Every finding on record at Envive of Muncie

Based on record review and interview, the facility failed to provide written notice to the residents and/or their representatives pertaining to transfer/discharge rights and the facility's bed hold policy for 3 of 3 residents reviewed for hospitalizations. (Resident's 4, 27, and 45). Findings include: 1. Resident 4's clinical record was reviewed on 3/30/26 at 12:59 p.m. Diagnoses included cerebral infarction (stroke), atrial fibrillation (irregular heart rhythm), and vascular dementia.A progress note, dated 8/13/25 at 7:45 p.m., indicated Resident 4 was lethargic and had to be fed for dinner. Her speech was garbled. She intermittently responded to verbal or tactile stimuli. Resident 4's family was at bedside and requested the resident to be sent to the emergency room (ER) for evaluation. The on-call provider, DON, and ambulance to transport were notified. Hospital called and was given report. Emergency Medical Technicians (EMTs) transported the resident to the hospital.Resident 4's clinical record lacked documentation indicating if the Notice of Transfer rights and bed hold policy was provided to the resident and/or provided to her representative.2. Resident 27's clinical record was reviewed on 3/30/26 at 10:54 a.m. Diagnoses included hyperosmolality (high solute concentration in the blood) and hypernatremia (high sodium level), tonsillar cancer, and nontraumatic subarachnoid hemorrhage (spontaneous bleeding into the space surrounding the brain).A progress note, dated 2/8/26 at 6:57 a.m., indicated Resident 27 had moist respirations and had difficulty breathing. Respirations were labored at 46. oxygen saturation reading was 55-62 % on room air. Provider was notified and a new order was received to send the resident to the ER and oxygen was to be applied at 15 L. A message left for Resident 27's representative. The DON was notified and 911 was called at 6:29 a.m. The resident was transferred to the local hospital and report was called to ER.A progress note, dated 2/8/26 at 12:49 p.m. indicated Resident 27's brother notified the facility that the resident was admitted to ICU with a diagnosis of severe pneumonia.Resident 27's clinical record lacked documentation indicating if the Notice of Transfer rights and bed hold policy was provided to the resident and/or his representative. A progress note, dated 2/23/26, indicated Resident 27 had an unresponsive episode in the dining room. Oxygen was placed on the resident. Oxygen saturation was 89%. Vital rechecked 15 minutes later. Heart rate was 38 and oxygen saturation was 74% with decreased responsiveness. Provider notified and received orders for ER evaluation. EMS contacted and provided transport to local hospital. Report called to local hospital. Family was notified.A progress note, dated 2/23/26 at 3:02 p.m., indicated Resident 27 was admitted to the hospital.Resident 27's clinical record lacked documentation indicating if the Notice of Transfer rights and bed hold policy was provided to the resident and/or his representative.3. Resident 45's clinical record was reviewed on 3/27/26 at 3:15 p.m. Diagnoses included anemia, hypertension (high blood pressure) and dementia. A progress note, dated 3/10/26 at 10:05 p.m., indicated Resident 45 had gray, heavy sediment in his urine with very foul odor. Resident's baseline was alert and orientated x3, and he asked the nurse where he was. The resident indicated that he did not feel good. On call provider and family were notified. The resident's family wanted the resident to be sent to ER. Family was concerned about him when they visited as he was not acting like himself.A progress note, dated 3/10/26 10:34 p.m., indicated an order was received for ER evaluation. 911 was notified and report was called to the hospital.A progress note, dated 3/10/26 10:58 p.m., indicated EMS was at facility to provide transport to the ER.A progress note, dated 3/11/26 4:00 a.m., indicated Resident 45 was admitted to the hospital for urosepsis.Resident 45's clinical record lacked documentation indicating if the Notice of Transfer rights and bed hold policy was provided to the resident and/or his representative.During an interview, on 3/30/26 at 1:30 p.m., the Social Services Director (SSD) indicated Resident 27 had a guardian who was notified when he went to the hospital. Resident 45 was his own representative; however, the facility usually notified his wife if he went to the hospital. Notice of Transfer forms and bed hold policies were not mailed out or given directly to residents or their family members. Forms were only sent to the ER at the time of the transfer.During an interview on 3/30/26 at 1:30 p.m., the DON indicated bed hold paperwork was sent to the hospital in a packet given to the EMTs at the time of the transfer.During an interview, on 3/31/26 at 9:43 a.m., RN 2 indicated if a resident had a change in their condition and needed to be sent out for an evaluation, the nurse was to notify the provider to get an order. The DON and family were to be notified of the transfer. All notifications were to be documented. The nurse was to complete a change in condition assessment, which consisted of step-by-step instructions and indicated what documentation needed to be completed. A progress note was to be entered, and a transfer form was to be completed. Upon notification of the EMS, report was to be called to the receiving facility. Paperwork was usually sent with EMTs and included the face sheet, medication list, the resident's code status, and a bed hold policy. The packet was sent with EMTs. No paperwork was given to residents. The bed hold was for the hospital to know the facility would take the resident back when discharged from the hospital.During an interview, on 3/31/26 at 1:45 p.m., the SSD indicated the nursing staff filled out a bed hold policy at the time of a resident's transfer to the hospital and she was given a copy. She then typed it out to make it more legible and placed it in a binder. She believed all bed holds went with the resident to the hospital and upon the family notifying the family of resident's transfer, they would tell them that the bed hold was sent to the hospital.During an interview, on 3/31/26 at 1:59 p.m., the DON indicated a transfer form was to be completed when a resident was transferred to the hospital. There was no documentation of what information, including the Notice of Transfer rights and bed hold policy, was sent to the hospital at the times of Resident 4, 27, and 45's hospitalizations. There was no documentation of Resident 4, 27, and 45 representatives having received the Notice of Transfer rights and bed hold policy at the time of each hospitalization. A current facility policy, dated 8/2024, titled Transfer or Discharge, Facility -Initiated, provided by the DON on 3/31/26 at 2:39 p.m., indicated the following: .20. Notice of Facility Bed-Hold and Return policies are provided to the residents and representatives within 24 hours of emergency transfer. 21. Notices are provided in a form and manner that the resident can understand, taking into account the resident's education level, language, communication barriers, and physical or mental impairments.Documentation of Facility-Initiated Transfer or Discharge. 1. When a resident is transferred or discharged from the facility the following information is documented in the medical record: 1.b. That an appropriate notice was provided to the resident and/or legal representative.410 IAC (Indiana Administrative Code) 16.2-3.1-3.1-12(a)(25)410 IAC 16.2-3.1-3.1-12(a)(26)

Based on record review and interview, the facility failed to administer the appropriate COVID-19 vaccinations per the Center for Disease and Control (CDC) guidance for 1 of 5 residents reviewed for infection control. (Resident 45)Finding includes:Resident 45's clinical record was reviewed on 3/27/26 at 3:15 p.m. Diagnoses included aortic valve insufficiency, heart disease, and muscle weakness.A quarterly Minimum Data Set (MDS) assessment, dated 3/9/26, indicated the resident's cognitive status was moderately impaired.A COVID-19 vaccine consent and a COVID-19 booster consent was signed by Resident 45's representative on 12/6/24.A review of the resident's vaccinations indicated the resident had not received a COVID-19 vaccination and the family representative had refused the vaccination in December 2024.The record lacked an updated or yearly COVID-19 vaccination consent or declination.During an interview, on 3/30/26 at 1:30 p.m., the DON indicated she was unable to locate current COVID-19 vaccination forms for Resident 45. The facility did not administer any vaccinations, and an off-site company was utilized to administer vaccinations to the residents. She was aware that another vaccine clinic needed to be scheduled but had not done it yet.During an interview, on 3/31/26 at 2:06 p.m., the DON indicated COVID-19 vaccinations were to be offered yearly.During an interview, on 3/31/26 at 2:24 p.m., the Infection Preventionist indicated residents were offered COVID-19 vaccinations.The Center for Disease and Control (CDC) website, accessed on 4/1/26 at 2:30 PM, indicated the following: COVID-19 Vaccination for Long-term Care Residents.Vaccine recommendations: CDC recommends an updated COVID-19 vaccine for most adults ages 18 years and older, including people who live and work in long-term care (LTC) settings, get 1 dose of an updated COVID-19 vaccine. CDC recommends everyone ages 65 and older including people who live and work in LTC settings, get 2 doses of an updated COVID-19 vaccine 6 months apart.Reminder: People who live in LTC settings must give consent or agree to getting a COVID-19 vaccine.410 IAC (Indiana Administrative Code) 16.2-3.1-18(b)(5)

Based on record review and interview, the facility failed to ensure a resident and/or the resident representative received a copy of the resident's baseline care plan following admission for 1of 3 residents reviewed for care plans. (Resident 8) Finding includes:Resident 8's clinical record was reviewed on 3/30/26 at 10:30 a.m.Census information indicated the resident was admitted to the facility on [DATE].The clinical record lacked documentation that the resident and/or the resident's representative was provided with a copy of the baseline care plan.During an interview, on 3/30/26 at 1:30 p.m., the Social Services Director (SSD) indicated she had not completed a baseline care plan conference review note for Resident 8 due to him not having had a care plan conference since his admission. As a result, no baseline care plan information was provided to Resident 8 or to his resident representative.During an interview, on 3/31/26 at 1:28 p.m., the SSD indicated baseline care plan information was to be conveyed to residents or their representative within 72 hours after a resident's admission to the facility. Baseline care plan information was permitted to be relayed over the phone. No phone contact was made with Resident 8's representative regarding baseline care plan information. Resident 8's cognitive status was intact, but cognitive functions fluctuated at times. She did not provide base line care plan information, verbally or written, to Resident 8. A current policy, dated 8/2024, titled Care Plans, Baseline, provided by the DON, on 3/31/26 at 2:39 p.m., indicated the following: Policy Statement: A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. Policy Interpretation and Implementation.4. The resident and/or representative are provided a written summary of the baseline care plan (in a language that the resident/representative can understand) that includes, but is not limited to the following: a. The stated goals and objectives of the resident; b. A summary of the resident's medications and dietary instructions; c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility; and d. Any updated information based on the details of the comprehensive care plan as necessary. 5. Provision of the summary to the resident and/or resident representatives is documented in the medical record.410 IAC (Indiana Administrative Code)16.2-3.1-30(a)

Based on record review and interview, the facility failed to offer and administer appropriate pneumococcal vaccinations per the Center for Disease and Control (CDC) guidance for 2 of 5 residents reviewed for vaccinations. (Resident 27 and 45)Findings include: 1. Resident 27's clinical record was reviewed on 3/27/26 at 10:54 a.m. Diagnoses included tonsillar cancer, traumatic brain injury, and diabetes (high blood sugar).A review of the resident's vaccinations included the following:The resident had a historical administration, dated 12/19/11, of Pneumovax 23 pneumococcal vaccination (PPSV 23). This was prior to the resident's admission to the facility.The clinical record lacked a Pneumococcal Vaccine Consent or Declination Form.The clinical record lacked any offering of the pneumococcal vaccines PCV 15, 20, or 21 as recommended by the CDC.2. Resident 45's clinical record was reviewed on 3/27/26 at 3:15 p.m. Diagnoses included aortic valve insufficiency, heart disease, and muscle weakness.A review of the resident's vaccinations indicated the resident had not received a pneumococcal vaccination.A Pneumococcal Vaccine Consent was signed on 12/6/24. The record lacked an updated consent or declination.The clinical record lacked any offerings of a pneumococcal vaccine. During an interview, on 3/30/26 at 1:30 p.m., the DON indicated she was unable to locate current pneumococcal vaccination forms for Resident 27 and 45. The facility did not administer any vaccinations, and an off-site company was utilized to administer vaccinations to the residents. She was aware that another vaccine clinic needed to be scheduled but had not done it yet.During an interview, on 3/31/26 at 2:06 p.m., the DON indicated pneumonia vaccinations were offered per guidelines.During an interview, on 3/31/26 at 2:24 p.m., the Infection Preventionist indicated residents were offered pneumococcal vaccinations.The Center for Disease and Control (CDC) website, accessed on 4/1/26 at 2:30 PM, indicated the following: Pneumococcal Vaccine Recommendations.Adults 50 years or older. Routine vaccination recommendations: Administer PCV (pneumococcal conjugate vaccines) 15, PCV20, or PCV21 for all adults 50 years or older who have never received any pneumococcal conjugate vaccine or whose previous vaccine history is unknown. PCV15: Additional vaccination recommended. If PCV15 is used, administer a dose of PPSV23 one year later. Only one dose of PPSV (pneumococcal polysaccharide vaccine) 23 is indicated. If PPSV23 was previously administered, another dose isn't needed. The patient's pneumococcal vaccinations are complete. PCV20 or PCV21: Additional vaccination not recommended. If PCV20 or PCV21 is used, a dose of PPSV23 isn't indicated. Regardless of which vaccine is used (PCV20 or PCV21), the patient's pneumococcal vaccinations are complete. Recommendation for shared clinical decision-making. Based on shared clinical decision-making, adults 65 years or older have the option to get PCV20 or PCV21, or to not get additional pneumococcal vaccines. They can get PCV20 or PCV21 if they have received both PCV13 (but not PCV15, PCV20, or PCV21) at any age and PPSV23 at or after the age of [AGE] years old.A current facility policy, dated 8/2024, titled Pneumococcal Vaccine, provided by the DON on 3/31/26 at 2:39 p.m., indicated the following: Policy Statement: All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Policy Interpretation and Implementation: 1. Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series and when indicated are offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident was completed the current recommended vaccine series. 2. Assessments of pneumococcal vaccination status are conducted within five (5) working days of their resident's admission if not conducted prior to admission.7. Administration of the pneumococcal vaccines are made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination.410 IAC (Indiana Administrative Code) 16.2-3.1-18(b)(5)

Based on observation, interview, and record review, the facility failed to mitigate the risk of accidents and injury by failing to ensure safety razors were securely stored in two shared bathrooms of 4 cognitively impaired residents (Resident C, Resident H, Resident N and Resident P) on the dementia unit. Findings include:1. During an observation of Resident C's bathroom (shared with Resident H), on 1/7/26 at 9:49 a.m., the unlocked tri-fold mirrored vanity above the sink contained a disposable razor. At the same time, the Memory Care Director entered the bathroom after speaking with Resident C and indicated that the razor should not be left in the residents' bathrooms.Resident C's clinical record was reviewed on 1/7/26 at 3:27 p.m. Diagnoses included hallucinations, cognitive communication deficit, and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.A quarterly MDS (Minimum Data Set) assessment, dated 10/10/25, indicated he had severe cognitive impairment.Resident H's clinical record was reviewed on 1/8/26 at 1:13 p.m. Diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, need for assistance with personal care. A quarterly MDS assessment, dated 1/8/26, indicated he had moderate cognitive impairment.2. During an observation of Resident N and Resident P's bathroom, accompanied by the Memory Care Director, on 1/7/26 at 9:53 a.m., the unlocked tri-fold mirrored vanity above the sink contained two disposable razors. Resident N and P's bathroom was accessible from the memory care unit's main dining room. The Memory Care Director indicated that Resident N and P's family brought the razors into the facility, and they should not have been left in the residents' bathrooms.Resident N's clinical record was reviewed on 1/8/26 at 12:33 p.m. Diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, cognitive communication deficit, and need for assistance with personal care.A quarterly MDS assessment, dated 12/30/25, indicated he had severe cognitive impairment.Resident P's clinical record was reviewed on 1/8/26 at 12:44 p.m. Diagnoses included unspecified dementia, moderate, with agitation and unspecified dementia, moderate, with anxiety.Her admission MDS assessment, dated 11/20/25, indicated she had moderate cognitive impairment.During an interview with CNA 12, on 1/8/26 at 10:17 a.m., she indicated Resident C was able to brush his own teeth, could walk but used a wheelchair and was able to take himself to the bathroom. Resident H needed some assistance but could take himself to the bathroom. Resident N and Resident P could toilet themselves and stood at the bathroom sink independently. She further indicated that she did not normally keep disposable razors in the residents' bathrooms. During an interview with the Administrator, on 1/8/26 at 1:56 p.m., he indicated he was unable to locate a policy for storage of disposable razors.This citation relates to Intakes 2700504 and 2706579. 3.1-45(a)(1)

Based on observation, interview, and record review, the facility failed to ensure a resident, who had not been deemed able to self-administer medications, received supervision during a nebulizer medication administration for 1 of 1 resident (Resident E) randomly observed receiving a nebulizer treatment.Findings include:During a random observation on 1/7/26 at 10:12 a.m., Resident E was observed lying in bed with a nebulizer machine running. At the same time, RN 8 was seated at the [NAME] hall nurses' station.At 10:14 a.m., RN 8 entered Resident E's room, turned off the nebulizer, assessed the resident's lung sounds, and exited the room. RN 8 indicated that she did not normally remain with residents during their nebulizer treatments.Resident E's clinical record was reviewed on 1/7/26 at 10:36 a.m. Diagnoses included cognitive communication deficit, vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, other schizophrenia, acute bronchitis, chronic obstructive pulmonary disease with (acute) exacerbation, acute cough, dyspnea, other specified symptoms and signs involving the circulatory and respiratory systems and chronic obstructive pulmonary disease.A quarterly MDS (Minimum Data Set) assessment, dated 11/25/25, indicated she was moderately cognitively impaired.Her medication orders included ipratropium-albuterol inhalation solution (breathing treatment medication) 0.5 mg (milligram) - 2.5 mg 3 mg/3 ml (milliliter) inhale one vial orally four times a day for shortness of breath and wheezing. The medication was to be administered by the clinician.Her current care plan, initiated on 3/3/25, indicated she had a potential for impaired gas exchange related to diagnoses of COPD (Chronic Obstructive Pulmonary Disease), dyspnea, rhinitis, shortness of breath and wheezing. Interventions included to administer medications as ordered.The clinical record lacked indication of Resident E being assessed as able to self-administer medications. During an interview with RN 5 on 1/8/26 at 11:15 a.m., she indicated she did not remain with the residents during their nebulizer treatments, but did go back to check on the residents during the treatment.A current facility policy titled Administering Medications through a Small Volume Nebulizer provided by the DON on 1/8/26 at 11:00 a.m. indicated the following: .Steps in the Procedure.24. Remain with the resident for the treatment.3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to ensure residents' personal care items were labeled and not cohorted with other resident's personal care items during observations for 3 shared bathrooms of 6 cognitively impaired residents (Resident C, Resident H, Resident F, Resident G, Resident J, Resident N and Resident P) on the dementia unit.Findings include:1.During an observation of Resident C's bathroom (shared with Resident H), on 1/7/26 at 9:49 a.m., the unlocked tri-fold mirrored vanity above the sink contained the following personal care items without resident identifiers:a. An empty bottle of Vashe Wound Cleanser.b. One partially used bottle of after shave gel.c. One open can of shaving cream.d. One partially used tube of perfumed body cream.e. Two denture brushes.f. One toothbrush.During the observation, the Memory Care Director entered the bathroom after speaking with Resident C and indicated that no one had wounds and they were not sure why the Vashe Wound Cleanser was in the bathroom.Resident C's clinical record was reviewed on 1/7/26 at 3:27 p.m. Diagnoses included hallucinations, cognitive communication deficit, and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.His quarterly MDS (Minimum Data Set) assessment, dated 10/10/25, indicated he had severe cognitive impairment.Resident H's clinical record was reviewed on 1/8/26 at 1:13 p.m. Diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, need for assistance with personal care. His quarterly MDS assessment dated [DATE] indicated he had moderate cognitive impairment.2. During an observation of Resident F and Resident G's bathroom (shared with Resident J), accompanied by the Memory Care Director, on 1/7/26 at 9:51 a.m., the unlocked tri-fold mirrored vanity above the sink contained the following personal care items without resident identifiers:a. One roll-on deodorant.b. One partially used tube of toothpaste.c. One partially used bottle of lotion.d. One toothbrush in a foam cup.Resident F's clinical record was reviewed on 1/8/25 at 12:56 p.m. Diagnoses included schizoaffective disorder, cognitive communication deficit, psychotic disorder with delusions due to known physiological condition, paranoidschizophrenia, dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, delusional disorders and Alzheimer's disease with late onset.Her quarterly MDS assessment, dated 11/8/25, indicated she had moderate cognitive impairment.3. During an observation of Resident N and Resident P's bathroom, accessible from the memory care unit's main dining room, accompanied by the Memory Care Director, on 1/7/26 at 9:51 a.m., the unlocked tri-fold mirrored vanity above the sink contained the following personal care items without resident identifiers:a. One partially used tube of skin repair cream.b. One toothbrush.c. One bottle of baby lotion.d. One container of cornstarch powder.e. Four incontinence briefs.Resident N's clinical record was reviewed on 1/8/26 at 12:33 p.m. Diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, cognitive communication deficit, and need for assistance with personal care.His quarterly MDS assessment, dated 12/30/25, indicated he had severe cognitive impairment.Resident P's clinical record was reviewed on 1/8/26 at 12:44 p.m. Diagnoses included unspecified dementia, moderate, with agitation and unspecified dementia, moderate, with anxiety.Her admission MDS assessment, dated 11/20/25, indicated she had moderate cognitive impairment.During the observations, the Memory Care Director indicated the residents' personal care items should have had resident identifiers on them.During an interview with CNA 12, on 1/8/26 at 10:17 a.m., she indicated Resident C was able to brush his own teeth, could walk but used a wheelchair and was able to take himself to the bathroom. Resident H needed some assistance but could take himself to the bathroom. Resident F could stand and ambulate in her wheelchair independently. She let staff know when she needed to use the bathroom and needed assistance pulling her pants up and down. Resident G and J were dependent on staff for mobility and toileting. Resident N and Resident P could toilet themselves and stood at the bathroom sink independently. She indicated that the personal care items should have resident identifiers on them and the facility would normally keep the items in the shower room, the residents' drawers, or in the residents' closets.During an interview with the Administrator, on 1/8/26 at 1:56 p.m., he indicated he was unable to locate a policy for the storage of residents' personal care items.This citation relates to Intake 2700504. 3.1-18(a)

Based on record review and interview, the facility failed to ensure consistent shift-to-shift reconciliation of narcotics was completed to mitigate risk of misappropriation. This deficient practice had the potential to affect 22 residents with controlled medications of 40 whose medications were stored and handled by the facility. Findings include:Review of the facility's August, September, and October 2025 narcotic shift- to- shift count sheets, provided by the Director of Nursing (DON) on 11/17/25 at 10:37 a.m., were reviewed on 11/17/25 at 1:13 p.m. Narcotic medication counts were not reconciled on the following dates and shifts: August 20258/2/25 - second shift8/3/25 -first shift8/7/25 -first shift8/16/25 - second shift8/17/25 - first and second shift8/20/25 - first and second shift8/22/25 - first shift8/24/25 - second shift8/27/25 - first shift8/29/25 - second shift8/30/25 - second shiftSeptember 20259/13/25 - first shift9/14/25 - second shift9/21/25 - first shift9/25/25 - first shift9/27/25 - first shift9/30/25 - second shiftOctober 202510/2/25 - first and second shift10/9/25 - first and second shift10/10/25 - first shift10/13/25 - second shift10/16/25 - second shift (the date was written 12/16/25 on the October 2025 count sheet.)10/26/25 - second shiftDates where the count was incorrect, blank, or illegible included the following:August 20258/8/25 - first shift - start of shift count was seven cards, one card (bubble pack of controlled medication typically containing 30 pills in the card) removed, end of shift count was seven cards.8/18/25 - first shift - start of shift count was six cards, one card was added, end of shift count was six cards.8/18/25 - second shift - start of shift count was 15 cards, two cards were added, one card was removed, end of shift count was written once and written over with another number, leaving the count illegible.8/22/25 - first shift - start of shift count was 14 cards, end of shift count was not documented.8/22/25 - first shift - start of shift count was 12 cards, end of shift count was 12 cards.8/25/25 - first shift - start of shift count was 10 cards, one card was added, end of shift count was 10 cards. 8/25/25 - first shift - start of shift count was six cards, three cards were removed, end of shift count was six cards.September 20259/5/25 - first shift - start of shift count was 14 cards, one card was removed, end of shift count was 14 cards.9/28/25 - second shift - start of shift count was eight cards, one card was removed, end of shift count contained both the numbers seven and eight and were marked through with a line.October 202510/12/25 - second shift - start of shift count was 13 cards, two cards were added, end of shift count was blank.10/13/25 - first shift - start of shift count was 13 cards, end of shift count was 13 cards.10/13/25 - second shift - start of shift count was 14 cards.10/16/25 - first shift - start of shift count was 13 cards, end of shift count was blank.10/16/25 - second shift - start of shift count was 13 cards, no cards were added or deleted, end of shift count was 12 cards.10/29/25 - first shift - start of shift count was 10 cards, one card was added, end of shift count was 11. The following day -10/30/25 - first shift - start of shift count was 10 cards and end of shift count was 10 cards.During an interview with the DON on 11/18/25 at 10:24 a.m., she indicated she had been employed by the facility since August of 2025. She did not like the system currently in place where cards were counted and documented during shift changes. Upon review of the narcotic shift-to-shift count sheets, she agreed some of the documentation was illegible and could see how inaccurate counts, blank spaces, or incomplete documentation had the potential for diversion. The narcotic shift-to-shift sheets did not specify which hall or cart the sheet(s) were pulled from. She just knew which carts correlated with the sheets.A current facility policy, titled Controlled Substances, provided by the DON on 11/18/25 at 10:24 a.m., indicated the following: .The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976) . 3. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up.5. Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count.6. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services.3.1-25(e)(2)(3)

Based on observation, interview, and record review, the facility failed to ensure shift to shift narcotic reconciliation was completed for 3 of 4 medication carts reviewed for medication storage. (A Unit, Cottage Unit, and C Unit medication carts) This deficient practice had the potential to affect 18 out of 30 residents who resided in the facility and received controlled medications from A Unit, Cottage Unit, and C Unit medication carts. Findings include: 1. During a medication storage observation of A Unit medication cart, accompanied by LPN 9 on 6/5/25 at 9:55 a.m., the Shift To Shift Narcotic Count record was reviewed and was missing LPN 9's signature and count when she took over the cart at the beginning of her shift on 6/5/25. LPN 9 immediately signed her name to the blank and indicated she had not signed nor recorded her count at the beginning of her shift. The last recorded count of controlled medications indicated there were 9 sheets and 9 cards. Upon counting the cards and sheets, LPN 9 indicated there were 8 sheets and 8 cards, which was a discrepancy from the last recorded count. She had not recognized nor notified anyone of the discrepancy. She believed the discrepancy was due to a calculation error two shifts prior, but it was not her duty to determine why there was a discrepancy. She should have reported the discrepancy to the DON. LPN 9 indicated there were additional missing signatures and counts on multiple dates and shifts in May and June 2025 for the A Unit medication cart. Review of the Shift To Shift Narcotic Count records for A Unit medication cart, from 5/1/25 through 6/5/25, lacked shift to shift reconciliation of controlled substances on the following dates and shifts: 5/3/25 - day shift 5/5/25 - day shift 5/5/25 - night shift 5/10/25 - day shift 5/10/25 - night shift 5/11/25 - day shift 5/13/25 - night shift 5/15/25 - night shift 5/16/25 - day shift 5/21/25 - day shift 5/22/25 - day shift 5/22/25 - night shift 5/24/25 - night shift 5/28/25 - night shift 5/30/25 - day shift 5/30/25 - night shift 5/31/25 - day shift 6/1/25 - day shift 6/5/24 - day shift 2. During a medication storage observation of Cottage Unit medication cart, accompanied by LPN 9 on 6/5/25 at 10:23 a.m., the Shift To Shift Narcotic Count record was reviewed and was missing LPN 9's signature and count when she took over the cart at the beginning of her shift on 6/5/25. Upon counting the cards and sheets, no discrepancies were found. During an interview, LPN 9 indicated she had not signed nor recorded the count at the beginning of her shift on 6/5/25 for the Cottage Unit medication cart. There were additional missing signatures and counts on multiple dates and shifts in May and June 2025 for the Cottage Unit medication cart. With each exchange of the medication carts, both staff exchanging the carts were required to count and verify the number of cards and sheets to ensure no discrepancies. When discrepancies were found with controlled medications, they were required to notify the DON immediately. Keys to a cart with controlled medication discrepancies should not have been accepted without the DON investigation and a resolution to the discrepancy. This was an opportunity for drug diversion. Review of the Shift To Shift Narcotic Count records for Cottage Unit medication cart, from 5/1/25 through 6/5/25, lacked shift to shift reconciliation of controlled substances on the following dates and shifts: 5/5/25 - day shift 5/6/25 - day shift 5/6/25 - night shift 5/10/25 - night shift 5/11/25 - day shift 5/11/25 - night shift 5/15/25 - night shift 5/16/25 - day shift 5/16/25 - night shift 5/17/25 - day shift 5/20/25 - night shift 5/22/25 - day shift 5/22/25 - night shift 5/23/25 - day shift 5/23/25 - night shift 5/24/25 - day shift 5/28/25 - night shift 5/29/25 - day shift 5/29/25 - night shift 5/30/25 - night shift 5/31/25 - day shift 5/31/25 - night shift 6/1/25 - day shift 6/1/25 - night shift 6/4/25 - day shift 6/5/25 - day shift 3. During a medication storage observation of C Unit medication cart, accompanied by RN 4 on 6/5/25 at 11:30 a.m., the Shift To Shift Narcotic Count record was reviewed. During an interview, RN 4 indicated there were missing signatures and counts on multiple dates and shifts in May and June 2025 for the C Unit medication cart. A count should have been documented along with signatures of both staff members during an exchange of the medication cart. Incomplete signatures or counts were not acceptable. Review of the Shift To Shift Narcotic Count records for C Unit medication cart, from 5/1/25 through 6/5/25, lacked shift to shift reconciliation of controlled substances on the following dates and shifts: 5/2/25 - day shift 5/6/25 - night shift 5/7/25 - day shift 5/10/25 - day shift 5/10/25 - night shift 5/11/25 - day shift 5/13/25 - day shift 5/13/25 - night shift 5/15/25 - day shift 5/15/25 - night shift 5/20/25 - day shift 5/20/25 - night shift 5/23/25 - night shift 5/24/25 - day shift 5/25/25 - day shift 5/29/25 - day shift 5/31/25 - day shift 5/31/25 - night shift 6/1/25 - day shift During an interview on 6/5/25 at 2:36 p.m., the DON indicated both staff members exchanging a medication cart were required to count the medication sheets, medication cards, compare the count with the last medication reconciliation to ensure there were not any discrepancies, record the count and provide signatures of acknowledgement. One was not able to identify if the reconciliation was completed when the medication reconciliation record was incomplete. A current facility policy, dated 8/2024, titled Controlled Substances, provided by the DON on 6/5/25 at 5:27 p.m., indicated the following: Policy Statement . The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976) . Dispensing and Reconciling Controlled Substances 4. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. 5. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage; b. Medication administration records; c. Declining inventory records; and d. Destruction, waste and return to pharmacy records. 6. Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count. 7. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services 3.1-25(b)(3)

Based on record review and interview, the facility failed to follow registered dietician recommendations and to notify the physician for a resident experiencing a progressive, unplanned weight loss for 1 of 1 residents reviewed for nutrition. (Resident 18) Finding includes: Resident 18's clinical record was reviewed on 6/6/25 at 11:08 a.m. Diagnoses included schizoaffective disorder, muscle weakness, unspecified obesity, and type 2 diabetes mellitus. A current order, initiated 12/30/24, indicated a regular texture, no added salt, consistent carbohydrate diet. A 5/11/25, quarterly, Minimum Data Set (MDS) assessment indicated Resident 18 was moderately cognitively impaired, required supervision by staff for eating, and had weight loss. Resident 18 weighed 157 pounds (lbs) on 5/3/25. Resident 18's weight record was reviewed and indicated the following: 175 pounds (lbs) on 12/1/24, 172.3 lbs on 1/2/25, 167.4 lbs on 2/3/25, 162.8 lbs on 3/27/25, 158.4 lbs on 4/18/25, and 157 lbs on 5/3/25. This reflected a 10.29% weight loss over a six-month period. Resident 18's meal consumption from 5/11/25 through 6/8/25 indicated the resident typically ate 51-75 % of her meals, occasionally 26-50 % of meals, and rarely 76-100 % of meals. A nutrition care plan, initiated on 2/21/25, indicated the resident would maintain their current weight through the next review. Interventions included weekly weights (2/21/25), serve diet as ordered (2/21/25), and the registered dietician to evaluate and make diet changes as needed (2/21/25). A 3/24/25 nutritional risk assessment indicated the resident's carbohydrate controlled diet be liberalized to a regular diet, to offer more calories and protein. A 3/24/25 nurse note indicated Resident 18's weight was down 4.8% in 30 days and 9% in 90 days, which was a significant weight loss. The resident received a carbohydrate controlled diet and the Registered Dietitian (RD) recommended to change this diet to a regular diet to offer more calories and protein. A 3/26/25 electronic mail (email) from the RD to the Interdisciplinary team (IDT) indicated to liberalize Resident 18's diet from carbohydrate controlled to a regular diet. A 3/26/25 nutritional risk assessment indicated the resident's carbohydrate controlled diet was to be liberalized to a regular diet, to offer more calories and protein. A 4/16/25 nutrition note indicated Resident 18's weight was without significant change in 30 days. The resident received a carbohydrate controlled diet and the RD recommended to change this diet to a regular diet which offers more calories and protein. The clinical record lacked documentation indicating the physician was notified of the resident's significant weight loss. The clinical record lacked an order to change the resident's diet or indication that the physician declined the recommendation to change the resident's diet. During an interview, on 6/6/25 at 1:39 p.m., the Director of Nursing (DON) indicated the facility held hybrid nutritional meeting with some interdisciplinary team (IDT) members attending in person and others by phone. The RD recommendations were sent by email to the IDT team and he (the DON) followed up on those recommendations. The RD documented in the electronic medical record (eMar). During a telephone interview, on 6/9/25 at 2:55 p.m., the RD indicated she reviewed resident weights weekly and held a clinical meeting to discuss the results and her recommendations. The recommendations are also sent via email to the IDT group. The RD indicated she recommended to liberalize Resident 18's diet in March 2025 to prevent further weight loss. During a follow-up interview, on 6/9/25 at 3:48 p.m., the DON indicated he was not aware that Resident 18 remained on a carbohydrate controlled diet. He indicated the clinical team should notify the physician of weight loss and RD recommendations. Any IDT members with the proper credentials could change a resident's diet order in the clinical record. A facility policy, dated 8/2024 and titled, Nutritional Assessment, provided by the Corporate Nurse Consultant on 6/9/25 at 3:29 p.m., indicated the following: .1. The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within the current baseline assessment timeframes) and as indicated by change in condition that places the resident at risk for impaired nutrition. 2. As part of the comprehensive assessment, the nutritional assessment will be a systematic multidisciplinary process that includes gathering and interpreting data and using the data to help define meaningful interventions for the resident at risk for or with impaired nutrition . 3.1-46(a)(2)

Based on observation, record review, and interview, the facility failed to ensure staff were educated in, and implemented, Enhanced Barrier Precautions (EBP) during high-contact care. (Resident 37) Finding includes: During an interview on 6/2/25 at 4:49 p.m., Resident 37 was in bed, with a tube feeding running, and indicated she had a sacral pressure injury. Staff wore gloves when they provided her wound care and other cares, but they did not wear gowns. During a wound observation on 6/5/24 at 4:10 p.m., RN 4 performed hand hygiene and donned gloves after the resident consented to a wound observation. She leaned forward over the resident's bed, without donning a gown and her pants were against the resident's bed linens. RN 4 unsecured the resident's brief and removed the resident's old dressing that was rolled up at the bottom. An open pressure injury to the sacrum was approximately the size of a pencil eraser and contained slough. RN 4 doffed her gloves, performed hand hygiene, and left the room to get some supplies. On 6/5/24 at 4:18 p.m., RN 4 returned to the resident's room with wound care supplies, performed hand hygiene and donned gloves. Wound care was provided per physician order without the use of a gown. Resident 37's clinical record was reviewed on 6/5/25 at 4:50 p.m. Diagnoses included unspecified severe protein-calorie malnutrition, dysphagia, and a stage 3 pressure ulcer (full-thickness tissue loss, where the skin is damaged and subcutaneous fat is visible) of the sacral region. Current orders included the use of EBP to reduce the risk of transmission of multi-drug resistant organisms every shift and cleanse area to the coccyx with wound cleanser, pat dry, apply skin prep to the periwound, apply medical grade honey, and cover with a bordered gauze daily. A 5/20/25, admission, Minimum Data Set (MDS) assessment indicated the resident was cognitively intact. She required maximal assistance for toileting, bathing, personal hygiene, lower body dressing, sit to stand, and transfers. The resident was at risk for pressure injuries. A current care plan, dated 5/23/25, indicated the resident required the use of enhanced barrier precautions related to the presence of a wound to reduce the risk of multi-drug resistant organism transmission. Interventions included EBP per the Center for Disease Control (CDC) guidelines during high contact resident care and precautions to remain in place until the resolution of the wound. Review of an admission assessment, dated 5/13/25, indicated the resident had a stage 3 wound to her coccyx on admission from the hospital. During an interview on 6/5/25 at 4:36 p.m., RN 4 indicated the resident had EBP and she did not wear a gown as required during the wound care observation. She forgot about EBP because she did not typically perform the residents wound care since it was scheduled to be changed on night shift. Gowns were readily available in the resident's closet. EBPs were in place to protect the resident from wound contamination as a result of any contaminants that may have been on RN 4's clothing. It also prevented RN 4 from carrying anything into other residents' rooms. She should have worn a gown and gloves during the resident's wound care. During an interview on 6/9/25 at 10:39 a.m., CNA 7 indicated she was familiar with the care of residents on Unit B. She did not know what EBP was. Her assignment was the B Unit and she also assisted on Unit A and Unit C. CNA 7 was unaware of any residents on the B Unit who required any specific precautions or additional personal protective equipment during high contact care. She was uncertain what needed to be worn for EBP. CNAs referenced the CNA assignment sheet to determine which residents required EBP. On 6/9/25 at 10:53 a.m., CNA 8 indicated she did not know what EBP was. She had worked on Unit A , Unit B, and Unit C in the last week and no one told her anyone required specific precautions on any of those units. When residents required specific precautions, she expected to find the information on the CNA assignment/report sheets. She also identified when residents required specific precautions because the residents' room doors were labeled with signage and personal protective equipment canisters were outside the residents' rooms. None of the CNA sheets for Unit A, Unit B, nor Unit C had any residents marked with EBP. She had not followed any specific precautions during high contact care for residents on Unit A, Unit B, nor Unit C over the last week. On 6/9/25 at 11:11 a.m., CNA 10 indicated EBP was utilized for residents with Clostridium difficile (an infectious bacteria) or other specific illnesses. A gown, gloves, and mask were required for EBP. She was assigned to Unit C and also assisted on Unit A and Unit B. She was made aware when residents required EBP by the sign on the resident's door, which explained which PPE was required. It was also included on the CNA report sheets if a resident required EBP. If PPE was necessary, she had to retrieve it from the clean utility room across from the nurses' station. She was unaware of any residents on Unit A, Unit B, nor Unit C who required EBP. During an observation on 6/9/25 from 11:39 a.m. to 11:50 a.m., CNA 10 answered Resident 37's call light. The resident indicated she was ready to get changed. CNA 10 went to the resident's closet and retrieved the resident's clothing and a clean incontinence brief and placed them on the resident's bed linens. The closet door contained signage for EBP and indicated everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also wear gloves and a gown for high contact resident care activities. The listed high-contact resident care activities included: dressing, bathing, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use, and wound care. A note was hand written on the sign that gowns were located in the closet. Without hand hygiene, CNA 10 donned gloves, prepared wash cloths for incontinence care, and took the supplies to the bedside. The CNA removed the resident's pajama pants with gloved hands as she leaned against the resident's bed linens. With the same gloves, CNA 10 reached into her right pants pocket, removed three trash bags from a roll, and placed the roll back into her pocket. The CNA leaned forward against the bed linens, removed the resident's pajama shirt, and removed the resident's incontinence brief. Incontinence care and a clean brief were provided by CNA 10. As CNA 10 leaned against the bed to put on the resident's pants and shirt, her name badge draped against the resident's bare abdominal skin next to her feeding tube site. With the contaminated gloves, the CNA repositioned the feeding tubing out of the way as she pulled the resident's shirt down. CNA 10 then placed her right arm around the resident's back and directly against the resident's clothing as she assisted the resident to reposition from lying to sitting on the side of the bed. The CNA's gloves were doffed and placed into the bag. Without hand hygiene, CNA 10 picked up the call light and a box of tissues from the resident's bed and handed them to the resident. CNA 10 did not wear a gown, perform hand hygiene, nor change gloves throughout the observation. She exited the resident's room with bags of dirty linens in both hands. During an interview on 6/9/25 at 11:51 a.m., CNA 10 indicated she had not seen the EBP sign affixed to the resident's closet door during the resident care observation, nor had she seen it before. As a result, she did not don a gown for the resident care observation. She should have donned a gown, gloves, and a mask prior to the resident's high-contact care. On 6/9/25 at 12:40 p.m., the DON indicated EBP was required for residents with invasive lines, catheters, feeding tubes, wounds with broken skin, and those colonized with a multi-drug resistant organism. A gown and gloves were required during high contact care for residents in EBP to include: wound care, incontinence care, clothing changes, and manipulation of invasive devices. He had provided an in-service about EBP, but was uncertain when it occurred. On 6/9/25 at 2:50 p.m., the DON indicated he was unable to provide information to show when EBP education was provided for staff and which staff had received the education. Unit B had five residents who required EBP and Unit C had two residents who required EBP. On 6/9/25 at 5:44 p.m., LPN 12 indicated she was an agency staff member. The facility had not provided education regarding EBP before she provided care for the residents in the facility. A current facility policy, dated 8/2024, titled Enhanced Barrier Precautions, provided by the DON on 6/9/25 at 2:49 p.m., indicated the following: Policy Statement . Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. Policy Interpretation and Implementation . 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity . 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and h. wound care (any skin opening requiring a dressing) . 5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. 6. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk 3.1-18(b)(2) 3.1-18(l)

Based on record review and interview, the facility failed to offer, educate, and/or administer pneumococcal vaccines per the Center for Disease and Control (CDC) guidance for 2 of 5 residents reviewed for immunizations. (Residents 3 and 4) Findings include: 1. Resident 3's clinical record was reviewed on 6/6/25 at 3:19 p.m. Diagnoses included chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus with diabetic neuropathy, and a stage 4 pressure ulcer of the sacral region. The clinical record lacked an order for the pneumococcal vaccine. Review of the resident's vaccinations included the following: The resident had a historical administration of Pneumovax 23 on 5/9/17, prior to admission to the facility. A Pneumococcal Vaccine Consent Form, dated 1/29/25, indicated education was provided and the resident's representative consented to administration of the vaccine. The vaccine was not administered. During an interview on 6/9/25 at 1:00 p.m., the DON indicated a Pneumococcal Vaccine Consent Form for Resident 3 was completed on 1/29/25. The facility had not administered Resident 3's pneumococcal vaccine and she was due to receive the next dose. 2. Resident 4's clinical record was reviewed on 6/5/25 at 2:30 p.m. Diagnoses included chronic pain syndrome, hypertension, and type 2 diabetes mellitus. The admission dated was 2/12/25. Current orders included may have pneumococcal vaccine one time if over the age of 65 and may have Pneumococcal vaccine once every 5 years if under the age of 65 (2/12/25) and annual flu and Pneumonia vaccine orders unless contraindicated (2/12/25). Review of the resident's vaccinations included the following: The resident had a historical administration of Pneumovax 23 on 9/15/14 and Prevnar 13 on 1/31/18, prior to admission to the facility. The clinical record lacked education and a signed consent/declination form for the pneumococcal vaccination. During an interview on 6/9/25 at 1:00 p.m., the DON indicated the facility had administered the vaccines when they were due in the past. The new owners had a different process, in which an outside provider was utilized to administer vaccines. The facility had not held a vaccine clinic with the outside provider. He was uncertain how immunizations/vaccines were handled when they were due in between the clinics. During an interview, on 6/9/25 at 4:26 p.m., the DON indicated he was unable to locate documentation or consents for Resident 4's pneumococcal vaccinations. A facility policy, dated 8/2022, titled, Influenza, Pneumococcal, and COVID-19 Immunizations, provided by the DON on 6/9/25 at 5:42 p.m., indicated the following: . Upon admission each resident/resident representative will be provided with information regarding the risk and benefits of influenza, pneumococcal, and COVID-19 immunizations. A copy will be retained in the medical record. 2. Upon admission each resident/resident representative will sign an informed consent form indicating the acceptance/refusal of immunization. A copy will be retained in the medical record and results added to the preventative health record in EHR . 6. Each resident will be offered, unless medically contraindicated, or already vaccinated, a pneumococcal vaccine per the attending physician's orders . 12. CDC recommends pneumococcal vaccinations (PCV 13 or Prevnar 13*, PPSV 23 or Pneumovax 23*, PVC 20 or Prevnar 20, PCV 15 or Vaxneuvance) for all adults 65 years or older . 3.1-18(b)(5)

A. Based on record review and interview, the facility failed to provide bed hold policy and transfer/discharge notifications to the resident and/or their representative for 3 of 3 residents reviewed for hospitalizations. (Residents 31, 24, & 191) B. Based on record review and interview, the facility failed to ensure appropriate transfer information was communicated to the receiving provider for 1 of 1 residents reviewed for discharge. (Resident 38) Findings include: A1. Resident 31's clinical record was reviewed on 6/6/25 at 1:41 p.m. Diagnoses included acute and chronic respiratory failure, chronic obstructive pulmonary disease (COPD), and hypertension. A 5/7/25, quarterly, Minimum Data Set (MDS) assessment indicated the resident was cognitively intact. A 3/4/25, discharge, MDS assessment indicated the resident discharged with a return anticipated. A 3/24/25 nurse's note indicated a new order to send the resident to the emergency room and all parties were aware. Review of a notice of transfer/discharge form, dated 3/4/25, indicated the resident was discharged to the hospital. The form indicated the facility must attach a copy of the facility's bed hold policy. The bed hold form was attached. The clinical record lacked indication to whom the transfer discharge form and the bed hold policy was provided. A2. Resident 24's clinical record was reviewed on 6/6/25 at 2:23 p.m. Diagnoses included frontal lobe and executive function deficit following a cerebral infarction, hypertension, and unspecified dementia. A 1/10/25, annual, MDS assessment indicated the resident was moderately cognitively impaired. A 4/2/25, discharge MDS assessment indicated the resident discharged with a return anticipated. A 4/2/25 nurse's note indicated the resident was in the hospital. Review of a notice of transfer/discharge form, dated 4/2/25, indicated the resident was discharged to the hospital. The form indicated the facility must attach a copy of the facility's bed hold policy. The bed hold form was attached. The clinical record lacked indication to whom the transfer discharge form and the bed hold policy was provided. A3. Resident 191's clinical record was reviewed on 6/6/25 at 2:32 p.m. Diagnoses included unspecified dementia, unspecified hypotension, and prediabetes. A 4/6/25, significant change, MDS assessment indicated the resident was moderately cognitively impaired. A 5/18/25, nurse's note indicated the resident was transferred to the hospital and the resident's daughter was informed. A 5/18/25, discharge, MDS assessment indicated the resident discharged with a return anticipated. A 5/27/25, entry, MDS indicated the resident returned to the facility. A 5/28/25, nurse's note indicated the resident was not acting right or responding to staff and a new order to send to the hospital was received. The resident's daughter was informed. A 5/28/25, discharge, MDS assessment indicated the resident discharged with a return anticipated. Review of a notice of transfer/discharge forms, dated 5/18/25 and 5/28/25, indicated the resident was discharged to the hospital. The forms indicated the facility must attach a copy of the facility's bed hold policy. The bed hold forms were attached. The clinical record lacked indication to whom the transfer discharge form and the bed hold policy was provided. During an interview, on 6/9/25 at 10:18 a.m., LPN 5 indicated, when a resident was sent to the hospital, the floor nurse would ensure a physician's order was received. The nurse would print out the resident documents including orders, pertaining labs, code status, family contact information, and care plans. LPN 5 indicated she printed out two copies and provided one to the resident and the other set to the ambulance or transportation driver. The resident's family was to be contacted as soon as possible. The discharge was documented in the discharge form in the electronic medical record. During an interview, on 6/9/25 at 3:50 p.m., the Corporate Nurse Consultant indicated he was not able to find documentation to verify if the resident or resident representatives had received copies of the transfer/discharge form or bed hold policy for the residents reviewed. A facility policy, dated 8/2024 and titled, Bed Holds and Returns, provided by the Corporate Nurse Consultant on 6/9/25 at 2:43 p.m., indicated the following: . A. All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during a period of absence (hospitalization or therapeutic leave). Residents, regardless of payor source, are provided written notice about these policies at least twice .b. notice 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours) 3. Multiple attempts to provide the resident representative with the notice 2 should be documented in cases where staff were unable to reach and notify the representative timely . B1. Resident 38's clinical record was reviewed 6/6/25 at 3:44 p.m. Diagnoses included right side hemiplegia, hypertension and unspecified heart failure. A 1/10/25, quarterly, MDS assessment indicated the resident was moderately cognitively impaired. A 3/31/25 nurse's note indicated the resident was going to be discharging to another long term care facility today. A 4/1/25, discharge, MDS assessment indicated the resident discharged without a return anticipated. A 4/1/25 nurse's note indicated the resident discharged to another facility. The resident's medications and paperwork were sent with the resident's daughter. Review of a notice of transfer/discharge form, dated 3/31/25, indicated the resident was discharged to another long term care facility. The forms indicated the facility must attach a copy of the facility's bed hold policy. The bed hold form was attached. The clinical record lacked indication of the resident's discharge information being communicated to the receiving facility. During an interview on 6/9/25 at 3:59 p.m., the SSD indicated Resident 38 had discharged to another facility. The resident's daughter was given the packet of resident information, along with the resident's medications. The facility provided the information to the transportation company or the family, if they provided the transportation. The staff would document in the clinical record who at the new facility received the verbal report on the resident and the resident's paper documentation. The SSD was unable to locate the documentation ensuring the new facility received the appropriate information for the resident's transfer. A facility policy, dated 8/2024 and titled, Discharge, Facility-Initiated, provided by the Corporate Nurse Consultant on 6/9/25 at 3:03 p.m., indicated the following: . b. discharge refers to the movement of a resident from a bed in one certified facility to another certified facility or other location in the community .Information Conveyed to Receiving Provider 1. Should a resident be transferred or discharged for any reason, the following information is communicated to the receiving facility or provider: a. The basis for the transfer or discharge .b. Contact information of the practitioner responsible for the care of the resident, c. Resident representative information . d. Advance directive information, e. All special instructions or precaution for ongoing care . f. Comprehensive care plan goals; and f. All other information necessary to meet the resident's needs, including but not limited to: resident status, baseline and current mental, behavioral, and functional status, recent vital signs, diagnoses and allergies, medications (including when last received), most recent relevant labs . a copy of the resident's discharge summary, and any other document, as applicable, to ensure a safe and effective transitions of care . 3.1-12(a)(6)(A)(i)

Based on record review and interview, the facility failed to offer, educate, and/or administer COVID-19 vaccines per the Center for Disease and Control (CDC) guidance for 1 of 5 residents reviewed for immunizations. (Residents 4) Finding includes: Resident 4's clinical record was reviewed on 6/5/25 at 2:30 p.m. Diagnoses included chronic pain syndrome, hypertension, and type 2 diabetes mellitus. The admission dated was 2/12/25. The resident had a historical administration of COVID-19 vaccinations on 1/22/21, 2/19/21, 12/28/21, 7/7/22, and 11/29/22, all prior to admission to the facility. Current orders included may test for COVID-19 as needed (2/12/25). The clinical record lacked education and a signed consent/declination form for the COVID-19 vaccination. During an interview on 6/9/25 at 1:00 p.m., the DON indicated the facility had not had a vaccine clinic to administer vaccinations. The new owners had a different process in which an outside provider was utilized to administer vaccines. The facility had not held a vaccine clinic with the outside provider. He was uncertain how immunizations/vaccines were handled when they were due in between the clinics. During an interview, on 6/9/25 at 4:26 p.m., the DON indicated he was unable to locate documentation or consents for Resident 4's COVID-19 vaccinations. The vaccination consents were part of the admission packet. A facility policy, dated 8/2022, titled, Influenza, Pneumococcal, and COVID-19 Immunizations, provided by the DON on 6/9/25 at 5:42 p.m., indicated the following: . Upon admission each resident/resident representative will be provided with information regarding the risk and benefits of influenza, pneumococcal, and COVID-19 immunizations. A copy will be retained in the medical record. 2. Upon admission each resident/resident representative will sign an informed consent form indicating the acceptance/refusal of immunization. A copy will be retained in the medical record and results added to the preventative health record in EHR .13. COVID-19 boosters will be offered and given based on the CDC recommendations 3.1-18(b)(5)

Based on observation, interview, and record review, the facility failed to ensure staff (LPN 1) followed the facility cleaning protocol for resident glucometers to reduce the risk of contamination and spread of infection for 5 of 5 residents reviewed for infection control during medication administration. (Resident B, H, J, K, and L) Findings include: During a medication administration observation on 4/15/25 at 5:02 a.m., the following infection control concerns were observed: LPN 1 removed the Resident B's glucometer from a plastic bag in the medication cart. The glucometer was placed directly on the medication cart while LPN 1 gathered supplies and medications. Upon entering the resident's room, LPN 1 placed the glucometer on the over the bed table. After performing the blood sugar check, LPN 1 returned to the medication cart and placed the glucometer directly on the cart. She then returned it to the plastic bag and secured it to the medication cart. The glucometer was not disinfected during the observation. The top of the medication cart was not cleaned/disinfected during the observation. The resident's over bed table was not cleaned prior to placing the glucometer on the table. LPN 1 removed the Resident H's glucometer from a plastic bag in the medication cart. The glucometer was placed directly on the medication cart while LPN 1 gathered supplies and medications. Upon entering the resident's room, LPN 1 placed the glucometer on the over the bed table. After performing the blood sugar check, LPN 1 returned to the medication cart and placed the glucometer directly on the cart. She then returned it to the plastic bag and secured it to the medication cart. The glucometer was not disinfected during the observation. The top of the medication cart was not cleaned/disinfected during the observation. The resident's over bed table was not cleaned prior to placing the glucometer on the table. LPN 1 removed the Resident J's glucometer from a plastic bag in the medication cart. The glucometer was placed directly on the medication cart while LPN 1 gathered supplies and medications. Upon entering the resident's room, LPN 1 placed the glucometer on the over the bed table. After performing the blood sugar check, LPN 1 returned to the medication cart and placed the glucometer directly on the cart. She then returned it to the plastic bag and secured it to the medication cart. The glucometer was not disinfected during the observation. The top of the medication cart was not cleaned/disinfected during the observation. The resident's over bed table was not cleaned prior to placing the glucometer on the table. LPN 1 removed the Resident K's glucometer from a plastic bag in the medication cart. The glucometer was placed directly on the medication cart while LPN 1 gathered supplies and medications. Upon entering the resident's room, LPN 1 placed the glucometer on the over the bed table. After performing the blood sugar check, LPN 1 returned to the medication cart and placed the glucometer directly on the cart. She then returned it to the plastic bag and secured it to the medication cart. The glucometer was not disinfected during the observation. The top of the medication cart was not cleaned/disinfected during the observation. The resident's over bed table was not cleaned prior to placing the glucometer on the table. LPN 1 removed the Resident L's glucometer from a plastic bag in the medication cart. The glucometer was placed directly on the medication cart while LPN 1 gathered supplies and medications. Upon entering the resident's room, LPN 1 placed the glucometer on the over the bed table. After performing the blood sugar check, LPN 1 returned to the medication cart and placed the glucometer directly on the cart. She then returned it to the plastic bag and secured it to the medication cart. The glucometer was not disinfected during the observation. The top of the medication cart was not cleaned/disinfected during the observation. The resident's over bed table was not cleaned prior to placing the glucometer on the table. During the medication administration observation, LPN 1 indicated each resident had their own glucometer. During an interview on 4/15/25 at 9:03 a.m., RN 2 indicated glucometers were to be cleaned and allowed to dry before placing them back into the plastic storage bag. During an interview on 4/16/25 at 1:27 p.m. , the DON indicated resident glucometers were to be cleaned/disinfected prior to returning them to the medication cart. Review of the manufacture's cleaning guidelines, provided by the Regional Nurse on 4/16/25 at 1:13 p.m., indicated the following: .The disinfecting procedure is needed to prevent the transmission of bloodborne pathogens . Review of a current policy, dated 8/2024 and titled Obtaining a Fingerstick Glucose Level, was provided by the Administrator on 4/15/25 at 10:17 a.m. and indicated the following: Steps in the Procedure 18. Clean and disinfect reusable equipment between uses according to the manufacture's instructions and current infection control standards of practice. This citation relates to Complaint IN00456768. 3.1-18(l)

Based on observation, interview, and record review, the facility failed to ensure potentially hazardous items were safely secured on the dementia unit. This deficient practice had the potential to impact 11 of 13 mobile residents who resided on the secured dementia unit. Findings include: During an observation on 8/14/24 at 3:10 p.m., residents were moving freely on the dementia unit. Some propelled themselves in a wheelchair while others ambulated either independently or with assistance devices, such as a walker. Employees were present and interacting with residents. However, not all residents were within the employees' line of sight. During an observation on 8/14/24 at 3:14 p.m., the right-side dining area in the dementia unit was observed to have an unlocked cabinet. The cabinet face had a sign which indicated ,This cabinet must remain locked at all times. The cabinet was unlocked. The cabinet door, which was ajar, could be easily opened. A combination lock was placed inside the cabinet on the center shelf. Inside the cabinet, there were the following potential hazardous items: a. 2 bottles of gel hand sanitizer. Both bottles of hand sanitizer gel contained a warning label which indicated, If ingested contact poison control. b. 1 open box of denture cleaning tablets which was approximately 3/4 full. The box had the capacity to hold 90 tablets. The box had a warning label which indicated, If ingested contact poison control. c. 13 disposable razors. During an interview on 8/14/24 at 3:30 p.m., the Dementia Unit Manager indicated the cabinet should have been locked. All thirteen residents who resided on the unit had a diagnoses of dementia or a related disorder. A current, 1/2016, facility policy titled, Storage and Security of Items Potentially Hazardous to Residents, provided by the Administrator on 3/14/24 at 3:55 p.m., indicated the following: .This facility shall provide each resident an environment that is as free as possible from hazards over which the facility has control, to include but not to be limited to safe storage of toxic chemicals and medication, and safe use If equipment and electrical appliances. Examples of such hazards might include .disabled locks or latches . Certain sharp items . may be appropriate for many residents but hazardous for others with cognitive impairment An untilled document, dated 8/14/24, provided by the Administrator on 8/15/24 at 10:40 a.m., indicated the following: 13 residents resided on the dementia unit. 2 of 13 residents required staff assistance for mobility. 11 of 13 residents were capable of independent locomotion by either walking or self propelling their wheelchair. 3.1-45(a)

Based on record review and interview, the facility failed to implement their antibiotic stewardship policy regarding initiation of antibiotic treatments for 4 of 4 residents reviewed for infection surveillance. (Residents 5, 8, 114, and 27) Findings include: A review of the facility Infection Control Surveillance binder was completed on 9/15/23 at 12:22 p.m., for the months of May, June, July, and August 2023. The Infection Monitoring Logs and supporting documentation indicated the following: a. On 5/3/23, Resident 5 had a respiratory infection. A McGeer Criteria (used for retrospectively counting true infections) form indicated the resident had a common cold. A physicians order, dated 5/3/23, indicated doxycycline hyclate (an antibiotic) 100 mg (milligram), two times a day for seven days for a diagnosis of upper respiratory infection. b. On 5/10/23, Resident 8 had a respiratory infection. A McGeer Criteria form indicated the resident had a common cold. A physician's order, dated 5/10/23, indicated azithromycin (an antibiotic) 250 mg, two tablets once daily for one day, for a diagnosis of acute cough. On 5/11/23, a physician's order indicated to administer azithromycin 250 mg, one tablet daily for four days. c. On 7/28/23, Resident 114 had a respiratory infection. A McGeer Criteria form indicated the resident had a common cold. A physician's order, dated 7/19/23, indicated cephalexin (an antibiotic) 500 mg, twice a day for seven days for acute sinusitis. d. On 8/7/23, Resident 8 had a respiratory infection. A McGeer Criteria form indicated the resident had a common cold. A physician's order, dated 5/10/23, indicated azithromycin (an antibiotic) 250 mg, two tablets once daily for one day, for a diagnosis of acute cough. On 5/11/23, a physician's order indicated to administer azithromycin 250 mg, one tablet daily for four days. e. On 8/10/23, Resident 27 had a respiratory infection. A McGeer Criteria form indicated the resident had a common cold. A physician's order, dated 8/10/23, indicated levofloxacin (an antibiotic) 500 mg, once a day for five days for an acute cough. During an interview on 9/15/23 at 2:25 p.m., the DON indicated he completes the McGeer's criteria for assessment when a resident became symptomatic. The prescribing of treatment was based on that assessment. He had not used the Loeb Minimum Criteria for Initiation of Antibiotics document to determine appropriateness of a prescribed antibiotic. The physician prescribed the medication and the order was completed as written. During an interview on 9/15/23 at 3:12 p.m., the Administrator indicated she had discussed antibiotic stewardship with the facility's provider. She had no documentation regarding this education. A current facility policy, revised 6/2018, titled, Antibiotic Stewardship Program (ASP), provided following the entrance conference on 9/11/23 by the Administrator, indicated the following: Policy: It is the policy of the facility to implement an Antibiotic Stewardship Program (ASP) which will promote appropriate use of antibiotics while optimizing the treatment of infections, at the same time reducing the possible adverse events associated with antibiotic use The policy included documents for McGeer's Criteria and Loeb Minimum Criteria for Initiation of Antibiotics. Review of a CDC education document titled Antibiotic Prescribing and Use, Common Cold, retrieved from https://www.cdc.gov/antibiotic-use/colds, indicated the following: .There is no cure for a cold. It will get better on its own-without antibiotics. Antibiotics won ' t help you get better if you have a cold. When antibiotics aren ' t needed, they won ' t help you, and their side effects could still cause harm. Side effects can range from mild reactions, like a rash, to more serious health problems. These problems can include severe allergic reactions, antibiotic-resistant infections and C. diff infection. C. diff causes diarrhea that can lead to severe colon damage and death .

Based on observation, interview and record review, the facility failed to ensure staff were trained on the proper technique when administering insulin from an insulin pen for 1 of 1 residents observed for insulin administration. (Resident 16) Findings include: During observation of medication administration for Resident 16 on 7/29/22 at 8:51 a.m., LPN 5 administered insulin per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN 5 dialed the pen dose to 10 and administered into resident's abdomen. She did not prime the new needle applied to the insulin pen. Review of resident's clinical record was completed on 7/29/22 at 2:42 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order date was unreadable on document provided. During an interview on 7/29/22 at 9:05 a.m., LPN 4 indicated she should have primed the new needle prior to administration. She indicated the procedure was to dial the dose to one unit and press the administration button. During an interview on 8/1/22 at 2:33 p.m., the Director of Nursing (DON) indicated the nurse should have primed the insulin needle for the [MEDICATION(S)] FlexTouch prior to administering insulin. Review of the manufacturer guidelines for the [MEDICATION(S)] FlexTouch Pen, provided by the DON on 8/1/22 at 2:40 p.m., indicated the following: Priming your [MEDICATION(S)] FlexTouch Pen: .Step 7: Turn the dose elector to select 2 units .Step 8: Hold the Pen with the needle pointing up. Tap the top of the Pen gently a few times to let any air bubbles rise to the top .Step 9: Hold the Pen with the needle pointing up. Press and hold in the dose button until the dose counter shows 0. The 0 must line up with the dose pointer. A drop of insulin should be seen at the needle tip .If you do not see a drop of insulin, repeat steps 7 to 9, no more than 6 times. 3.1-37(a)

Based on observation, record review and interview, the facility failed to ensure a resident was assisted with a meal in a dignified manner for 1 of 1 residents reviewed for dignity. (Resident 138) Findings include: During an observation of meal service on 7/28/22 at 11:40 a.m., LPN 4 was observed assisting Resident 138 to eat. LPN 4 stood to the right of the resident, providing bites to resident who lifted her head upwards to consume food. Resident 138's clinical record was reviewed on 7/28/22 at 2:15 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A resident care sheet, provided by LPN 5 on 7/29/22 at 1:58 p.m., indicated Resident 138 required a mechanical soft diet. During an interview on 7/28/22 at 11:45 a.m., after LPN 4 obtained a chair and sat down on the resident's right side, she indicated it was okay to feed a resident while standing. During an interview on 7/28/22 at 11:58 a.m., the Administrator indicated resident's should not be assisted to eat while standing. A Licensed Nurse Job Description, provided by the Administrator on 8/1/22 at 10:56 a.m., included, but was not limited to, Essential Job Functions: .3. Help to maintain the self respect, personal dignity and physical safety of each resident. A Licensed Nurse Orientation Checklist for LPN 4, dated 12/1/21, provided by the Administrator on 8/1/22 at 10:56 a.m., included, but was not limited to, Areas of Orientation .Resident Meal Time. The Instructed and Voiced Understanding column was initial as completed on 12/1/21. A current facility policy, dated 10/2014, titled, Feeding Residents, provided by the Administrator on 7/28/22 at 1:48 p.m., included, but was not limited to, the following: PROCEDURE: .6. Sit on unaffected side, eye level with resident, facing them. 3.1-3(t)

Based on observation , interview and record review, the facility failed to prevent resident to resident abuse in a dependent resident, for 1 of 5 residents reviewed for accidents. (Resident 7) Findings include: During an observation on 7/26/22 at 2:51 p.m., Resident 7 sat on a chair in the lounge on the memory care unit and repetitively wrapped a blanket around her baby doll. During an attempted interview at the time of observation on 7/28/22 at 9:24 a.m., the resident was not interviewable. She was unable to state her name when asked and propelled herself with her feet about the memory care unit in her wheelchair. As she propelled in her wheelchair, she kissed her baby doll and spoke to the baby doll in incomprehensible words. During an interview on 7/28/22 at 9:58 a.m., Certified Nurse's Aide (CNA) 6 indicated she was familiar with the care of Resident 7 and she was one of the residents with advanced cognitive impairment related to her diagnoses. She was made aware of a resident to resident altercation between Resident 7 and another resident on 6/3/22 and staff were not required to keep Resident 7 away from any other residents. She was unaware of previous altercations. The perpetrator no longer resided at the facility. During an interview on 7/28/22 at 10:02 a.m., the Administrator indicated Resident 7 was the victim during the resident altercation on 6/3/22. The perpetrator was discharged to another facility after the incident occurred for the residents' safety. On 7/28/22 at 10:25 a.m., a review of the facility reported resident to resident altercation on 6/3/22, indicated the following: evening CNA stated she heard yelling from a room. When she walked out to hallway she saw res [resident 7] being hit by another resident. Res [Resident 7] then hit back until they were broken up. Both residents have no injuries. During an interview on 7/28/22 at 2:07 p.m., Registered Nurse (RN) 7 indicated she was familiar with the residents' care on the memory care unit and the resident to resident altercation on 6/3/22. Resident 7 ambulated anywhere in her wheelchair and the perpetrator got agitated if Resident 7 bumped into her while she moved about in her wheelchair on the memory care unit. On 6/3/22, the evening CNA reported to RN 7 she heard yelling from a room and when she walked out to the hallway, the perpetrator hit Resident 7 and Resident 7 hit the perpetrator back. Resident 7 was known to show some aggression with staff during staff care and lacked understanding. Resident 7's clinical record review was completed on 7/28/22 at 2:23 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medications included, but were not limited to, [MEDICATION(S)] (Alzheimer's disease management) 10 milligrams by mouth daily for dementia with behavioral disturbance. A quarterly Minimum Data Set (MDS) assessment, dated 4/29/22, indicated the resident had severe cognitive impairment. She required extensive assistance to total dependence on staff for bed mobility, transfers, locomotion on unit, dressing, eating, toileting, personal hygiene, and bathing. A resident to resident altercation care plan indicated the resident had altercations on 3/27/22, 4/1/22 and 6/3/22. Interventions included, but were not limited to, separate the residents if applicable, place resident on 15 minute checks to ensure safety or one-to-ones as needed, as directed by immediate supervisor on duty, provide activity of choice and interest to direct attention such as section was left blank. A care plan for verbal behavioral symptoms directed towards others such as: threatening others, screaming at others, and cursing at others, was last updated on 6/7/22. Interventions included, but were not limited to the following: attempt to identify the immediate causal factor or event that precipitates the behavior, remove the resident or other from the area as appropriate or necessary, attempt to use diversion, distraction, and reorientation to calm the resident such as a quiet environment. Review of a Mood and Behavior Communication Memo, dated 3/27/22, indicated the resident was slapped by another resident. Review of a Mood and Behavior Communication Memo, dated 4/1/22, indicated the resident was slapped by another resident. A Nurse's Note, dated 6/3/22 at 4:30 p.m., indicated the resident sat in the hallway and was hit by another resident. The clinical record lacked further Nurse's notes related to altercations. During an interview on 7/28/22 at 2:42 p.m., the Administrator indicated on the following dates, the same perpetrator slapped Resident 7: 3/27/22, 4/1/22, and 6/3/22. After the resident to resident altercation on 6/3/22, the perpetrator was sent out to behavioral health. During an interview on 7/28/22 at 3:17 p.m., the Administrator indicated the perpetrator, in the 3 above mentioned resident to resident altercations, returned to the facility on [DATE] and was discharged to another health care facility on 7/14/22. During an interview on 7/28/22 at 4:35 p.m., the Administrator indicated when a resident slapped another resident there was potential for the resident to receive injuries but no injuries were found. A request was made for any progress notes related to the resident to resident altercations on 3/27/22 and 4/1/22. Additional nursing notes were not provided. During an interview on 7/29/22 at 9:26 a.m., the MDS Coordinator indicated abuse included, but was not limited to, resident to resident or staff to resident physical abuse. A resident to resident altercation that did not result in physical injuries would still be considered abuse. During an interview on 7/29/22 at 10:32 a.m., RN 7 indicated abuse included, but was not limited to, physical abuse between a staff to a resident or physical abuse between a resident to a resident. It was still classified as abuse when there is physical abuse between 2 residents even if injuries were not identified. During an interview on 8/1/22 at 1:30 p.m., the Administrator indicated he did not have any further documents regarding the resident to resident altercations on 3/27/22 and 4/1/22. Further documentation was not provided. A current policy, titled ABUSE PROHIBITION, REPORTING AND INVESTIGATION, provided by the Administrator on 7/29/22 at 11:30 a.m., indicated the following: POLICY: This facility shall prohibit and prevent abuse, neglect, misappropriation of resident property, and exploitation Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm 3.1-27(a)(1)

Based on observation, interview and record review, the facility failed to ensure no significant weight loss occurred for 1 of 3 residents reviewed for nutrition (Resident 33). This deficient practice resulted in a significant weight loss of 14% in 6 months. Finding include: During a dining observation, on 7/10/18 at 8:32 a.m., Resident 33 was in the main dining room. She was being assisted with her meals by staff cueing and encouragement. She was observed taking sips of fluids and small bites of her meal when strongly encouraged. The clinical record for Resident 33 was reviewed, on 7/12/18 at 9:11 a.m. Her [DIAGNOSES REDACTED]. A quarterly MDS (minimum data set) assessment, dated 3/16/18, indicated she had severe cognitive impairment. She had no weight loss. A nutrition care plan, dated 11/27/17, indicated an alteration in nutritional/hydration status. Interventions included, but were not limited to: a regular diet, provide preferences, encourage fluids, yogurt with meals, offer substitutes, assist with meals and monitor weights. A care plan, dated 6/4/18, indicated she had the potential for weight loss. Interventions included, but were not limited to: encourage resident to consume as much of her meal as possible, monitor intake at meals, monitor weight at least monthly, offer food replacements as needed, supplements as ordered, weekly weights and medications per physician orders. A physician order, dated 11/17/17, indicated she was to receive yogurt with meals. A physician order, dated 1/22/18, indicated she was to receive [MEDICATION NAME] (appetite stimulant) 7.5 milligrams daily. A physician order, dated 6/1/18, indicated she was to receive ice cream at dinner. A physician order, dated 6/1/18, indicated she was to receive breeze (nutritional high calorie shake) with all meals. A physician order, dated 6/1/18, indicated she was to have super cereal (high calorie) at breakfast. On 7/12/18 at 10:00 a.m., a review of the past 6 months of weights indicated: a. On 1/1/18, she weighed 150 pounds b. On 2/4/18 she weighed 145 pounds (3.3% weight loss) c. On 3/4/18 she weighed 145 pounds d. On 4/1/18 she weighed 144 pounds (4% weight loss) e. On 5/1/18 she weighed 141 pounds (6% weight loss) f. On 6/1/18 she weighed 133 pounds (11.3% weight loss) g. On 7/1/18 she weighed 129 pounds. (14% weight loss) There were no interventions added, assessments completed, dietary consults or reviews done for this resident from (MONTH) to June. A Nutritional assessment, dated 11/27/17, indicated she was ordered a regular diet and was to receive yogurt with meals. This assessment indicated all her nutritional needs were met. The clinical record lacked any additional assessments. Review of meal consumption record, indicated the following: a. (MONTH) (YEAR), she consumed less then 75% of meals for 53 of 90 meals. b. (MONTH) (YEAR), she consumed less then 75% of meals for 65 of 93 meals. c. (MONTH) (YEAR), she consumed less than 75% of meals for 33 of 34 meals documented as of 7/12/18. A speech therapy recommendation, dated 6/7/18, indicated to change to a pureed diet and supervise/assist with all meals. During an interview with LPN 21, on 7/12/18 at 1:17 p.m., she indicated the resident had been having a normal slow decline, but nothing significant had happened in the last couple months to contribute to the significant weight loss. During an interview with Corporate Nurse Consultant 1, on 7/13/18 at 10:59 a.m., she indicated the resident had been placed on weekly monitoring for her weight loss. She could not identify when the interventions were started on the nutrition care plan, as they were not dated and it had been updated a couple times. She did not know if the interventions were started before or after the significant weight loss. She could not indicate what interventions were put in place to prevent weight loss and what interventions were put in place after the identified significant weight loss. During an interview with the Administrator, on 7/13/18 at 11:42 a.m., she indicated between 1/22/18 and 6/1/18 there were no interventions implemented to prevent the resident's significant weight loss. A current policy titled Skin and Weight Assessment Team was provided by Corporate Nurse Consultant 2, on 7/13/18 at 9:52 a.m. This policy indicated, .It is the protocol of this facility to aggressively review and address those residents exhibiting significant/insidious wright change or skin breakdown. These residents will be monitored by SWAT (skin and weight assessment team) on a weekly basis involving all applicable disciplines in an effort to improve each resident's nutritional status .This team will monitor those residents at nutritional risk and determine the appropriate intervention(s) to best address each resident's need. 3.1-46

Based on interview and record review the facility failed to provide adequate supervision for severely cognitively impaired residents (Resident B and Resident D) which resulted in resident to resident altercations for 2 of 4 residents reviewed for abuse (Resident C and Resident D). These altercations resulted in Resident C receiving a fractured left ankle and Resident D receiving a laceration to the left eyebrow. Findings include: A. The clinical record for Resident B was reviewed on 5/23/2018 at 11:13 AM. [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment, dated 12/15/2017, was reviewed on 5/23/2018 at 11:13 AM. The MDS indicated Resident B was severely cognitively impaired with a BIMS (Brief Interview for Mental Status Score) of 2. Review of a current care plan, dated 2/12/2018 and last reviewed on 5/14/2018, indicated the following: The resident exhibits physical behavioral symptoms directed towards others such as: hitting. 2/1/2018 resident hit another resident who hit him. 5/14/2018 resident tackled another resident. Review of a current care plan, dated 4/12/2018 and last reviewed on 5/3/2018, indicated the following: The resident exhibits verbal behavioral symptoms directed towards others such as: threatening others. When staff asked resident to take a shower, resident refused and told staff 'I'll beat your ass'. Verbal aggressive with staff. Review of a Mood and Behavior Communication Memo, dated 5/10/2018 at 3:00 PM, indicated the resident was agitated and entered Resident C's room. Staff attempted to redirect but resident continued to stare at Resident C. Review of a facility reportable incident, dated 5/14/2018, indicated Resident C was walking in the hallway and Resident B slammed his door shut, then opened his door and tackled Resident C to the floor and landed on top of him. Review of a nursing progress note, dated 5/14/2018 at 6:00 PM, indicated staff observed Resident B push another resident to the floor. Staff attempted to get Resident B off the other resident. He was also observed squeezing the other resident's thigh hard and was told to let go. Resident B got to his feet and kicked the other resident. Review of an Accident and Incident Report and Investigation dated 5/14/2018 at 6:00 PM, indicated Resident C had ben pushed to the ground by Resident B and had his right thigh squeezed. Resident C was then kicked by Resident B before staff could separate them. Resident C left hip pain and was sent to the hospital for evaluation and treatment. Review of the emergency room final report, dated 5/14/2018 at 7:08 PM, indicated Resident C complained of left shoulder, left hip, left knee and left foot pain. X-ray results indicated the resident had a left ankle fracture and a sprained left shoulder. Review of a Mood and Behavior Communication Memo, dated 5/17/2018 at 9:15 AM, indicated the resident was agitated and physically aggressive. The resident became physically aggressive when staff attempted to redirect him out of Resident C's room. Review of a Mood and Behavior Communication Memo, dated 5/18/2018 at 4:00 PM, indicated the resident was agitated. The resident was with a family member and went to the lounge. Resident C was already in the lounge. Resident B sat in a chair and glared at Resident C. He could not be redirected to his room by his family member and attempted to get closer to Resident C. The clinical record for Resident C was reviewed on 5/23/2018 at 11:55 AM. [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment, dated 12/15/2017, was reviewed on /23/2018 at 11:55 AM. The MDS indicated Resident C was severely cognitively impaired with a BIMS (Brief Interview for Mental Status Score) of 4. Review of a current care plan, dated 5/15/2018, indicated the following: The resident has potential for fear and anxiety due to: incident that occurred on 5/14/2018. Review of a current care plan, dated 5/14/2018 and last reviewed on 5/21/2018, indicated the following: The resident has had a recent fracture and is at risk for pain and infection. List specific location of fracture: left ankle. During an interview on 5/24/2018 at 9:43 AM., Employee 3 indicated staff were aware of Resident B's behaviors towards Resident C. Whenever Resident B was anywhere near Resident C you could see his facial expression change and he would clench his fist tight. Employee 3 indicated Resident B had it in for Resident C. During an interview on 5/24/2018 at 10:07 AM., Employee 1 indicated Resident B would stare at Resident C to the point Resident C became irritated. Employee 1 would stand in front of Resident B to block his view and try to distract him. During an interview on 5/24/2018 at 10:30 AM., Employee 2 indicated staff were aware Resident B would stare at Resident C, but they did not know the reason. Staff were being [MEDICAL CONDITION] of Resident B. B. The clinical record for Resident D was reviewed on 5/23/2018 at 12:32 PM. [DIAGNOSES REDACTED]. Review of the most recent Quarterly Minimum Data Set (MDS) assessment, dated 2/3/2018, was reviewed on 5/23/2018 at 12:32 PM. The Staff Assessment for Mental Status indicated Resident D was moderately cognitively impaired. Review of a current care plan, dated 9/26/2017 and last reviewed on 2/5/2018, indicated the following: Potential for resident to resident altercations due to incident that occurred on .2/18/2018. Review of a facility reported incident, dated 2/11/2018, indicated Resident D was observed hitting Resident B on the shoulder. Review of a facility Resident to Resident Abuse form, dated 2/11/2018 at 11:20 AM, indicated Resident D walked up to Resident B and hit him on the shoulder unprovoked. Resident B immediately hit Resident D back in the left eyebrow causing a 1 cm x 1 cm laceration. Resident B sustained no injury. Review of an Accident and Incident Report and Investigation dated 2/11/2018 at 11:20 AM, indicated Resident B was approached and hit by Resident D. Resident B hit Resident D back with a closed hand. During an interview on 5/23/2018 at 2:12 PM, Employee 7, indicated Resident D hit Resident B without provocation and Resident B hit back on reflex. This Federal tag relates to Complaint IN 510. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure a resident was safely assisted to stand for peri-care in a manner to prevent being lowered to the floor in an unsafe manner when she became weak and her legs buckled resulting in contact with the floor and two fractures of the right lower extremity for 1 of 1 resident reviewed for a fracture following being lowered to the floor in a sample of 4. (Resident #B) Findings include: The clinical record for Resident #B was reviewed on 6/25/14 at 10:20 a.m. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 5/12/14, indicated Resident #B was moderately cognitively impaired and required extensive assistance of two staff members for transfers and toileting. The MDS indicated the resident had impairment in range of motion of bilateral upper and lower extremities. The MDS indicated the resident was not steady from a seated to standing position without staff assistance. A physician's orders [REDACTED]. Hospice orders, dated 5/8/14, indicated the resident was a fall risk. The orders indicated "Use 2 person assistance and gait belt for all transfers." A hospice "Safe Handling and Movement" assessment indicated the "Patient's Level of Assistance" was "Dependent-Patient requires staff to lift more than 35 pounds of the patient's weight, or is unpredictable in the amount of assistance offered. In this case assistive devices should be used." The assessment indicated 2 staff were needed to transfer/turn the resident and a gait belt should be used. A facility reported "Incident Report Form", initially called in to ISDH on 6/17/14, with a follow-up report, dated 6/20/14, faxed to ISDH, included, but was not limited to, the following: ...Brief Description of Incident: On 6/16/14, fractures were noted to (name of Resident #B) left tibia and fibula. (name of resident) was lowered to the floor by three CNAs on 6/15/14 after the staff were assisting her to stand and the resident's knees buckled. Type of Injury/Injuries: Fracture to left tibia and left fibula ... Follow up: On 6/15/14 at 11 am, the resident was standing with the assist of two staff members as per her plan of care. A third staff member was providing peri-care to the resident. While the resident was standing, her knees buckled and the staff lowered her to the floor. No injuries were noted at the time of occurrence and no complaints of pain. At 8 pm, there was bruising noted to the right and left shin area. The MD (medical doctor) and family were notified and the physician did not order any new treatment. On 6/16/14, the resident was seen by the nurse practitioner (NP). The NP ordered X-rays to be done of the left knee. At 5:30 pm, X-ray results arrived at the facility indicating fractures of the left tibia and fibula. The MD was contacted and an immobilizer was ordered. Family was updated and requested an appointment be made to (Orthopedic facility) for the resident. The resident was being transported to (Orthopedic facility) on 6/17/14. During transport, the driver re-routed the resident to the hospital ER (emergency room ) for evaluation due to pain. The resident was eventually admitted to the hospital after hospice services were stopped. Please note: The resident has a [DIAGNOSES REDACTED]. There is a history of Prednisone use. There is also a history of hip and pelvic fractures. The resident was experiencing a decline both physically and mentally over the course of past 6 months and was a hospice patient while at the facility...." The reportable incident above included the names of the 3 CNAs providing care which will be now be referred to as CNA #1, #2, and #3. CNA #1 was interviewed on 6/25/14 at 1:55 p.m. CNA #1 indicated the three CNAs were attempting to change the resident's brief and provide peri-care while standing her up from her specialized wheelchair when the above noted incident occurred on 6/15/14. CNA #1 indicated she was the one who was standing the resident up and did so facing the resident with her arms under the residents arms and wrapped around the resident in a 'bear hug' manner. She indicated CNA #2 was present but he did not assist with standing the resident. She indicated CNA #3 was going to provide peri-care while she stood up the resident. She indicated she stood the resident up once and the resident's legs weakened and buckled and she sat her back down. She indicated she paused for a minute and then stood the resident up by herself in the same manner a second time and the resident's legs buckled again and she lowered her to the floor with the resident in a kneeling position with her legs under her body. She indicated there was a mild 'thump' when the resident hit the floor. CNA #1 indicated CNA #2 went and got the nurses who checked the resident. She indicated the resident did not appear to be injured at that time. CNA #1 indicated she worked until 8 p.m. that evening and helped CNA #4 transfer the resident back to bed after supper around 7:30 p.m. She indicated the two CNAs transferred the resident by lifting her under her arms and grabbing the back of her pants. She indicated the resident screamed out when the leg rest of her chair was lowered and during the transfer. She indicated the resident usually was uncomfortable during transfers and called out, but this was different and she appeared to be in more pain. When the resident was undressed, the CNAs noted the bruising to her legs and notified RN #5 who was on duty that evening. When queried if a gait belt had been used for either of the transfers noted above, CNA #1 indicated "No". CNA #2 was interviewed on 6/25/14 at 2:10 p.m. CNA #2 indicated he had been present on 6/15/14 when Resident #B was lowered to the floor. He indicated he was the "spotter" and had not lifted the resident until her legs buckled and he tried to help. He indicated she went down in a kneeling position and made contact with the floor. He indicated the other two CNAs stayed with the resident while he went and got the nurses. When queried if a gait belt had been used while they were trying to stand the resident for peri-care, he indicated "No". CNA #3 was unavailable for interview. Review of her written statement related to the event was as follows: "I (name of CNA #3), witnessed the incident where (name of resident) got lowered to the floor. (CNA #1) was holding (name of resident) up so I could clean her up after she pottied. (CNA #2) was our spotter in case something happened. (Name of resident) went limp and just stopped helping stand, so (CNA #1) held onto her and lowered her slowly down, while (CNA #2) tried to hold (name of resident) while she went down...." The DoN (Director of Nursing) and Assistant DoN (ADoN) were interviewed on 6/25/14 at 4:15 p.m. Additional information was requested related to the CNAs not using a gait belt, the resident being lifted by one staff member prior to being "lowered to the floor" which resulted in left leg fractures, the CNAs continuing to transfer the resident without a gait belt later in the day after she had already been unstable and her legs had buckled during care. The facility failed to provide any additional information. The RN consultant was interviewed on 6/26/14 at 2:40 p.m. She indicated the facility had no specific policy for assisting a resident to stand during changing of a brief, but indicated safety measures would be the same as for a resident transfer. Review of the current facility policy, dated 9/05, titled "Transferring a Resident from Bed to Chair", provided by the RN Consultant on 6/26/14 at 2:40 p.m., included, but was not limited to, the following: "...Procedure: ...8. Apply gait belt to waist if resident requires weight bearing assist. (see gait belt procedure) 9. Using gait belt-grasp sides of belt with both hands and assist resident to standing position; pivot turn and sit resident in chair...." This federal tag relates to Complaint IN 176. 3.1-45(a)(2)