Every finding on record at George Ade Memorial Health Care Center

Based on observation, record review, and interview, the facility failed to ensure a resident's dignity was maintained related to an uncovered urinary catheter bag and a resident's choice was honored for bathing for 2 of 2 residents reviewed for dignity. (Residents G and 57)Findings include: 1.On 3/3/26 at 9:53 a.m. Resident G was observed lying in bed. A urinary catheter bag was hanging from the side of the bed with visible urine in the bag. There was no cover over the bag, and the bag was visible from the hallway. On 3/3/26 at 2:47 p.m. Resident G was observed lying in bed. A urinary catheter bag was hanging from the side of the bed with visible urine in the bag. There was no cover over the bag, and the bag was visible from the hallway. On 3/4/26 at 11:23 a.m. Resident G was observed lying in bed. A urinary catheter bag was hanging from the side of the bed with visible urine in the bag. There was no cover over the bag, and the bag was visible from the hallway. Record review for Resident G was completed on 3/4/26 at 2:23 p.m. Diagnoses included, but were not limited to, obstructive and reflux uropathy, urine retention, and neuromuscular dysfunction of the bladder. A Care Plan, updated 2/9/26, indicated the resident had impaired urinary elimination and had an indwelling catheter. During an interview on 3/4/26 at 3:29 p.m., the Director of Nursing was made aware the urinary catheter bag was visible from the hallway and the facility's catheter care policy was requested. A facility policy, received as current from the Director of Nursing, titled Catheter Care, indicated .Catheter covers/dignity bags are used to preserve the resident's dignity and privacy when out of the room or per residents request. Nursing staff are responsible for the application and securing of catheter bag covers/dignity bags . 2. During an interview on 3/2/26 at 3:31 p.m., Resident 57 indicated that she was supposed to receive three showers a week. The aides had gotten the resident ready for a shower and took her down to the shower room. She had noticed her usual shower chair was not there and so she started to back herself out of the shower room. LPN 2 pushed her wheelchair back into the shower room and said that she was always complaining about her showers and so she was going to take one now. The resident felt that she was forced to take a shower. Resident 57's record was reviewed on 3/3/36 at 2:03 p.m. The Quarterly Minimum Data Set (MDS) assessment, dated 12/9/25, indicated the resident was cognitively intact and required substantial/maximal assistance for showering/bathing. A Care Plan, revised on 2/9/26, indicated the resident had a self-care deficit. Interventions included, but were not limited to, the resident needed assistance with bathing on Tuesday, Friday, and Sunday evening shifts. A Facility Reported Incident, dated 3/4/26, indicated Resident 57 reported that LPN 2 had pushed her back into the shower room forcefully. LPN 2 told her that she had been refusing showers and was not going to refuse and she had to take one. Resident 57 felt that this was verbal abuse telling her she had to take a shower. The staff member was immediately suspended pending investigation. Social Services interviewed other alert residents to see if there were any other issues. The Investigation Form, dated 3/4/26, indicated the incident occurred in the previous week when LPN 2 forced Resident 57 to take a shower. The incident met the definition of abuse, as Resident 57 indicated it was verbal abuse. Actions taken during the investigation included LPN 2 was immediately suspended, residents were interviewed on the unit with no findings, LPN 2 was suspended for 3 days and assigned more in-servicing related to abuse and resident rights, all staff in-serviced on abuse. The Summary indicated the resident did feel safe and does not have a problem with the nurse as long as she does not force her to take a shower. The incident was substantiated because residents' rights were violated. A statement by the Social Service Designee, dated 3/4/26, indicated during an interview with Resident 57, she stated that LPN 2 had taken her right away and was verbally abusive stating that she could not refuse her shower. A statement written by CNA 2, on 3/4/26, indicated CNA 1 had talked to the resident and the resident agreed to allow the NA to shower them before dinner. The NA got the resident into the shower room, and the resident did not like the chair that was in there. The NA went to find the chair she wanted but was unable to locate the chair. The NA went back to the nurses' station and said that the resident did not want their shower unless we could find the right chair. LPN 2 got up and said that the resident was going to take a shower and that she would handle it. CNA 1 and CNA 2 heard some commotion from the shower room and went to see what was going on and LPN 2 was telling the resident that she was going to take a shower and that we were going to help. LPN 2 had her arms under the resident's arms and was assisting her to stand up and grab onto the bar. CNA 1 helped LPN 2 stand up the resident and got her situated in the shower chair. The NA indicated she could handle it from there and finish the shower. A written statement by CNA 3, dated 3/4/26, indicated CNA 3 had asked the resident if she wanted to take a shower and responded that she didn't want it until after dinner. CNA 3 told LPN 2 that the resident did not want the shower until after dinner so the person relieving CNA 3 would have to do it because the shift ended at 6:00 p.m. LPN 2 said No she's taking it now, and then went into the residents room, moved her bedside table that was in front of her, and told the resident she was taking her shower now. CNA 3 assisted the resident with her shower and the resident indicated she was upset with LPN 2 because she did not want to take her shower before dinner. A statement written by NA 1, on 3/5/26, indicated she was getting Resident 57 into the shower, and the resident indicated it was the wrong chair. The NA searched for the chair but was unable to find it. Other staff members indicated the chair was no longer at the facility, so Resident 57 then indicated she was not going to take her shower and she wanted to refuse. The resident started back towards her room because she did not want to use the chair that hurt her. NA 1 said ok. LPN 2 then said no that the resident needed the shower, so she was getting it and started to take the resident back to the shower. Then two aids, CNA 1 and CNA 2, helped the resident get into the shower and then NA 1 helped her with the shower. The resident was upset and saying no. The resident was still upset during the shower and after the shower, but she was not giving NA 1 trouble or anything while giving care to her. NA 1 indicated she did not feel like she was forced to give the shower to the resident, but she felt that the resident was forced to take the shower and the other staff had NA 1 do it. During an interview on 3/6/26 at 8:56 a.m., the Director of Nursing indicated the investigation resulted in the nurse being suspended and she was going to have to do more in-service training on resident rights. The nurse was trying to encourage the resident to take her shower, however the line was crossed. 410 IAC (Indiana Administrative Code) 16.2-3.1-3(a)(1)410 IAC (Indiana Administrative Code) 16.2-3.1-3(t)

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) comprehensive assessment was accurately completed related to a Wanderguard alarm (wearable device that alarms when approaching a restricted area) not documented for a resident with history of wandering for 1 of 21 MDS assessments reviewed. (Resident 37) Finding includes:The record for Resident 37 was reviewed on 3/3/26 at 8:59 a.m. Diagnoses included, but were not limited to, dementia and Parkinson's disease. The Quarterly Minimum Data Set (MDS) assessment, dated 1/26/26, indicated the resident had moderate cognitive impairment, required partial to moderate assistance with shower, personal hygiene, and taking footwear on and off. The alarm assessment was marked as 0 indicating not used. The Physician's Order, dated 12/15/25, indicated Wanderguard to right wrist. Monitor for proper placement every shift and functioning daily. During an interview on 3/5/26 at 1:44 p.m., the MDS Coordinator indicated she thought the Wanderguard was discontinued. When asked for policy regarding MDS, she indicated she used the Resident Assessment Instrument (RAI). The Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1, dated October 2025, indicated P0200: Alarms. Coding Instructions. Identify all alarms that were used at any time (day or night) during the 7-day look back period. After determining whether or not an item listed in P0200 was used during the 7-day look back period, code the frequency of use:. Code 0, not used: if the device was not used during the 7-day look back period. Code 1, used less than daily: if the device was used less than daily. Code 2, used daily: if the device was used on a daily basis during the look back period .Coding Tips.Wander/elopement alarm includes such bracelets, pins/buttons worn on the resident's clothing, sensors in shoes, or building/unit exit sensors worn by/attached to the resident that activates an alarm and /or the staff when the resident nears or exits a specific area or the building. This includes devices that are attached to the residents assistive device (e.g., walker, wheelchair, cane) or other belongings. 410 IAC (Indiana Administrative Code) 16.2-3.1-31(i)

Based on observation, record review and interview, the facility failed to update care plans to reflect the resident's transfer status for 1 of 19 resident care plans reviewed. (Resident 16)Finding includes:On 3/2/26 at 3:18 p.m., Resident 16 was observed lying in bed. The resident indicated she required a Hoyer lift (mechanical device to transfer an individual) for staff to transfer her out of bed. Sometimes the facility was short staffed and they would not always have 2 staff members to transfer her out of bed.Record review for Resident 16 was completed on 3/3/26 at 2:14 p.m. Diagnoses included, but were not limited to stroke and anxiety.The Annual Minimum Data Set (MDS) assessment, dated 12/2/25, indicated the resident was cognitively intact. The resident was dependent on staff for transfers.A Care Plan, dated 12/5/24 and revised 3/2/26, indicated the resident had a self care deficit related to impaired mobility. An intervention included for staff to assist with transfers.A Care Plan, dated 12/6/24 and revised 3/2/26, indicated the resident was at risk for falls due to impaired mobility and weakness. An intervention included for staff to assist with transfers and ambulation.The Care Plans lacked any documentation the resident required a Hoyer lift for transfers. During an interview on 3/4/26 at 10:47 a.m., LPN 1 indicated the resident required a Hoyer lift for transfers.During an interview on 3/4/26 at 10:49 a.m., the Director of Nursing indicated the Care Plans should have been updated to indicate the resident was a 2 person assist with a Hoyer lift for transfers. 410 IAC (Indiana Administrative Code) 16.2-3.1-35(b)(1)

Based on observation, record review, and interview, the facility failed to provide activities to support the psychosocial well-being of cognitively impaired, dependent residents for 1 of 1 resident reviewed for activities. (Resident H)Finding includes:On 3/2/26 at 10:18 a.m., Resident H was observed lying flat in bed with her eyes open staring at the ceiling. The bed had half side rails with padding on them and the curtain was pulled. The resident was unable to see out into the hall as her bed was furthest from the door. There was no television or music on at the time of observation. The resident was picking at her hair repeatedly. There was an activity occurring in the dining room at the time. On 3/2/26 at 2:59 p.m. and 3:10 p.m., Resident H was observed lying flat in bed with her eyes open staring at the ceiling. The bed had half side rails with padding on them and the curtain was pulled. The resident was unable to see out into the hall as her bed was furthest from the door. There was no television or music on at the time of observation. The resident was picking at her hair repeatedly.On 3/4/26 at 10:03 a.m., Resident H was observed lying flat in bed smacking her teeth together and pulling at the top of her hair. There were no activities occurring in her room. On 3/4/26 at 1:44 p.m., Resident H was observed lying flat in bed smacking her teeth together and pulling at her hair. There was an activity occurring in the Main Dining Room at the time of observation. On 3/5/26 at 10:30 a.m., Resident H was observed lying flat in bed. There were no activities occurring in her room at the time. On 3/5/26 at 11:11 a.m., Resident H was observed up in a Broda chair. A staff member took her to the dining room located in the Oak Blvd Unit. There was musician visiting for the activity occurring in the main dining room at the time. On 3/5/26 at 2:23 p.m., Resident H was observed in her room lying in the bed. There were no activities occurring in the room at the time. There was an activity in the main dining room. Resident H's record was reviewed on 3/4/26 at 2:21 p.m. Diagnoses included, but were not limited to, Alzheimer's disease, major depressive disorder, and psychotic disorder with delusions. The Annual Minimum Data Set (MDS) assessment, dated 1/5/26, indicated the resident was severely impaired for daily decision making. The staff assessment of daily and activity preferences indicated the resident preferred receiving a shower, family or significant other involvement in care discussions, reading books/newspapers/magazines, listening to music, being around animals such as pets, and participating in religious activities or practices. A Care Plan, revised on 2/8/26, indicated activities: the resident shows little awareness of programs, and can complete few or no simple tasks, and was on palliative care. Interventions included, but were not limited to, assist to programs which may be most comfortable and potentially stimulating, target, sing a long, church services, special events and music programs, modify length of programs based on attention span, position chair in a location which enables frequent one-on-one staff contact during activities, and simplify tasks, segment steps or tasks. The January and February 2026 Activity Logs indicated the resident received daily room visits. During an interview on 3/6/26 at 10:00 a.m., the Activity Director indicated the staff go to the resident's room daily for a room visit which includes talking, reading, and/or massage. They have tried to get her to go to activities and she doesn't respond or says, lay down. The staff are supposed to go into the resident's room and turn on music for her.410 IAC (Indiana Administrative Code) 16.2-3.1-33(a)

Based on observation, record review, and interview, the facility failed to ensure residents received the necessary treatment and services related to not notifying the physician when a resident was having frequent diarrhea for 1 of 1 resident reviewed for constipation/diarrhea. (Resident 16) The facility also failed to ensure physician's orders were followed related to a resident's catheter securement device for 1 of 1 resident reviewed for catheters. (Resident 52) Findings include:1. On 3/2/26 at 3:18 p.m., Resident 16 was observed lying in bed. The resident indicated she had been having episodes of diarrhea for a while. Record review for Resident 16 was completed on 3/3/26 at 2:14 p.m. Diagnoses included, but were not limited to stroke and anxiety. The Annual Minimum Data Set (MDS) assessment, dated 12/2/25, indicated the resident was cognitively intact. The resident was dependent on staff for transfers and toileting hygiene. The resident was always incontinent of bowel and bladder. The March 2026 Physician's Order Summary (POS) indicated an order for loperamide (antidiarrheal medication) 2 mg. Take 2 capsules by mouth after 1 unformed stool then take 1 capsule by mouth after each stool thereafter as needed. The February 2026 Medication Administration Record (MAR) indicated the loperamide was administered on 2/6/26 at 4:34 p.m., and again on 2/21/26 at 6:48 p.m. A Progress Note, dated 2/28/26 at 9:19 a.m., indicated the resident had two episodes of diarrhea and her stomach was upset. The March 2026 MAR indicated the loperamide was administered on 3/3/26 at 6:52 p.m., due to the resident had three episodes of diarrhea. The follow up indicated the medication was not effective and the resident had another episode of diarrhea. There was no documentation indicating the physician was notified after the resident had multiple episodes of diarrhea. During an interview on 3/4/26 at 11:20 a.m., the Director of Nursing (DON) indicated she was unable to provide any documentation the physician was notified after the resident had multiple episodes of diarrhea. 2. On 3/2/26 at 11:30 a.m., Resident 52 was observed sitting up in her bed. She had a catheter draining clear, yellow urine to gravity. The catheter tubing was secured to her right leg using an adhesive catheter securement device. On 3/4/26 at 10:07 a.m., Resident 52 indicated the adhesive for the catheter securement device rips her skin open. She was not sure what type of securement was being used at the time. The resident was covered with a blanket at the time. Resident 52's record was reviewed on 3/4/26 at 11:31 a.m. Diagnoses included, but were not limited to, neuromuscular dysfunction of bladder and retention of urine. The Quarterly Minimum Data Set (MDS) assessment, dated 12/2/25, indicated the resident was cognitively intact and had an indwelling catheter. A Physician's Order, dated 3/1/26, indicated to place clean abdominal pads to the bilateral inner upper thighs to keep catheter tubing off the skin and do not use catheter securement device, the resident's skin will blister. A Care Plan, revised on 3/2/26, indicated the resident was at risk for infection related to an invasive indwelling urinary catheter secondary to neurogenic bladder dysfunction and retention of urine. Interventions included, but were not limited to, catheter care every shift. During an interview on 3/5/26 at 8:50 a.m., the Director of Nursing indicated the resident had been out to the hospital and came back over the weekend. The hospital had put the adhesive on the resident and the staff should have noticed it and removed it. The adhesive had caused problems to her skin previously. The Director of Nursing had assessed the skin and there were no new issues at the time from the adhesive. 410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on observation, record review, and interview, the facility failed to provide treatment for limited range of motion related to splints not in place for 2 of 3 residents reviewed for range of motion (ROM). (Residents G and H)Findings include:1.On 3/2/26 at 11:10 a.m., Resident G was observed sitting in his wheelchair in his room. There was no splint in place to his left hand. The splint was observed on his bed. On 3/3/26 at 2:47 p.m., Resident G was observed lying in bed. There was no splint in place to his left hand. The splint was observed on the seat of his wheelchair. On 3/3/26 at 11:24 a.m., Resident G was observed lying in bed. There was no splint in place to his left hand. The splint was observed on the seat of his wheelchair. He indicated he had a splint that he would wear to on his left hand sometimes. He was unable to put it on himself and unsure when he was supposed to wear it. The resident's record was reviewed on 3/4/26 at 2:23 p.m. Diagnoses included, but were not limited to, hemiplegia left non dominant side. The Quarterly Minimum Data Set (MDS) assessment, dated 1/12/26, indicated the resident was cognitively intact and had impaired ROM to the upper and lower extremities on one side. A Care Plan, updated 2/9/26, indicated the resident required the use of a splint due to contracture of the left hand. The interventions included to apply the splint per schedule. A Physician's Order, dated 3/1/26, indicated left hand splint 2-4 hours daily or as tolerates to help prevent future contractures. There were no times to indicate when the splint should be on or off. The Medication Administration Record and the Treatment Administration Record, dated 3/2026, indicated the left-hand splint had been in place as ordered. There were no documented refusals or times to indicate when the splint was on or off. During an interview on 3/5/26 at 8:43 a.m., the Director of Nursing indicated there had been no clear schedule of when the splint was to be worn, the orders were updated, and it would now be put on at night. 2. On 3/2/26 at 10:34 a.m., at 2:59 p.m., and 3:10 p.m., Resident H was observed lying flat in bed with her eyes open staring at the ceiling. The resident had no palm protector in place to the left hand. On 3/4/26 at 10:03 a.m., Resident H was observed lying flat in bed smacking her teeth together and pulling at the top of her hair. The resident had no palm protector in place to the left hand. On 3/4/26 at 1:44 p.m., Resident H was observed lying flat in bed smacking her teeth together and pulling at her hair. The resident had no palm protector in place to the left hand. Resident H's record was reviewed on 3/4/26 at 2:21 p.m. Diagnoses included, but were not limited to, Alzheimer's disease and adult failure to thrive. The Annual Minimum Data Set (MDS) assessment, dated 1/5/26, indicated the resident was severely impaired for daily decision making and had a limitation in range of motion to one side on the upper extremity. A Physician's Order, dated 3/1/26, indicated palm protector to the left hand on in the morning and off at night. The March 2026 Medication and Treatment Administration Record indicated the palm protector was applied as ordered daily from 3/1/26 thru 3/4/26. During an interview on 3/5/26 at 8:50 a.m., the Director of Nursing indicated she had no further information to provide. This citation relates to Intake 2724581. 410 IAC (Indiana Administrative Code) 16.2-3.1-42(a)(2)

Based on record review and interview, the facility failed to ensure residents were provided with adequate equipment to prevent falls for 1 of 5 residents reviewed for accidents. (Resident D)Finding includes:Resident D's record was reviewed on 3/3/26 at 3:10 p.m.The Quarterly Minimum Data Set (MDS) assessment, dated 12/16/25, indicated the resident was moderately cognitively impaired and was dependent on staff for showering/bathing.An Event: Safety Events - Fall, dated 3/3/26 at 10:27 a.m., indicated the resident had a fall in the shower room while receiving a shower. There were no injuries. A Progress Note, dated 3/3/26, indicated the shower chair tipped in the shower and the resident was lowered to the floor by the CNA. The resident did not hit her head. There were no injuries. The physician and Director of Nursing were notified.During an interview on 3/3/26 at 3:40 p.m., CNA 4 indicated she did not typically work on the unit that Resident D resides on, so for care questions she had to rely on the other aids that were there most often. She was told that the resident usually had a larger lay down chair that was for bariatric residents. It was a rented chair that the facility no longer rented. The other option was a regular shower chair that did not recline/lay down, which was used for Resident D's shower on 3/3/26. The shower was provided for Resident D and everything was going fine. She indicated she started to dry her off and was going to bring the shower chair forward in the shower towards the heat. The chair that was used had arm rests on it, so she had unlocked the wheels and pulled the arm rests forwards. As soon as she started to pull, the chair tipped forward towards the aid. CNA 4 was able to hold the resident up and then safely lower her to the ground with no injuries. The aide then called for help, and they were able to get the resident into her wheelchair. The chair that was used had the appropriate weight capacity of 400 pounds; however, the resident's shape was not proportionate, and the aide had to reposition her multiple times at first to get her bottom half into the chair correctly. The aide indicated she had checked with the staff again about using the chair because once the resident was sitting in it, she still did not feel the chair was safe to use due to the resident's size and weight distribution in the chair.During an interview on 3/4/26 at 9:59 a.m., Resident D indicated she was dumped from the shower chair yesterday. The shower chair had tipped over on her when the aide went to move her in the shower room. Multiple staff had to come in and get her back into her wheelchair. She had been using a long bed for showering and the facility got rid of it recently. The resident indicated she was refusing to take a shower with that type of chair anymore because she was afraid that she would fall again.During an interview on 3/4/26 at 2:28 p.m., the Social Service Designee indicated the facility had been renting a bariatric lay down shower chair for two to three months and then they decided to purchase a chair. The residents did not like the one that was purchased because it did not have the reclining feature. She indicated she was recently told to rent the old chair again.During an interview on 3/4/26 at 3:28 p.m., the Director of Nursing indicated the facility was looking into buying a bigger shower chair and they were renting one to try out the sizes. They had purchased a new chair and sent the rented chair back. The new chair worked for some of the residents, but not all due to the size of the chair. The facility was going to resume the rental with the bariatric lay down chair.This citation relates to Intake 2724581.410 IAC (Indiana Administrative Code) 16.2-3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure physician's orders were followed related to a fluid restriction for 1 of 1 resident reviewed for hydration. (Resident 52)Finding includes: Resident 52's record was reviewed on 3/4/26 at 11:31 a.m. Diagnoses included, but were not limited to, heart failure.The Quarterly Minimum Data Set (MDS) assessment, dated 12/2/25, indicated the resident was cognitively intact. A Care Plan, revised on 3/3/26, indicated the resident was on a fluid restriction. Interventions included, but were not limited to, fluid restrictions as ordered and monitor and record intake.A Physician's Order, dated 3/1/26, indicated document fluid intake with medication every shift. A Physician's Order, dated 3/2/26, indicated diet: regular and 1,200 milliliters (ml) per day fluid restriction. The Intake: Fluids documentation section indicated the resident had 1,030 ml on 3/1/26, 1,080 ml on 3/2/26, and 900 ml on 3/3/26. The March 2026 Medication Administration Record indicated the resident received 510 ml of fluid on 3/1/26, 540 ml of fluid on 3/2/26, and 360 ml of fluid on 3/3/26 with medication pass. During an interview on 3/5/26 at 8:50 a.m., the Director of Nursing indicated the order needed to be clear on how much fluid each department was to give the resident as that was not specific to reflect 600 ml for nursing and 600 ml for dietary. She had no further information to provide. 410 IAC (Indiana Administrative Code) 16.2-3.1-46(a)

Based on observation, record review, and interview, the facility failed to ensure residents received proper treatment and care related to oxygen administration, implementing physician's orders, and testing for a resident with respiratory symptoms for 2 of 3 residents reviewed for respiratory care. (Residents 32 and 12)Findings include:1.On 3/3/26 at 9:39 a.m. Resident 32 was observed seated at a table in the Main Dining Room. Oxygen was in place via nasal cannula and the portable tank was set at 2 liters. On 3/3/26 at 2:52 p.m. Resident 32 was observed in the Main Dining Room doing a coloring activity. Oxygen was in place via nasal cannula and the portable tank was set at 2 liters. On 3/4/26 at 11:29 a.m. Resident 32 was observed seated at a table in the Main Dining Room. Oxygen was in place via nasal cannula and the portable tank was set at 2 liters. Resident 32's record was reviewed on 3/4/26 at 11:58 a.m. Diagnoses included, but were not limited to, emphysema and asthma. A Physician's Order, dated 3/1/26, indicated oxygen 2-4 liters as needed (PRN) to keep sats above 90%. The Medication and Treatment Administration Records, dated 3/2026, lacked any documentation that the PRN oxygen had been administered or titrated. During an interview on 3/4/26 at 3:29 p.m., the Director of Nursing (DON) was made aware the PRN oxygen had not been signed off as administered. The facility's oxygen administration policy was requested. A facility policy, received as current from the Director of Nursing, titled Oxygen Therapy, indicated .12. Turn on liter flow to the ordered rate. Make residents comfortable. Visit frequently to observe response to oxygen therapy .18. Record oxygen therapy on the treatment or special record and nursing notes if PRN. Include type of catheter, liter flow, and response to treatment .21. Document time, type of oxygen device used, assessment findings, precipitating factors, liter flow, residents' response to procedure, teaching, and level of understanding. 2. On 3/2/26 at 12:20 p.m., Resident 12 was observed laying in her room with eyes closed. She had an intermittent cough. Resident 12's record was reviewed on 3/5/26 at 2:24 p.m. The Quarterly Minimum Data Set assessment, dated 2/2/26, indicated the resident was severely cognitively impaired. A Progress Note, dated 2/17/26 at 1:45 p.m., indicated the resident's appetite was poor, temperature was 99.4 degrees Fahrenheit, skin pale, and cough was noted. She was given Tylenol for comfort. A Physician's Note, dated 2/18/26 at 7:42 p.m., indicated the resident had cough, congestion, no fever, and no respiratory distress. Labs/Data indicated COVID/Flu negative. The assessment indicated viral upper respiratory infection. The plan indicated Robitussin. A Progress Note, dated 2/28/26 at 6:06 a.m., indicated the resident had a moist congested cough. Her lungs had expiratory crackles to the upper left lobe and diminished and the right upper lobe was clear. A Progress Note, dated 3/2/26 at 10:35 p.m., indicated the resident had a cough that was dry and non-productive with diminished lung sounds. The February 2026 Physician Order Summary indicated there were no orders for Robitussin. The record lacked documentation of any COVID/Flu testing completed on 2/18/26 when the cough started. There was a COVID test recorded on 2/25/25 which was negative. During an interview on 3/6/26 at 10:07 a.m., the Director of Nursing indicated she was unable to find documentation of a COVID/Flu test for 2/18/26. There were no orders implemented for Robitussin. The physician was supposed to put that order in himself. 410 IAC (Indiana Administrative Code) 16.2-3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure a resident received adequate supervision and assistance to prevent accidents, related to one staff member (CNA 1) assisting a resident with a shower who was care planned for two staff assistance for activities of daily living (ADL's) resulting in the resident falling in the shower and receiving an abrasion to the right knee and a laceration to the right eyebrow that required four sutures. The resident also had a decline in normal functioning related to ambulation after the fall and was diagnosed eight days later with a fractured right hip for 1 of 3 residents reviewed for accidents and supervision. (Resident D)Finding includes: Resident D's record was reviewed on 11/12/25 at 1:18 p.m. The diagnoses included, but were not limited to, right hip fracture, Alzheimer's disease, dementia, and moderate intellectual disabilities.A Care Plan, dated 7/16/25, indicated a self-care deficit was present related to the impaired cognitive status. The interventions included assistance would be provided with bathing and transfers.A Care Plan, dated 7/16/25, indicated a risk for falls. The interventions included verbal reminders not to ambulate or transfer without assistance would be provided.A Care Plan, dated 10/13/25, indicated a behavior of threatening harm to the staff. On 10/16/25, an intervention of care in pairs was added to the care plan.A Fall Assessment, dated 10/21/25 at 3:59 p.m., indicated a high risk for falls.A Quarterly Minimum Data Set assessment, dated 10/21/25, indicated a severely impaired cognitive status, physical behaviors and rejection of care were present for one to three days and verbal behaviors were present for four to six days. There was no impairment of the upper and lower extremities. Supervision was required for dressing and hygiene. Bathing had been refused. He was independent for bed mobility, sitting to standing, transfer and ambulation.A Nurse's Progress Note, dated 10/23/25 at 6 a.m. and recorded as a late entry on 10/23/25 at 6:51 a.m., indicated the resident had fallen in the shower when he attempted to get out of the shower chair. A laceration above the right eye, four centimeters (cm) by 1 cm was received when he hit his head on the shower chair. A one cm abrasion was noted to the right knee. The resident was transferred to the hospital Emergency Room.A Nurse's Progress Note, dated 10/23/25 at 9:59 a.m., indicated the resident returned from the Emergency Room, four sutures were present on the laceration of the right eyebrow. A CT scan of the head and neck had been completed and were negative for injuries.An Indiana Department of Health (IDOH) reported incident, dated 10/23/25, indicated the incident occurred on 10/23/25 at 6:01 a.m. The resident was in the shower and attempted to stand from the shower chair and fell. The injuries included a one cm abrasion to the right knee and a four cm by one cm laceration to the right eyebrow that required four sutures. First aid was administered at the time of the fall, and the resident was transferred to the hospital Emergency Room. The facility investigation of the fall, dated 10/23/25, indicated the resident was in the shower chair and he attempted to stand. CNA 1 was in front of the resident and attempted to assist him back on the shower chair. The shower chair moved, and he fell on his right knee and buttocks. He also hit his head on the shower chair. CNA 1 was re-educated that the resident was care planned to be care in pairs. The CNA Care Card (care plan interventions), attached to the investigation of the fall, indicated the resident required cares in pairs.A typed statement from CNA 1, dated 10/23/25 and unsigned by CNA 1, indicated the shower had been given so he could go to BINGO. She was drying him off and when she was going to dry his feet, he stood up from the shower chair. She stood in front of him to assist him back in the chair and the shower chair tolled back and he fell on his buttocks and right knee. She thought he hit his head on the shower chair. His head was bleeding, pressure was applied and the nurse was notified.A Rehabilitation Screen form, dated 10/23/25, indicated the resident had been moderately independent and had a fall in the shower. He now complained of right knee and leg pain and was in a wheelchair for safety. A recommendation was given for the physician to look at the leg to rule out injury and then therapy would be provided.A Nurse's Note, dated 10/23/25 at 5:24 p.m., indicated the Physician gave the approval for therapy to evaluate and treat the resident.The Nurses' Progress Notes indicated the following:On 10/24/25 at 3:48 a.m., the resident was able to move all his extremities as usual.On 10/24/25 at 4:48 a.m., he complained of right leg pain and acetaminophen was administered as ordered.On 10/25/25 at 7:57 a.m., the resident was yelling, nurse. He indicated his legs would not work while standing. He refused to walk. A wheelchair was provided.On 10/25/25 at 9:53 a.m., there were no complaints of pain or discomfort from the fall.On 10/26/25 at 10:35 a.m., A CNA reported to the nurse that the resident had complained of pain to the right lower extremity during a transfer. He had been using a wheelchair since he had been out of bed. The resident pointed to his right thigh and the right side of his face when asked about the pain. Acetaminophen was given as ordered by the physician.On 10/26/25 at 12:16 p.m., the resident was hesitant to use his right leg during transfers. He was agitated and tried to stand and stated his leg hurt. On 10/26/25 at 9:47 p.m., the resident had severe pain in the right knee and neck at 9:40 p.m. There was decreased strength and range of motion of the right leg and edema of the right knee and right foot. Acetaminophen was administered as ordered by the physician and the resident was assisted to bed and positioned with his right leg elevated. The physician was notified.On 10/27/25 at 11:54 A.M., the resident was assisted to the bathroom and would not stand. He required two staff to transfer on and off the toilet. He indicated his legs were hurting. The physician was made aware of the pain.On 10/27/25 at 6:35 p.m., an order was received from the physician for a right knee x-ray.On 10/28/25 at 1:31 a.m., the resident complained of right knee pain. A wheelchair was used for mobility. There was no redness or swelling to the right knee.A Physician's Progress Note, dated 10/29/25 at 7:39 p.m., indicated it was very difficult to evaluate the resident related to dementia. He complained of back, right leg, and right knee pain and still had trouble walking. The right leg had full passive range of motion. The right knee x-ray was negative for injuries.A Nurse's Progress Note, dated 11/1/25 at 6:40 a.m., indicated the CNA reported the right leg appeared shorter than the left. There was a discoloration of the right hip of light yellow in color with a purple color in the center and measured six cm by five cm. The resident complained of pain to the right leg when touched. The right leg was shorter than the left and rotated laterally. An order for a right hip x-ray was obtained from the physician and the resident remained non-weight bearing.A right hip x-ray report, dated 11/1/25, indicated a right femoral neck fracture.A Nurse's Progress Note, dated 11/1/25 at 12:38 p.m., indicated a physician's order was obtained to transfer the resident to the hospital.A Hospital Discharge summary, dated [DATE], indicated a right hemiarthroplasty (artificial implant) was completed to the right hip.A Nurse's Progress Note, dated 11/4/25 at 4:30 p.m., indicated the resident was transferred back to the facility from the hospital.An undated investigation of the fall, signed by the Director of Nursing (DON), indicated in a discussion with the physician, there may have been an undiagnosed fracture caused by the fall on 10/23/25 and it had not manifested until 11/1/25.During an interview on 11/12/25 at 1:32 p.m., the DON indicated the CNA who completed the shower should have had someone else with her for care in pairs. The root cause of the right hip fracture was from the fall on 10/23/25.During a telephone interview on 11/12/25 at 2:47 p.m., the physician indicated the fracture could have been caused by the fall on10/23/25. The resident was receiving therapy and was not doing well with the leg pain. Due to the resident's cognitive status, it was hard to determine what all was going on as he could not always tell staff where the pain was located.The facility Fall Prevention and Post-Fall Action policy, dated 7/23/21, was received as current from the DON but was not applicable.This citation relates to Intake 2658600. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure a resident received care in accordance with professional standards of practice related to a lack of assessments with changes in condition after a fall including pain, weight bearing, and ambulation status which delayed treatment for a fractured right hip for 1 of 3 residents reviewed for quality of care. (Resident D)Finding includes:Resident D's record was reviewed on 11/12/25 at 1:18 p.m. The diagnoses included, but were not limited to, right hip fracture, Alzheimer's disease, dementia, and moderate intellectual disabilities.A Quarterly Minimum Data Set assessment, dated 10/21/25, indicated a severely impaired cognitive status, physical behaviors and rejection of care were present for one to three days and verbal behaviors were present for four to six days. There was no impairment of the upper and lower extremities. Supervision was required for dressing and hygiene. Bathing had been refused. He was independent for bed mobility, sitting to standing, transfer and ambulation.A Nurse's Progress Note, dated 10/23/25 at 6 a.m. and recorded as a late entry on 10/23/25 at 6:51 a.m., indicated the resident had fallen in the shower while he attempted to get out of the shower chair. A laceration above the right eye, four centimeters (cm) by 1 cm was received when he hit his head on the shower chair. A one cm abrasion was noted to the right knee. The resident was transferred to the hospital Emergency Room.A Nurse's Progress Note, dated 10/23/25 at 9:59 a.m., indicated the resident returned from the Emergency Room, four sutures were present on the laceration of the right eyebrow. A CT scan of the head and neck had been completed and were negative for injuries.A Rehabilitation Screen form, dated 10/23/25, indicated the resident had been moderately independent and had a fall in the shower. He now complained of right knee and leg pain and was in a wheelchair for safety. A recommendation was made for the physician to look at the leg to rule out injury and then therapy would be provided.A Nurse's Note, dated 10/23/25 at 5:24 p.m., indicated the physician gave the approval for therapy to evaluate and treat the resident.The Nurses' Progress Notes indicated the following:On 10/24/25 at 3:48 a.m., the resident was able to move all his extremities as usual.On 10/24/25 at 4:48 a.m., he complained of right leg pain and acetaminophen was administered as ordered. There was no nursing assessment of the right leg documented on 10/24/25.On 10/25/25 at 7:57 a.m., the resident was yelling, nurse. He indicated his legs would not work while standing. He refused to walk. A wheelchair was provided.There was no nursing assessment of the right leg documented on 10/25/25.On 10/26/25 at 10:35 a.m., A CNA reported to the nurse that the resident had complained of pain to the right lower extremity during a transfer. He has been using a wheelchair since he had been out of bed. The resident pointed to his right thigh and the right side of his face when asked about the pain. Acetaminophen was given as ordered by the physician.There was no nursing assessment of the right leg documented on 10/26/25 after the pain was reported.On 10/26/25 at 12:16 p.m., the resident was hesitant to use his right leg during transfers. He was agitated and tried to stand and stated his leg hurt. There was no nursing assessment of the right leg documented on 10/26/25 when the pain continued.On 10/26/25 at 9:47 p.m., indicated at 9:40 p.m. the resident had severe pain in the right knee and neck. There was decreased strength and range of motion of the right leg and edema of the right knee and right foot. Acetaminophen was administered as ordered by the physician and the resident was assisted to bed and positioned with his right leg elevated. The physician was notified.On 10/27/25 at 11:54 A.M., the resident was assisted to the bathroom and would not stand. He required two staff to transfer on and off the toilet. He indicated his legs were hurting. The physician was made aware of the pain.There was no nursing assessment of the legs documented.On 10/27/25 at 6:35 p.m. an order was received from the physician for a right knee x-ray.A Physician's Progress Note, dated 10/29/25 at 7:39 p.m., indicated it was very difficult to evaluate the resident related to dementia. He complained of back, right leg, and right knee pain and still had trouble walking. The right leg had full passive range of motion. The right knee x-ray was negative for injuries.A Medicare Meeting Report, dated 10/30/25, indicated the resident ambulated with moderate to maximum assistance of one - two staff members with a front-wheeled walker. The gait training indicated he used a front-wheeled walker with moderate to maximum assistance of two staff.A Nurse's Progress Note, dated 11/1/25 at 6:40 a.m., indicated the CNA reported the right leg appeared shorter than the left. There was a discoloration of the right hip of light yellow in color with a purple color in the center and measured six cm by five cm. The resident complained of pain to the right leg when touched. The right leg was shorter than the left and rotated laterally. An order for a right hip x-ray was obtained from the Physician and the resident remained non-weight bearing.A right hip x-ray report, dated 11/1/25, indicated a right femoral neck fracture.A Nurse's Progress Note, dated 11/1/25 at 12:38 p.m., indicated a physician's order to transfer the resident to the hospital.A Hospital Discharge summary, dated [DATE], indicated a right hemiarthroplasty (artificial implant) was completed to the right hip.A Nurse's Progress Note, dated 11/4/25 at 4:30 p.m., indicated the resident was transferred back to the facility from the hospital.During an interview on 11/12/25 at 2:29 p.m., Physical Therapist (PT) 1 indicated the resident had pain with flexion of the right hip. There was an x-ray of the right knee that showed no fracture. He would complain of pain in the right leg from the mid-thigh down past the knee. He was able to bear weight and could walk 10 feet with maximum assistance of two. His gait had a limp, which was not normal for him. Before the fall he was independent with ambulation. There was a big discrepancy in his status after the fall. His complaints of pain would vary, one day he didn't have pain, the next day he would. There was range of motion to the right knee though it was limited due to the pain. He required two staff to transfer him and some days he would not bear any weight.During an interview on 11/12/25 at 2:47 p.m., the Director of Nursing (DON), indicated she had only asked for the right knee to be x-rayed because this is what he had hurt when he fell. She acknowledged no further assessments had been completed by the nurses when the right leg pain increased and the functional status of the right leg had changed until 11/1/25.This citation relates to Intake 2658600.3.1-37

Based on observation, record review, and interview, the facility failed to ensure a resident with a pressure ulcer received the necessary treatment and services to promote healing related to a treatment not implemented timely for 1 of 3 residents reviewed for pressure ulcers. (Resident 30) Finding includes: On 1/24/25 at 1:38 p.m., the resident's left foot DTI (deep tissue injury) was observed with LPN 1. There was a small circular dark purple area about 1 cm (centimeter) x 1 cm to the bottom lateral side of the foot. The resident's record was reviewed on 1/23/25 at 1:08 p.m. Diagnoses included, but were not limited to, hypertension, cerebral infarction, and Alzheimer's disease. The Admission Minimum Data Set (MDS) assessment, dated 11/29/24, indicated the resident was cognitively impaired and had a current unhealed pressure ulcer/DTI. A Care Plan, updated 12/2/24, indicated the resident had a DTI to his left lateral foot. The interventions included to treat per Physician's order. A Progress Note, dated 11/22/24 at 1:42 p.m., indicated the resident was a new admission to the facility. A dark brownish purple area was noted to his left foot. The Admission Observation, dated 11/22/24, indicated the resident had a pressure ulcer injury to the left foot outer aspect. It was brownish purple in color and measured at 0.8 cm x 3 cm. A Progress Note, dated 11/26/24 at 6:22 p.m., indicated a dry red maroon discoloration was observed to the resident's left outer foot. The edges were starting to lift. A new order was received for skin prep daily. A Physician's Order, dated 11/26/24, indicated to apply skin prep to the left outer plantar DTI daily. The Treatment Administration Record (TAR), dated 11/2024, lacked any treatment to the left lateral foot from 11/22/24, when the area was first noted, through 11/26/24. The skin prep treatment was first documented as completed on 11/27/24. During an interview on 1/23/25 at 2:15 p.m., the Director of Nursing (DON) indicated they should have put a treatment in place when they had identified the DTI upon admission. A facility policy, titled Skin Condition and Pressure Ulcer Assessment, indicated, .7. At the earliest sign of a pressure or other type of ulcer, or skin tear, resident, legal representative, and attending physician will be notified. The Director of Nursing will be notified daily using 24-hour condition report. The size and description will also be described in the nursing notes and a pressure or non-pressure event will be completed in the EMR . 3.1-40(a)(2)

Based on observation, record review, and interview, the facility failed to ensure fall precautions were in place for a resident with a history of falls for 1 of 3 residents reviewed for accidents. (Resident 52) Finding includes: On 1/21/25 at 11:23 a.m., Resident 52 was observed lying in bed. Her wheelchair was at her bedside. There were no anti-rollback bars noted to her wheelchair. On 1/22/25 at 2:53 p.m., Resident 52 was observed seated in her wheelchair in the hall near the Nurse's Station. There were no anti-rollback bars noted to her wheelchair. On 1/23/25 at 9:56 a.m., Resident 52 was observed seated in her wheelchair at the Nurse's Station. There were no anti-rollback bars noted to her wheelchair. The record for Resident 52 was reviewed on 1/22/25 at 1:14 p.m. Diagnoses included, but were not limited to, dementia with behavioral disturbance, anxiety disorder, and hypertension. The Significant Change Minimum Data Set (MDS) assessment, dated 12/26/24, indicated the resident was cognitively impaired. She had one fall with no injury since the prior assessment and required partial to moderate staff assistance with bed mobility. A Care Plan, updated 12/31/24, indicated the resident was at risk for falls due to weakness and impaired mobility. An intervention, dated 11/26/24, indicated anti-roll back bars to wheelchair. A Progress Note, dated 11/25/24 at 11:44 a.m., indicated the resident was found sitting on the floor in the dining room. She was assisted back to her wheelchair by staff. The cameras were reviewed, and she had scraped her back and head on the table when she fell . An IDT (interdisciplinary team) note, dated 11/26/24 at 9:58 a.m., indicated the team had reviewed the resident's fall and anti-rollback bars had been applied to her wheelchair for safety. During an interview on 1/23/25 at 10:46 a.m., the Director of Nursing (DON) indicated there should have been anti-rollback bars on the resident's wheelchair. A facility policy, titled Fall Prevention, indicated, .The Interdisciplinary Team will use their initial assessment to determine how to provide the safest environment for each patient. Safety interventions will be initiated as needed for each patient .II. Fall risk interventions include: .F. Implement patient targeted interventions to reduce risk . 3.1-45(a)

Based on observation, record review, and interview, the facility failed to ensure residents received proper treatment and care related to oxygen administration for 1 of 2 residents reviewed for respiratory care. (Resident 4) Finding includes: On 1/21/25 at 2:36 p.m., Resident 4 was observed seated in his wheelchair in the hallway outside his room. He had no oxygen in place. On 1/22/25 at 2:52 p.m., Resident 4 was observed seated in his wheelchair in the hallway outside his room. He had no oxygen in place. On 1/23/25 at 9:55 a.m., Resident 4 was observed seated in his wheelchair in the therapy room. He had no oxygen in place. Record review for Resident 4 was completed on 1/22/25 at 1:17 p.m. Diagnoses included, but were not limited to, congestive heart failure, chronic respiratory failure, and type 2 diabetes mellitus. The Annual Minimum Data Set (MDS) assessment, dated 1/7/25, indicated the resident was cognitively impaired and received oxygen therapy. A Care Plan, updated 1/7/25, indicated the resident had heart failure and chronic respiratory failure with a history of a pulmonary nodule. The interventions included to administer oxygen as ordered and as needed. A Care Plan, updated 1/7/25, indicated the resident was at risk for respiratory distress related to respiratory failure and hypoxia. The interventions included to administer oxygen as ordered. The Physician's Order Summary, dated 1/2025, indicated an order for oxygen 2-4 L (liters) per nasal cannula every shift. There were no other instructions or parameters listed. A Progress Note, dated 1/6/25 at 8:52 p.m., indicated the resident had a diagnosis of chronic respiratory failure with hypoxia and had an order for oxygen 2-4 L, which he refused during the day and sometimes at night. A Progress Note, dated 1/7/25 at 7:14 p.m., indicated the resident had a diagnosis of chronic respiratory failure and was oxygen dependent during the night only. The Medication Administration Record (MAR), dated 1/2025, indicated the oxygen had been signed off as administered every shift. An oxygen saturation was documented every shift, but the rate of oxygen administered was not documented. There were not any documented refusals. During an interview on 1/23/25 at 11:13 a.m., the Director of Nursing indicated she had updated the Physician, and the oxygen orders were now PRN (as needed). A facility policy, titled Oxygen Therapy, indicated, .12. Turn on liter flow to the ordered rate .18. Record oxygen therapy on the treatment or special record and nursing notes if PRN. Include type of catheter, liter flow, and response to treatment . 3.1-47(a)(6)

Based on observation, record review and interview, the facility failed to attempt alternative measures and assess the necessity for bed rails for 1 of 1 resident reviewed for bed rails. (Resident 52) Finding includes: On 1/21/25 at 11:23 a.m., Resident 52 was observed lying in bed. There were half length side rails to the top of the bed on both sides. On 1/21/25 at 1:41 p.m., Resident 52 was observed lying in bed. There were half length side rails to the top of the bed on both sides. The record for Resident 52 was reviewed on 1/22/25 at 1:14 p.m. Diagnoses included, but were not limited to, dementia with behavioral disturbance, anxiety disorder, and hypertension. The Significant Change Minimum Data Set (MDS) assessment, dated 12/26/24, indicated the resident was cognitively impaired. She required partial to moderate staff assistance with bed mobility, was receiving hospice services, and bed rails were not used as a physical restraint. A Care Plan, updated 12/31/24, indicated the resident was at risk for falls due to weakness and impaired mobility. An intervention, dated 11/26/24, indicated to provide with safety device or appliance as needed. The Physician's Order Summary, dated 1/2025, lacked any orders for side rails. There was a lack of any evaluation or assessment completed for the use of side rails. During an interview on 1/23/25 at 11:13 a.m., the Director of Nursing (DON) indicated she was unable to find any assessment for the side rails but would have one completed now. She was unsure if any other interventions had been attempted prior to the side rails. On 1/24/25, the DON provided a Side Rail Assessment, dated 1/23/25. The bilateral top half side rails were to be used when in bed for assistance with transfers and bed mobility. A facility policy, titled Side Rails, indicated, .2. An assessment will be performed to determine if full length side rails are needed to treat medical symptoms. Use of full side rails require a Physician's Order. A one half side rail will be used in accordance with assessed need and resident desires . 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure residents were treated with dignity, related to urinary drainage bags not covered, for 2 or 4 residents reviewed for dignity. (Residents C and D) Findings include: 1. Resident C was observed on 10/18/24 at 4:19 a.m., 4:34 a.m., and 5:49 a.m. lying in bed. The urinary drainage bag was attached to the side of the bed closest to the door. The urinary drainage bag was uncovered with urine present and visible in the bag. Resident C's record was reviewed on 10/18/24 at 1:31 p.m. The diagnoses included, but were not limited to, cerebral palsy and moderate intellectual disabilities. A Quarterly Minimum Data Set (MDS) assessment, dated 9/29/24, indicated a moderately impaired cognitive status, was dependent for activities of daily living, and had an indwelling urinary catheter. 2. Resident D was observed asleep in bed at 4:30 a.m. The urinary catheter drainage bag was attached to the bed frame on the side of the bed and was uncovered with urine present and visible in the bag. During an observation on 10/18/24 at 4:52 a.m., Resident D was awake and sitting on the side of the bed. The urinary drainage bag remained attached and uncovered on the side of the bed. There was urine present and visible in the bag. CNA 1 entered the room and asked the resident if he would like to get out of bed or lie back down. Resident D opted to get up for the day. After morning care had been completed by CNA 1, She placed the urinary drainage bag under the wheelchair seat next to the urinary drainage bag cover and assisted the resident to the common area across from the Nurses' Station. During an interview on 10/18/24 at 5:15 a.m., LPN 2 indicated the urinary drainage bag was to be placed in the urinary drainage bag cover. Resident D's record was reviewed on 10/18/24 at 2:10 p.m. The diagnoses included, but were not limited to, dementia, history of urinary tract infections, and urinary retention. An Admission MDS assessment, dated 9/27/24, indicated a moderately impaired cognitive status, supervision was required for oral hygiene and hygiene and moderate assistance was required for bathing. An indwelling urinary catheter was present. A facility urinary catheter care policy, dated January 2013 and received from the Director of Nursing as current, indicated catheter covers/dignity bags were to be used to preserve the resident's dignity and privacy. 3.1-3(t)

Based on observation, record review, and interview, the facility failed to ensure residents who required assistance with activities of daily living (ADL's) received oral care and assistance with placement of eyeglasses for 2 of 3 residents reviewed for ADL's. (Residents B and D) Findings include: 1. During an observation on 10/18/24 at 6:30 a.m., CNA 3 and CNA 4 entered Resident B's room. CNA 3 washed the resident's face and checked to ensure she had not been incontinent of urine or bowel. A mechanical lift was used to transfer the resident from the bed to the Broda Chair (reclining chair). Her hair was brushed and the glasses were cleaned and applied. Oral care had not been completed. Resident B's record was reviewed on 10/18/24 at 9:07 a.m. The diagnoses included, but were not limited to, Alzheimer's disease. An Annual Minimum Data Set (MDS) assessment, dated 10/8/24, indicated long and short term memory problems and was dependent on staff for hygiene and oral hygiene. A Care Plan, dated 10/9/24, indicated a deficit in self care. The interventions indicated the staff were to assist with oral care twice daily. 2. During an observation on 10/18/24 at 4:52 a.m., CNA 1 provided morning care to Resident D. The resident's face and underarms were washed and incontinent care had been provided. He was dressed in clean clothing and assisted out to the common area by CNA 1. Oral care had not been completed and eyeglasses were not placed on the resident. The resident was observed with natural bottom teeth. Resident D's record was reviewed on 10/18/24 at 2:10 p.m. The diagnoses included, but were not limited to, dementia, history of urinary tract infections, and urinary retention. An Admission MDS assessment, dated 9/27/24, indicated a moderately impaired cognitive status, supervision was required for oral hygiene and hygiene and moderate assistance was required for bathing. The vision was adequate with corrective lenses. The Resident Care Card, identified as current by CNA 1 on 10/18/24 at 5:15 a.m., indicated the resident was to wear glasses. A Care Plan, dated 9/20/24, indicated a deficit in self-care. The interventions indicated assistance would be provided for oral care for his upper denture and lower natural teeth twice a day and as needed. During an interview on 10/18/24 at 10:36 a.m., the Director of Nursing indicated oral care was to be provided daily with morning care. During an interview on 10/18/24 at 3:29 p.m., CNA 5 indicated the resident would sometimes refuse to wear his glasses. An undated oral hygiene policy, received from the Director of Nursing as current on 10/18/24 at 1:17 p.m., indicated oral hygiene was to be completed for the teeth, gums, and mouth. Oral hygiene was an essential part of the morning and evening care. An undated morning care policy, received from the Director of Nursing as current on 10/18/24 at 1:17 p.m., indicated the resident was to be assisted with oral hygiene and eyeglasses were to be cleaned and placed on the resident. This citation relates to Complaint IN00444647. 3.1-38(a)(3) 3.1-38(a)(3)(C)

Based on observation, record review, and interview, the facility failed to ensure a resident with a urinary catheter and history of urinary tract infections received proper care and services related to improper placement of the urinary catheter drainage bag and tubing, catheter care not completed, and the outlet tube was not disinfected after emptying the urinary drainage bag, for 1 of 2 residents reviewed for urinary catheters. (Resident D) Finding includes: During an observation on 10/18/24 at 4:52 a.m., Resident D was awake and sitting on the side of the bed. CNA 1 entered the room and asked the resident if he would like to get out of bed or lie back down. Resident D opted to get up for the day. The urinary drainage bag on the side of the bed contained a large amount of clear yellow urine. CNA 1 unattached the urinary drainage bag from the side of the bed and placed the bag on the floor. She changed the resident's pants and each time after threading the catheter through the leg of the pants, the drainage bag was placed on the floor. The urinary drainage bag laid on the floor throughout the morning care and CNA 1 had stepped over the urinary drainage bag on the floor several times during the morning care. The catheter tubing was also on the floor and the resident was observed rolling the tubing with his foot. CNA 1 then placed the plastic urine measuring container on the floor and opened the outlet tube and drained the urine from the bag. After 850 cubic centimeters of urine was drained, the outlet tubing was clamped and returned to the holder on the drainage bag without being disinfected. The resident stood up on the side of the bed. The brief was soiled with bowel movement. CNA 1 washed the buttocks and placed a clean incontinent brief on the resident and completed dressing the lower part of his body. The urinary catheter was not washed. The resident was then assisted to the wheelchair. CNA 1 placed the urinary drainage bag under the wheelchair seat. The catheter tubing was on the floor. At the time of the observation, CNA 1 indicated she was unsure if the catheter tubing could be touching the floor and stated, it usually is. She then assisted the resident in the wheelchair to the Nurses' Station, with the catheter tubing still on the floor. During an interview on 10/18/24 at 5:15 a.m., LPN 2 indicated the catheter tubing was not to be touching the floor. Resident D's record was reviewed on 10/18/24 at 2:10 p.m. The diagnoses included, but were not limited to, dementia, history of urinary tract infections, and urinary retention. An Admission Minimum Data Set assessment, dated 9/27/24, indicated a moderately impaired cognitive status, supervision was required for oral hygiene and hygiene and moderate assistance was required for bathing. An indwelling urinary catheter was present. A Care Plan, dated 9/20/24, indicated a there was a risk for infections related to an indwelling catheter. The interventions indicated, the urinary drainage bag was to be stored in a protective bag, the drainage system was not to touch the floor, and catheter care was to be completed every shift and as needed. A facility urinary catheter care policy, dated January 2013 and received from the Director of Nursing as current, indicated the urinary drainage bags and tubing were to be positioned to prevent touching of the floor. The outlet tubes were to be disinfected with an antiseptic after emptying the drainage tube. The resident was to receive perineal and catheter care with soap and water at least twice daily. 3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to ensure correct Personal Protective Equipment (PPE) was used by a staff members (CNA 1 and CNA 6) when providing care to residents (Residents D and C) who were in Enhanced Barrier Precautions (EBP) for two random observations for infection control. Findings include: 1. During an observation on 10/18/24 at 4:52 a.m., CNA 1 entered Resident D's room and prepared to start the morning care without any PPE being worn. CNA 1 was stopped before care was started. CNA 1 indicated if the resident was on EBP, there was usually a cart outside of the room. She acknowledged a sign above the bed, which indicated the resident was on EBP. CNA 1 then donned the PPE and began the morning care. Resident D's record was reviewed on 10/18/24 at 2:10 p.m. The diagnoses included, but were not limited to, dementia, history of urinary tract infections, and urinary retention. An Admission Minimum Data Set (MDS) assessment, dated 9/27/24, indicated a moderately impaired cognitive status, supervision was required for oral hygiene and hygiene and moderate assistance was required for bathing. An indwelling urinary catheter was present. A Care Plan, dated 10/4/24, indicated EBP was required. The interventions included PPE would be used when care was provided. A sign would be placed outside the door that indicated EBP was required. The staff were to wear gown and gloves while care was provided and a face shield was to be worn if needed. A Physician's Order, dated 10/1/24, indicated enhanced barrier precautions were ordered. 2. During an observation on 10/18/24 at 5:49 a.m., CNA 6 prepared to complete morning care for Resident C without any PPE being worn. CNA 6 was stopped prior to the start of the care. She acknowledged a sign on the wall above the bed that indicated the resident was on EBP. She then donned a gown and gloves. Resident C's record was reviewed on 10/18/24 at 1:31 p.m. The diagnoses included, but were not limited to, cerebral palsy, moderate intellectual disabilities. A Quarterly MDS assessment, dated 9/292/4, indicated a moderately impaired cognitive status, was dependent for all activities of daily living, and an indwelling catheter was present. A Care Plan, dated 10/4/24, indicated EBP was required. The interventions included PPE would be used when care was provided. A sign would be placed outside the door that indicated EBP was required. The staff were to wear gown and gloves while care was provided and a face shield was to be worn if needed. A Physician's Order, dated 10/1/24, indicated enhanced barrier precautions were ordered. During an interview on 10/18/24 at 2:20 p.m., the Director of Nursing indicated the signs for EBP had been moved to above the residents' beds to make it a little more confidential. A facility EBP policy, dated August 2024, and received from the Director of Nursing as current, indicated EBP was to be used during high contact activities, which included hygiene and bathing activities. EBP was to be used if the resident had an indwelling device, which included indwelling urinary catheters. Gowns and gloves would be available near or outside the resident's room. 3.1-18(b)

Based on observation, record review, and interview, the facility failed to ensure a care plan was reviewed and revised to include changes related to splint use for a resident with contractures for 1 of 16 resident care plans reviewed. (Resident 35) Finding includes: On 1/8/24 at 9:54 a.m., Resident 35 was observed in his bed. Both hands were contracted at the wrist (a fixed tightening of muscles that prevents normal movement of associated body part) and there were no splints in place. A sign above the bed indicated to place splints on both hands/arms in the morning and after dinner for 2-3 hours, unless he asked for them off. On 1/9/24 at 8:50 a.m. and 2:14 p.m., 1/10/24 at 8:32 a.m. and 9:58 a.m., the resident was observed without splints on his hands. The resident's record was reviewed on 1/10/24 at 8:40 a.m. Diagnoses included, but were not limited to, cerebral palsy, moderate intellectual disabilities and contracture of muscle multiple sites. The Quarterly Minimum Data Set assessment, dated 9/20/23, indicated the resident was cognitively intact, and was dependent on staff assistance for all ADLs (activities of daily living). The current ADL Functional Status/ Rehabilitation Potential Care Plan indicated the resident had self care deficit related to impaired mobility and impaired cognitive abilities and weakness secondary to cerebral palsy with multiple contractures. Interventions included, but were not limited to, assist with repositioning and bed mobility, and assist with eating and drinking fluids. There was no intervention related to assisting with splint application. During an interview with RN 1 on 1/10/24 at 9:58 a.m., she indicated she was not aware if the resident wore splints. During an interview with Occupational Therapy Assistant 1 at that same time, she indicated the resident was supposed to wear the splints for 2-3 hours a day unless he declined. During an interview with the Director of Nursing on 1/10/24 at 10:09 a.m., she indicated Physician's Orders would be updated to include the splints and the care plan would be updated. 3.1-35(e)

Based on observation, record review, and interview, the facility failed to ensure treatment orders were followed resulting in the deterioration of a pre-existing wound, the development of a new wound, and lack of treatment for [REDACTED]. (Resident 16) Finding includes: During a confidential interview on 2/14/17 at 11:17 a.m., an employee indicated Resident 16 was being treated for [REDACTED]. The clinical record for Resident 16 was reviewed on 2/14/17 at 11:22 a.m. [DIAGNOSES REDACTED]. The Significant Change MDS (Minimum Data Set) assessment, completed on 1/26/17, indicated the resident was cognitively impaired, was totally dependent on two staff for transfers, needed extensive assist of two staff with bed mobility and toileting, and was incontinent of bowel and bladder. An initial wound assessment was competed on 1/5/17 at 3:43 a.m., indicating an area measuring 0.3 cm x 0.0 cm (centimeters) was observed to the right outer ankle with edges even and attached. [MEDICAL CONDITION] (swelling) was surrounding the wound bed. The wound bed was intact, dark red skin color, and there was no drainage present. A wound note, dated 1/9/17 at 2:36 a.m., indicated the open area to the right outer ankle measured 0.2 cm x 0.3 cm. Edges were even and attached, wound bed with 100% intact dull dark red scab. There was no drainage. A physician's orders [REDACTED]. A Nurse's progress note, dated 1/11/17 at 3:36 p.m., indicated an Unna's boot was applied to the resident's leg. A wound note, dated 1/17/17 at 2:13 a.m., indicated the right outer ankle was wrapped in an Unna's boot. The record lacked documentation of any assessment of the wound. A wound note, dated 1/24/17 at 2:01 a.m., indicated the right outer ankle continued to be wrapped in an Unna's boot. The record lacked documentation of any assessment of the wound. A wound note, dated 1/31/17 at 2:55 a.m., indicated the right outer ankle continued to be wrapped in an Unna's boot as ordered. Record lacked documentation of any assessment of the wound. A Nurse's progress note, dated 2/2/17 at 2:10 p.m., indicated a CNA notified the nurse the dressing to the resident's right ankle was seeping. The area was assessed, cleansed with normal saline (a clear, sterile solution) and wrapped with kerlix (a gauze wrap). The area measured 2.4 x 2.0 cm, a foul odor and a moderate amount of brown drain were noted. A Nurse's progress note, dated 2/2/17 at 2:15 p.m., indicated the CNA notified the nurse of drainage on the Unna's boot. The boot was removed, an open area was measuring 1.0 x 0.5 cm was observed. The wound bed was red with a moderate amount of drainage. The edges were macerated (an area that is softened or become softened by soaking in a liquid). The doctor was notified at that time. A Nurse's progress note, dated 2/3/17 at 8:15 a.m., indicated the right foot was wrapped with kerlix and heel protectors were placed. The doctor was aware but no orders were given. A Nurse's progress note, dated 2/4/17 at 1:28 p.m., indicated the physician saw the resident's wounds and the resident had pressure areas to the right malleolus (a bony projection on either side of the ankle) and right lateral foot. An order was noted for [MEDICATION NAME] (used as a wound gel for its antibacterial and dead tissue-removing properties) to the wound bed with a kerlix wrap every other day. A wound note, dated 2/7/17 at 2:53 a.m., indicated the open area to the right heel measured 1.6 x 1.4 x >0.1 cm. The edges were even and attached with a dull red discoloration surrounding the wound bed. The wound bed was 95% red beefy granulation (new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process) and 5% yellow tissue. A small amount of serosanguineous (clear fluid and blood) drainage was noted with no odor. The area was cleansed with NS (normal saline) and [MEDICATION NAME] was applied to the wound bed, then covered with a non-adherent pad and secured with kerlix. A wound note, dated 2/07/17 at 2:58 a.m., indicated the open area to the outer ankle measured 2.0 x 1.8 x 0.4 cm. The edges were defined and unattached with dull red discoloration surrounding wound bed, wound bed with 85% green slough (dead tissue), 10% red beefy granulation and 5% dark black discoloration. A moderate amount of serosanguineous drainage was observed with no odor present. The area was cleansed with NS and [MEDICATION NAME] blue (an absorptive pad that prevents bacterial from growing) to the wound bed, the area was covered with non-adherent pad and secured with kerlix. The TAR (Treatment Administration Record) was reviewed and indicated the treatment for [REDACTED]. The record lacked a wound treatment for [REDACTED]. [MEDICATION NAME] blue was ordered for the open area to the right ankle on 2/10/17. A wound note, dated 2/14/17 at 12:44 a.m., indicated the open area to the right heel wound measured 1.0 x 1.5 x 0.1 cm. The edges were defined and unattached with pink surrounding the wound bed. The wound bed was red beefy granulation and 25% yellow tissue. A small amount of serosanguineous drainage was observed with no odor present. The area was covered with a non-adherent pad then wrapped with kerlix. A wound note, dated 2/14/17 at 12:46 a.m., indicated the open area to the right outer ankle measured 2.4 x 2.3 x 0.3 cm. The edges were defined and unattached with pink skin surrounding wound bed. The wound bed was 75% green slough, 25% pink tissue. A small amount of [MEDICAL CONDITION] (clear drainage with puss) drainage present with no odor present. The area was cleaned with NS and [MEDICATION NAME] blue was applied to the wound bed it was wrapped with kerlix. On 2/15/17 at 9:01 a.m., wound care was observed. Wound measurements and assessment were consistent with the the wound nurse's previous assessment. Interview with the DON (Director of Nursing) on 2/14/17 at 1:15 p.m., indicated she was aware of the wounds to the resident's right foot and the Unna's boot should have been removed on 1/23/17 per order, but was not removed until 2/2/17. The wound nurse should also have removed the Unna's boot to complete weekly wound measurements and treatments to the area. Interview with the Wound Nurse on 2/15/16 at 2:10 p.m., indicated she had not removed the Unna's boot to assess the wound because day shift had applied them and she did not want to remove them. She further indicated the boots should have been removed to complete an assessment and weekly measurements were not completed per policy and should have been. A policy titled, Non-decubitus Skin Conditions, dated January 2016, was provided by the DON on 2/16/17 at 3:54 p.m. The policy indicated . Responsibility: Licensed Nurse or QMA (Qualified Medication Aid) under the supervision of Licensed Nurse . Procedure: 1. Upon identification of a skin tear, an ecchymotic (bruised) area, a skin rash, or blister .5. Physician and responsible party are to be notified initially. 6. Weekly evaluation of identified areas is to be done and recorded. 3.1-40(a)(2)