call light in reach. During an interview on 6/28/23 at 8:20 a.m., the Director of Nursing (DON) indicated all residents should have a call light in reach. There was no reason for a resident to have a call light out of reach. On 6/28/23 at 8:28 a.m., the DON provided a policy titled Call light Policy, dated November 2020, and indicated it was the current policy being used by the facility. A review of the policy indicated Purpose: To respond to the resident's requests and needs in timely manner .4. Call lights will be kept within the residents reach when in room .6. Check to ensure the call light is in the resident's reach prior to leaving room . 3.1-3(v)(1)

Based on interview and record review, the facility failed to develop and implement a comprehensive care plan for monitoring the side effects of psychotropic and antipsychotic medications for 1 of 5 residents reviewed for medication monitoring. (Resident 71) Finding includes: On 6/28/23 at 4:15 p.m., Resident 71's clinical record was reviewed. The diagnoses included, but were not limited to, post-traumatic stress disorder (PTSD), dementia in other diseases classified elsewhere, mild, with anxiety; unspecified mood (affective) disorder, and generalized anxiety disorder. Physician orders included, but were not limited to: - donepezil HCL (for treatment of behavioral and cognitive effects of cognitive effects of dementia) tablet - give 5 mg (milligrams) by mouth one time a day for mood disorder, start date 2/20/23 and no stop date noted; - fluoxetine HCL (antidepressant) 20 mg capsule - give 1 dose by mouth one time a day for mood disorder, start date 2/20/23 and no stop date noted; and - zyprexa (antipsychotic) oral tablet 2.5 mg - give 1 tablet by mouth one time a day for mood disorder, start date 2/20/23 and no stop date noted. The Quarterly MDS (Minimum Data Set) assessment, dated 6/9/23, indicated Resident 71 was severely cognitively impaired, had anxiety disorder, PTSD, unspecified mood (affective) disorder, and dementia in other diseases classified elsewhere, mild, with anxiety. Resident received antipsychotic and antidepressant medications. Resident 71's care plan indicated: -Resident is at risk of adverse reactions r/t [related to] antipsychotic medications, start date 3/29/23 and target date 8/13/23 .will have no adverse reactions noted r/t psychotropic/antipsychoactive medications through next review .target date 8/13/23 .; -Antidepressant medication use .start date 3/29/23 .; and -Antipsychotic medication use .start date 3/29/23 . The clinical record indicated Resident 71's Physician prescribed zyprexa, donepezil HCL, and fluoxetine HCL on 2/20/23. The comprehensive care plan for monitoring the side effects of those medications were not initiated until 3/29/23. During an interview on 6/29/23 at 1:11 p.m., the Director of Nursing Services (DNS) indicated the medication monitoring should have been included as part of the comprehensive care plan when those medications were prescribed. On 6/29/23 at 12:50 p.m., the DNS provided an undated copy of the Care Plans Protocol and indicated it was the current policy in use by the facility. A review of the policy indicated, .care plan be completed or modified within 7 days of Completion date of comprehensive assessments. Facilities should also evaluate the appropriateness of the care plan .care plans should be revised on an on-going basis to reflect changes in the resident the care the resident is receiving .must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being . 3.1-35(a)

Based on interview and record review, the facility failed to obtain orders for a laboratory services for 3 of 3 residents reviewed. (Resident 28, Resident 29, Resident 71). Findings include: 1. On 6/26/23 at 11:45 a.m., Resident 28's clinical record was reviewed. Resident 28's diagnosis included, but was not limited to, Type II diabetes melllitus (a chronic condition that happens because of a problem in the way the body regulates and uses sugar as a fuel). Resident 28's physician orders were reviewed. Resident 28 had an order with an active status for an Hgb A1C test for every 3 months; the order date was for 2/8/23 and the order lacked a start date or an end date. On 6/29/23 at 9:55 a.m., Resident 28's pharmacy recommendations were reviewed. A pharmacy record review, dated for 4/20/23, indicated missing lab results for Resident 28. The recommendation stated, Resident [28] has a lab order for an AC [the A1C test-also known as the hemoglobin A1C or HgbA1c test-is a simple blood test that measures your average blood sugar levels over the past 3 months] to be drawn q [every] 3 months. Results were unavailable in the record at the time of review. The pharmacy recommendation also included the following handwritten statements of, initial lab order on 2/8/23 and April draw performed on 4/28/23. On 6/29/23 at 1:05 p.m., the DON (Director of Nursing) indicated that Resident 28's Hgb A1C blood draw laboratory test should have been entered with a start date and should have been drawn when the order was placed in February. 38466 2. On 6/28/23 at 2:31 p.m. the clinical record of Resident 29 was reviewed. The diagnosis included, but was not limited to, Diabetes Mellitus with diabetic autonomic (poly) neuropathy (a type of nerve damage caused by diabetes). Physician orders included, but were not limited to to the following: -Lab - A1C [a simple blood test that measures your average blood sugar levels over the past three months to help the health care team manage diabetes] every three months due 11/21/22 every 90 days .start date 11/18/2022 and no stop date noted .; The monthly Consultant Pharmacist Recommendation documents indicated the following: - The monthly pharmacy review, dated 1/19/23, indicated Resident has a lab order for A1C q [every] 3 months ordered on 11/18/22 for draw on 11/21/22. Results were unavailable in the record at time of review. Please follow up with lab to have results forwarded or lab scheduled to be drawn. - The monthly pharmacy review, dated 6/19/23, indicated Resident has a lab order for A1C q [every] 3 months that was due in May. Results were unavailable in the record at time of review. Please follow up with lab to have results forwarded or lab scheduled to be drawn. During an interview on 6/29/23 at 2:47 p.m., the Director of Nursing Services (DNS) indicated Resident 29's physician orders for the A1C labs should have been drawn and monitored. 3. On 6/28/23 at 4:15 p.m. the clinical record of Resident 71 was reviewed. The diagnosis included, but were not limited to, Type 2 Diabetes Mellitus (DM) with diabetic neuropathy (a type of nerve damage caused by diabetes), Type 2 DM with unspecified complications, and acute kidney failure. The monthly Consultant Pharmacist Recommendation document, dated 6/19/23, indicated This resident has diabetes with no A1C level [a simple blood test that measures your average blood sugar levels over the past three months to help the health care team manage diabetes] available from the past 6 months. Please consider A1C level at this time and every 6 months thereafter . During an interview on 6/29/23 at 2:47 p.m., the Director of Nursing Services (DNS), indicated Resident 71 should have had scheduled routine AIC lab draws. During an interview, on 6/30/23 at 8:47 a.m., the DNS indicated nursing staff should have clarified with Resident 71's physician and obtained the routine A1C lab draws. On 6/29/23 at 12:00 p.m., the DNS provided a copy of the Physician Orders Policy/Guidelines document, dated November 2022, and indicated it was the current policy in use by the facility. A review of the policy indicated, .physician orders are reviewed and noted accordingly per licensed nursing staff .nursing responsibilities: current medications orders plus allergies and pertinent laboratory test results .new orders will be reconciled by 2 nurses to verify accuracy . On 6/30/23 at 9:05 a.m., the Administrator provided a copy of the Diagnostic - Laboratory - Radiology policy, dated November 2022, and indicated it was the current policy in use by the facility. A review of the policy indicated.The facility will provide or obtain laboratory services to meet the needs of its residents and will be responsible for the quality and timeliness of the services .the facility will file in the resident's clinical record .diagnostic reports . 3.1-49(a)

Based on observation, interview, and record review, the facility failed to ensure the daily posted nurse staffing reflected the actual hours worked by staff for 5 of 5 days during the survey. Finding includes: During an observation on 6/26/23 at 11:00 a.m., the posted daily staffing lacked actual hours worked by staff. On 6/27/23 at 8:30 a.m., the same was observed. On 6/28/23 at 9:00 a.m., the same was observed. On 6/29/23 at 8:45 a.m., the same was observed. On 6/30/23 at 8:10 a.m., the same was observed. During an interview on 6/30/23 at 9:15 a.m., the DON (Director of Nursing) indicated the facility should have included the actual hours worked on the daily staffing postings. On 6/30/23 at 1:15 p.m., the DON provided a policy, dated as revised on 11/2022 and titled, Nursing Services - Nurse Staffing Information, and indicated it was the policy currently in use. The policy indicated, The facility will post the following information daily: .c. The total number and the actual hours worked .

Based on observation, record review, and interview, the facility failed to ensure two staff provided care to a dependent resident which resulted in the resident having rolled out of bed during care and sustained a fracture for 1 of 5 residents reviewed for falls. (Resident 32) Findings include: On 5/12/21 at 11:30 a.m., Resident 32 was seated in a Broda chair (mobile chair that assists patients who have limited mobility with comfortable positioning). The resident was observed to have a soft splint to his left leg. The clinical record of Resident 32 was reviewed on 5/12/21 at 2:15 p.m. Diagnoses included, but were not limited to, [CONDITION(S)] (paralysis of one side of the body) related to a [CONDITION(S)] (CVA), contracture of bilateral knees and bilateral ankles (deformity and rigidity of the joints on the left and right side), and cognitive communication deficit. A Quarterly Minimum Date Set (MDS) assessment, dated 3/12/21, indicated Resident 32 was extensively dependent on staff when rolling side to side on the bed, required the extensive assist of two persons for bed mobility, and was severely cognitively impaired. A care plan, dated 7/3/14 and current through 7/6/21, indicated Resident 32 was at risk for falls related to decreased safety awareness, diagnoses of seizures, history of combativeness during care, weakness, unsteadiness, impaired coordination, impaired vision, diagnoses of [CONDITION(S)], and use of multiple high fall risk medications. Interventions to prevent falls included having two person assistance and using a mechanical lift to assist the resident in and out of bed, and staff education that the resident was a two person assist with personal care was updated on 5/5/21. A care plan, dated 7/3/14 and current through 7/6/21, indicated Resident 32 was extensive assistance for bed mobility, transfers, and ADL (activities of daily living), due to weakness, unsteadiness, [CONDITION(S)], contracture of both ankles and knees, limited mobility, and cognitive impairment. Interventions to prevent falls included to provide extensive two person assist with bathing and dressing. Review of Resident 32's CNA care sheet, dated 5/2/21 indicated, Resident Care . Ambulation/Mobility/Transfer .assist resident getting in and out of bed with two-person assistance using mechanical lift . requires two-person assistance with transfers and bed mobility with mechanical lift . requires 1 person assistance with grooming and hygiene. Review of a facility reported incident (FRI), dated 5/2/21 at 11:01 a.m., indicated while CNA 5 was providing care, .resident went to roll over and rolled out of bed onto the floor. The nurse's assessment, at that time, indicated the resident appeared to have no injuries noted and the resident denied any pain. Resident 32's Nurses Notes indicated the following: -On 5/4/21, the nurse assessed the resident and indicated he was expressing non-verbal pain, due to the fall on 5/2/21. The resident's Physician was notified and they ordered x-rays for hip and pelvis. No fracture had been identified. -On 5/5/21 the resident expressed non-verbal pain when receiving care and being repositioned. The Nurse Practitioner increased his pain medication and to be taken for seven days. -On 5/6/21, the resident was sent to the hospital for a second x-ray, due to expressed non-verbal pain. -On 5/6/21 the resident returned from the hospital. Resident 32 had been placed in a splint for a distal femur fracture (thigh/upper leg bone). Interview, on 5/14/21 at 11:15 a.m., the Administrator indicated on 5/2/21 CNA 5 had provided care to Resident 32 without the assistance of a second staff present. Interview, on 5/17/21 at 9:45 a.m., the DON indicated Resident 32 was an extensive assist of 2 staff and all the care plan was updated on 5/5/21 that staff were educated to use 2 staff and the CNA care sheets were updated to a 2 person assist with hygiene. The updates were completed after the fall. On 5/17/21 at 3:50 p.m., the DON provided a policy, dated 2/18/20, titled: Falls management, and indicated it was the policy currently used by the facility. A review of the policy indicated .Patients will be assessed for falls those determined to be at risk will receive appropriate interventions to reduce and minimize injury. 3.1-45(a)(2)

Based on interview and record review, the facility failed to routinely assess a pressure wound, ensure physician orders [REDACTED]. Findings include: On 2/8/21 at 12:00 p.m., Resident D's closed clinical record was reviewed. [DIAGNOSES REDACTED]. The resident was discharged on [DATE] and transferred to another long term care nursing facility. Resident D's admission MDS (Minimum Data Set) assessment, dated 10/20/20, indicated the resident was moderately cognitively impaired, required extensive assistance of 1 staff member with ADL's (Activities of Daily Living), and was at risk for the development of pressure ulcers. A care plan initiated on 10/14/20, for Resident D indicated, Resident at risk for further skin breakdown related to immobility and [MEDICAL CONDITION] on head and neck . Interventions . Provide wound treatment as ordered . Weekly skin check by licensed nurse . Weekly wound assessment . Resident D's progress notes indicated the following: -Skin-Pressure Ulcer Note, dated 10/25/20 at 10:00 a.m., indicated the resident acquired an unstageable suspected deep tissue injury (an ulcer that has full thickness tissue loss and is covered by extensive dead tissue or by a scab) to the left heel and it was acquired in house. The wound measured 12 centimeters (cm) by 5 cm and a blood blister was present. -Wound Evaluation & Management Summary, dated 10/28/20, indicated, .(Resident) has an unstageable DTI (deep tissue injury) of the left, posterior heel for at least 1 day duration . Dressing Treatment Plan . Alginate calcium (treatment to maintain physiologically moist microenvironment that promotes healing and the formation of granulation/connective tissue) apply once daily for 30 days . Foam with border apply once daily for 30 days . Skin prep apply once daily for 30 days . This form was completed by the wound doctor. -Skin-Pressure Ulcer Note, dated 11/01/20 at 10:00 a.m., indicated the resident's DTI to left heel measured 12 cm by 4.5 cm and a blood blister was present. Wound dressings were not indicated as being used on the DTI, only skin prep. Interventions indicated, heel suspension device. -Wound Evaluation & Management Summary, dated 10/28/20, indicated, .a thorough wound care assessment and evaluation was performed today. (Resident) has an unstageable (due to necrosis (dead tissue/cells)) of the left, posterior heel for at least 7 days duration . Wound Size (L x W x D): 6 x 6 x 0.1 cm . Dressing Treatment Plan . Alginate calcium apply once daily for 23 days; Santyl (treatment to beak up and remove dead tissue) apply once daily for 30 days . Foam border apply once daily for 23 days . Skin prep apply once daily for 23 days. During this visit another unstageable wound was discovered on the resident's right heel, which measured 2.5 cm by 1.5 cm. During this visit both heel wounds required debridement (the removal of dead or infected skin tissue) to help the wounds heal. -Wound Evaluation & Management Summary, dated 11/11/20 indicated, . Focused Wound Exam UNSTAGEABLE OF THE LEFT, POSTERIOR HEEL . Wound Size (L x W x D): 5.5 x 5 x 0.1 cm . UNSTAGEABLE OF THE RIGHT, POSTERIOR HEEL .Wound Size . 2.5 x 2 x 0.1 cm . -Wound Evaluation & Management Summary, dated 11/18/20, indicated, . Focused Wound Exam UNSTAGEABLE OF THE LEFT, POSTERIOR HEEL . Wound Size (L x W x D): 5 x 5 x 0.1 cm . UNSTAGEABLE OF THE RIGHT, POSTERIOR HEEL .Wound Size . 2 x 2 x 0.1 cm . -Wound physician progress notes [REDACTED]. There was no mention of the new DTI wound to Resident D's right heel in the facility's assessments. No new skin assessments were performed by the facility following 11/1/20. Resident D's December, 2020, physician's orders [REDACTED]. -10/13/2020, Wound(s): Monitor sites(s) daily for status of surrounding tissue and wound pain. Monitor for status of dressing(s), if applicable additional documentation in NN (nursing notes) if needed every shift for wounds. -10/28/2020, Cleanse wound on left heel with normal saline. Pat dry. Apply calcium alginate and cover with [MEDICATION NAME] (wound dressing designed for wounds with heavy drainage) dressing. One time a day. -10/27/20, Waffle Boot to be applied on left foot for pressure relief, monitor for proper fit and signs of excess skin pressure or redness every shift . -11/4/2020, Cleanse R (right) heel with normal saline. Pat dry. Apply calcium alginate and cover with [MEDICATION NAME] dressing. One time a day. Resident D's Medication Administration Record [REDACTED] -For the month of October, skin prep spray was not applied to the left heel for 1 day shift and 2 night shifts. -For the month of October, the waffle boot on the left heel was not monitored for 2 night shifts. -For the month of October, the wound sites were not monitored for status of surrounding tissue and wound pain for 3 day shifts, 2 evening shifts, and 2 night shifts. -For the month of November, the waffle boot on the left heel was not monitored for 5 day shifts. -For the month of November the skin prep spray was not applied to left heel blister for 5 day shifts and 1 evening shift. -For the month of November, the wound sites were not monitored for status of surrounding tissue and wound pain for 5 day shifts, 2 evening shifts, and 3 night shifts. -From December 1, 2020 to December 7, 2020, the wound sites were not monitored for status of surrounding tissue and wound pain for 2 day shifts and 2 night shifts. There was no MAR/TAR documentation in regard to implementing the wound doctor's orders of calcium alginate, Santyl, and foam border, for the dressing changes on both of Resident D's heels. A care plan initiated on 10/28/20, for Resident D indicated, Rt. (right) heel deep tissue injury to proximal side . Interventions: Area followed weekly by nursing . Check area Q (every) shift for signs and symptoms of infection, Dressing changer per MD (doctor) order, heels floated while in bed . The resident's care plans lacked documentation of an intervention of turning and repositioning the resident to reduce pressure. There was no care plan implemented related to the left heel DTI. Resident D's Discharge Minimum Data Set assessment, dated 12/7/20, indicated the resident had 1 unstageable pressure injury presenting as deep tissue injury. Resident D's Discharge Transition Plan, undated, indicated, . Skin Condition: Skin issues identified, Left Heel deep tissue injury - utilizes waffle boot . Treatments: Cleanse heel with normal saline. Pat dry. Apply calcium alginate and cover with [MEDICATION NAME] dressing . Resident D's admission progress note (from long term care nursing facility transferred to), dated 12/7/20, from the facility they were discharged to indicated, Resident arrived at 4:45 pm and was assessed . has blanchable stage 2 (partial thickness loss of skin tissue presenting as a shallow open ulcer with a red/pink wound bed. May also present as an intact or open/ruptured filled blister.) on rt buttocks at top . Stage 2 on coccyx (tailbone) . Resident has a stage 3 on rt heel 75% sloth (shed) (sic), drainage and hard and red around edges. Measures at 5 1/2 cm x 3 1/2 cm . unstageable wound on left heel, has dark cap, eschar tissue (shedding of dead tissue), sloth (sic) around edges and left side has odor. Resident has dark spots and bruising on top of feet. Resident's toenails are thick long and misshaped. Resident states . pain in heels head area and buttocks and coccyx. During an interview, on 2/9/21 at 3:00 p.m., the Director of Nursing indicated Resident D was very sick with COVID-19 in November, 2020, and questioned if they would recover. The resident would not have had wound doctor visits due to being COVID positive and under isolation. During an interview, on 2/10/21 at 1:15 p.m., the wound doctor indicated that he did not see Resident D after 11/18/20, due to the resident having a COVID-19 diagnosis. During an Interview, on 2/10/21 at 3:00 p.m., the Director of Nursing indicated that she could not find documentation related to staff implementing Resident D's wound doctor's orders for the dressing changes on both heels. That was around the time that we went live (to using electronic health records) and there was a lot of confusion back then for a few weeks. I think his orders did not carry over. She indicated the facility does not routinely document when residents are turned and repositioned. On 2/10/21 at 3:45 p.m., the Director of Nursing provided the facility policy, Skin Integrity Management, revised on 1/31/20, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . Implement Special Wound Care treatments/techniques, as indicated and ordered . Review care plan weekly and revise as indicated . This Federal tag relates to Complaint IN 490. 3.1-40(a)(2)

Based on interview and record review, the facility failed to prevent an unstageable and stage 3 pressure injuries from developing and failed to identify the pressure injuries prior to being unstageable and failed to implement interventions for the prevention and treatment of [REDACTED]. (Resident D) Findings include: The clinical record for Resident D was reviewed on 9/25/19 at 12:08 p.m. The [DIAGNOSES REDACTED]. An admission nursing assessment, dated 5/30/19, noted no pressure injuries to Resident D's skin. An Admission Minimum Data Set (MDS) Assessment, dated 6/7/19, indicated Resident D required total assistance with activities of daily living with 1 to 2 staff person for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. Resident D was marked at risk for developing pressure ulcers and no pressure ulcers were noted at the time of the assessment. A risk for skin breakdown care plan was initiated on 5/31/19. Interventions included to encourage resident to consume all fluids of choice during meals and weekly wound assessment to include measurements and description of wound status. A weekly skin assessment was conducted on the following day(s) with no pressure injuries noted: 6/6/19 6/13/19 6/20/19 6/27/19 7/4/19 7/11/19 There were no other skin assessments and/or progress notes that indicated Resident D's skin integrity until 8/6/19. A Practitioner Note, dated 8/6/19 at 8:59 a.m., indicated the following, .Patient is seen today for complaints of his second toe on the left foot having some bleeding. The tip of the toe does have a small open sore. Patient is also having pustular discharge from the great toe previous partial amputation A progress note, dated 8/6/19 at 4:32 p.m., indicated the following, .res (resident) seen by wound MD on rounds today, unstageable wound to right buttock meas. (measuring) 6.0 x 4.0 x utd (unable to determine depth). moderate serous (clear, pale yellow) drainage. 100% necrotic (dead tissue). stage 3 pressure to left buttock meas. (measuring) 4.0 x 2.0 x 0.1. moderate serous drainage noted. 100% granulation tissue. wound to left distal 4th doe meas. (measuring) 1.0 x 1.0 x 0.1. light serous drainage noted 100% necrotic. list distal second toe meas. (measuring) 0.5 x 0.5 x 0.1. light serous drainage. 100% granulation (new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process) tissue noted A Wound Physician note, dated 8/6/19, indicated the following, .unstageable of the right buttock .stage 3 pressure wound of the left buttock .wound of the left, distal, first toe .surgical excisional debridement procedure .wound was cleansed with normal saline and anesthesia was achieved with using topical [MEDICATION NAME]. Then with clean surgical technique, curette (a surgical instrument used to remove material by a scraping action) was used to surgically excise 1.00 (square centimeters) of devitalized tissue and necrotic subcutaneous fat and surrounding connective tissues were removed at a depth of 0.2 cm (centimeters) .wound of the left, distal, second toe Physician orders, dated 8/8/19, were noted for the treatment of [REDACTED]. The treatment order was noted 2 days after the pressure injuries were identified on 8/6/19. The risk for skin breakdown care plan was updated, 8/8/19, indicating the following, .8/8/19 Open area left distal 1st toe .8/8/19 Open area right buttock .8/8/19 stage 3 pressure injury left buttock .Goal .Wounds to left 1st and 2nd toe and wounds to bilateral buttocks will heal within the next 90 days There were no new interventions added on the updated care plan on 8/8/19. A Nutritional Assessment, dated 8/12/19, noted significant weight loss at 12.6% in one month. An unstageable pressure injury noted to right buttock, stage 3 pressure injury to left buttock and wound to left, distal, 4th toe. Supplements included Ensure with meals, but also commented on how Resident D brought in own nutritional supplement that he previously drank three times daily. There was no caloric and/or other nutritional needs documented for nutritional support of wound healing. A Wound Physician note, dated 8/13/19, indicated a surgical excisional debridement procedure was performed on Resident D's unstageable pressure injury to his right buttock and the wound to his left, distal, first toe. The wound to the left, distal, second toe was resolved. A Wound Physician note, dated 8/20/19, indicated another surgical excisional debridement procedure was performed to Resident D's right buttock pressure injury and the wound to his left, distal, first toe. Another pressure injury was noted and identified as an unstageable deep tissue injury (DTI) to Resident D's left lateral heel. There was deterioration noted to the pressure injuries involving the right buttock and left, distal, first toe. A Wound Physician note, dated 8/27/19, indicated another surgical excisional debridement procedure was performed to Resident D's right buttock pressure injury, the wound to his left, distal, first toe, and the left buttock pressure injury. There was deterioration noted to the left buttock pressure injury. A Wound Physician note, dated 9/3/19, indicated another surgical excisional debridement procedure was performed to Resident D's right buttock pressure injury and the wound to his left, distal, first toe. There were three new areas identified as an unstageable of the right, lateral foot that surgical excisional debridement was performed, an unstageable deep tissue injury of the right, lateral foot, and an unstageable deep tissue injury to the right, distal, lateral foot. The following measurements were noted: Right buttock at 4 x 4 x 0.1 centimeters, Left buttock at 2.5 x 1 x 0.1 centimeters, Left, distal, first toe at 0.5 x 0.5 x 0.1 centimeters, Left, lateral heel at 1 x 1 centimeters, Right, lateral foot at 3 x 2 x 0.1 centimeters, Right, lateral foot at 2 x 1.5 centimeters, & Right, distal, lateral foot at 2 x 1 centimeters. A physician order, dated 9/4/19, noted the following, .Santyl Ointment .Apply to necrotic wound left foot topically every night shift for wound care . The order had a start date of 9/4/19 and it was never signed off of the Medication Administration Record [REDACTED] A physician order, dated 9/4/19, noted the following, .Skin prep wipes .Apply to 2 right lat (lateral) foot wounds topically every night shift for wound care The order had a start date of 9/4/19 and it was never signed off of the Medication Administration Record [REDACTED] A physician order, dated 9/4/19, noted the following, .off loading boot to BLE (bilateral lower extremities) at all times every shift for wound care The order had a start date of 9/4/19 and it was never signed off of the Medication Administration Record [REDACTED] Resident D was hospitalized for [REDACTED]. An Admission Note, dated 9/6/19, indicated the following, .He (Resident D) is developing sacral ulcers from lying in bed all the time .6. Pressure ulcer .unstageable this time Hospital records were obtained and indicated the following with Resident D's skin integrity, .Wound Care Note .September 08, 2019 .R (right) ischium (the curved bone forming the base of each half of the pelvis): unstageable extensive R (right) ischial pressure ulcer. Very foul odor, [DIAGNOSES REDACTED] (superficial reddening of the skin) and indurated especially on medial margins. Areas of red tissue but increased amount of necrotic tissue covering wound base. no palpable or visible bone at this time. Increased amount of purulent (consisting of, containing, or discharging pus) drainage from area of undermining and small tract goes medially .L (left) ischium: small unstageable pressure ulcer with possible moisture breakdown component .Bilateral feet: pt (patient) with neuropathic/pressure ulcers all over feet and heels. R (right) worse than left. Most of the areas are stable black eschar The records indicated Resident D was given 2 intravenous antibiotics for 7 days related to soft tissue infection. A skin integrity care plan, revised 9/18/19, indicated the following, .Resident at risk for skin breakdown related to impaired mobility, fragile skin and has actual skin breakdown .Interventions .Offloading boots to bilat (bilateral) lower extremity at all times .Provide wound treatment as ordered .Provide supplements as ordered .Weekly wound assessments to include measurements and description of wound status An interview conducted with the Director of Nursing (DON), on 9/25/19 at 1:38 p.m., indicated her expectations were for nursing staff to conduct weekly skin assessments and if any new skin impairment is identified they were to contact the DON and the physician to ensure that the skin impairment was followed-up with. A treatment was to be implemented at the time of an identified skin impairment that warranted a treatment. A policy titled Skin Integrity Management, revised 7/1/19, was provided by the Administrator on 9/26/19 at 4:25 p.m. The policy indicates the following, .3.2 Perform skin inspection on admission/re-admission and weekly .3.3 Perform wound observations and measurements and complete Skin Integrity Report .3.4 Perform daily monitoring of wounds or dressings for presence of complications or declines and document .4. Develop comprehensive, interdisciplinary plan of care including prevention and wound treatments, as indicated The Administrator indicated this was the current policy being utilized by the facility. This Federal tag relates to Complaint IN 545. 3.1-40(a)(1) 3.1-40(a)(2)

Based on interview and record review, the facility failed to ensure fall events were documented appropriately, investigate fall events, update the care plan to reflect new interventions and conduct an interdisciplinary team meeting post fall event that resulted in repeated falls and a fall with emergency transfer to the hospital and requiring stitches for forehead wound closure for 1 of 3 residents reviewed for accidents. (Resident C) Findings include: The clinical record for Resident C was reviewed on 9/25/19 at 11:40 a.m. The [DIAGNOSES REDACTED]. An Admission Minimum Data Set (MDS) Assessment, dated 7/14/19, indicated Resident C had a fall incident in the last month prior to admission to the facility, but no falls since his admission to the facility. Resident C had a Brief Interview for Mental Status (BIMS) score of 7, indicative of cognitive impairment. Resident C required extensive assistance with one staff person for personal hygiene, toilet use, dressing, transfers and bed mobility. A care plan for falls, initiated on 8/27/19 and current, indicated the following, .Resident is at risk for falls: Impaired mobility, [MEDICAL CONDITION] .Goal .Resident will have no falls with injury x_90 days The interventions initiated, on 8/27/19, included the following, .non skid footwear .medication evaluation as needed .place call light within reach while in bed or close proximity to the bed .maintain a clutter-free environment in the resident's room and consistent furniture arrangement .When resident is in bed, place all necessary personal items within reach .Monitor for and assist toileting needs .Encourage resident to attend all activities that maximize their full potential while meeting their need to socialize An SBAR (Situation, Background, Assessment, Recommendations) form, dated 7/5/19, indicated the following, .Resident was noted in room lying on his left side. He has vision impairment an unsteady gait. mild contusion to the back of his head (sic). ROM (range of motion) WNL (within normal limits) A section of the SBAR form titled Advance Care Planning Information and Nursing Notes (for additional information on the Change in Condition) were noted to be blank. There were no progress notes documenting a description and/or immediate action taken when Resident C fell on [DATE]. A Fall Log, for (MONTH) and (MONTH) of 2019, noted Resident C having a fall event on 8/18/19 and 9/23/19. This log was generated by the system Risk Management. An SBAR form, dated 8/18/19, indicated there was a fall event with Resident C, but no description of the event was noted on the form. A section of the SBAR form titled Advance Care Planning Information and Nursing Notes (for additional information on the Change in Condition) were noted to be blank. A progress note, dated 8/18/19, indicated the following, .writer witnessed resident sitting on the floor near his room. resident placed in chair per protocol. resident behavior is baseline. no s/s (signs or symptoms) or c/o (complaint of) pain A document from Risk Management System, dated 8/18/19, indicated the following, .Writer witnessed resident sitting on the floor. writer called for assistance and resident placed in chair per protocol An SBAR form, dated 8/21/19, indicated there was a fall event with Resident C, but no description of the event was noted on the form. A section of the SBAR form titled Advance Care Planning Information and Nursing Notes (for additional information on the Change in Condition) were noted to be blank. A progress note, dated 8/21/19, indicated the following, .CNA (Certified Nursing Assistant) staff alerted writer to res (resident) room, res (resident) found on floor near bed. Writer and CNA placed res (resident) in w/c (wheel chair). res (resident) assessed for injuries none found (sic), vitals were wnl (within normal limits) An SBAR form, dated 8/30/19, indicated there was a fall event with Resident C, but no description of the event was noted on the form. A section of the SBAR form titled Advance Care Planning Information and Nursing Notes (for additional information on the Change in Condition) were noted to be blank. A progress note, dated 8/30/19, indicated the following, .Res (resident) found on floor in room. No injuries noted at this time. Neuros (neurological checks) started. Admin (Administrator) notified and message left for daughter (name of daughter) A progress note, dated 9/22/19 at 10:02 p.m., indicated Resident C was found on the floor in his room with no injuries noted. There was no incident report and/or change in condition form that would include a description and follow-up with the fall event. Resident C's care plan for falls, initiated on 8/27/19, indicated the fall interventions remained unchanged. An SBAR form, dated 9/23/19, indicated there was a fall event with Resident C, but no description of the event was noted on the form. A progress note, dated 9/23/19 at 6:03 p.m., indicated the following, .Resident found on floor outside of room [ROOM NUMBER] lying facedown next to wheelchair. This writer rolls resident over on to back into supine position. resident sustained [REDACTED]. (approximately) 3.0 x 0.4 x 0.3 (centimeters). laceration line jagged, with copious amt (amount) of blood draining from area. No complaints of pain verbalized while first aide being given .911 called for transfer to hospital Another document from Risk Management System, dated 9/23/19, indicated the following, .Resident found on floor outside of room [ROOM NUMBER] lying facedown next to wheelchair. This writer rolls resident over on to back into supine position. resident sustained [REDACTED]. (approximately) 3.0 x 0.4 x 0.3 (centimeters). laceration line jagged, with copious amt (amount) of blood draining from area. No complaints of pain verbalized while first aide being given .911 called for transfer to hospital Hospital records, dated 9/23/19, indicated the following, .1: Fall .You had a fall at your extended care facility. This resulted in a cut over your right eye. The cut was stitched up and treated with anti-bacterial cream .Hospital Course: .Discussed with ECF (extended care facility) who state patient's mental status is confused at baseline, alert and oriented x1, has issues with falls An interview conducted with Registered Nurse 14, at 9/26/19 at 11:45 a.m., indicated Resident C is a fall risk and has had multiple fall events. The staff now keep Resident C at the nurses station so the staff can keep a closer eye on him. There was no documentation related to a fall follow-up for any fall events for Resident C, prior to 9/23/19. The fall care plan lacked updated interventions with each fall event to prevent recurrent falls. An interview conducted with the Director of Nursing (DON), on 9/25/19 at 1:38 p.m., indicated all fall events were reviewed in the care meeting that is held daily, Monday through Friday. The staff reviewed contributing factors, determine root cause (why) of the fall, and develop interventions. There had been a concern with agency nursing staff not charting effectively in the computer system. The facility was in the process of getting that under control. The system Risk Management was where the staff input a fall event and it triggered management staff to follow-up with the fall event under Risk Management. Not all staff create that event under Risk Management, because it can be seen as double charting. Falls were an issue with having agency nursing staff and incomplete documentation. By the time you find the issue with incomplete documentation, the agency staff person is no longer coming to the facility. The expectations are for staff to complete a change in condition form to describe the fall event, document in Risk Management, and conduct neurological assessments per facility policy. The staff would follow-up with each fall event and document the fall in Risk Management. With Resident C, there were some fall events not documented in the change in condition form and/or Risk Management. The DON indicated that could be the reason for the lack of fall follow-up for Resident C's fall events. A policy titled, Falls Management, revised 3/15/16, was provided by the Administrator on 9/25/19 at 10:30 a.m. The policy indicated the following, .Patients will be assessed for falls risk as part of the nursing assessment process. Those determined the be at risk will receive appropriate interventions to reduce risk and minimize injury .Patients experiencing a fall will receive appropriate care and investigation of the cause .5. If patient falls: .5.2 Utilize the Fall Response Protocol .5.2.1 Perform Neurological Assessment .5.3 Document accident/incident: .5.3.1 As a new event in the Risk Management System (RMS) .5.3.2 On a Change of Condition Note .5.3.4 Investigation using the Fall Investigation/QA and other appropriate tools in RMS .5.4 Update care plan to reflect new interventions .5.5 Conduct interdisciplinary team meeting within 72 hours of fall .5.6 The Center Executive Director and Center Nurse Executive will conduct a post fall review The Administrator indicated this was the current policy being utilized by the facility. This Federal tag relates to Complaint IN 481. 3.1-45(a)(2)

Based on interview and record review, the facility failed to address significant weight loss, ensure weights were obtained as ordered and per policy, and document the intake of a supplement that resulted in a hospitalization and the placement of a feeding tube for malnutrition for 2 of 2 residents reviewed for [MEDICAL TREATMENT] and 2 of 3 residents reviewed for pressure ulcers. (Resident D, H, and J) Findings include: 1. The clinical record for Resident D was reviewed on 9/25/19 at 12:08 p.m. The [DIAGNOSES REDACTED]. The following weights were noted in Resident D's clinical record: 5/30/19- 184.2 pounds, 6/5/19- 194.6, 6/10/19- 193.6, 6/20/19- 183.2, 7/16/19- 174.0, & 8/5/19- 152. A Nutritional Assessment, dated 6/10/19, noted no recommendations due to stable weight and no pressure injuries noted. A nutrition care plan, initiated 6/10/19, indicated the following, .Resident is at nutritional risk for decline d/t (due to) Dx (diagnosis) of CKD ([MEDICAL CONDITION]), [MEDICAL TREATMENT] .Interventions .Monitor for changes in nutritional status .House supplement as ordered The care plan was updated 8/12/19. A Weight Change note, dated 7/17/19, indicated the following, .174.0 .-5% change over 30 day .Res (resident) is a total dependent feed .re wt (re-weight) requested, wt (weight) loss if confirmed most likely due to attending [MEDICAL TREATMENT] and [MEDICAL CONDITION] loss No re-weight was noted for the timeframe in Resident D's clinical record. A Practitioner Note, dated 7/18/19, indicated the following, .Patient is seen today for follow up continued weight loss despite starting on prostat (liquid protein formula) daily and assistance with feeding .poor appetite .Weight loss/poor appetite likely 2/2 (due to) chronic disease state: Increase prostat to bid (twice daily) .Start [MEDICATION NAME] 7.5 mg (milligrams) qhs (at hours of sleep) for appetite stimulant. Weekly weights, notify NP (Nurse Practitioner) of 2 lb (pound) or more weight loss A physician order, dated 7/18/19, indicated the following, .Nourishment with meals for weight gain Double protein (sic) There were no indications of what specifically the nourishment was to include and how much in milliliters was the resident supposed to be consuming per the physician order. A physician order, dated 7/19/19, was noted for weekly weight. There was no documentation of such in Resident D's clinical record during his stay at the facility. A Practitioner Note, dated 8/6/19 at 8:59 a.m., indicated the following, .Weight loss/poor appetite likely 2/2 (due to) chronic disease state: Increase prostat to bid (twice daily) .Start [MEDICATION NAME] 7.5 mg (milligrams) qhs (at hours of sleep) for appetite stimulant. Weekly weights, notify NP (nurse practitioner) of 2 lb (pound) or more weight loss .Double protein on meal trays A Nutritional Assessment, dated 8/12/19, noted significant weight loss at 12.6% in one month. An unstageable pressure injury noted to right buttock, stage 3 pressure injury to left buttock and wound to left, distal, 4th toe. Supplements included Ensure with meals but also commented on how Resident D brought in own nutritional supplement that he previously drank three times daily. There was no caloric and/or other nutritional needs documented for the need of wound healing. The Medication Administration Record [REDACTED]. Resident D was hospitalized for [REDACTED]. A radiograph document, dated 9/15/19, indicated a [MEDICATION NAME] (name of feeding tube) was placed. A Radiology Procedure document, dated 9/20/19, indicated Resident D was considered to have surgical gastrostomy placement (procedure in which a gastrostomy tube is placed into your stomach for nutritional support) related to malnutrition. 2. The clinical record for Resident H was reviewed on 9/27/19 at 11:28 a.m. The [DIAGNOSES REDACTED]. Resident H was readmitted to the facility, from the hospital, on 3/12/19 and 5/2/19. The following weights were noted for Resident H: 1/7/19- 134.4, 2/22/19- 135.8, 3/19/19- 122.2, 3/20/19- 122.2, 5/21/19- 108.0, 6/5/19- 104.0. 7/24/19- 126.6, 8/1/19- 120.8, & 9/9/19- 147.6. There was no readmission weight for the date(s) of 3/12/19 and 5/2/19, upon return to the facility from the hospital. A physician order, dated 3/7/19, was noted for a house supplement daily. A Nutritional Assessment, dated 3/25/19, noted a weight of 122.2 from 3/20/19. Resident H had 10% weight loss over the course of a month. She continued on a house supplement once daily. A Nutritional Assessment, dated 5/9/19, noted a weight of 122.2 from 3/20/19. There was no recent weight obtained for Resident H. She continued on a house supplement twice daily. A physician order [REDACTED]. A Nutritional Assessment, dated 8/12/19, noted a weight of 120.8 from 8/1/19. Resident H had 11% weight loss noted and she continued on a house supplement twice daily. A nutrition care plan, revised 8/12/19 and current, indicated the following, .nutritional risk r/t (related to) impaired skin integrity, hx (history) significant weight changes, varied po (by mouth) intake with meals .Interventions .Weigh per protocol 3a. The clinical record for Resident J was reviewed on 9/27/19 at 1:08 p.m. The [DIAGNOSES REDACTED]. A nutrition care plan, revised 7/18/19 and current, indicated the following, .(name of Resident J) is at potential nutritional risk due to the need for [MEDICAL TREATMENT] with increased nutritional needs .Interventions .Weigh resident and alert dietitian and physician to any significant loss or gain .provide supplement BID (twice daily) as ordered The following weights were noted for Resident J: 4/1/19- 160.4, 5/17/19- 156, 6/12/19- 158, 7/17/19- 148.8, 9/10/19- 149.8, & 9/26/19- 149.4. A physician order, start date of 12/4/18, indicated the following, .obtain dry weight from [MEDICAL TREATMENT] every Tuesday The July, 2019, treatment administration record noted no weekly weight documented on 7/2/19, 7/9/19, 7/16/19, 7/23/19 and 7/30/19. The August, 2019, treatment administration record noted no weekly weight documented on 8/7/19, 8/14/19, 8/21/19 and 8/28/19. A physician order, start date of 9/9/19, indicated the following, .Weigh weekly and document The September, 2019, treatment administration record noted no weekly weight documented on 9/3/19, 9/17/19 and 9/24/19. 3b. A physician order, dated 6/5/19, indicated the following, .nepro (specialized supplement for people on [MEDICAL TREATMENT]) with lunch and dinner The July, 2019, Medication Administration Record [REDACTED]. The August, 2019, Medication Administration Record [REDACTED]. An interview conducted with the DON, on 9/27/19 at 2:23 p.m., indicated obtaining weights have been a focus and our expectations are for the staff to follow physician orders [REDACTED]. It's also expected for documentation to be complete and accurate on the treatment administration record and medication administration record. A policy titled Nutrition/Hydration Management, revised 3/15/16, was provided by the DON on 9/27/19 at 2:15 p.m. The policy indicated the following, .6. Develop an interdisciplinary plan of care for enhancing oral intake and promoting adequate nutrition and hydration .8 Monitor patient's weight as ordered .9. Review Dietitian's progress notes to identify ongoing progress and recommendations .10 Revise patient's care plan as needed .12. Document: .12.2 Administration of oral supplements The DON indicated this was the current policy being utilized by the facility. A policy titled Supplementation, revised 6/15/18, was provided by the DON on 9/27/19 at 2:15 p.m. The policy indicated the following, .2. Medical food supplements require a physician's/APP's (advanced practice providers) order .2.1 Physician/APP order includes House Supplement, amount, and frequency .2.3 Physician/APP order for speciality products require name of product, amount, and frequency .6. Nursing documents administration and amount consumed .7. Dietitian or designee monitors acceptance of supplements, evaluates outcomes and documents findings a minimum of quarterly The DON indicated the policy was the current policy being utilized by the facility. A policy titled Weights and Heights, revised 8/1/18, was provided by the Director of Nursing (DON) on 9/27/19 at 2:30 p.m. The policy indicated the following, .Patients are weighed upon admission and/or readmission, then weekly for four weeks and monthly thereafter The DON indicated the policy was the current policy being utilized by the facility. This Federal tag relates to Complaint IN 389. 3.1-46(a)(1)

Based on observation, interview, and record review, the facility failed to adequate supervise and implement interventions to prevent a resident who was declining in condition and at risk for falls from falling and receiving a significant head injury, for 1 of 3 residents reviewed for falls in a sample of 3. (Resident #B) Findings include: Resident #B was observed on 04/18/2011 at 10:35 a.m. to be in a geri chair near the nurse's station in the common area on the East Wing. The resident was observed to have a fading bruise around her right eye and right cheek bone. Interview with the Assistant Director of Nursing (ADoN) on 04/18/2011 at 10:35 a.m. indicated Resident #B had fallen about three weeks ago and was sent to the hospital with an intracranial hemorrhage. The ADoN indicated the resident was a Hospice resident, was not interviewable, had dementia and [DIAGNOSES REDACTED], and was total care. Resident #B's clinical record was reviewed on 04/18/2011 at 1:50 p.m. and indicated the resident was originally admitted to the facility on [DATE] and recently re-admitted on [DATE]. The resident's [DIAGNOSES REDACTED]. Resident #B's most recent significant change Minimum Data Set (MDS) assessment, dated 03/22/2011, indicated the resident was severely cognitively impaired with daily decision making skills, had unclear speech, was rarely understood and sometimes could understand what was being said. The MDS assessment indicated the resident needed extensive assist of 1 person with bed mobility, transfers, ambulation, dressing, eating, toileting, hygiene, and bathing. The resident was frequently incontinent of bowel and bladder. The resident had a steady decline in condition with complaints of pain, being tired, poor appetite, weight loss, and increased problems with concentration, speaking, and moving. The Resident Fall Evaluation, dated 03/02/2011, indicated the resident was at risk for falls. Risk factors included, but were not limited to, a change in mobility, change in gait, change in transfer ability, need for assistance with bed mobility, transfer or ambulation, resident is incontinent and confused, resident wanders, has had changes in medications and new medications, and the resident wears glasses. Resident #B's clinical record indicated the resident was admitted to Hospice services on 03/04/2011. The Hospice Nursing Narrative Summary dated 03/04/2011 indicated the patient was weak, had pain in bones, had grimacing, decreased appetite, refuses meals, decreased strength, increased mental status changes, was incontinent of bowel and bladder, was total care for all activities of daily living, and used a wheelchair for ambulation by staff. The Hospice Nursing Summary indicated safety issues which included limited range of motion, bone or joint problems, bone pain, total assist, vision impaired, decreased endurance, fatigue, weakness, support needed during transfer and ambulation, bowel and bladder incontinence, precautions needed for seizures and falls. Interdisciplinary Progress Notes dated 03/09/2011 indicated the resident ambulated independently, is periodically unsteady, so staff will walk with her. The notes indicated the resident had not been feeling well recently and had been smiling less due to pain and being tired. The resident was noted to be feeling tired, having a poor appetite, trouble concentrating, and moving less and so slowly that others would notice. Interdisciplinary Progress Notes dated 03/25/2011 at 9 a.m. indicated the resident had a grand mal seizure while sitting in wheelchair in hallway. "Resident continually refusing meds over several days...." Notes dated 03/26/2011 at 11 p.m. indicated the resident was up "ambulating in room into hallway attempted to redirect res (resident) several xs (times) back to bed due to gait unsteady. Walked c (with) res c min. (minimal) assist to East Wing lounge et (and) layed res on couch s (without) difficulty." Interdisciplinary Progress Notes dated 03/28/2011 at 3:30 a.m. indicated the resident was incontinent of urine and care was provided; repositioned in bed and call light in reach. Interdisciplinary Progress Notes dated 03/28/2011 at 4:45 a.m. indicated, "CNA called this writer into room et (and) found res laying on floor on her back next to bed c a bump on her forehead et blood on her forehead and on the floor. Res eyes open et responding to this writer. Res moaned out in pain when this writer touched her forehead. Other nurse called into room. 911 called by this writer. BP (blood pressure) 118/80 P (pulse)114 R (respirations) 18. Res had black and blue (R) (right) eye et swollen." Further notes indicated the resident was sent to the hospital and family and physician were notified. Notes dated 03/28/2011 at 11 a.m. indicated the resident was admitted to the hospital with [REDACTED]. Hospital records dated 03/28/2011 indicated, "... ECF (extended care facility) resident fell down this morning striking her head. She was found by staff down on the ground and was uncertain exact timeframe. Patient does have chronic dementia and metastatic [DIAGNOSES REDACTED] stage IV. ... Patient received CT of her head demonstrating parenchmal bleed, subdural hematoma...." The Physician Discharge Summary dated 03/30/2011 indicated discharge [DIAGNOSES REDACTED]. The resident's care plan for problem of fall risk related to weakness, unsteadiness, limited mobility, impaired cognition, psychotropic drug use with onset date of 12/17/09 and recently updated on 03/28/2011 with "fall unwitnessed out of bed," indicated approaches of the following: monitor and document for changes in behavior, such as increased agitation, decline in mental status, etc.; keep call bell within reach of resident, remind to call for assistance; monitor for s/sx of UTIs or other infectious process; provide resident with clean glasses daily; provide well lit, clutter free environment; provide assist for toileting as needed; engage resident in active participation in activity programming; keep frequently used objects within reach; evaluate resident for change in vision, change in mental status, med medication, medication side effects, gait disturbance, and/or orthostatic hypertension; strips at bedside was added on 06/28/10; and pressure alarm to bed at all times was added 03/28/2011 after the fall with the subdural hematoma. Interview with the Director of Nursing (DoN) and Administrator on 04/18/2011 at 2:30 p.m. indicated the investigation of the fall included interviewing the nurse and CNA who claimed they had just checked on the resident 5 minutes prior to the fall and she was fine. Interview with the DoN and Administrator on 04/19/2011 at 11:50 a.m. indicated their investigation was in the computer and the DoN pulled off the documentation which showed the unwitnessed fall was not thoroughly investigated, but supported the above documentation of a lapse of 1 hour and 15 minutes between checks on the resident, not 5 minutes between checks as the DoN had thought. The facility failed to implement interventions for a resident who was in an active declining condition to prevent her from falling out of bed and having received a significant head trauma - subdural hematoma. This Federal tag is related to Complaint IN 825. 3.1-45(a)(1) 3.1-45(a)(2)