Every finding on record at Envive of Huntington

Based on interview and record review, the facility failed to protect residents' rights to be free from misappropriation of medications for 2 of 3 residents reviewed for misappropriation. (Resident B and C) The deficient practice was corrected on 8/6/26, prior to the start of the survey, and was therefore past noncompliance.Findings include:Review of a facility-reported incident submitted to Indiana Department of Health, on 8/5/26 at 3:26 p.m., indicated QMA 3 allegedly altered Resident B's oxycodone (opiate pain medication for severe pain) and methadone (opiate pain medication used for severe pain and/or opiate dependency) controlled count sheets, along with Resident C's Percocet (opiate pain medication for moderate to severe pain) controlled count sheet.During an interview, on 8/26/26 at 9:05 a.m., the Administrator indicated RN 4 removed Resident B's last hydrocodone (opiate pain medication) from the medication card. RN 4 noticed the prescription label felt thicker than usual. It turned out to be a photocopy of the prescription label attached to the original controlled count sheet. The photocopy of the prescription label was glued on top of the original label. The controlled count sheet had an original count of 60 pills, but the form was filled out to show a starting count of 50 pills. The Administrator felt the discrepancy on the count sheet happened a day or two prior. QMA 3 was the first and second signature starting off the narcotic count sheet. All counts were incorrect. The facility performed an audit of all controlled count sheets and found Resident B had a discrepancy on her methadone count sheet and Resident C had a discrepancy on his Percocet count sheet. QMA 3 was listed on all three count sheets. QMA 3 was brought into the conference room and interviewed by the facility. QMA 3 became super defensive and refused a drug screen. QMA 3's employment was terminated that same day.During an interview, on 8/26/26 at 9:35 a.m., the DON indicated the original controlled count sheet for Resident B's hydrocodone had a photocopied prescription label glued on top of the original label. The original count received was changed from 60 pills to 50 pills. QMA 3 was the first two signatures on the starting count of the narcotic count sheet.The facility's investigation of the incident, reviewed on 8/26/26 at 9:54 a.m., the following items:Pain Assessments and resident interviews were conducted on 8/7/26, which included Resident B and Resident C. Both residents felt their pain was well controlled.Resident B's oxycodone count sheet showed a starting count of 40 pills. On 7/26/26, across from QMA 3's signature, a prior balance was crossed out, and a new balance of 41 pills was written next to the original remaining balance. The original balance numbers had the appearance of having been altered, and new remaining balance numbers were written on top of the originals. On 7/28/26, across from QMA 3's signature, the balance was marked 32 pills. The following line showed a balance of 27 pills, and the next line showed a count of 24 pills.Resident B's methadone count sheet showed a starting balance of 60 pills. Resident B received one tablet every six hours. On 7/26/26, the sheet showed a remaining balance of 46 pills. On the next line, dated 7/26/26 and across from QMA 3's signature, the remaining balance was marked 43 pills.Resident D's Percocet count sheet showed a starting balance of 60 pills. Resident B received two tablets four times a day. The starting balance was 60 pills. On 8/1/26, the count showed a balance of 52 pills. The next line, dated 8/1/26 and across from QMA 3's signature, showed a balance of 48 pills.Facility employee statements included the following:QMA 3 indicated she did not notice anything with the sheet. When asked how she did not notice that 10 pills were missing from the card, she indicated she was busy and did not notice anything at all.The Administrator and Chief Operating Officer interviewed QMA 3 regarding the missing medication. Information was shown to QMA 3 regarding a copied medication sheet. QMA 3 indicated she knew nothing about the incident. QMA 3 was shown where her name was signed off and the discrepancy within the form, and where the numbers she wrote matched the numbers rewritten down the page. QMA 3 continued to deny involvement and blamed other staff for not counting and setting up their medications. QMA 3 indicated she was being picked on and that the Administrator had known about the incident. QMA 3 was asked to take a drug test but declined. QMA 3 indicated she did not know what happened to the missing medication and stated that what she did at home was no one's business. She was suspended pending investigation.The Administrator and DON interviewed QMA 3, who indicated she was not paying attention and did not notice 10 pills had been punched out on the new narcotic sheet.The DON received a count sheet from RN 4, who questioned the sticker label on the sheet. RN 4 informed the DON that the paper felt thicker. The narcotic sheet appeared to have been photocopied and tampered with, with the cut-out sticker label glued to the photocopy. No original copy was found at the time of the finding of the tampered sheet. The DON immediately notified the Administrator of the tampered sheet. The DON confirmed with RN 4 that she did not notice the altered sheet until she removed it from the narcotic book. The DON confirmed with RN 4 that RN 4 did not tamper with the narcotic sheet.Resident B's oxycodone Medication Administration Record indicated the prescription label was placed in the top left corner appeared ripped off and glued back on. The back of the label had torn paper pieces on it and was slightly sticky, as if it had been removed and replaced.During an interview, on 8/26/26 at 11:34 a.m., RN 4 indicated she took Resident B's oxycodone narcotic sheet to be scanned after using the last pill in the medication card. The prescription sticker felt thicker than normal, so she took the sheet to the DON. RN 4 indicated she did not recall the narcotic sheet being marked with numbers crossed out down the page.During an interview, on 8/26/26 at 11:57 a.m., LPN 7 indicated she did not recall anything wrong with Resident B's oxycodone narcotic sheet until RN 4 brought it to her attention. RN 4 attempted to call the pharmacy to obtain authorization to pull oxycodone from the Emergency Drug Kit (EDK) because Resident B was out of the medication, but the pharmacy indicated it was too early for the resident to have run out of medication. RN 4 and LPN 7 noticed the prescription label was peeling at the edges, and they reported it to the DON. Shift-to-shift counts were completed after every shift or exchange of keys. LPN 7 did not recall having issues with the shift-to-shift reconciliation counts.During an interview, on 8/26/26 at 12:46 p.m., LPN 5 indicated shift-to-shift count sheets had been accurate. LPN 5 indicated Resident B's oxycodone count sheet did not look tampered with when she saw it last.Resident B's clinical record was reviewed on 8/26/26 at 3:00 p.m. Diagnoses included opioid dependence, diabetes with diabetic polyneuropathy (nerve damage throughout the body caused by elevated blood sugars) and arthritis.Current orders included oxycodone (opioid pain medication) 10 milligram (mg) tablet by mouth four times a day, methadone (opioid pain medication) 5 mg tablet by mouth every six hours for chronic pain and methadone 5 mg tablet, give a half tablet by mouth every six hours for pain, give with five mg to equal 7.5 mg.An 8/13/26, quarterly, Minimum Data Set (MDS) assessment indicated Resident B was cognitively intact.Resident C's clinical record was reviewed on 8/26/26 at 3:35 p.m. Diagnoses included muscle wasting and atrophy in the right and left shoulders and upper arms, alcohol abuse, adjustment disorder, other psychoactive substance abuse and difficulty walking.Current orders include Percocet 7.5-325 mg 2 tablets five times a day for pain.A 5/27/26, quarterly, Minimum Data Set (MDS) assessment indicated Resident B was cognitively intact.During an interview, on 8/26/26 at 3:03 p.m. QMA 8 indicated shift-to-shift count sheets were completed at the start and end of each shift. The count sheets had never been inaccurate to her recollection.During an interview, on 8/26/26 at 3:09 p.m., QMA 9 indicated Resident B's oxycodone count sheet did not look tampered with when she last saw it. She indicated numbers were not struck out with new numbers written beside them. Shift-to-shift count sheets were completed at the start and end of each shift. Shift-to-shift count sheets had been inaccurate a few times and she reported these incidents to management.During an interview, on 8/27/26 at 9:05 a.m., LPN 6 indicated she did not recall Resident B's oxycodone narcotic count sheet being marked up or tampered with. She indicated residents never complained about increased pain when QMA 3 was working. QMA 3 was not available for interview during the survey dates. A current facility policy, dated 8/24, titled Controlled Substances provided by the Administrator, on 8/27/26 at 1:10 p.m., indicated the following: .Controlled substances are counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals sign the designated controlled substance record The deficient practice was corrected on 8/6/26, prior to the start of the survey, when the facility educated all nurses and QMAs regarding controlled substance monitoring, audited all medication counts, and developed an audit plan to mitigate the risk of recurrence.410 Indiana Administrative Code (IAC) 16.2-3.1-28(a)This citation relates to Intake 3135801.

Based on observation, interview, and record review, the facility failed to ensure care plans were reviewed and revised with appropriate and individualized fall prevention interventions to mitigate the risk for further falls for 4 of 4 residents reviewed for accidents. (Residents B, C, D and E)Findings include: 1.Resident B's clinical record was reviewed on 4/6/26 at 10:39 a.m. Diagnoses included essential (primary) hypertension, syncope and collapse, muscle weakness (generalized), unsteadiness on feet, need for assistance with personal care, and cognitive communication deficit. A 2/19/26, admission, Minimum Data Set (MDS) assessment indicated he had severe cognitive impairment. He used a wheelchair for mobility. He was dependent for toileting, lower body dressing, footwear, personal hygiene, bed mobility, sit to stand, and transfers. He had no falls at that time. His medications included muscle rub cream (pain reliever) twice daily, finasteride (treat benign prostatic hyperplasia) 5 mg daily, diclofenac sodium gel (topical) (pain reliever) twice daily, and amlodipine besylate (treat hypertension) 10 milligram (mg) daily. He had an order, dated 2/12/26, for quarter side rails for mobility, positioning, and to aid with bed mobility. A current fall care plan, initiated on 2/12/26, indicated he was at risk for falls and fall related injury due to history of falls, decline in mobility, and cognitive impairment. His intervention was to anticipate and meet his needs (2/12/26). A skilled charting note, dated 2/22/26 at 3:10 p.m., indicated he was alert and oriented to person. There was no change in cognitive status, and visual hallucinations were present. He was sitting in the hallway and concerned about the large truck that was going to back over him if he was not urgently removed from the area. A fall risk assessment, dated 3/2/26, indicated he was at risk for falls. A fall risk evaluation note, dated 3/2/26 at 11:00 a.m., indicated he had a fall. The immediate intervention was education to call for assistance before attempting to stand or transfer. An Interdisplinary (IDT) note, dated 3/2/26 at 11:43 a.m., indicated he fell due to confusion and attempted to stand and walk independently. He was educated and reminded to call for assistance prior to standing. The care plan lacked an updated individualized intervention to mitigate the risk for further falls. A fall risk assessment, dated 3/8/26, indicated he was at risk for falls. A Situation, Background, Assessment, and Recommendation (SBAR) summary, dated 3/8/26 at 7:03 p.m., indicated he had a fall, he was observed standing up and taking several steps falling on to his bottom then lying on the floor. He remained stable and was assisted to his wheelchair. A fall risk evaluation note, dated 3/8/26 at 7:14 p.m., indicated the resident had a fall. The immediate intervention was education to ask for help when wanting to stand or transfer to a new location. An IDT note, dated 3/11/26 at 3:20 p.m., indicated he was confused at baseline with the diagnosis of cognition communication deficit. He thought he was walking back to his room at time of fall. He participated in physical and occupational therapy services. He was sitting at the nurses' station with proper footwear and was educated to call for assistance prior to attempting to stand. The care plan lacked an updated individualized intervention to mitigate the risk for further falls. A fall risk assessment, dated 3/13/26, indicated he was at risk for falls. A fall risk evaluation note, dated 3/13/26 at 8:35 p.m., indicated he had a fall. The immediate interventions included assessing for injuries, obtaining vital signs, completing neurological checks, providing wound care and following the facility neurological flow sheet. The care plan lacked an updated individualized intervention to mitigate the risk for further falls. On 3/13/26, an order was received for mupirocin (antibiotic) ointment 2% to apply to skin tears twice daily for wounds on top of his bilateral hands and forehead. A fall risk assessment, dated 3/14/26, indicated he was at risk for falls. A SBAR summary, dated 3/14/26 at 12:00 a.m., indicated he had a fall and he sustained a skin tear. The care plan lacked an updated individualized intervention to mitigate the risk for further falls. A fall risk evaluation note, dated 3/14/26 at 7:00 p.m., indicated he had a fall and was sent to the emergency room for evaluation and treatment per family request. A nurses note, dated 3/14/26 at 8:45 p.m., indicated he had a witnessed fall after leaning forward and sliding out of his wheelchair. He did not hit his head. The family was notified, came to the facility, and requested him to be sent to the emergency room. He had no new injuries. His neurological checks and vital signs were within normal limits. 2.Resident C's clinical record was reviewed on 4/6/26 at 12:07 p.m. Diagnoses included essential (primary) hypertension, type 2 diabetes mellitus without complications, restless legs syndrome, hemiplegia and hemiparesis following cerebral infarction affecting right non-dominant side, muscle weakness (generalized), other symptoms and signs involving the musculoskeletal system, need for assistance with personal care, other abnormalities of gait and mobility, chronic fatigue, and low back pain. A 1/5/26, quarterly, MDS assessment indicated he had severe cognitive impairment. He used a wheelchair for mobility. He required partial to moderate assistance with toileting hygiene, upper body dressing, sitting to stand, chair/bed-to-chair transfer, toilet transfer. He required substantial to maximal assistance with lower body dressing, footwear, and personal hygiene. He required supervision to touch assistance for bed mobility and walking 10 feet. His medications included furosemide (treat hypertension) 20 mg daily, levocetirizine dihydrochloride (treat allergies) 5 mg daily, lisinopril (treat hypertension) 40 mg daily, pramipexole dihydrochloride (treat restless leg syndrome) 0.25 mg daily, spironolactone (treat hypertension) 0.5 mg daily, trazodone (treat insomnia) 75 mg daily, venlafaxine 37.5 mg daily, ticagrelor (antiplatelet) 90 mg twice daily, and carvedilol (treat hypertension) 3.125 mg twice daily. A current care plan, revised on 8/13/25, indicated he was at risk for falls/injury due to decreased mobility secondary to hemiplegia/hemiparesis of the right nondominant side, chronic obstructive pulmonary disease (COPD), arthropathic psoriasis, history of falls, and use of high-risk medications. His interventions included non-skid strips in front of recliner (4/21/25), encouraging him to wear gripper socks/ shoes prior to transfers (8/4/25), and using a wheelchair for all locomotion/transfers (10/16/25). The CNA assignment sheet indicated he walked and the lacked documentation of fall interventions. A fall risk assessment, dated 12/31/25, indicated he was at risk for falls. A nurses note, dated 1/13/26 at 3:09 p.m., indicated he was found sitting on the floor and yelled for nursing. He indicated that he was walking without his walker in his room, fell on his left knee and landed on his bottom. He did not hit his head. The area on his left knee was cleaned and covered with a band aid. A fall risk evaluation note, dated 1/13/26 at 3:26 p.m., indicated he had a fall and was educated on calling for assistance. An IDT note, dated 1/16/26 at 10:14 a.m., indicated he fell while ambulating without walker in bedroom. He was on the physical therapy caseload. His intervention included educating him on fall precautions and the importance of utilizing an ambulation device. He verbalized understanding. The care plan lacked an updated individualized intervention to mitigate the risk for further falls. A fall risk assessment, dated 2/8/26, indicated he was at risk for falls. An incident note, dated 2/8/26 at 3:19 p.m., indicated he activated his call light and was found sitting on the floor in front of his chair. His wheelchair was within reach with both brakes locked and had footwear on at the time of the fall, he had been attempting to move the laundry from plastic hangers to wooden hangers and placing them in the closet. He denied hitting his head and had slight redness on his lower back. A fall risk evaluation note, dated 2/8/26 at 3:32 p.m., indicated the immediate intervention were obtaining his vital signs and assessing his cognitive status. He was assisted to his chair, his clothes were moved to the wooden hangers and hung up for him. Environmental services was notified that his clothes needed to be placed on wooden hangers in the future so that he did not try to move them himself. An IDT note, dated 2/9/26 at 11:08 a.m., indicated that he fell while ambulating in bedroom and attempted to put his clothes away. He was educated to call for assistance for daily activities such as putting clothing away. He was receiving therapy services.The care plan lacked an updated individualized intervention to mitigate the risk for further falls. A fall risk assessment dated [DATE] indicated he was not at risk for falls. A nurses note, dated 3/24/26 at 11:46 a.m., indicated he was lying on the floor in front of his wheelchair. He indicated his wheelchair was not locked. He had pain to his head and bottom with a small bump noted on the back of his head. An IDT note, dated 3/30/26 at 9:17 a.m., indicated he fell from his wheelchair. Interventions included adding a non-slip pad to his wheelchair cushion. The intervention was not added to the resident's care plan. During an interview with Resident C, on 4/6/26 at 1:17 p.m., he was observed sitting in his wheelchair wearing flip-flops. He indicated he had several falls due to his legs giving out and to prevent further falls he sat in his wheelchair and used his call light. 3. Resident D's clinical record was reviewed on 4/6/26 at 12:35 p.m. Diagnoses included chronic obstructive pulmonary disease, primary generalized (osteo) arthritis, chronic pain syndrome, peripheral vascular disease, muscle weakness (generalized), unsteadiness on feet, and cognitive communication deficit. A 12/30/25, annual, MDS assessment indicated she had severe cognitive impairment. She used a wheelchair for mobility. She was dependent for toileting hygiene and footwear. She required partial to moderate assistance with upper body dressing, personal hygiene, bed mobility, and transfers. She required substantial to maximal assistance with lower body dressing. She had no falls at that time. Her medications included duloxetine (treat depression) 60 mg daily, Ozempic (weight loss) 0.25 mg subcutaneously weekly, buspirone 5 mg three times daily, gabapentin (treat neuropathy) 800 mg three times daily, methadone (narcotic)10 mg every six hours, and oxycodone (narcotic) 15 mg every six hours. A current care plan, revised on 8/19/25, indicated she was at risk for falls/injury due to impaired mobility, impaired cognition, fluctuating need for assist with Activities of Daily Living (ADL) care, and the use of high fall risk medications. Her interventions included ensuring assistive mobility device was within reach (2/24/22), non-skid/gripper socks (2/24/22), education to ask for assistance with transfers, ensuring assistive devices were within reach (6/22/23), nonskid strips to chair (7/29/24), and wearing Crocs during transfers (1/14/25). The CNA assignment sheet indicated she transferred herself and she had nonskid strips in front of her recliner. A fall risk assessment, dated 1/13/26, indicated she was at risk for falls. A late entry fall risk evaluation note, dated 1/22/26 at 4:50 a.m. and created on 1/23/26 at 6:49 a.m., indicated she had a fall. The immediate intervention were replacing the non-skid strips in front of her recliner that are no longer nonskid and agreeing to wear Crocs when sleeping so that if she falls asleep again with her electric recliner in the lifted position, she would have non-skid shoes on when she started to slide out of her recliner. An incident note, dated 1/22/26 at 4:50 a.m., indicated she was found on her back on the floor in front of her electric recliner which was in an elevated position. She indicated she did not know what happened, she woke up and was on the floor. She had soft, fuzzy, thick regular socks on her feet. A fall risk assessment, dated 1/22/26, indicated she was at risk for falls. An IDT note, dated 1/26/26 at 2:07 p.m., indicated she had fallen while in her recliner. She was not wearing proper footwear, only soft fuzzy socks with no grip. Interventions were educating her on the importance of wearing proper footwear, and maintenance to replace nonskid strips in front of her recliner. The intervention was not added to the resident's care plan. A fall risk evaluation note, dated 2/10/26 at 6:20 p.m., indicated she had a fall. Immediate interventions were monitoring and following facility flow sheet for neurological checks with full assessment. The care plan lacked an updated individualized intervention to mitigate the risk for further falls. A fall risk assessment, dated 2/10/26, indicated she was not at risk for falls. A SBAR summary, dated 2/11/26 at 12:43 p.m., indicated she fell while attempting to sit down in recliner during transfer. She missed the recliner and slid onto her bottom. The care plan lacked an updated individualized intervention to mitigate the risk for further falls. An IDT note, dated 2/17/26 at 2:47 p.m., indicated her fall interventions included reminding her to feel for the chair on the back of her knees prior to sitting down to ensure that the chair is in fact behind her. She verbalized understanding. A late entry incident note, dated 3/6/26 at 5:30 p.m. and created on 3/7/26 at 5:48 p.m., indicated she used the restroom and attempted to stand to wash her hands. She leaned against the wall and landed on her bottom. She did not utilize her call light and her wheelchair in the locked position. A late entry fall risk evaluation note, dated 3/6/26 at 5:47 p.m. and created on 3/7/26 at 6:02 p.m., indicated she had a fall. The immediate interventions were notifying the nurse practitioner, reminding Resident D to call for assistance, and assessing her neurological status. The care plan lacked an updated individualized intervention to mitigate the risk for further falls. A fall risk assessment, dated 3/6/26, indicated she was not at risk for falls. An IDT note, dated 3/11/26 at 3:16 p.m., indicated she fell while washing hands after using the bathroom by herself as she did not use her call light. Interventions included encouraging her to utilize her call light for assistance with any ADLs. She refused therapy services. A nurses note, dated 3/15/26 4:58 p.m., indicated yelling was heard and she found laying beside her wheelchair on the bathroom floor leaning against the wall. She indicated that she didn't know how she fell again, it was explained that there was urine on the floor. She was transferred back into her wheelchair. She complained of a headache and elbow pain with bruising noted. A fall risk assessment, dated 3/15/26, indicated she was at risk for falls. An IDT note, dated 3/16/26 at 1:55 p.m., indicated she had urine under her feet when she attempted to get up and fell. She had nonskid strips in front of her chair and was wearing nonskid socks. The CNAs were notified to check and change her frequently. The care plan lacked an updated individualized intervention to mitigate the risk for further falls.4.Resident E's clinical record was reviewed on 4/6/26 at 2:14 p.m. Diagnoses included pain in right hip, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, bilateral primary osteoarthritis of knee, peripheral vascular disease, essential (primary) hypertension, muscle weakness (generalized), difficulty in walking, not elsewhere classified, unsteadiness on feet, need for assistance with personal care, and unspecified dementia, severe, with agitation. A 3/18/26, admission, MDS assessment indicated she had severe cognitive impairment. She had physical and verbal behavioral symptoms directed towards others and wandering. She used a wheelchair for mobility. She was dependent with toileting and footwear. She required partial to moderate assistance with upper body dressing and personal hygiene. She required substantial to maximal assistance for lower body dressing, bed mobility, and transfers. She had one fall with no injury. A current care plan, revised on 3/13/26, indicated she was at risk for falls/fall related injury due to history of falls, required assist with transfers cognitive impairment. Interventions included anticipating and meeting her needs (3/11/26), ensuring call light was within reach and encouraging use (3/11/26), ensuring pathways were free of clutter (3/11/26), keeping personal items within reach (3/11/26), and therapy screening, evaluation and treatment as indicated (3/11/26). The CNA assignment sheet indicated she walked and lacked the documentation for fall interventions. A nurses note, dated 3/18/26 at 4:10 a.m., indicated a resident was heard yelling out Help, Resident E was not in her room and in her bed where she had been. CNAs searched the 200 hall and found Resident E lying on her back on top of blankets and her wheelchair cushion in the 200-hall conference room. She was barefoot and indicated her feet were hot and she took her socks off. She fell and that the pillow under her was always slippery each time she was in the chair. Prior to falling she was scooting herself in her chair and the pillow scooted her to the floor. Resident E's nonskid socks were in her bed in her room. An IDT note, dated 3/23/26 at 12:35 p.m., indicated she had an unwitnessed fall from her chair while self-propelling in the conference room. She had dementia and increased confusion at night. Interventions included dycem under her cushion and the psychiatric nurse practitioner was notified and increased her Seroquel dosage. The care plan lacked an updated individualized intervention to mitigate the risk for further falls. A fall risk assessment, dated 3/23/26, indicated she was at risk for falls. During an interview, on 4/6/26 at 1:48 p.m., CNA 7 indicated they kept Resident B at the nurses' station in his wheelchair due to confusion. He required assistance toileting assistance, and he was not cognitively able to use a call light. He fell out of his wheelchair because he believed he could still walk. Resident C disliked nonskid socks and preferred flip flops. Fall interventions for the residents were located in the CNA book or communicated verbally in report. The CNA assignment sheets sometimes contained interventions. During an interview, on 4/6/26 at 1:54 p.m., CNA 14 indicated Resident B had dementia and tremors and once believed he was falling from a ladder while holding onto a handrail and standing up from his wheelchair. He did not understand how to use the call light. Resident E was a two person assist and needed total care. She could not toilet herself and was very confused due to dementia and yelled out. She needed redirection and was an exit seeker. They made sure that she had nonskid socks on to prevent her from falling. Resident D had bouts of confusion recently and needed two-person assistance with toileting and she was unaware that she had been incontinent. To prevent further falls for Resident D, she wore nonskid socks and she had nonskid strips in front of her chair. When Resident D was alert, she used her call light, when she was not alert, they had to check on her every two hours. New fall interventions were shared in morning report or on the CNA assignment sheets. During an interview, on 4/6/26 at 2:37 p.m., LPN 4 indicated the nurses checked for fall interventions and add interventions if needed. The nurses were able to add new fall interventions to the resident's care plan. Fall interventions were located in the resident's care plan, Kardex or in the treatment administration record. The CNA assignment sheets indicated if the resident was a fall risk but not the interventions. She was not aware who updated the CNA assignment sheets. During an interview, on 4/6/26 at 3:08 p.m., the Administrator indicated that the nurse completed a risk management assessment after a fall then every morning, during the clinical meeting, they discussed falls and interventions. An IDT note was documented and the intervention, if needed, would go into the care plan. The nurse would initiate an intervention and then as a team, they reviewed it. The fall interventions would be located on the CNA sheets and in the tasks on the point of care. The DON updated the CNA sheets for the fall interventions. A current facility policy, titled Falls - Clinical Protocol, provided by the Administrator on 4/6/26 at 12:05 p.m. indicated the following: Monitoring and Follow-Up. 1. e. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. a. Frail elderly individuals are often at greater risk for serious adverse consequences of falls. b. Risks of serious adverse consequences can sometimes be minimized even if falls cannot be prevented. c. If interventions have been successful in fall prevention, the staff will continue with current approaches and will discuss periodically with the physician whether these measures are still needed; for example, if the problem that required the intervention has resolved by addressing the underlying cause. d. If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified) and also reconsider the current interventions. This citation relates to Intake 2968021. 410 Indiana Administrative Code (IAC) 16.2-3.1-35(b)(1)

Based on observation and interview, the facility failed to ensure hair coverings were utilized by dietary staff to ensure hygienic meal preparation. This deficient practice had the potential to affect 43 of 43 residents who received meals from the facility kitchen.Findings include: On 3/16/26 at 7:36 a.m., during breakfast service, the following was observed:The Dietary Manager was walking throughout the kitchen without a hair cover or beard cover. His beard was approximately the length of a pencil top eraser. The Dietary Manager plated 43 plates of food without wearing a hair cover or beard cover.During an interview, on 3/16/26 at 7:58 a.m., the Dietary Manager indicated he was unaware he needed to wear a hair cover or a beard net, as his hair was so short.A posted sign on the kitchen door indicated the following: Hair nets must be worn beyond this point.During an interview, on 3/18/26 at 1:51 p.m., the Administrator indicated the Dietary Manager should have worn a hair net and beard net cover while he was in the kitchen.A current facility policy, dated 1/2023, titled Culinary Personal Hygiene, provided by the Administrator on 3/20/26 at 12:06 p.m., indicated the following: . Personal Cleanliness: All employees working in the culinary department must wear a clean hair restraint which effectively covers all hair. Dietary employees with facial hair must also wear a beard restraint 410 IAC (Indiana Administrative Code) 16.2-3.1-21(i)(2)410 IAC 16.2-3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure medications were stored in a manner to prevent loose pills in the medication cart drawers and eye drops had opened dates to indicate when to discard them for 2 of 2 medication carts reviewed for medication storage.Findings include: During a medication storage observation, on 3/17/26 at 8:29 a.m., accompanied by RN 3, a white round pill inscribed with 54/27 and a blue round pill was found in the second drawer on the left side of the 200-hallway medication cart. A clear oval capsule, one white round pill inscribed 40, a white round pill inscribed EP 117, and a white round pill inscribed B05 was found in the third drawer on the left side of the 200- hallway medication cart. RN 3 indicated that the pills should be destroyed in the drug buster (a drug disposal liquid). The medication carts were cleaned out during third shift. Two eye drop containers were opened without open dates written on the container or box. RN 8 indicated that eye drop containers should have an open date written on them.During a medication cart observation, on 3/17/26 at 8:54 a.m., accompanied by LPN 4, a white round pill inscribed PH 020 and a white oblong pill inscribed ZF 41 was found at the bottom of 100- hallway's medication cart. LPN 4 indicated that the pills should be destroyed in the drug buster solution. She was unsure how often medication carts were cleaned out.During an interview, on 3/18/26 at 1:45 p.m., the DON indicated eye drop containers should have an opened date written on them. Medication carts should be cleaned out every shift. Any loose pills would be destroyed using the drug buster solution.During an interview, on 3/20/26 at 2:26 p.m., the DON indicated 21 residents received medications from the 100- hallway medication cart and 25 residents received medications from the 200- hallway medication cart.A current facility policy, titled Medication Labeling and Storage, provided by the Administrator on 3/20/26 at 2:17 p.m., indicated the following: .Medication Storage: 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner 410 IAC (Indiana Administrative Code) 16.2- 3.1-25(o)(s)

Based on interview and record review, the facility failed to provide mail delivery to residents on Saturdays for 7 of 7 residents interviewed during a Resident Council group interview. (Residents 6, 14, 15, 16, 24, 36, 37) Findings include:During the Resident Council group interview, on 3/18/26 at 10:00 a.m., regular attendees reported that mail was not delivered within the facility on Saturdays. Resident 36 indicated the staff member responsible for mail delivery was not present on weekends, and any mail received by the facility on Saturday was held until Monday before being distributed. Residents 6, 14, 15, 16, 24, and 37 confirmed that mail received on Saturdays was routinely delayed until Monday.During an interview, on 3/20/26 at 9:38 a.m., the Activities Director indicated the facility had previously provided mail delivery on Saturdays; however, since the staff member responsible for weekend mail delivery was no longer employed by the facility, residents had not received mail on Saturdays for approximately the past month and a half.During an interview with the Administrator, on 3/20/26 at 1:36 p.m., she indicated mail was supposed to be delivered within the facility on Saturdays.A current facility policy, titled Mail and Electronic Communication, provided by the Administrator on 3/20/26 at 12:59 p.m., indicated the following: .Residents are allowed to communicate privately with individuals of their choice and may send and receive personal mail, email and other electronic forms of communication confidentially. 4. Mail and packages will be delivered to the resident within twenty-four (24) hours of delivery on premises or to the facility's post office box (including Saturday deliveries) . 410 IAC (Indiana Administrative Code) 16.2 - 3.1-3(p)(3)

Based on observation, interview, and record review, the facility failed to ensure a resident received hypodermoclysis (infusion of hydrating fluids in the fatty layer of skin) in accordance with physician orders regarding rate of infusion and failed to ensure hydration fluids were not administered after their expiration date for 1 of 1 residents reviewed for parental fluids. (Resident 20) Findings include: During a random observation, on 3/16/26 at 9:01 a.m., Resident 20 was observed sitting in a wheelchair in her room. A bag of normal saline (NS) 0.9% was transfusing at a rate of 150 mL/HR (milliliter per hour) as indicated by the dial knob. The dial knob had a red arrow pointed at 150. The bag had a marking of 3/14 written on it, and that it was the second bag infused.During a random observation, on 3/16/26 at 9:32 a.m., Resident 20 was sitting in a wheelchair in her room. A bag of normal saline 0.9% dated 3/14 was running at 150mL/HR per the dial knob.During an observation, on 3/16/26 at 9:34 a.m., with LPN 4 and the DON present, the following was observed: Resident 20 was sitting in a wheelchair with a bag of normal saline hanging and actively infusing. LPN 4 reached down, grabbed the infusion tubing above the turn dial knob, turned around, and then showed the solution was running at 60 mL/HR. The red arrow on the turn dial knob was now pointing at 60.At the time of observation, the DON indicated the NS solution should run at 60 mL/HR.At the time of observation, LPN 4 indicated Resident 20's orders were for the NS to run at 60 mL/ HR.Resident 20's clinical record was reviewed on 3/17/26 at 1:51 p.m. Diagnoses included syncope and collapse, difficulty in walking, adult failure to thrive, muscle weakness, bradycardia, kidney disease, and heart failure.Current physician orders included may begin hypodermoclysis at 60 mL/HR for two liters of NS. May discontinue once second bag is finished. One time only for fluids for 3 days.A March 2026 Medication Administration Report (MAR) indicated the first bag of normal saline was started on 3/12/26 at 3:17 p.m. The second bag of normal saline administration time was missing from the MAR report.A progress note, dated 3/12/26 at 3:17 p.m., indicated hypodermoclysis at 60mL/HR for two liters of NS was started by the previous nursing shift.A progress note, dated 3/16/26 at 3:44 p.m., indicated Resident 20 completed a second liter of fluids. The hypodermoclysis was discontinued per the Nurse Practitioner (NP) order. Area was clean and intact. No concerns were noted at that time.During an interview, on 3/16/26 at 1:58 p.m., the Administrator indicated the facility did not have a policy regarding how long a normal saline bag was good for once the bag had been punctured.During an interview, on 3/20/26 at 9:53 a.m., RN 5 indicated once a bag of normal saline was punctured, it was only good for 24 hours.During an interview, on 3/20/26 at 10:17 a.m., the facility pharmacist indicated a bag of normal saline for infusion was only good for 24 hours once punctured.During an interview, on 3/20/26 at 11:03 a.m., the DON indicated the hypodermoclysis policy indicated 24-48 hours, so that was what the facility went by.The National Library of Medicine website at https://pmc.ncbi.nlm.nih.gov/articles/PMC3189676/#:~:text=4%2C12%2C22,practices)%20during%20these%20time%20periods was accessed on 3/23/16 at 11:10 a.m., guidance included: . Once punctured, a normal saline (0.9% NaCl) bag for hypodermoclysis (subcutaneous infusion) should ideally be used within 24 hours, as standard guidelines recommend changing solution bags daily, even if not empty.A current facility policy, dated 8/2024, titled Hypodermoclysis, provided by the Administrator on 3/20/26 at 2:17 p.m., indicated the following: .Preparation: Review the order. The order for hypodermoclysis should include: Type and quantity of solution or dose of medication; Rate of infusion; duration of treatment 410 IAC (Indiana Administrative Code) 16.2-3.1-47(a)(2)

Based on interviews and record reviews, the facility failed to protect a resident's (Resident B) right to be treated with dignity and respect by CNA 6 when the resident requested their assistance for 1 of 3 residents reviewed for dignity. Findings include:Findings include:Resident B's clinical record was reviewed on 1/30/26 at 8:54 a.m. Diagnoses included vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety and need for assistance with personal care. Her quarterly Minimum Data Set (MDS) assessment, dated 11/21/25, indicated she was cognitively intact. She used a walker and a manual wheelchair for mobility. She required substantial to maximal assistance with lower body dressing and sitting to standing. She required partial to moderate assistance with upper body dressing and personal hygiene. She was dependent with transfers. Her current care plan for risk for impaired communication, revised on 1/12/26, indicated that she was hard of hearing. Her interventions initiated on 11/14/24 included allow adequate time for her response, minimize environmental stimuli, observe effectiveness of communication strategies and provide clear, simple instructions. She had a current care plan, initiated on 1/7/26, that indicated that she had a psychosocial wellbeing problem potential related to negative interactions with others. A progress note, dated 1/8/26 at 4:10 p.m., indicated the resident's representative was notified regarding an incident with a CNA. A progress note dated 1/8/26 at 4:29 p.m., indicated the resident denied any issues and was not experiencing any signs or symptoms of distress. The facility investigation, provided by the Administrator on 1/30/26 at 9:23 a.m., included the following information: A 1/7/26, typed statement signed by the Activity Director indicated she reported to the Administrator that she heard someone yelling loudly while she was putting things away in the activity room. She heard the person state You can't keep pushing your call light unless you need something, there are other people I need to take care of. When the Activity Director stepped out of the Activity room, she saw CNA 6 coming out of Resident B's room. A 1/7/26 typed statement signed by the Administrator and the Director of Nursing (DON) indicated that upon entering Resident B's room, the DON and Administrator applied Personal Protective Equipment (PPE) due to Resident B being in isolation related to COVID-19. Resident B was asked if she had experienced any trouble with staff. The Administrator raised her voice because Resident B could not hear through the PPE mask. Resident B indicated that CNA 6 told her she could not turn on her call light because staff were busy and she did not feel abused. The Administrator and DON informed Resident B that staff should not tell her that she could not use her call light. In an interview, CNA 6 indicated that Resident B turned on her call light, and she responded after applying PPE. Resident B asked who was going to complete her menus. CNA 6 indicated that Resident B could not hear her, so she raised her voice and told her that she would help her later. Resident B indicated that she still could not hear her and CNA 6 left the room. Resident B then turned on her call light again. The Administrator indicated to CNA 6 that it was unprofessional, and the residents had the right to turn on their call light. The Administrator encouraged CNA 6 to get help if she was feeling frustrated with a certain resident. A typed statement, dated 1/8/26 and signed by the Activity Assistant, indicated, on January 7th, she and the Activity Director were cleaning out the storage room, as the Activity Assistant walked back into the activity room, she heard an aide using a very loud and angry tone. The Activity Director stepped out of the activity room, and they both looked to see where it was coming from, however, the doors were closed. The Activity Director heard an aide tell the resident that she could not keep pushing her call light if she didn't need something, because there were other people she needed to take care of and she didn't have time to keep coming into her room. At that point, they saw CNA 6 coming out of Resident B's room. A typed statement, dated 1/8/26, signed by the Social Service Director and the Administrator, indicated that a staff member made the Administrator aware that CNA 6 also told the resident that she would not change her because she was too busy. Upon being told the information, an investigation was immediately initiated, and CNA 6 was suspended. When Resident B was interviewed, she denied the need to use the restroom, and indicated she did not feel abused. Resident B's roommate was interviewed and denied that Resident B needed to use the restroom. Resident B's roommate indicated CNA 6 indicated to Resident B not to turn on her call light on unless she needed something. CNA 6 received education related to Resident Rights 12/2024 and Abuse 1/2025. CNA 6 could not be reached for an interview during the survey date. During an interview on 1/30/26 at 8:41 a.m., Resident B indicated that she did not have concerns with staff. During an interview on 1/30/26 at 11:36 a.m., the Administrator indicated that CNA 6 was not suspended on 1/7/26 because the incident was just unprofessionalism. CNA 6 was suspended on 1/8/26 due to the additional statement on 1/8/26 that CNA 6 refused to toilet Resident B. During an interview on 1/30/26 at 12:05 p.m. QMA 5 indicated at times you needed to speak loudly to Resident B, but the volume and tone used were different. Resident B had confusion and repeated herself and turned on her call light a lot. QMA 5 considered abuse as telling a resident they couldn't turn on their light and refusing to take a resident to the bathroom. During an interview on 1/30/26 at 1:35 p.m., CNA 7 indicated she was standing outside of Resident B's closed door and heard CNA 6 tell Resident B to stop putting her call light on and she wasn't going to take her to the bathroom. Resident B turned on her call light again and CNA 7 assisted her to the bathroom. CNA 7 reported to the Administrator on 1/7/26 that CNA 6 told Resident B to stop putting her call light on. The next day, on 1/8/26, in a following up interview with the Administrator, CNA 7 reported that CNA 6 also told Resident B that she would not take her to the bathroom. A 9/2022 facility policy, titled Resident Abuse, Neglect and Exploitation Procedural Guidelines, provided in the facility's investigation by the Administrator on 1/30/26 at 9:23 a.m., indicated the following: .Envive Healthcare (EHC) has developed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident abuse and neglect .3. Definitions: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being .c. Deprivation of goods and services by staff: staff has the knowledge and ability to provide care and services, but choose not to do it, or acknowledge the request for assistance from a resident(s), which result in care deficits to a resident(s) This citation relates to Intake 2712215. 3.1-3(a)

Based on interview and record review, the facility failed to report allegations of verbal abuse and neglect timely and with accurate information to the State Agency for 1 of 3 residents reviewed for abuse. (CNA 6 and Resident B)Findings include:The facility's investigation was provided by the Administrator, on 1/30/26 at 9:23 a.m., and included the following information: A 1/8/26 Facility Reported Incident indicated on 1/8/26 it was reported to the Administrator that CNA 6 had allegedly yelled at Resident B. The 1/11/26 follow up indicated it was found that CNA 6 had raised her voice as she was in full PPE and Resident B could not hear her through her mask. CNA 6 indicated that she did indicate to the resident not to turn on her call light unless she needed something. CNA 6 was educated on professionalism.The incident report lacked indication of an allegation of threat to withhold services from the resident. A 1/7/26, typed statement signed by the Activity Director indicated she reported to the Administrator that she heard someone yelling loudly while she was putting things away in the activity room. She heard the person state You can't keep pushing your call light unless you need something, there are other people I need to take care of. When the Activity Director stepped out of the Activity room, she saw CNA 6 coming out of Resident B's room. A 1/7/26 typed statement signed by the Administrator and the Director of Nursing (DON) indicated that upon entering Resident B's room, the DON and Administrator applied Personal Protective Equipment (PPE) due to Resident B being in isolation related to COVID-19. Resident B was asked if she had experienced any trouble with staff. The Administrator raised her voice because Resident B could not hear through the PPE mask. Resident B indicated that CNA 6 told her she could not turn on her call light because staff were busy and she did not feel abused. The Administrator and DON informed Resident B that staff should not tell her that she could not use her call light. In an interview, CNA 6 indicated that Resident B turned on her call light, and she responded after applying PPE. Resident B asked who was going to complete her menus. CNA 6 indicated that Resident B could not hear her, so she raised her voice and told her that she would help her later. Resident B indicated that she still could not hear her and CNA 6 left the room. Resident B then turned on her call light again. The Administrator indicated to CNA 6 that it was unprofessional, and the residents had the right to turn on their call light. The Administrator encouraged CNA 6 to get help if she was feeling frustrated with a certain resident. A typed statement, dated 1/8/26, signed by the Activity Assistant indicated on January 7th, she and the Activity Director were cleaning out the storage room, as the Activity Assistant walked back into the activity room, she heard an aide using a very loud and angry tone. The Activity Director stepped out of the activity room, and they both looked to see where it was coming from, however, the doors were closed. The Activity Director heard an aide tell the resident that she could not keep pushing her call light if she didn't need something, because there were other people she needed to take care of and she didn't have time to keep coming into her room. At that point, they saw CNA 6 coming out of Resident B's room. A typed statement, dated 1/8/26, signed by the Social Service Director and the Administrator, indicated that a staff member made the Administrator aware that CNA 6 also told the resident that she would not change her because she was too busy. Upon being told the information, an investigation was immediately initiated, and CNA 6 was suspended. When Resident B was interviewed, she denied the need to use the restroom, and she did not feel abused. Resident B's roommate was interviewed and denied that Resident B needed to use the restroom. Resident B's roommate indicated CNA 6 indicated to Resident B not to turn on her call light on unless she needed something. CNA 6's Employee Corrective Action form, dated 1/7/26, indicated she received education on speaking properly to residents and to talk with leadership regarding ways to talk with residents when frustrated. The form was signed by CNA 6. CNA 6's Employee Corrective Action form, dated 1/8/26, indicated she was suspended for two days and would report to her supervisor to resume duties on 1/10/26 at 6:00 p.m. The form was signed by CNA 6. CNA 6 was educated on the facility's policy and procedure for Harassment and Standards of Behaviors on 1/17/26. An undated in-service titled Abuse for all staff included CNA 6's signature. CNA 6's timecard indicated she worked on 1/7/26 from 1:54 p.m. to 9:57 p.m., on 1/8/26 from 5:53 a.m. to 2:00 p.m. and on 1/10/26 from 5:54 p.m. to 6:03 a.m.During an interview on 1/30/26 at 11:36 a.m., the Administrator indicated that CNA 6 was not suspended on the 1/7/26 because the incident was considered unprofessional. CNA 6 was suspended on 1/8/26 due to an additional statement received on 1/8/26 that CNA 6 refused to toilet Resident B. During an interview on 1/30/26 at 1:35 p.m., CNA 7 indicated she was standing outside of Resident B's closed door and heard CNA 6 tell Resident B to stop putting her call light on and she wasn't going to take her to the bathroom. Resident B turned on her call light again and CNA 7 assisted her to the bathroom. CNA 7 reported to the Administrator on 1/7/26 that CNA 6 told Resident B to stop putting her call light on. The next day, on 1/8/26, in a following up interview with the Administrator, CNA 7 reported that CNA 6 also told Resident B that she would not take her to the bathroom. A current facility policy, titled Abuse, Neglect, Exploitation and Misappropriation, Reporting, and Investigating, provided by the Administrator on 1/30/26 at 2:37 p.m. indicated the following: .Reporting Allegations to the Administrator and Authorities .1 .the suspicion must be reported immediately to the administrator and to other officials according to state law .3. Immediately is defined as: h. within two hours of an allegation involving abuse .Investigating Allegations .1. All allegations are thoroughly investigated .6. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete Cross reference F550. This citation relates to Intake 2712215. 3.1-28(c)

Based on interview and record review, the facility failed to promote and protect resident dignity by ensuring residents' written consent was received per facility policy before posting photographs and videos on the facility's social media platforms for 2 of 8 residents reviewed. (Resident D and E)Findings include:A facility social media posting, on 7/28/25, showed a photograph of Resident D during an arts and crafts activity. A facility social media posting, on 8/13/25, showed photographs of some of the facility's residents at a lake during a meal. Resident E was pictured in the online photographs. Resident D's clinical record was reviewed on 9/19/25 at 10:34 a.m. Diagnoses included dementia, depression, and mild cognitive impairment.During an interview, on 9/19/25 at 11:45 a.m., the Administrator indicated Resident D did not have a signed photography/video release form in her admission packet.A consent record, provided by the Administrator, on 9/19/25 at 2:12 p.m., indicated Resident D signed consent for photographs intended for medical records and activities. The consent did not include social media release.Resident E's clinical record was reviewed on 9/19/25 at 10:40 a.m. Diagnoses included diabetes, bipolar disorder, and heart failure.A 8/7/25, quarterly, Minimum Data Set (MDS) assessment indicated Resident E was cognitively intact.During an interview, on 9/19/25 at 11:12 a.m., the Administrator indicated Resident E did not have a signed photography/video consent release form in his admission packet.During an interview, on 9/19/25 at 1:09 p.m., Resident D indicated she was aware pictures were taken of her and were used within the facility and were on the facilities social media pages. She did not have a concern with the posted pictures. Resident E was unavailable for an interview during the survey on 9/19/25. On 9/19/25 at 1:23 p.m., the DON confirmed photography on the facilities social media posts included Resident D and Resident E.A current facility policy, titled Videotaping, Photographing, and other imaging of Residents, provided by the Administrator, on 9/19/25 at 2:32 p.m., indicated the following: .2.Staff may not take or release images or recordings of any resident without explicit written consent. Written consent must be obtained from the resident or representative prior to obtaining images or recordings of the resident for any purposes other than investigation of abuse, neglect, or emergencies, and photography obtained for personal/ family use at the verbal request of the resident or family This citation relates to Intake 2609206.3.1-3(t)

Based on observation and interview, the facility failed to implement facility policy for assistive device use during a mobility transfer of a physically dependent resident for 1 of 1 residents reviewed for transfers. (Resident M)Findings include:Resident M's clinical record was reviewed on 9/19/25 at 11:43 a.m. Diagnoses included Parkinson's disease, muscle weakness, tremors and difficulty in walking.Current orders included weight bearing as tolerated with hip (protection) precautions.A 9/12/25, quarterly, Minimum Data Set (MDS) assessment indicated the resident was cognitively intact. Resident M had upper and lower extremity impairment on one side. Resident M was dependent on staff members for chair/bed to chair transfers.Resident M's current care plan included: I have an Activity of Daily Living (ADL) self- care performance deficit related to Parkinson's disease, tremors, and weakness initiated on 4/4/25 and reviewed on 8/7/25. Interventions included transfers required extensive assistance with two staff members. CNA may use mechanical lift as needed.During an observation, on 9/19/25 at 10:24 a.m., CNA 3 and CNA 5 transferred Resident M without the use of an assistive device or gait belt. Both CNAs placed their arms under Resident M's armpits before lifting resident up and out of his recliner. They both cued Resident M to move his feet while they transferred resident over to his bed. After foley catheter and incontinence care was completed, CNA 3 and CNA 5 transferred resident from his bed back into his recliner by grabbing Resident M under his armpits. Both CNAs cued Resident M to use his feet as they transferred him into his recliner.During an interview, on 9/19/25 at 10:41 a.m., CNA 3 and CNA 5 both indicated they should have used a gait belt to transfer Resident M.On 9/19/25 at 10:59 a.m., RN 4 indicated staff should have used a gait belt while Resident M was transferred.On 9/19/25 at 11:06 a.m., the DON indicated Resident M required a gait belt during transfers. A current policy, titled Safe lifting and Movement of Residents, provided by the Administrator, on 9/19/25 at 11:54 a.m., indicated the following: .1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. 4. Staff responsible for direct resident care will be trained in the use of manual (gait/ transfer belts) and mechanical lifting devices This citation relates to Intake 2616293. 3.1-37(a)

Based on observation and interview, the facility failed to maintain appropriate infection control practices during urinary catheter and incontinence care for 1 of 3 residents reviewed for infection control. (Resident M)Findings include:Resident M's clinical record was reviewed on 9/19/25 at 11:43 a.m. Diagnoses included Parkinson's disease, diabetes, muscle weakness, and tremors.A 9/12/25, quarterly, Minimum Data Set (MDS) assessment indicated resident was cognitively intact. Resident M had upper and lower extremity impairment on one side. Resident M was dependent on staff members for toileting.Resident M's current care plan included: I have an Activity of Daily Living (ADL) self- care performance deficit related to Parkinson's disease, tremors, and weakness initiated on 4/4/25 and reviewed on 8/7/25. Interventions included toilet use: assistance with toileting needs, dependent on two staff members.During an incontinence care observation, on 9/19/25 at 10:24 a.m., CNA 3 washed her hands and put on gloves. Resident M had had a small bowel movement. After providing incontinence care and redressing the resident, CNA 3, still wearing the same gloves used to provide incontinence care, touched Resident M's call light and his bed controls before she walked over to the trash can and removed her gloves. After she removed her gloves, CNA 3 performed hand hygiene.During an interview, on 9/19/25 at 10:41 a.m., CNA 3 indicated she should have removed her gloves before she touched Resident M's call light and bed controls.On 9/19/25 at 10:59 a.m., RN 4 indicated staff should remove their gloves and perform hand hygiene before touching a residents call light or bed controls after providing incontinence care.On 9/19/25 at 11:06 a.m., the DON indicated she would expect staff to remove gloves and perform hand hygiene before touching anything as their gloves would be considered dirty.A current policy, titled Handwashing/ Hand Hygiene, provided by the Administrator, on 9/19/25 at 11:54 a.m., indicated the following: .All personnel shall follow the handwashing/ hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors This citation relates to Intake 2616293. 3.1-18(l)

Based on interview and record review, the facility failed to ensure an anti-hypotensive medication was ordered and administered according to indication for use for 1 of 8 residents reviewed for medication administration. (Resident 21) Findings include: Resident 21's clinical record was reviewed on 1/23/25 at 10:17 a.m. Diagnoses included anoxic brain damage (lack of oxygen to the brain) not elsewhere classified, type 1 diabetes mellitus, end stage renal disease (kidney failure), dependence on renal dialysis, bipolar disorder, and hypertension (high blood pressure). Current medications included midodrine (medication used to increase blood pressure) 2.5 milligram (mg), take one tablet three times a day every Tuesday, Thursday, Saturday, and Sunday for hypotension, hold if systolic (top number) blood pressure was greater than 120 millimeter of mercury (mmHg) and midodrine 5 mg, take one tablet three times a day every Monday, Wednesday, and Friday; hold if systolic blood pressure was less than 120 mmHg. A December 2024 MAR indicated Midodrine 2.5 mg was administered as follows: On 12/14/24 at 7:30 a.m., when his systolic blood pressure was 126 mmHg. During an interview, on 1/23/25 at 9:51 a.m., the DON indicated the order for Midodrine 5 mg give one tablet by mouth three times a day every Monday, Wednesday, and Friday for hypotension and to hold if systolic blood pressure was less than 120 mmHg was written incorrectly. The order should state to hold the medication if systolic blood pressure was greater than 120 mmHg. Whichever nurse worked alongside the nurse who placed the medication order, that staff member would double check to make sure the order was put in the computer correctly. Staff were not administering the medication correctly as the order was written to hold the medication if Resident 21's systolic blood pressure was below 120 mmHg. During an interview, on 1/23/25 at 11:00 a.m., the Nurse Practitioner (NP) 6 indicated the order for Midodrine 5 mg give one tablet by mouth three times a day every Monday, Wednesday, and Friday for hypotension and to hold if systolic blood pressure is less than 120 mmHg was written incorrectly. The medication should have been held if the residents systolic blood pressure was greater than 120 mmHg not less than 120 mmHg. Almost all verbal orders were sent to him electronically to be reviewed and signed. It was an error on his part as well. With the midodrine being at a low dose, it would increase Resident 21's blood pressure both systolic and diastolic by 10-20 points each. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure residents did not receive antipsychotic medication without indication related to targeted behavior expressions and mental health diagnoses for 1 of 6 residents reviewed for unnecessary medications. (Resident 28) Findings include: Resident 28's clinical record was reviewed on 1/22/25 at 10:15 a.m. Diagnoses included bipolar disorder, mild intellectual disabilities, paranoid personality disorder, delusional disorder, and major depressive disorder, recurrent, severe, without psychotic features. Resident 28's quarterly Minimum Data Set (MDS) assessments, dated 2/23/24, 4/17/24, and 6/24/24, indicated in section I (medical diagnoses), the resident did not have a psychotic disorder: An annual MDS assessment, dated 9/24/24, indicated the resident did have a psychotic disorder, categorized as other than schizophrenia. A quarterly MDS assessment, dated 12/23/24, indicated the resident did have a psychotic disorder (other than schizophrenia). A care plan, initiated on 10/20/22, indicated the resident used antipsychotic medication(s) related to paranoid personality disorder. Interventions included administration of psychotropic medications as ordered by physician, and consider dosage reduction when clinically appropriate, A care plan, initiated 10/23/24, indicated the resident exhibited signs and symptoms of depression, such as being tearful, withdrawn from activities, agitation, and restlessness. Interventions included administering medications as ordered and to monitor and document side effects and effectiveness of medications. Discuss with the resident her fears and issues regarding health or other subjects. Review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy. A care plan, revised on 11/19/24, indicated the resident used an anti-anxiety medication for restlessness and agitation. Interventions included administering anti-anxiety medications as ordered, and monitor for side effects and effectiveness every shift. Monitor the resident for safety. Anti-anxiety medication are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia. There was an increased risk of falls, broken hips, and legs. Monitor/document/report, as needed, any adverse reactions to anti-anxiety therapy such as drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgement, memory loss, forgetfulness, etc . Unexpected side effects included mania, hostility, rage, aggressive or impulsive behavior, and hallucinations. A current care plan, revised 4/2/24, indicated the resident demonstrated cognitive impairment, in particular, with her short term memory. She had a diagnosis of mild intellectual impairment. The goal was she would remain oriented to her name and her personal surroundings daily. Interventions included administering medications as ordered, monitor and document side effects and effectiveness, ask yes and/or no question in order to determine her needs, cue, reorient, and supervise as needed, engage the resident in simple, structured activities that avoid overly demanding tasks, keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. A current 4/2/24 care plan indicated the resident demonstrated cognitive impairment and as an adverse result, her communication ability was impaired. The goal was for the resident to continue to verbally express her basic needs daily. Interventions included anticipating and meeting her needs, allow her adequate time to respond, repeat as necessary, and not to rush her during conversations. Encourage the resident to continue stating thoughts even if she was having difficulty expressing herself. Monitor and document nonverbal indicators of discomfort or distress. A current 4/2/24 care plan also indicated the resident suffered with bipolar disorder and as an adverse result, she had increased potential for mood decline. Interventions included administering anti-depressant medication as prescribed, assist the resident, family, and caregivers to identify strengths, positive coping skills, and to reinforce these. Encourage the resident to express her feelings, provide behavioral health consults as needed, and monitor/record/report to the medical director any acute feelings of sadness, loss of pleasure, loss of interest in activities, feelings of worthlessness or guilt, and any changes in sleep patterns. Observe for signs and symptoms of mania or hypomania, racing thoughts, euphoria, increased irritability, frequent mood changes, pressured speech, flight of ideas, and marked changes in need for sleep, agitation or hyperactivity. A current 4/2/24 care plan indicated the resident heard voices tell her she was going to have to move back to a group home. She did not want to go back. The voices also told her they were going to move in with her at her apartment and she did not want them to. She wanted to stay here (the facility). Interventions included a behavior monitoring program, medication reviews as indicated, and to assure her the hallucination was not real and that she was safe. Engage in activities and assist to an area with less stimulation. Current physician orders included the following: Lorazepam (a benzodiazepine used to treat anxiety) 1 mg one time a day for anxiety, dated 1/3/25 at 9:00 a.m., Paliperidone (antipsychotic) oral tablet, extended release, 1.5 mg one time a day every Monday, related to bipolar disorder and paranoid personality disorder, dated 11/25/24 at 9:00 a.m., Paliperidone tablet, extended release, 3 mg one time a day every Tuesday, Wednesday, Thursday, Friday, Saturday, and Sunday, related to bipolar disorder and paranoid personality disorder, dated 11/22/24 at 9:00 a.m., Sertraline HCL (antidepressant) oral tablet, 50 mg, 1 tablet by mouth one time a day related to other specified depressive episodes. Give with 25 mg tablet for total dose of 75 mg daily, dated 4/10/24 at 9:00 a.m., and Sertraline HCL oral tablet 25 mg, 1 tablet by mouth one time a day to be given with 50 mg tablet for a total dose of 75 mg daily, dated 4/10/24 at 9:00 a.m. A behavior note, dated 9/24/24 at 4:39 p.m., indicated the resident was interviewed to complete a PHQ-9 depression assessment. After the interview was completed, the resident became tearful, saying she could hear voices of people who were not there. She could not determine what they were saying, but she could hear voices. The floor nurse was notified. A social services progress note, dated 12/20/24 at 11:25, indicated the resident became tearful, afraid she was going to be discharged or moved to another facility. After receiving reassurance from the social service director (SSD), she did calm down. The SSD indicated the resident was very childlike in her mannerisms and seemed to be intellectually challenged. She also seemed to have some cognitive deficits that hindered her emotionally. A progress note, dated 12/21/24 at 8:07 a.m., indicated the resident was tearful. She thought the facility had given away her room and she had nowhere to go. She was reassured that her room had not been taken. She continued to be tearful and chose to lay down for a nap. A progress note, dated 12/27/24 at 12:27 p.m., indicated the resident was making rude comments in the dining room. Her overall mood seemed different. She was fearful that she was going to have to move. The resident's distress required redirection several times during the noon meal. A progress note, dated 1/1/25 at 12:41 p.m., indicated the resident was tearful, sad, and bawling, stating the staff was going to kick her out and she would have nowhere to go. A progress note, dated 1/2/25 at 11:01 A.M., indicated the resident had failed the gradual dose reduction of the anti-anxiety medication lorazepam 1 mg, and was to resume the medication once daily for anxiety. A review of pharmacy medication regimen reviews, on 1/22/25 at 1:46 p.m., indicated the following: A progress note, dated 10/17/24 at 11:53, indicated a gradual dose reduction (GDR) meeting was held. Lorazepam was reviewed for a GDR attempt. The interdisciplinary team (IDT) determined to change the lorazepam 1 mg daily to as needed (PRN) for 14 days, then review. It was clinically contraindicated to reduce the antipsychotic paliperidone or the antidepressant sertraline while attempting to reduce the lorazepam at that time. A progress note, dated 10/17/24, at which time the lorazepam dose had been changed to as needed, indicated no changes were made to sertraline or paliperidone because reducing more than one psychotropic could cause undo distress that could negatively impact the resident's function and well-being. A progress note, dated 10/31/24 at 8:56 a.m., indicated the lorazepam was due for review. It had been on hold for 14 days with no use. The IDT team decided to discontinue the lorazepam order at that time, related to non-use. A progress note, dated 11/21/24 at 11:45 a.m., indicated a GDR meeting was held that morning. The IDT team discussed medications and determined to attempt a GDR of the antipsychotic paliperidone. The plan was to decrease the Monday dose to 1.5 mg and continue the Tuesday through Sunday dose at 3 mg. Further review of progress notes indicated no behaviors, including hallucinations or delusions, for the following time periods: 6/20/24 - 7/20/24 - No behaviors. 7/21/24 - 8/20/24 - No behaviors. 8/21/24 - 9/20/24 - No behaviors. During an interview with the MDS Coordinator, on 1/22/25 at 1:58 p.m., she indicated the psychiatric nurse practitioner had added the diagnosis of delusional disorder to the resident's chart on 9/19/24. During an interview with RN 4, on 1/23/25 at 1:02 p.m., she indicated the resident's ability to understand conversations often waxed and waned. The resident could become tearful and easily upset. She could be difficult to redirect, it took time to get her to calm down. She could become tearful at any given time, sometimes during meals. During an interview with LPN 5, on 1/23/25 at 1:07 p.m., she indicated the resident could understand if asked specific questions. The resident was more of an observer. Her tearfulness was random and not prompted by anything in particular. She could be difficult to redirect. She could take a piece of a conversation and direct it towards herself (mistakenly), causing her distress. Many times, the resident's response seemed more like an anxiety response. During an interview with CNA 8, on 1/23/25 at 2:06 p.m., she indicated Resident 28 could understand when speaking with her. She would sometimes cry or say ouch when being touched, even gently. The resident could be calmed down. CNA 8 never observed the resident to be inconsolable. Conversations with Resident 28 were not like conversing with an adult. She required reassurance and responded well when the staff spent time with her or gave her a hug. A facility policy, revised 8/2024, provided by the administrator on 1/22/25 at 12:30 p.m., and titled Antipsychotic Medication Use, indicated the following: Policy Statement - Residents will not receive medications that are not clinically indicated to treat a specific condition. 1) Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. 2) The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others .4) The attending physician and facility staff will identify acute psychiatric episodes and will differentiate them from enduring psychiatric conditions 3.1-48(a)(6)

Based on record review and interview, the facility failed to provide notice of transfer/discharge to a representative of the Office of the State Long-Term Care Ombudsman for 1 of 2 residents reviewed for hospitalization . (Resident 21) Findings include: Resident 21's clinical record was reviewed on 1/23/25 at 10:17 a.m. Diagnoses included, but were not limited to, Type 1 diabetes mellitus, bipolar disorder, anoxic brain damage, and end stage renal disease. On 3/25/24, Resident 21 was showing signs and symptoms of diabetic ketoacidosis. The resident was lethargic and nauseated. His blood glucose level was checked and resulted in a reading of HI. He was transferred to the emergency room for evaluation and treatment. The clinical record lacked an Ombudsman notification for a transfer/discharge on this date. On 5/18/24, the resident refused to go to dialysis, refused all medications, and had a blood glucose reading of HI. The nurse practitioner gave an order for the resident to be transferred to the emergency room . He was then transferred to another acute care facility to receive dialysis. On 10/8/24, the resident complained of a headache. His blood pressure was 226/127 (normal blood pressure ranges from 110/70 to 120/80). He was sent to the emergency room and transferred from there to another acute care facility where he was treated for hypertension, hyperglycemia (high blood glucose), and hyperkalemia (high potassium). On 12/8/24, the resident was anxious, restless, and refused to take his medications. He was sent to the emergency room for evaluation and treatment. He was admitted to the acute care facility. During a review of monthly Ombudsman notifications, provided by the Social Services Director (SSD) on 1/23/25 at 12:30 p.m., the records lacked notification of Resident 21's transfers for the following months: March 2024, May 2024, October 2024, and December 2024. During an interview, on 1/23/25 at 2:22 p.m., the Social Services Director indicated a report was run monthly, which included transfers and discharges. She would provide these reports to the Ombudsman on a monthly basis, via email. If a resident had been put on a bed-hold status, the electronic health record would not notify her of a resident's hospitalization . It was her understanding that the Ombudsman should only be notified if the resident had been discharged and their return was not anticipated. During an interview, on 1/23/25 at 2:58 p.m., the Administrator indicated the facility did not have a policy addressing notification of the Ombudsman. 3.1-12(a)(6)(A)(iv)

Based on interview and record review, the facility failed to obtain blood pressure readings before administering an anti-hypotensive medication per physician order for 1 of 8 residents reviewed for medication administration. (Resident 27) Findings include: Resident 27's clinical record was reviewed on 1/21/25 at 9:28 a.m. Diagnoses included alcoholic cirrhosis of liver with ascites (a chronic liver disease caused by excessive alcohol consumption, leading to scarring and damage to the liver), muscle weakness, dysphagia (swallowing difficulties), essential hypertension (high blood pressure), alcoholic polyneuropathy (nerve damage caused by chronic alcohol abuse). Current medications included midodrine 10 mg, take one tablet by mouth two times a day for decreased blood pressure; hold if blood pressure was greater than 120/80 mmHg. A December 2024 Medication Administration Record (MAR) indicated midodrine 10 mg was given on 12/28/24 at 9:00 a.m., when Resident 27's blood pressure was outside the parameters for the medication. His blood pressure was documented at 148/89. A January 2025 MAR indicated midodrine 10 mg was held when Resident 27's blood pressure was not documented in the MAR, under the vital signs tab, or in the progress note as follows: On 1/3/25 at 9:00 p.m. On 1/7/25 at 9:00 p.m. On 1/9/25 at 9:00 p.m. On 1/12/25 at 9:00 p.m. On 1/16/25 at 9:00 p.m. On 1/17/25 at 9:00 p.m. During an interview, on 1/22/25 at 1:15 p.m., QMA 3 indicated an X marked on the MAR indicated the medication was not given. Staff would document vitals on the MAR when giving the medication, under the vitals tab, or in the progress note. During an interview, on 1/22/25 at 1:20 p.m., RN 4 indicated if a resident's vital signs were outside the parameters, they would be documented on the MAR. During an interview, on 1/22/25 at 1:30 p.m., LPN 5 indicated vital signs would be documented under the progress note tab in the MAR. Vital signs could also be documented under the vitals tab or progress notes. During an interview, on 1/22/25 at 1:32 p.m., the DON indicated staff were checking off that the parameters for the medication were checked but not necessarily meaning that the medication was administered. A current policy, titled Administering Medications, provided by the DON, on 1/23/25 at 12:40 p.m., indicated the following: .4. Medications are administered in accordance with prescriber orders, including any required time frame 3.1-48(a)(3)

Based on interview and record review, the facility failed to review and revise care plan interventions for dialysis and pressure injury management for 2 of 13 residents reviewed for care plans. (Residents 21 and 27) Findings include: Resident 21's clinical record was reviewed on 1/23/25 at 10:17 a.m. Diagnoses included hypertension, type 1 diabetes mellitus, anoxic brain damage, and end stage renal disease. A physician order, dated 10/18/24 at 9:00 a.m., indicated a pre-dialysis assessment was to be completed every Monday, Wednesday, and Friday. A physician order, dated 10/18/24 at 3:30 p.m., indicated a post-dialysis assessment was to be completed every Monday, Wednesday, and Friday. A current care plan, initiated 3/7/24, indicated the resident had renal insufficiency related to end stage renal disease. The resident required hemodialysis. An intervention, initiated on 10/6/22 and revised on 3/7/24, indicated the resident was to go for scheduled dialysis appointments. He received dialysis Tuesday, Thursday, and Saturday. During an interview, on 1/23/25 at 9:15 a.m., LPN 5 indicated the dialysis days and times should be in the resident's orders and on the medication administration record (MAR). The electronic record system prompted nurses to perform the pre-assessments and post-assessments on dialysis days. During an interview, on 1/23/25 at 9:29 a.m., RN 4 indicated there was a bar at the top of the resident's care profile which indicated dialysis was Monday, Wednesday, and Friday between 9:30 a.m. and 3:15 p.m. 49411 2. Resident 27's clinical record was reviewed on 1/21/25 at 9:28 a.m. Diagnoses included alcoholic cirrhosis of liver with ascites (a chronic liver disease caused by excessive alcohol consumption, leading to scarring and damage to the liver), muscle weakness, dysphagia (swallowing difficulties), essential hypertension (high blood pressure), alcoholic polyneuropathy (nerve damage caused by chronic alcohol abuse), and pressure ulcer of left buttock, unstageable. A nursing progress note, dated 9/22/24 at 10:36 a.m., indicated the CNA notified the writer that Resident 27 had a purplish area to his left buttock, which was not open at that time. The area was cleansed, and a comfort dressing was applied. Resident 27 denied any pain or discomfort. The physician, DON, and the residents representative were notified of the area. A nursing progress note, dated 9/24/24 at 10:52 a.m., indicated Resident 27 continued with worsening overall decline in his condition. He had increased confusion, difficulty staying awake and alert, increased edema and increased abdominal distention. The Nurse Practitioner (NP) was notified, and the resident was sent to the emergency room (ER) by EMS for evaluation and treatment. A nursing progress note, dated 10/5/24 at 4:10 p.m., indicated Resident 27 returned from the hospital accompanied by hospital staff. Resident 27 was alert and oriented and had a pressure injury to his left buttock and multiple areas of bruising to his upper extremities. The resident denied any pain or discomfort. Resident 27's care plan was not updated to include the presence of a pressure injury, nor a goal for healing and interventions for management of the injury. A skin Assessment document, dated 10/15/24 at 3:06 a.m., indicated Resident 27 had skin discolorations or impairments on his skin and was not a new area of discoloration or impaired skin integrity. The wound location was on Resident 27's left buttock, which was an open area. Treatment continued as ordered and the wound NP assessed the area weekly. A quarterly Minimum Data Set (MDS) assessment, dated 10/12/24, indicated Resident 27 had one unstageable (cannot be accurately staged due to the presence of a thick layer of dead tissue (eschar) or slough that obscures the underlying wound bed) pressure ulcer due to coverage of the wound bed by slough and/or eschar. Resident 27 required substantial/ maximal assist by staff members for toileting hygiene, upper body dressing, personal hygiene, rolling to the left and right, sit to lying, lying to sitting, chair/bed to chair transfer, toilet transfer and tub/shower transfer. He had no impairment to his upper and lower extremities. Resident 27's clinical record continued to lack a care plan for the management of the unstageable pressure injury to his left buttock. A current care plan focus, initiated and revised on 1/17/25, indicated Resident 27 had an unstageable pressure ulcer/injury to his left buttock. He was at risk for complications related to wound healing and at risk for developing another pressure ulcer. Interventions included the following: Administer treatments as ordered and monitor for effectiveness. Assess/record/monitor wound healing. Measure length, width, and depth where possible. Assess and document the status of wound perimeter, wound bed and healing progress. Report improvements and declines to the physician. Encourage and assist resident to change position frequently. Follow facility policies/protocols for the prevention/treatment of skin breakdown. Pressure reducing mattress to bed. Pressure relieving cushion to wheelchair/chair. Supplements as ordered to promote healing. During an interview, on 1/21/25 at 2:42 p.m., the DON indicated Resident 27 admitted from the hospital on 10/5/24 with a pressure injury on his left buttock. His interventions included a low air loss mattress, turn and reposition every two hours as tolerated, and pressure reducing cushions to his wheelchair. During an interview, on 1/21/25 at 2:49 p.m., Social Services indicated care plans were updated quarterly, and she tried to keep them updated continuously. She ran orders every morning, anything new with any resdient would show up on the orders. Resident 27's care plan should have been updated when he returned from the hospital. A current policy, titled Care Plans, Comprehensive Person-Centered, provided by the Administrator on 1/22/25 at 11:59 a.m., indicated the following: .12. The interdisciplinary team reviews and updated the care plan: When there has been a significant change in the resident's condition, when the desired outcome is not met, when the resident has been readmitted to the facility from a hospital stay, and at least quarterly, in conjunction with the required quarterly MDS assessment 3.1-35(e)

Based on interview and record review, the facility failed to protect a resident from sexual abuse perpetrated by an employee engaging in sexually-toned conversations and behavior for 1 of 1 resident reviewed for sexual abuse. (Resident B) Findings include: During an interview on 9/18/24 at 10:51 a.m., Resident B indicated he and DE5 (Dietary Employee 5) had been Facebook Friends and communicated via Facebook Private Messenger. They had friendly conversations at first. It became obvious to him that DE 5 liked him more than a friend. She became flirty. She had sent him pictures of herself in pajamas. On another occasion, she had messaged him that she was wearing only a bra and panties. Because she had a fiancee, the resident ended the relationship. To Resident B, being engaged was the same as almost married or married. During the interview, Resident B displayed multiple conversations on Private Messenger between him and DE5. The last message was dated May 29, 2024. The message indicated he had felt the conversations should stop now because the employee was in a committed relationship. Resident B indicated their conversations had ended shortly after the May 29 message. Some time in May, he had told the Social Services Director (SSD) he thought DE5 liked him as more than friends. The SSD told him he should stop private messaging her. He had been trying to handle it all himself, but decided to tell the SSD. The SSD did not speak to him again about the matter. The Previous Administrator had never spoken with him about messaging with DE5. No employee in any department had asked him any questions regarding his conversation from May, when he told the SSD, until September 2024 when the new Administrator asked him questions one day ago. Resident B's clinical record was reviewed on 9/18/24 at 10:27 a.m. Current diagnoses included toxic encephalopathy, spastic hemiplegia of the left non-dominate side and depression. A 7/2/24, quarterly, MDS (Minimum Data Set) assessment indicated the resident was cognitively intact. The clinical record lacked documentation or care planning regarding the resident making false statements. A copy of a messenger screen shot, provided by the Administrator on 9/18/24 at 1:09 p.m. and had been obtained as part of her incident investigation, indicated Laying on the bed I'm in just my bra and panties. The screen shots were identified as being provided by Resident B as part of the facility's investigation. The screen shots were consistent with the messages shown by Resident B during the 9/18/24 interview. During an interview on 9/18/24 at 11:49 a.m., the Administrator indicated, on 9/17/24, the facility received an anonymous call alleging Resident B and DE5 were having an unknown type of personal relationship. She asked questions of the caller and was provided no additional information. She began an investigation immediately and learned Resident B and DE5 had been conversational through Facebook Private Messenger. The conversations may have been inappropriate in nature. The resident had provided screen shoots of the messages and there was questionable content. She had suspended the employee. The Social Services Director (SSD) and Dietary Manager (DM) indicated they had both been aware of the messaging relationship. The DM told her she had informed the previous administrator. The current Administrator indicated she could not find a file, notes, an investigation, a facility reported incident, or other documentation regarding the allegation, nor an investigation by the previous administrator. During a phone interview on 9/18/24 at 1:21 p.m., DE5 indicated she had been Facebook Friends and Facebook Private Messaged with Resident B. She understood that the facility had expectations about what type of interactions staff could have with residents. She had a personality that could be seen as flirty. She had sent a photo of herself in pajamas, which covered her body, to Resident B. Sending that photo may have crossed the line for staff-resident interaction. She had once sent a message that stated she was wearing only her bra and panties while messaging. She indicated the message about her bra and panties may have crossed the line for staff to resident interaction. She had said I like you to the resident and it could have been romantic in nature. She thought he was a cutie. The DM had spoken to her once or twice about messaging with Resident B. Their conversations had continued after the DM had spoken to her. The previous administrator had never spoken to her about messaging with Resident B. Since the DM spoke to her in around May, no other facility leadership had ever spoken to her about messaging with Resident B until the new administrator did, and she was suspended. She and the resident had stopped messaging months ago maybe the end of May or first of June. They had definitely stopped messaging by the Fourth of July. During an interview on 9/18/24 at 12:14 p.m., the Social Services Director (SSD) indicated Resident B had spoken to her about thinking DE5 liked him as more than a friend. She told the resident to cease messaging DE5. She did not make an entry in the resident's clinical record. She did not know the date. It was more than a couple months ago. She did pass on the information to the previous administrator. The previous administrator did not ask her for a written statement and she put nothing in writing. The previous administrator indicated she was aware and the DM told her and it had been addressed. She did not follow-up with the resident to determine if the situation was resolved. During an interview on 9/18/24 at 1:32 p.m., the DM indicated she had been aware of DE5 and Resident B messaging on their phones, in approximately May 2024. Her first understanding was they were just talking and saying good night and such. She had told DE5 to stop because these things can go too far and bad things could come from it. Then two employees came to her again (DE6 and DE7) and one or both of them said the two were now messaging inappropriate things like the size of male genitals. On both occasions, she went to the previous administrator and reported her concerns. When told about the messaging about genitals, the previous administrated responded we facility could not do anything unless they were actually having sex. The DM had no documentation or notes regarding when she reported to the previous administrator, statements from staff, when she told DE5 to cease messaging, or any information related to the resident and staff messaging one another. During an interview on 9/19/24 at 9:53 a.m., DE6 (Dietary Employee 6) indicated she worked with DE5. She had reported concerns regarding DE5 messaging with Resident B to the DM. She believed she told the DM two or more times about her concerns with DE5 and the resident messaging. At first it seemed too friendly, and maybe flirty. DE5 talked to her about the resident and called him a cutie. DE5 would talk about Resident B regularly. Then she learned the two were talking about inappropriate thing like the size of male genitalia. She then reported her concerns again to the DM. She had reported her concerns more than a couple of months ago. A current, 1/1/23, policy titled, Abuse and Neglect Policy, provided by the Administrator on 9/18/24 at 1:56 p.m., indicated sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. A current, 8/2024, facility policy titled, Abuse, Neglect, Exploitation and Misappropriation, Reporting and Investigating, provided by the Administrator on 9/19/24 at 10:45 a.m., indicated the administrator or the individual making the allegation immediately reports .to the following agencies: a. The state licensing/certification agency . Investigation: 1. All allegations are thoroughly investigated. The administrator initiates the investigation. 6. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. 7. The individual conducting the investigation as a minimum: . t. interview the person(s) reporting the incident; u. interview any witnesses to the incident; w. interview the resident (as medically appropriate) or the resident's representative; .bb. document the investigation completely and thoroughly. A current, July 2016, policy, titled E-mail, Internet and Social Media Use, provided by the Administrator on 9/18/24 at 2:00 p.m., indicated social media platform will be used only within the legal, ethical and professional boundaries established by state and federal privacy laws, professional standards of practice, and facility policy. This citation relates to Complaint IN00443474. 3.1-27(a)

Based on interview and record review, the facility failed to report an allegation of sexual abuse to the Indiana Department of Health when the concern was initially identified for 1 of 1 residents reviewed for reporting abuse to the state agency. (Resident B) Findings include: During an interview on 9/18/24 at 10:51 a.m., Resident B indicated he and DE5 (Dietary Employee 5) had been Facebook Friends and communicated via Facebook Private Messenger. They had friendly conversations at first. It became obvious to him that DE 5 liked him more than a friend. She became flirty. She had sent him pictures of herself in pajamas. On another occasion, she had messaged him that she was wearing only a bra and panties. Because she had a fiancee, the resident ended the relationship. To Resident B, being engaged was the same as almost married or married. During the interview, Resident B displayed multiple conversations on Private Messenger between him and DE5. The last message was dated May 29, 2024. The message indicated he had felt the conversations should stop now because the employee was in a committed relationship. Resident B indicated their conversations had ended shortly after the May 29 message. Some time in May, he had told the Social Services Director (SSD) he thought DE5 liked him as more than friends. The SSD told him he should stop private messaging her. He had been trying to handle it all himself, but decided to tell the SSD. The SSD did not speak to him again about the matter. The Previous Administrator had never spoken with him about messaging with DE5. No employee in any department had asked him any questions regarding his conversation from May, when he told the SSD, until September 2024 when the new Administrator asked him questions one day ago. A copy of a messenger screen shot, provided by the Administrator on 9/18/24 at 1:09 p.m. and had been obtained as part of her incident investigation, indicated Laying on the bed I'm in just my bra and panties. The screen shots were identified as being provided by Resident B as part of the facility's investigation. The screen shots were consistent with the messages shown by Resident B during the 9/18/24 interview. During an interview on 9/18/24 at 11:49 a.m., the Administrator indicated, on 9/17/24, the facility received an anonymous call alleging Resident B and DE5 were having an unknown type of personal relationship. She asked questions of the caller and was provided no additional information. She began an investigation immediately and learned Resident B and DE5 had been conversational through Facebook Private Messenger. The conversations may have been inappropriate in nature. The resident had provided screen shoots of the messages and there was questionable content. She had suspended the employee. The Social Services Director (SSD) and Dietary Manager (DM) indicated they had both been aware of the messaging relationship. The DM told her she had informed the previous administrator. The current Administrator indicated she could not find a file, notes, an investigation, a facility reported incident, or other documentation regarding the allegation, nor an investigation by the previous administrator. During an interview on 9/18/24 at 12:14 p.m., the Social Services Director (SSD) indicated Resident B had spoken to her about thinking DE5 liked him as more than a friend. She told the resident to cease messaging DE5. She did not make an entry in the resident's clinical record. She did not know the date. It was more than a couple months ago. She did pass on the information to the previous administrator. The previous administrator did not ask her for a written statement and she put nothing in writing. The previous administrator indicated she was aware and the DM told her and it had been addressed. She did not follow-up with the resident to determine if the situation was resolved. During a phone interview on 9/18/24 at 1:21 p.m., DE5 indicated she had been Facebook Friends and Facebook Private Messaged with Resident B. She understood that the facility had expectations about what type of interactions staff could have with residents. She had a personality that could be seen as flirty. She had sent a photo of herself in pajamas, which covered her body, to Resident B. Sending that photo may have crossed the line for staff-resident interaction. She had once sent a message that stated she was wearing only her bra and panties while messaging. She indicated the message about her bra and panties may have crossed the line for staff to resident interaction. She had said I like you to the resident and it could have been romantic in nature. She thought he was a cutie. The DM had spoken to her once or twice about messaging with Resident B. Their conversations had continued after the DM had spoken to her. The previous administrator had never spoken to her about messaging with Resident B. Since the DM spoke to her in around May, no other facility leadership had ever spoken to her about messaging with Resident B until the new administrator did, and she was suspended. She and the resident had stopped messaging months ago maybe the end of May or first of June. They had definitely stopped messaging by the Fourth of July. During an interview on 9/18/24 at 1:32 p.m., the DM indicated she had been aware of DE5 and Resident B messaging on their phones, in approximately May 2024. Her first understanding was they were just talking and saying good night and such. She had told DE5 to stop because these things can go too far and bad things could come from it. Then two employees came to her again (DE6 and DE7) and one or both of them said the two were now messaging inappropriate things like the size of male genitals. On both occasions, she went to the previous administrator and reported her concerns. When told about the messaging about genitals, the previous administrated responded we facility could not do anything unless they were actually having sex. The DM had no documentation or notes regarding when she reported to the previous administrator, statements from staff, when she told DE5 to cease messaging, or any information related to the resident and staff messaging one another. During an interview on 9/19/24 at 9:53 a.m., DE6 (Dietary Employee 6) indicated she worked with DE5. She had reported concerns regarding DE5 messaging with Resident B to the DM. She believed she told the DM two or more times about her concerns with DE5 and the resident messaging. At first it seemed too friendly, and maybe flirty. DE5 talked to her about the resident and called him a cutie. DE5 would talk about Resident B regularly. Then she learned the two were talking about inappropriate thing like the size of male genitalia. She then reported her concerns again to the DM. She had reported her concerns more than a couple of months ago. A current, 1/1/23, policy titled, Abuse and Neglect Policy, provided by the Administrator on 9/18/24 at 1:56 p.m., indicated sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. A current, 8/2024, facility policy titled, Abuse, Neglect, Exploitation and Misappropriation, Reporting and Investigating, provided by the Administrator on 9/19/24 at 10:45 a.m., indicated the administrator or the individual making the allegation immediately reports .to the following agencies: a. The state licensing/certification agency . Investigation: 1. All allegations are thoroughly investigated. The administrator initiates the investigation. 6. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. 7. The individual conducting the investigation as a minimum: . t. interview the person(s) reporting the incident; u. interview any witnesses to the incident; w. interview the resident (as medically appropriate) or the resident's representative; .bb. document the investigation completely and thoroughly. This finding relates to IN00443474. 3.1-28(c)

Based on interview and record review, the facility failed to complete a thorough investigation regarding sexual misconduct of an employee until approximately 4 months following the facility being informed for 1 of 1 resident reviewed for timely investigation of allegations of abuse. (Resident B) Findings include: During an interview on 9/18/24 at 10:51 a.m., Resident B indicated he and DE5 (Dietary Employee 5) had been Facebook Friends and communicated via Facebook Private Messenger. They had friendly conversations at first. It became obvious to him that DE 5 liked him more than a friend. She became flirty. She had sent him pictures of herself in pajamas. On another occasion, she had messaged him that she was wearing only a bra and panties. Because she had a fiancee, the resident ended the relationship. To Resident B, being engaged was the same as almost married or married. During the interview, Resident B displayed multiple conversations on Private Messenger between him and DE5. The last message was dated May 29, 2024. The message indicated he had felt the conversations should stop now because the employee was in a committed relationship. Resident B indicated their conversations had ended shortly after the May 29 message. Some time in May, he had told the Social Services Director (SSD) he thought DE5 liked him as more than friends. The SSD told him he should stop private messaging her. He had been trying to handle it all himself, but decided to tell the SSD. The SSD did not speak to him again about the matter. The Previous Administrator had never spoken with him about messaging with DE5. No employee in any department had asked him any questions regarding his conversation from May, when he told the SSD, until September 2024 when the new Administrator asked him questions one day ago. Resident B's clinical record was reviewed on 9/18/24 at 10:27 a.m. Current diagnoses included toxic encephalopathy, spastic hemiplegia of the left non-dominate side and depression. A 7/2/24, quarterly, MDS (Minimum Data Set) assessment indicated the resident was cognitively intact. The clinical record lacked documentation or care planning regarding the resident making false statements. A copy of a messenger screen shot, provided by the Administrator on 9/18/24 at 1:09 p.m. and had been obtained as part of her incident investigation, indicated Laying on the bed I'm in just my bra and panties. The screen shots were identified as being provided by Resident B as part of the facility's investigation. The screen shots were consistent with the messages shown by Resident B during the 9/18/24 interview. During an interview on 9/18/24 at 11:49 a.m., the Administrator indicated, on 9/17/24, the facility received an anonymous call alleging Resident B and DE5 were having an unknown type of personal relationship. She asked questions of the caller and was provided no additional information. She began an investigation immediately and learned Resident B and DE5 had been conversational through Facebook Private Messenger. The conversations may have been inappropriate in nature. The resident had provided screen shoots of the messages and there was questionable content. She had suspended the employee. The Social Services Director (SSD) and Dietary Manager (DM) indicated they had both been aware of the messaging relationship. The DM told her she had informed the previous administrator. The current Administrator indicated she could not find a file, notes, an investigation, a facility reported incident, or other documentation regarding the allegation, nor an investigation by the previous administrator. During a phone interview on 9/18/24 at 1:21 p.m., DE5 indicated she had been Facebook Friends and Facebook Private Messaged with Resident B. She understood that the facility had expectations about what type of interactions staff could have with residents. She had a personality that could be seen as flirty. She had sent a photo of herself in pajamas, which covered her body, to Resident B. Sending that photo may have crossed the line for staff-resident interaction. She had once sent a message that stated she was wearing only her bra and panties while messaging. She indicated the message about her bra and panties may have crossed the line for staff to resident interaction. She had said I like you to the resident and it could have been romantic in nature. She thought he was a cutie. The DM had spoken to her once or twice about messaging with Resident B. Their conversations had continued after the DM had spoken to her. The previous administrator had never spoken to her about messaging with Resident B. Since the DM spoke to her in around May, no other facility leadership had ever spoken to her about messaging with Resident B until the new administrator did, and she was suspended. She and the resident had stopped messaging months ago maybe the end of May or first of June. They had definitely stopped messaging by the Fourth of July. During an interview on 9/18/24 at 12:14 p.m., the Social Services Director (SSD) indicated Resident B had spoken to her about thinking DE5 liked him as more than a friend. She told the resident to cease messaging DE5. She did not make an entry in the resident's clinical record. She did not know the date. It was more than a couple months ago. She did pass on the information to the previous administrator. The previous administrator did not ask her for a written statement and she put nothing in writing. The previous administrator indicated she was aware and the DM told her and it had been addressed. She did not follow-up with the resident to determine if the situation was resolved. During an interview on 9/18/24 at 1:32 p.m., the DM indicated she had been aware of DE5 and Resident B messaging on their phones, in approximately May 2024. Her first understanding was they were just talking and saying good night and such. She had told DE5 to stop because these things can go too far and bad things could come from it. Then two employees came to her again (DE6 and DE7) and one or both of them said the two were now messaging inappropriate things like the size of male genitals. On both occasions, she went to the previous administrator and reported her concerns. When told about the messaging about genitals, the previous administrated responded we facility could not do anything unless they were actually having sex. The DM had no documentation or notes regarding when she reported to the previous administrator, statements from staff, when she told DE5 to cease messaging, or any information related to the resident and staff messaging one another. During an interview on 9/19/24 at 9:53 a.m., DE6 (Dietary Employee 6) indicated she worked with DE5. She had reported concerns regarding DE5 messaging with Resident B to the DM. She believed she told the DM two or more times about her concerns with DE5 and the resident messaging. At first it seemed too friendly, and maybe flirty. DE5 talked to her about the resident and called him a cutie. DE5 would talk about Resident B regularly. Then she learned the two were talking about inappropriate thing like the size of male genitalia. She then reported her concerns again to the DM. She had reported her concerns more than a couple of months ago. A current, 1/1/23, policy titled, Abuse and Neglect Policy, provided by the Administrator on 9/18/24 at 1:56 p.m., indicated sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. A current, 8/2024, facility policy titled, Abuse, Neglect, Exploitation and Misappropriation, Reporting and Investigating, provided by the Administrator on 9/19/24 at 10:45 a.m., indicated the administrator or the individual making the allegation immediately reports .to the following agencies: a. The state licensing/certification agency . Investigation: 1. All allegations are thoroughly investigated. The administrator initiates the investigation. 6. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. 7. The individual conducting the investigation as a minimum: . t. interview the person(s) reporting the incident; u. interview any witnesses to the incident; w. interview the resident (as medically appropriate) or the resident's representative; .bb. document the investigation completely and thoroughly. This finding relates to IN00443474. 3.1-28(c) 3.1-28 (d)

Based on observation, interview, and record review, the facility failed to ensure hand hygiene was completed before and after moments of resident contact during random observations. Findings include: During a random observation, on 4/2/24 at 9:52 a.m., Restorative Aide 4 propelled Resident 17 back to his room in his wheelchair. Upon entering his room, she helped the resident adjust his foot pedals and brought his bedside table over to him before exiting his room. No hand hygiene was performed after exiting the resident's room. During an interview, on 4/2/24 at 9:54 a.m., Restorative Aide 4 indicated she had hand sanitizer in her work room. She tried to go back to her work room between each resident contact to perform hand hygiene, but sometimes if she saw another resident requiring therapy, she would take them down to her work room before performing hand hygiene. During a random observation, on 4/2/24 at 10:07 a.m., the Activities Director entered Resident 5's room and assisted the resident with putting on her oxygen tubing. Upon exiting the resident's room, the Activities Director followed Resident 5 into the crafting room, where she picked up a box containing crafting supplies and distributed the items to Resident 5 and 14. No hand hygiene was performed before touching and distributing the crafting supplies. During an interview, on 4/3/24 at 8:46 a.m., the Activities Director indicated most of the time, she carried hand sanitizer in her pocket. She also had hand sanitizer in her work room. She was supposed to perform hand hygiene before and after entering a resident's room. During an interview, on 4/5/24 at 3:00 p.m., the DON and Nurse Consultant both indicated they expected staff to perform hand hygiene before and after entering resident rooms where care was performed. A current facility policy, dated 2/2022 and titled Hand Washing/ Hand Hygiene, provided by the Corporate Nurse on 4/3/24 at 4:20 p.m., indicated the following .Health Care Workers shall use hand hygiene at times such as: Before/after having direct physical contact with residents 3.1-18(l)

Based on observation, interview and record review, the facility failed to ensure individualized interventions were updated to prevent the deterioration of a pressure ulcer for 1 of 2 residents reviewed for pressure ulcers (Resident 24). This deficient practice resulted in a resident's stage 3 pressure ulcer worsening without intervention. Findings include: During an observation, on 7/19/22 at 12:59 p.m., Resident 24 was sitting upright in a tilt-in-space positioning chair. On 7/19/22 at 2:31 p.m., she was lying in bed on her back, the head of the bed was elevated 45 degrees. On 7/20/22 at 9:54 a.m., she lying in bed on her back, the head of the bed was elevated 30 degrees. On 7/21/22 at 2:56 p.m., she was sitting up in her room in the tilt-in-space positioning chair. Her clinical record was reviewed on 7/19/22 at 9:50 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Schedule follow-up appointment with the wound clinic, the order date was 6/13/22. Maintain 16 Fr indwelling urinary catheter with 10 ml (milliliter) bulb due to wounds on sacrum, the order date was 6/13/22. [MEDICATION(S)] (foam dressing) border to sacrum/heels/elbows, change dressing every three days and as needed for soilage or dislodgement, the order date was 6/13/22. Turn every two hours, the order date was 6/13/22. Up in chair as tolerated: waffle cushion while up in chair. Please remind her to shift weight by forward leaning, side to side movement, lifting thighs or marching movements. Do not leave her on the chair for an extended period of time without weight shifts, the order date was 6/13/22. Resource 2.0, give 240 ml every day and night shift for malnutrition and wound healing, the order date was 6/20/22. Pro-Stat (nutritional supplement) liquid, give 30 ml two times a day for low [MEDICATION(S)] and protein, the order date was 6/24/22. Mighty shake (nutritional supplement), one with each meal, the order date was 6/27/22. Low air loss mattress in bed due to stage 3 pressure ulcer, every shift for healing, the order date was 7/1/22. Wash stage 3 pressure area with baby shampoo, rinse with running water, pat dry. Pack wound with calcium alginate rope (absorbent dressing) and cover with bordered tape. Change every three days and as needed if loose or soiled, the order date was 7/1/22. A 6/17/22 admission MDS (Minimum Data Set) assessment indicated she had admitted to the facility on [DATE]. The staff assessment for her mental status indicated he short and long term memory problems, cognitive skills for daily decision making was severely impaired- never/rarely made decisions. She had a stage 3 pressure ulcer present on admission. A 7/11/22 quarterly MDS assessment indicated she had severe cognitive impairment. She required extensive assistance with bed mobility, locomotion on and off the unit, dressing, eating, toilet use and personal hygiene and was totally dependent for transfers. She was at risk for the development of pressure ulcers and had a stage 3 pressure ulcer that was present on admission. She had an indwelling urinary catheter and was always incontinent of bowel. A current care plan , dated 6/14/22, indicated an alteration in skin integrity as evidenced by stage 3 pressure ulcer to coccyx related to stage IV [CONDITION(S)] with metastasis, chemo-induced stomatitis and gastro-intestinal ulcers, moderate protein-calorie malnutrition, body mass index greater than 40 and a history of COVID. The goal, with an initiated date of 6/14/22 and a target date of 7/5/22, indicated the resident's pressure ulcer would show signs of healing and remain free from infection by/through review date. Interventions, all dated 6/14/22, included, but were not limited to, encourage and assist the resident to change positions frequently, provide assistive device as needed to enable resident to move as independently as possible, teach resident/family the importance of changing positions for prevention of pressure ulcers, encourage small frequent position changes and educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. A current care plan, with a revised date of 6/20/22, indicated she was at risk for impaired skin integrity related to impaired mobility, incontinent and history of skin breakdown. The goal, with a revised date of 6/17/22 and a target date of 7/5/22, indicated the resident would have no complications related to skin impairment through the review date. Interventions included, but were not limited to, pressure reducing mattress on bed, revised date of 6/17/22, observe skin with daily cares and notify nurse of any new or worsening areas, revised date of 6/17/22 and pressure reducing cushion in wheel-chair, dated 6/20/22. An Admission Nursing Evaluation assessment, date opened was 6/14/22 at 2:27 p.m. and the date locked was 6/17/22 at 4:18 p.m., indicated she at high risk for skin breakdown and had a stage 3 pressure ulcer that had measured in length 3.2 cm (centimeter), width was 1.6 cm and the depth was 2.0 cm, the wound bed was dry and red. A nurse progress note, dated 6/14/22 at 9:25 p.m., indicated dressings were in place and she was turned every two hours without issues, and complained of pain when buttocks was touched. A MDS note, dated 6/17/22 at 11:19 a.m., indicated she was extensive to dependent assistance with all care. A Nurse Practitioner progress note, dated 6/21/22 at 10:00 a.m., indicated poor appetite and weight loss. The Malnutrition section indicated she was started on multiple nutritional supplements and provided education on diet. The Skin section indicated the coccyx wound was failing to heal. A Nurse Practitioner progress note, dated 6/24/22 at 10:00 a.m., indicated protein level was 5.3 (normal value 6.0 to 8.0) and [MEDICATION(S)] level was less than 1.5 (normal value 3.5 to 5.5). The Malnutrition section indicated to start Pro-Stat 30 ml twice a day and continue nutritional supplements. The Skin section indicated the coccyx wound was failing to heal. A wound assessment, date opened was 6/24/22 at 12:10 p.m. and the date locked was 7/1/22 at 5:26 p.m., indicated the stage 3 pressure ulcer to her coccyx, length measured 3.0 cm, width measured 1.7 cm and the depth measured 2.0 cm, 26-50% of the wound bed had granulation tissue, 51-75% had slough (dead tissue, yellow, tan, gray, green or brown), increased redness to surrounding skin, wound edges rolled and the wound status indicated the wound was improving. A wound assessment, dated 7/1/22 at 5:49 p.m., indicated the stage 3 pressure ulcer to her coccyx, length measured 3.3 cm, width measured 1.6 cm and the depth measured 2.0 cm, 76-100% of the wound bed with slough, wound with a foul odor, rolled edges and the wound status indicated no change. The clinical record did not include that individualized interventions had been updated. A wound assessment, dated 7/8/22 at 11:46 p.m., indicated the stage 3 pressure ulcer to her coccyx, length measured 3.0 cm, width measured 1.2 cm and the depth measured 2.0 cm, 51-75 % of the wound bed with slough and a foul odor, wound edges irregular and the wound status indicated no change. The clinical record did not include that individualized interventions had been updated. A wound assessment, dated 7/15/22 at 2:13 p.m., indicated the stage 3 pressure ulcer to her coccyx, length measured 6.0 cm, width measured 7.5 cm and the depth measured 4.0 cm. 26-50% of wound bed with granulation tissue, 26-50% with slough and 0-25% with eschar (dead tissue, tan, brown or black), wound edges irregular and the wound status indicated deteriorated. Nurse Practitioner notified and no new orders had been received. The clinical record did not include that individualized interventions had been updated. During an interview, on 7/20/22 at 1:55 p.m., the Wound Nurse indicated if a wound did not show improvement after two weeks or if the wound deteriorated, she would update the care plan and contact the physician to request a treatment change. If no improvement with the next assessment she would contact physician for order to change the treatment. The order for [MEDICATION(S)] border to sacrum/heels/elbows should have been discontinued. An appointment with a wound clinic had not been scheduled. A review of a current facility policy, titled SKIN MANAGEMENT PROGRAM, with a revised date of 10/2013 and provided by the Nurse Consultant on 7/22/22 at 9:11 a.m., indicated POLICY: This facility will assess/identify the presence of risk factors that may contribute to the development of pressure ulcers and other skin alterations in an effort to prevent skin breakdown and/or further deterioration limited by the individual's recognized pathology and pre-existing co-morbid conditions Review of a current facility policy, titled CARE PLAN DEVELOPMENT AND REVIEW, with a revised date of 9/17 and provided by the Nurse Consultant on 7/22/22 at 10:47 a.m., indicated .5. The comprehensive care plan shall then be developed and shall describe the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being 3.1-40(a)(2)

A. Based on record review and interview, the facility failed to ensure a resident received insulin as ordered by a physician and receive appropriate hypoglycemic treatment for 1 of 4 reviewed for quality of care (Resident B). This deficient practice resulted in Resident B requiring medical attention following a hypoglycemic episode. B. Based on interview and record review, the facility failed to ensure a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The immediate jeopardy began on 4/17/22, when Resident B became unresponsive with a blood glucose level of 24 Milligrams per deciliter (Mg/dL). Prior to physician notification, the nurse attempted to place packets of sugar under her tongue when [MEDICATION(S)] was unavailable. The nurse was unable to obtain a blood pressure and notified the Nurse Practitioner (NP) and Director of Nursing (DON) of the change in condition. Resident B's blood glucose level was rechecked and was 29. The Emergency Medical Team (EMT) arrived and placed an Intravenous line (IV) and the resident was sent to the hospital where she remained until readmission on 4/27/22. The resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The administration record indicated the resident received [MEDICATION(S)] 4 times daily. The Administrator and Vice President (VP) of clinical support were notified of the immediate jeopardy on 5/10/22 at 5:02 p.m. Findings include: A. The clinical record for Resident B was reviewed on 5/9/22 at 2:00 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Admission Minimum Data Set (MDS), dated [DATE], indicated the resident was cognitively intact. She required two-person assistance with bed mobility, transfer and toileting. A health care plan, dated 4/13/22, indicated the resident had diabetes mellitus. Interventions included, but were not limited to, administer diabetes medication as ordered and monitor for any signs and/or symptoms of [CONDITION(S)]. Review of hospital discharge orders/summary, dated 4/4/22, the following medications included, but were not limited to, a. blood sugar diagnostic testing 4 strips daily. b. [MEDICATION(S)] (long-acting insulin) 100 unit/mL, give 14 units daily, maximum daily dose 14 units. c. [MEDICATION(S)] (fast-acting insulin) 100 unit/mL, give 4 units three times daily with meals, maximum daily dose 12 units. The facility failed to transcribe the hospital discharge medications on physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order for [MEDICATION(S)] was not clarified on admission. Resident B's April 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/4/22, the residents blood glucose level was 142. No additional glucose levels were noted or insulin administered. On 4/15/22, the residents blood glucose level was 200. No additional glucose levels were noted or insulin administered. The April MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note, dated 4/15/22 at 1:29 p.m., indicated to discontinue [MEDICATION(S)] routine with meals. The order indicated to check blood glucose levels before meals and at night for 1 week. The April MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing progress note, dated 4/17/22 at 10:34 a.m., indicated the nurse was called to the resident's room by the Qualified Medication Aide (QMA) due to the resident being unresponsive. The resident had shallow respiration and her blood glucose was checked and found to be 24. The QMA was instructed to call the ambulance. The nurse attempted to place sugar under the resident's tongue. She was unable to obtain a blood pressure. The NP and DON were notified of the change in condition. The nurse continued to call the resident by name and place sugar packets under the tongue with no response from the resident. The blood glucose was rechecked and was 29. Her skin remained pale and EMTs arrived, and they checked her blood glucose, and it was 36. An IV was started and infused blood sugar was then 120. Resident B opened he eyes but would not respond to her name. The resident only moaned or grunted when spoken to and EMTs decided to send to the hospital for evaluation. The NP and DON were notified of the transfer to the hospital. A progress note, dated 4/17/22 at 3:03 p.m., indicated staff called the hospital for an update and was told the resident did answer some yes and no questions, but was not responding appropriately. The resident was beginning transferred a larger hospital. A progress note, dated 4/27/22 at 5:13 p.m., indicated the resident was readmitted . Her left arm was discolored and bruised from IV and her respiration were regular and non-labored. On 5/10/22 at 5:02 p.m., the VP of clinical support indicated the original orders were the discharge summary. The facility only presented the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . She indicated the facility currently had 2 emergency [MEDICATION(S)] kits in the Emergency Drug Kit Emergency (EDK). During an interview 5/9/22 at 12:15 p.m. with the Administrator and Director of Nursing (DON), staff would have to get a code from the pharmacy to access Pxyis MedStation (automated medication dispensing system) to get [MEDICATION(S)]. The DON was not aware of any resident who recently required [MEDICATION(S)], but indicated Resident B went to the hospital for low blood sugar. During an interview on 5/9/22 at 3:19 p.m., QMA 1 indicated a couple weeks ago, she went to take Resident B her medication and found her sweating. QMA 1 indicated LPN 2 bought a glucose meter down and she thought her blood sugar was 29. LPN 2 had not yet been down to the room. LPN 2 had QMA 1 go to the Emergency Drug Kit (EDK) and get [MEDICATION(S)] (to treat very low blood sugar) and there was none. She then went to the kitchen got juice, straw and some packets of sugar. She thought [MEDICATION(S)] was normally in the EDK and after that, she ordered 2 kits for the EDK. On 5/11/22 at 3:20 p.m., the VP of clinical support, indicated she did not see an order to discontinue blood glucose testing. During an interview on 5/11/22 at 3:23 p.m., LPN 2 indicated earlier in the day on 4/17/22, Resident B yelled what's up to her. Resident B only complained about a sore ankle at that time. The CNA's would have taken her breakfast between 8:00-8:30 a.m. She was finishing medication administration when QMA 1 came and asked her if she needed any help. QMA 1 took the resident her morning medications and then came back out and called for her to come into the room. Resident B was cool, clammy and her eyes were rolled back. She told QMA 1 to go to the EDK and get [MEDICATION(S)]. QMA 1 came back and said there was no [MEDICATION(S)]. The breakfast trays had not been picked up so QMA 1 grabbed some packets of sugar. With a gloved hand, LPN 2 dipped her finger into the sugar and slid under her tongue. QMA 1 was calling 911 from her cell phone in the room. She thought the EDK had [MEDICATION(S)], but they had not had a brittle diabetic in the facility for some time. She usually gave insulin around 9:00 a.m., but she had not given her any on that day. She could not say she followed the facility policy related to hypoglycemic episodes, but felt she was doing what was best for the resident. The Nurse Practitioner (NP) was notified and she did not think he was made aware they did not have any [MEDICATION(S)] and she did not receive any orders. A hospital cardiology consult, dated 4/26/22, indicated the resident was admitted following a blood glucose in the 20's with some mild [CONDITION(S)]. The resident was noted to have a right pleural effusion and underwent a thoracentesis on 4/21/22. B. During an interview on 5/10/22 at 9:40 a.m., Resident H indicated he had some teeth pulled and the dentist wanted him to use a salt rinse after the extraction. He indicated over the weekend he mentioned it to a staff member who said there was not an order in the chart and she was not supposed to be there, but would look into on Monday. The clinical record for Resident H was reviewed on 5/10/22 at 9:49 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly MDS assessment, dated 2/22/22, indicated the resident was cognitively intact. He required extensive two-person assistance for all activities of daily living. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the hard chart, an order dated, 5/4/22 at 12:30 p.m., indicated to rinse starting 5/5/22, every 6 hours for 2 days. A progress note, dated 5/6/22 at 12:34 p.m., indicated the resident had his left wisdom tooth pulled. During an interview on 5/10/22 at 12:13 p.m., LPN 4 indicated he put in the order to change the cotton every 9.5 hours, but did not put in the order for the salt wash. On 5/11/22 at 3:20 p.m., the VP of clinical support indicated she was not in the facility daily, but ideally the physician and NP would put in their own orders. She was unsure of the system they had in place to ensure any order that was given or written was entered into the computer. The National Library of Medicine, January 4, 2022 [CONDITION(S)] medical management indicated for a patient unable to take oral agents, a 1-mg intramuscular (IM) injection of [MEDICATION(S)] can be administered. Review of a current, dated 4/2022, facility policy, titled Blood Glucose Monitoring, provided by the VP of clinical support on 5/10/22 at 10:34 a.m., indicated the following: POLICY It is the policy of this facility to administer immediate treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . PROCEDURE Residents who have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If the resident has not received specific blood glucose call parameters the physician will be notified of any blood glucose less than 70 or if the resident is having signs or symptoms of high or low blood sugar. .A resident with blood glucose below 70 requires as assessment for symptoms of [CONDITION(S)] Immediate treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . .Blood glucose less than 70 and the resident is unable to consume PO intake: Administer PRN IM or oral glucose as ordered. Recheck blood glucose in 15 minutes, document findings and current resident status and notify MD. If there is no PRN order notify the MD immediately A current facility policy, dated 4/2022, titled Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] All new orders will be entered into Point Click Care by the nursing staff or provider The immediate jeopardy that began on 4/17/22 was removed on 5/11/22 when the facility reviewed, verified and validated all diabetic orders, in-serviced all licensed staff and QMA's on appropriate interventions relating to blood glucose monitoring and responding to hypoglycemic episodes, ensured all diabetic orders have call parameters and [MEDICATION(S)] available in the EDK. The noncompliance remained at a level of no actual harm with the potential for more than minimal harm as the monitoring and education remained ongoing. This Federal tag relates to Complaint IN 657 and IN 891. 3.1-37(a)

Based on observation, interview and record review, the facility failed to monitor significant weight loss and to ensure additional interventions were in place to prevent further weight loss for 1 of 4 reviewed for weight loss. (Resident C) This deficient practice resulted in Resident C having a 10.4% weight loss from December to January. Findings include: During an interview on 1/5/22 at 11:02 a.m., CNA 3 indicated she assisted Resident AC with breakfast. The resident had biscuits and gravy and she did not give her any supplements such as yogurt. During an observation on 1/6/22 at 8:54 a.m., Resident C was being assisted with breakfast. The breakfast consisted of oatmeal, pancakes, ground sausage and juice. No yogurt was noted on her tray. The clinical record for Resident C was reviewed on 1/5/22 at 10:28 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A health care plan, dated 1/19/21 and last revised 8/26/21, indicated the resident had incurred weight loss related to dementia and confusion. Interventions included, but were not limited too, monitor consumption and encourage resident to consume 100% of meals, ice cream for dinner and yogurt at lunch and dinner. An order, dated 8/17/21, indicated to serve yogurt at breakfast and chart percentage consumed. A health care plan was updated 1/6/22 and indicated the resident has significant weight loss in 1 month. Interventions included, but were not limited to, monitor intake and record each meal and provide supplements as ordered. Review of the monthly weights, the following weights were noted in 2021: June 130.2 lbs. July 134.5 lbs. August 135.5 lbs. September 147.4 lbs. October 141.8 lbs. November 137.0 lbs this is a 7.06% loss December 137.0 lbs. A nutritional assessment, dated 11/15/21, indicated the resident was on a regular diet and was to receive yogurt at breakfast. Her current Body Mass Index (BMI) was 22.9. A nutrition progress note, dated 11/15/21, indicated an addendum to the nutritional assessment was made. The report indicated there were no current weight available and the resident recently had Covid-19. A Nurse Practitioner (NP) progress note, dated 12/20/21, indicated over the past few days, the resident has had increased confusion, ambulating shorter distance and requiring assistance with Activities of Daily Living (ADL). The resident was bed-bound all day and required staff assistance to be fed. The resident was also having difficulty swallowing food, fluid and medications. The physical exam indicated the resident had altered mental status and abnormal findings included crackles in her lower lobes on auscultation. The plan included an hospice evaluation and treatment if indicated. An order, dated 12/20/21, indicated to obtain a weight as soon as possible. Review of the meal consumption record for December, the resident refused or had a meal intake of less than 50% and was not offered a substitute on 20 occasions for breakfast, 22 occasions for lunch and 15 occasions for supper. A physician order, dated 12/21/21, indicated a mechanical soft diet. Review of the January Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record lacked any documentation in January yogurt had been provided. Review of the ADL report for January, staff documented the resident was dependent on staff to assist with meals on 7 occasions. The clinical record lacked any documentation for meal assistance on 1/1/22 or 1/2/22. Review of the meal consumption record for January, the resident refused or had a meal intake of less than 50% and was not offered a substitute on 3 occasions for breakfast and 2 occasions for supper. On 1/6/22, Resident B weighed 122.8, this was a 10.4% loss. During an interview on 1/6/22 at 3:08 p.m., the Registered Dietitian (RD) Consultant indicated she changed Resident C's diet today to pleasure feedings. She recommended to change to Med Pass 2.0 (balanced fortified nutrition to supplement calories) to avoid further weight loss and skin breakdown. She indicated it has been difficult to have Nutrient Adequacy Ratios (NARs) meeting since Covid-19 and she was currently covering several buildings, but a new RD will be assigned to this facility soon. A facility policy, revised 9/08, titled, Weight Assessment and Intervention, which was provided by the Administrator on 1/5/22 at 3:22 p.m., indicted the following: The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. .Weight Assessment .3. Any weight change of 5% or more since last weight assessment will be retaken the next day is verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing. .Analysis .2. The Physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss. For example: a. Cognitive or functional decline; b. Chewing or swallowing abnormalities; c. Pain; d. Medication-related adverse consequences Care Planning 1. Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and include the Physician, nursing staff, the Dietitian, the Consultant Pharmacist, and the resident or resident's legal surrogate. .Interventions 1. Interventions for undesirable weight loss shall be based on careful consideration of the following: a. Resident choice b. Nutrition and hydration needs .g. The use of supplements and/or feeding tubes This Federal tag relates to Complaint IN 711 3.1-46(1)

Based on interview and record review, the facility failed to provide treatment and services to prevent the development of pressure ulcers for 7 of 7 residents reviewed for pressure ulcers. This deficient practice resulted in the Resident B developing a pressure wound and the wound worsening from unstageable to stage 4 with osteo[DIAGNOSES REDACTED] requiring intravenous antibiotic and hospitalization (Resident B and D). The immediate jeopardy began on 12/26/19 when the Nurse Practitioner noted worsening pressure ulcers. The resident was sent directly from the wound center to the hospital on [DATE] until she discharged on [DATE]. The Executive Director was notified of the immediate jeopardy on 2/25/20 at 5:22 p.m. Findings include: 1. The closed clinical record for Resident B was reviewed on 2/24/20 at 11:56 a.m. [DIAGNOSES REDACTED]. The most recent admission Minimum Data Set (MDS) assessment, dated 10/18/19, indicated the resident was severely cognitively impaired. She required two-person assistance for bed mobility, transfer, eating and toileting. She was at risk for the development of pressure ulcers and admitted with unhealed pressure ulcers. She had 3 stage-2 pressure ulcers. The facility implemented a pressure reducing bed and chair, as well as, pressure ulcer care. An admission/re-admission assessment, dated 10/11/19, indicated the resident admitted with 3 open areas on the posterior side of her body. A health care plan, dated 10/23/19, indicated the resident was at risk for developing pressure ulcers. Interventions included, but were not limited to, encourage nutrition/hydration and pressure reducing cushion to bed. A health care plan, dated 1/3/20, indicated the resident had a pressure ulcer. Interventions included, but were not limited to, dressing/treatment as ordered, encourage and assist resident to turn every two hours and monitor for efficacy of treatment progress. A discharge MDS assessment, dated 1/23/20, indicated the resident had 1 stage-2 and 1 unstageable pressure ulcer. She also had 1 suspected deep tissue injury. The resident weight on admission (10/11/19) was 242.9 and the discharge weight 183.4 on 1/23/20. This was a 24.5% weight loss. The initial pressure ulcer assessments, dated 10/11/19, indicated the following pressure ulcers were present on admission: a. Left gluteal, stage 2, 1.0 cm x 0.3 cm x > 0.1 cm. b. Right gluteal, stage 2, 1.3 cm x 0.5 cm x >0.1 cm. c. Coccyx, stage 2, 2.0 cm x 1.3 cm x >0.1 cm. On 10/12/19, a new order was received to apply [MEDICATION NAME] (silicone adhesive border dressing) to the open areas on the coccyx. The dressing was to be changed daily and as needed. A Registered Dietician (RD) note, dated 10/24/19, indicated the resident admitted to the facility 10/11/19 with a weight of 236.8 lbs. She had multiple pressure areas and a surgical incision. She was on a regular diet and took a multivitamin. On 11/1/19, the left and right gluteal wounds were healed. On 11/8/19, the coccyx wound was healed. A new order was received on 12/26/19 to apply [MEDICATION NAME] Ag (antimicrobial dressing) to the coccyx wound and change daily and as needed. Review of the Treatment Administration Record (TAR), no treatments were completed in December for the [MEDICATION NAME] Ag. A clinical visit, dated 12/31/19, the Nurse Practitioner (NP) indicated the resident presented with the complaint of a wound. The wound started unknown ago. The resident's condition worsened and the wound had become larger and darker. The wounds were identified as the following: a. Left ankle, unstageable, 2.0 cm x 2.0 cm and covered with eschar. b. Left outer foot, unstageable, 2.4 cm x 1.7 cm, wound bed covered with eschar. c. Left outer foot (near pinky toe), unstageable, 1.6 cm x 1.7 cm, cover with black eschar. d. Coccyx, stage 2, 7.0 cm x 5.0 cm, wound bed with some [MEDICATION NAME]. e. Left hip, stage 2, 2.5 cm x 0.8 cm, wound bed with some [MEDICATION NAME]. A new order was received on 12/31/19 to apply skin prep (liquid film-forming dressing) to the unstageable wound on the left outer foot daily. The order also indicated to cleanse the left outer ankle with soap and water, pat dry and apply Santyl (enzymatic [MEDICATION NAME] ointment) daily and cover with a foam dressing. A Braden scale (a tool used for predicting pressure ulcer risk), dated 1/9/20, indicated a score of 13, moderate risk for developing a pressure ulcer Review of the January TAR, the [MEDICATION NAME] Ag treatment to the coccyx was not completed on 1/2/20, 1/5/20, 1/8/20 or 1/9/20. During a clinical visit, dated 1/2/20, the NP indicated the resident was seen for pain related to a pressure injury on the coccyx. The note indicated the wound started several weeks ago and was worsening. The resident was started on [MEDICATION NAME] (narcotic-like pain reliever) twice daily. The plan indicated the resident had abnormal weight loss and pain. The NP indicated the coccyx wound was a stage 3 and to continue with current treatment. The initial pressure ulcer assessments, dated 1/3/20, indicated the following pressure ulcers were observed: a. Coccyx, unstageable, 7.0 cm x 5.0 cm. b. Left outer, middle foot, suspected deep tissue injury, 2.4 cm x 1.7 cm. c. Left outer, front foot, suspected deep tissue injury, 1.6 cm x 1.7 cm. d. Left hip, stage 2, 2.5 cm x 0.8 cm x <0.1 cm. e. Left outer ankle, unstageable, 2.0 cm x 2.0 cm. The weekly pressure assessment indicated the following wound measurements: a. On 1/10/20, the coccyx wound measured 5.5 cm x 2.0 cm. and on 1/17/20 the coccyx wound measured 5.1 cm x 5 cm. b. On 1/10/20, the left outer, middle wound on the left foot measured 2.2 cm x 1.7 cm. The wound was healed by 1/17/20. c. On 1/10/20, the left outer, front middle wound on the left foot measured 1.5 cm x 2.0 cm. and on 1/17/20, the left outer, front middle wound on the left foot measure 1.2 cm x 1.8 cm. d. The left hip wound measured 2.5 cm x 0.8 cm x 0.1 cm on 1/10/20 and was healed by 1/17/20. e. The left outer ankle wound measured 2.0 cm x 2.0 cm on 1/10/20 and 2.3 cm x 2.1 cm x 0.1 cm on 1/17/20. A new order was received on 1/10/20 to discontinue [MEDICATION NAME] Ag and changed to cleanse the coccyx with wound cleanser, pat dry and apply a small amount of Santyl to the black tissue in the wound and cover with [MEDICATION NAME] Ag and change daily and as needed. The resident was also referred to the wound clinic. Review of the January TAR, the treatment was not completed on 1/11/20, 1/12/20, 1/14/20, 1/16/20 or 1/17/20. Review of the January week skin assessment, assessments were completed 1/6/20 and 1/13/20. An assessment was not completed on 1/20/20. A new order was received on 1/17/20 to apply a wet to dry dressing to the coccyx wound using Dakin's solution (a type of hypochlorite solution) 0.125% twice daily and cover with a foam dressing. The order also indicated to use a foam bordered dressing to the wound on the left ankle and change every other day and as needed. Review of the January TAR, the Dakin's treatment was completed only once daily 1/17/20 through 1/23/20. The treatment was to be done twice daily. On 1/23/20, Resident B had a scheduled wound clinic appointment. The visit indicated a stage 4 coccyx wound, stage 2 left buttock wound, left ankle with a fat layer exposed and a foot ulceration with unspecified severity. The physical assessment indicated frequent loud moans and the resident was unable to reposition herself. She had very little movement of the lower body but was able to move her arms. The wound exam indicated the coccyx wound had visible bone exposed and was foul-smelling. A large piece of dark material was lifted out of the wound. The bone was visible and palpated. The assessment indicated the resident had several pressure ulcers and the most significant was the area on the coccyx, which most likely needed surgical debridement. The assessment indicated Complete healing will be a long term goal with input from consulting disciplines at this time. The resident was sent to the emergency room for intractable pain in addition to severely necrotic coccyx area wound. The emergency room report, dated 1/23/20, indicated the resident had an infected sacral decubitus wound and was brought to the hospital with [MEDICAL CONDITION] from the wound. The initial treatment included, but was not limited to, intravenous fluids and intravenous antibiotics for soft [MEDICAL CONDITION]. The hospital recommended she be transferred to another hospital to be seen by infectious disease. The receiving hospital indicated the resident presented with chronic weakness and a chronic decubitus ulcer with some concern [MEDICAL CONDITION]. The skin assessment indicated a deep foul-smelling ulcer over the sacral region. The resident had significant pain and discomfort. There was a chronic non-healing ulcer of the lateral aspect of the left ankle joint. An Magnetic Resonance Imaging (MRI) was completed on 1/30/20. The results showed a large posterior soft tissue wound that measured approximately 5.0 cm x 5.0 cm extending to a depth of approximately 2.0 cm. There was osteo[DIAGNOSES REDACTED] (inflammation of bone or bone marrow, usually due to infection of the coccyx). Trace fluid and [MEDICAL CONDITION] suggested early involvement and small abscess that measured 0.4 cm x 1.0 cm. The plan included to continue [MEDICATION NAME] (used to treat infections) and [MEDICATION NAME] (to treat moderate to severe infections), blood cultures and a wound care consult. The discharge summary indicated the resident was seen by surgery service an no operative debridement was felt necessary. The resident had a [MEDICATION NAME] Radiologist (IR) drain of the abscess in the left piriformis (small muscle located deep in the buttock). The resident was followed by infectious disease who recommended long term IV antibiotics upon discharge. 2. During wound care observation on 2/27/20 at 2:20 p.m. with the Corporate Nurse Consultant, the Resident D was noted to have a stage-2 pressure ulcer to the left, inner elbow. The resident also had bilateral wounds on the inner buttocks. The clinical record for Resident D was reviewed on 2/26/20 at 11:20 a.m. [DIAGNOSES REDACTED]. The most recent significant change MDS assessment, dated 11/29/19, indicated the resident was severely cognitively impaired. She had two, stage-2 pressure ulcers and 2-unstageable pressure ulcers. She required two-person assistance for bed mobility. A health care plan, dated 11/22/19 and revised 12/12/19, indicated the resident was at risk for the development of a pressure ulcer related to being non-ambulatory and limited range of motion. Interventions included, but were not limited to, pressure reducing cushion to chair and pressure reducing mattress. The resident was provided with a low air loss mattress on 11/22/19. A health care plan, dated 11/22/19 and revised 2/25/20, indicated the resident had an open area to the right and left inner buttocks and left inner elbow, as well as, existing left outer ankle and right inner heel wounds. Interventions included, but were not limited to, treatment as ordered, turn and reposition every 2 hours and low air loss mattress. A weekly skin assessment, date 2/18/20, indicated no new skin areas were noted. On 2/25/20, two new areas were noted, one on the left inner elbow and bilateral wounds on the inner buttocks. An initial pressure ulcer assessment, dated 2/25/20, indicated the following pressure ulcers: a. Right inner buttocks, stage 2, 3.2 cm x 2.0 cm x 0.1 cm. b. Left inner buttocks, stage 2, 2.5 cm x 2.8 cm x 0.1 cm. c. Left inner elbow, stage 2, 1.5 cm x 1.5 cm x 0.1 cm. A Braden scale completed on 2/25/20, indicated the resident was at moderate risk to develop a pressure ulcer. A new order was received on 2/25/20 to discontinue skin prep to the bilateral heels and left outer ankle. The new order indicated to apply skin prep to the right inner heel and wrap with Kerlix every shift. Also to apply [MEDICATION NAME] to the left inner elbow daily for seven days and covered with [MEDICATION NAME] (non-adherent dressing) and wrap with Kerlix (woven gauze dressing). The wound was to be reevaluated in seven days. A new order was received on 2/25/20 to apply [MEDICATION NAME] (skin protectant) to the left and right open areas on the buttocks and change every shift and as needed. The dressing was to be done daily for 7 days then reevaluated. Review of the TAR, the treatment was not completed during the 2:00 p.m.-10:00 p.m. shift on 2/26 or 2/27/20. On 2/26/20, the RD ordered Active liquid protein (nutritional supplement) 30 mL to be given through the gastrostomy tube twice daily for 8 weeks for wound healing. During an interview on 2/25/20 at 2:50 p.m., the Director of Nursing (DON) indicated she was doing weekly skin assessments and the former Assistant Director of Nursing (ADON) was to file them in the DON's skin book. She had been the DON for approximately 2 years. On 2/25/20 at 4:05 p.m., the Nurse Consultant and DON indicated during one of the visits from the Nurse Consultant late in 2019, they discovered gaps in several systems. The weekly skin assessments were not being completed. On 2/26/20 at 5:15 p.m., the Corporate Nurse Consultant indicated they were unable to find any Braden scale assessments for 2019. They were also unable to find any December weekly skin assessment sheets. Confidential interviews for staff were completed. Exact times and dates withheld to maintain anonymity. Employee 7 indicated the facility did not have any QAA meetings or do any SWAT (Skin and Weight Assessment Team) meetings. The DON did not ever look at the wounds and was recently forced to by the corporate office. Several residents have wounds and they were not being measured correctly or identified correctly. Review of a current facility policy, dated 10/2014, titled PRESSURE ULCER PREVENTION, which was provided by the DON on 2/25/20 at 5:40 p.m. indicated the following: PURPOSE: To prevent pressure ulcers and promote healing. POLICY: Personal will identify those residents most likely to experience skin breakdown, and take precautions necessary to prevent breakdown. .PROCEDURE: 1. Identify those residents at risk 2. Resident's care plan should include relevant goals and approaches .4. Reposition resident approximately every two hours 5. Inspect skin for redness/open areas during provision of daily care. .7. Resident's physician shall be notified documented in the clinical record. .11. Maintain or improve nutrition and hydration, where feasible. 12. If resident's intake is inadequate, notify physician. The immediate jeopardy that began on 12/26/19 was removed on 2/26/20 when the facility reeducated staff regarding pressure ulcers, weekly skin assessments, weight loss and ensuring interventions were in place for those at risk, but the non-compliance remained at no actual harm, but potential for minimal harm because system monitoring had not been completed. This Federal tag relates to Complaint IN 210. 3.1-40(a)(1) 3.1-40(a)(2)

Based on, record review and interview the facility failed to monitor significant weight loss and to ensure additional interventions were in place to prevent further weight loss for 1 of 7 reviewed for weight loss. This deficient practice resulted in the resident having an 18% weight loss with no interventions between 10/11/19 and 11/19/19. (Resident B) Findings include: The closed clinical record for Resident B was reviewed on 2/24/20 at 11:56 a.m. [DIAGNOSES REDACTED]. The most recent admission Minimum Data Set (MDS) assessment, dated 10/18/19, indicated the resident was severely cognitively impaired. She required two-person assistance for bed mobility, transfer, eating and toileting. She was at risk for the development of pressure ulcers and admitted with unhealed pressure ulcers. She had 3 stage-2 pressure ulcers. The facility implemented a pressure reducing bed and chair, as well as, pressure ulcer care. An admission/re-admission assessment, dated 10/11/19, indicated the resident admitted with 3 open areas on the posterior side of her body. The resident weight on admission (10/11/19) was 242.9 lbs and the discharge weight 183.4 on 1/23/20. This was a 24.5% weight loss. A health care plan, dated 10/23/19, indicated the resident required staff assistance for meal consumption. Interventions included, but were not limited to, staff will set-up meals, assist and encourage resident at each meal and document meal consumption to promote dietary assessment and intervention. A new order received on 10/30/19 to downgrade to a mechanical soft diet with thin liquids and assist as needed. An interdisciplinary care plan conference record, dated 10/31/19, indicated the resident required maximum assist of 2 staff persons for most Activities of Daily Living (ADL). She was on a mechanical soft diet with thin liquids and her skin was intact. On 11/7/19, Resident B weighed 211.8 lbs, a 12.8% weight loss. On 11/19/19, the resident weighed 198.8 lbs, a 18.2% weight loss. The clinical record lacked interventions added to prevent further weight loss between 11/7/19 and 11/19/19. Review of the meal consumption record for January, the resident ate less than 25% of her meals on 42 occasions and the record lack if the resident was offered and/or refused alternate food. On 2/25/20 at 4:05 p.m., the Nurse Consultant and Director of Nursing (DON) indicated during one of the visits from the Nurse Consultant late in 2019, they discovered gaps in several systems. Confidential interviews for staff were completed. Exact times and dates withheld to maintain anonymity. Employee 7 indicated the facility did not have any QAA (Quality Assessment and Assurance) meetings or do any SWAT (Skin and Weight Assessment Team) meetings. On 2/26 at 5:15 p.m., the Nurse Consultant indicated the facility did not do the QAA meetings and they did not identify any concerns related to skin and weights. A facility policy, dated 10/14, titled SKIN & WEIGHT ASSESSMENT TEAM (SWAT) PROTOCOL, which was provided by the Nurse Consultant on 2/27/20 at 10:16 a.m., indicted the following: PROTOCOL It is the protocol of this facility to aggressively review and address those residents exhibiting significant/insidious weight change or skin breakdown. These residents will be monitored by SWAT on a weekly basis .Indicators of needed implementation of SWAT monitoring: 5% or greater weight loss in one month 7.5% .90 days . 10% .180 days . Open areas of Stage II or greater 3. Consumption records, weights, intake and output records .during the SWAT meeting. This Federal tag relates to Complaint IN 210. 3.1-46(1)

Based on observation, interview, and record review the facility failed to implement interventions for care of a dependent resident for 1 of 4 residents reviewed for accidents. This deficient practice resulted in one staff member rolling the resident to her side while the resident was in her bed and then the resident falling out of bed and sustaining a [MEDICAL CONDITION] kneecap. (Resident 18) Findings include: During an interview on 2/10/20 at 3:37 p.m., Resident 18 indicated she fell out of bed a while ago after a staff member rolled her too close to the edge of the bed. She indicated she fell to the floor and injured her knee. On 2/14/20 at 9:00 a.m., Resident 18's clinical record was reviewed. [DIAGNOSES REDACTED]. A current significant change Minimum Data Set (MDS) assessment, dated 12/19/19, indicated the resident was moderately cognitively impaired. She was totally dependent on staff for transfers and required extensive staff assistance of two for bed mobility and toileting. She had a fall with major injury since her prior MDS assessment. A current bed mobility health care plan, dated 2/13/20, indicated the resident required staff assistance of two staff members for bed mobility related to weakness, [MEDICAL CONDITIONS], and impaired cognition. Interventions included, but were not limited to, the resident will be assisted to turn and reposition approximately every two hours or more as tolerated. A current falls health care plan, dated 2/13/20, indicated the resident had multiple risk factors for falls related to a history of falls, weakness, non-ambulatory, impaired cognition, [DIAGNOSES REDACTED], [MEDICAL CONDITIONS], vitamin D deficiency, [MEDICAL CONDITION], and history of fracture to right patella. Interventions included, but were not limited to, ensure the resident used assistive devices as indicated, hoyer lift used for transfers, monitor vital signs as indicated, keep frequently used items within reach, and scoop mattress. A current health care plan for vitamin D deficiency, dated 2/13/20, indicated the resident had a [DIAGNOSES REDACTED]. Interventions included, but were not limited to, vitamin D3 as ordered, calcium with vitamin D as ordered, identify risk for falls and implement appropriate interventions due to increased risk of fracture from falls, and lab as ordered by the physician to evaluate for treatment efficacy. Review of a Nurses Note, dated 12/10/19 at 3:30 p.m., indicated the resident rolled out of bed while being cleaned up and landed on floor. The resident's bilateral lower extremities were bleeding and her left elbow was out of alignment. An ambulance was called and the resident was sent to the emergency room . Review of an Accident and Incident Report and Investigation, dated 12/10/19, indicated the resident fell in her room while CNA 2 rolled the resident to change her. Review of a progress note, dated 12/10/19, indicated, but was not limited to, a [MEDICAL CONDITION] patella. During an interview, on 2/14/20 at 09:53 a.m., QMA (Qualified Medication Aide) 2 indicated the resident required two person assistance with the hoyer lift. During an interview, on 2/14/20 at 11:15 a.m the DON indicated the CNA's had access to bed mobility assistance requirements on the CNA assignment sheets. During an interview, on 2/14/20 at 2:47 p.m., the DON provided a copy of the current CNA assignment sheet She indicated the CNA assignment sheet lacked bed mobility assistance information for each resident. During an interview, on 2/14/20 at 3:04 p.m., the DON indicated CNA 2 was the only staff member that assisted the resident during the fall on 12/10/19. During an interview, on 2/17/20 at 2:48 p.m., CNA 2 indicated he was the only CNA that assisted the resident to turn on 12/10/19 and resulted in a fall. A current policy, titled FALL PREVENTION PROGRAM, provided by the DON on 2/14/20 at 2:56 p.m., indicated the following: .POLICY: It is the policy of this facility to identify any resident who is at increased risk for falls. Identified residents shall be monitored by the Interdisciplinary Team (IDT) in an effort to implement fall prevention interventions that minimize occurrence of falls thereby minimizing resident risk of injury .PROCEDURE: 5. Any suggested interventions shall be addressed with the physician and legal representative with orders obtained as warranted. Interventions shall then be communicated to appropriate disciplines per additions to assignment sheets, etc 3.1-45(a)