Every finding on record at Glen Oaks Health Campus

Based on observation, interview, and record review, the facility failed to report a fall with injuries of unknown source, to the Indiana Department of Health, for 1 of 3 residents reviewed for reporting. (Resident B) Findings include:The clinical record for Resident B was reviewed on 4/27/26 at 12:25 p.m. The diagnoses included, but were not limited to, pulmonary embolism (blockage in a lung artery), prosthetic heart valve, and hyperlipidemia (abnormally high fats/cholesterol in the blood). The admission Minimum Data Set (MDS) assessment, dated 2/27/26, indicated Resident B was cognitively intact, used a walker/wheelchair for ambulation, required partial/moderate assistance with toileting, and was at risk for falls. A progress note, dated 4/16/26 at 6:15 a.m., indicated Resident B was found on the floor in the bathroom without a pulse with a small amount of blood noted under Resident B's head. During an interview with the Director of Health Services (DHS) and Executive Director (ED) on 4/28/26 at 11:53 a.m., they indicated Resident B had a small laceration to her forehead after the fall and with the medical director indicated the resident's fall was from a cardiac event, they did not report it to the department of health. During an interview with the Coroner on 4/28/26 at 2:25 p.m., the Coroner indicated he was called by EMS (Emergency Medical Services) the morning of 4/16/26, and told he did not need to investigate the scene because nothing was suspicious or un-natural about the death, but once the family had got to view her body more thoroughly at the funeral home, they found what appeared to be a quarter to half dollar shaped deep laceration to the left side of the resident's forehead. Photos of Resident B were provided by Funeral Director 12 on 4/29/26 at 12:43 p.m. The photos indicated there was a deep cut on the middle left side of forehead before the hair line where there was a quarter sized area where tissue and blood were visible. Funeral Director 12's written report, dated 4/20/26, indicated the Funeral Director Intern who arrived to pick up Resident B's body noticed a clear shower cap was placed over the residents head. Upon examining it further found a large open wound to Resident B's forehead above the left eye. The injury was approximately 2 inches in diameter and exposed the skull. This Citation relates to intake 2988395.

Based on interview and record review, the facility failed to supervise a resident in the restroom who was high risk for falls, resulting with the resident having a fall, for 1 of 3 residents reviewed for accidents. (Resident B) Findings include:The clinical record for Resident B was reviewed on 4/27/26 at 12:25 p.m. The diagnoses included, but were not limited to, chronic congestive heart failure (long-term condition where the heart's pumping efficiency decreases, causing blood back up, fluid to accumulate in tissues, and insufficient oxygen delivery to organs), atherosclerotic heart disease (condition where plaque builds up in the heart's arteries), and type 2 diabetes mellitus. The admission Minimum Data Set (MDS) assessment, dated 2/27/26, indicated Resident B was cognitively intact, used a walker/wheelchair for ambulation, required partial/moderate assistance with toileting, and was at risk for falls. A progress note, dated 4/16/26 at 6:15 a.m., indicated Resident B was found on the floor in the bathroom without a pulse. A witness statement, dated 4/16/26, indicated Licensed Practical Nurse (LPN) 5 assisted Resident B to the toilet and left the resident alone to finish. The LPN instructed the resident to use the call light when she was finished. During an interview on 4/27/26 at 12:00 p.m., Certified Resident Care Assistant (CRCA) 3 indicated she was doing her rounds the morning of 4/16/26 around 6:15 a.m. to 6:20 a.m., she found Resident B lying on the floor unresponsive in the bathroom. CRCA 3 indicated she was unaware that Resident B was in the bathroom, but the resident would use the call light for help. CRCA 3 indicated Resident B's call light was not on. During an interview with Registered Nurse (RN) 4 on 4/27/26 at 12:21 p.m., the RN indicated she was called to Resident B's room around 6:15 a.m. by CRCA 3 and found Resident B on the floor in the bathroom unresponsive. A family interview was conducted on 4/27/26 at 10:35 a.m. The family member indicated when they received the call about Resident B's passing, the nurse on the phone told them she had only left Resident B for 5 minutes. A plan of care, dated 2/23/26, indicated Resident B was at risk for falls related to weakness. The interventions included, but were not limited to, staff to assist with transfers as needed. A Fall Management Guidelines policy was provided by the Executive Director (ED) on 4/28/26 at 12:24 p.m. It indicated,.mitigate fall risk factors and implement preventative measures. This Citation relates to intake 2988395 410 IAC (Indiana Administrative Code) 3.1-45(a)

Based on observation, interview, and record review, the facility failed to timely dispose of outdated food and to ensure refrigerated items were not open to air with the potential to affect 53 of 53 residents residing at the facility.Findings include: On 11/18/25 at 11:00 a.m., the facility kitchen was observed with the Dietary Manager (DM). The walk-in refrigerator was observed to have a large roll of ground beef labeled with a date received of 10/24/25. The DM indicated the roll of ground beef had not been pulled from the freezer. The plastic casing of the ground beef roll indicated to use or freeze by 11/2/25. The DM indicated the ground beef would be thrown away. On 11/21/25 at 11:45 a.m., the walk-in refrigerator was observed with the DM. The walk-in refrigerator had a rack with multiple trays of bacon, a pan of chocolate cake, and trays with slices of cherry pie. All the trays were unwrapped and open to air. The dietary manager indicated that the cherry pie was for dinner that evening. The chocolate cake was from the day before, and the bacon was prepped for the next morning. The trays were not covered with plastic wrap. On 11/21/25 at 2:00 p.m., the Nurse Consultant (NC) provided the Storage Policy, last revised 7/10/25, that read .Food and supplies shall be properly stored to keep foods safe and preserve flavor, nutritive value, and appearance .Refrigerated Storage . Food is covered, dated and stored loosely to permit air circulation . 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to maintain infection control practices by administering a pill medication that had been dropped on a medication cart and picked up with their bare hands, and ensure hand hygiene was performed prior to donning gloves for 8 of 20 randomly observed medication administrations. ( Resident 4, Resident 10, Resident 28, Resident 40, Resident 51, Resident 53, Resident 56 and Resident 65) Findings include: 1 The clinical record for Resident 65 was reviewed on 11/20/25 at 11:26 a.m. The resident's diagnosis included, but was not limited to, heart failure. On 11/21/25 at 11:26 a.m., Registered Nurse (RN) 28 was observed administering medications to Resident 65. RN 28 performed hand hygiene using alcohol-based hand gel (ABHG) and prepared Resident 65's medications for administration. RN 28 entered Resident 65's room and administered the oral medications. She then assessed Resident 65's lungs using a stethoscope to listen to lung sounds. RN 28 picked up the plastic bag that contained the nebulizer set, sat the bag on the bedside table and went to the bathroom and donned a pair of gloves. RN 28 did not perform hand hygiene prior to donning the gloves. RN 28 then dispensed the nebulizer medication into the nebulizer handset, turned on the machine and handed the nebulizer handset to Resident 28. RN 28 doffed the disposable gloves and left the room. RN 28 performed hand hygiene using ABHG when she returned to the medication cart. 2. The clinical record for Resident 53 was reviewed on 11/12/25 at 11:34 a.m. The resident's diagnosis included, but was not limited to, diabetes. On 11/21/25 at 11:34 a.m., RN 28 was observed administering medications to Resident 53. RN 28 performed hand hygiene using ABHG and prepared Resident 53's medications. RN 28 entered Resident 53's room and administered the oral medications. She then obtained a pair of gloves and a paper towel from the bathroom. RN 28 put the paper towel on the bedside table and removed and prepared to obtain Resident 53's blood sugar. RN 28 donned the pair of gloves and performed the blood sugar check. RN 28 did not perform hand hygiene prior to donning the gloves. After the blood sugar was obtained, RN 28 removed the items used to check the blood sugar and doffed the gloves. She gathered the items and left the room. RN 28 performed hand hygiene when she returned the medication cart. 3.The clinical record for Resident 40 was reviewed on 11/19/25 at 10:00 a.m. The diagnoses for Resident 40 included, but were not limited to, epilepsy. An observation was made of a medication administration for Resident 40 with Registered Nurse (RN) 10 on 11/20/25 at 10:52 a.m. RN 10 was observed at the medication cart preparing the resident's oral medication and eye drops. During that time, RN 2 had donned gloves at the medication cart. She was observed touching her hair with her gloved hands. She then went to the resident's room and knocked on the door with her gloved hands. After, she administered the resident's medications and eye drops to the resident. There was no observation RN 10 had utilized hand hygiene prior to donning on her gloves nor changing of the gloves prior to the administration of the medications. 4. The clinical record for Resident 4 was reviewed on 11/19/25 at 10:15 a.m. The diagnoses for Resident 4 included, but were not limited to, type 2 diabetes mellitus. An observation was made of medication administration for Resident 4 with RN 10 on 11/20/25 at 10:58 a.m. RN 10 was observed preparing to obtain Resident 4's blood sugar reading utilizing a glucometer. During that time, RN 10 donned gloves and entered the resident's room. She obtained the resident's blood sugar reading and then doffed her gloves. There was no hand hygiene observed prior to donning the gloves. 5. The clinical record for Resident 10 was reviewed on 11/19/25 at 10:30 a.m. The diagnoses for Resident 10 included, but were not limited to, hypertension. An observation was made of a medication administration for Resident 10 with RN 10 on 11/19/25 at 11:00 a.m. RN 10 was observed pulling medications and eye drops from the medication cart. She then donned gloves and entered the resident's room. After, she administered the medications and eye drops to the resident with her gloved hands. There was no observation of hand hygiene prior to donning gloves. 6. The clinical record for Resident 28 was reviewed on 11/19/25 at 10:30 a.m. The diagnoses for Resident 28 included, but were not limited to, type 2 diabetes mellitus. An observation was made of a medication administration for Resident 28 with RN 10 on 11/19/25 at 11:05. RN 10 was observed preparing the resident's medication administration at the medication cart. During that time, she donned gloves to obtain the resident's blood sugar reading utilizing a glucometer. She then entered the resident's room and obtained the resident's blood sugar reading. There was no hand hygiene prior to donning the gloves. 7. The clinical record for Resident 51 was reviewed on 11/19/25 at 11:30 a.m. The diagnoses for Resident 51 included, but were not limited to, morbid obesity. An observation was made of a medication administration for Resident 51 with RN 10 on 11/20/25 at 11:09 a.m. RN 10 was observed preparing to obtain the resident's blood sugar reading utilizing a glucometer at the medication cart. She had donned gloves and entered the resident's room. After, she obtained the resident's blood sugar reading. There was no observation of hand hygiene prior to donning the gloves. 8. The clinical record for Resident 56 was reviewed on 11/19/25 at 12:00 p.m. The diagnoses for Resident 56 included, but were not limited to, cerebral palsy. An observation was made of a medication administration for Resident 56 with RN 10 on 11/20/25 at 11:22 a.m. RN 10 was observed preparing the medication at the medication cart. During that time, RN 10 had dropped a pill medication on top of the medication cart. She then picked up the pill medication with her bare hands and placed it in the medication cup. She then entered the resident's room and administered the medication. An interview was conducted with the Nurse Consultant on 11/21/25 at 1:31 p.m. She indicated the staff should be utilizing hand hygiene prior to donning gloves. A hand hygiene policy was provided by the NC on 11/21/25 at 2:36 p.m. It indicated, .The purpose of this policy is to: handwashing is the single most important factor in preventing transmission of infections. Hand hygiene is a general term that applies to either handwashing or the use of an antiseptic hand rub, also known as alcohol-based hand rub.1. All health care workers shall utilize hand hygiene frequently and appropriately.3. Health Care Workers (HCW) shall use hand hygiene at times such as: c. before and after having direct physical contact with residents, d. after removing gloves, worn per standard precautions for direct contact with excretions or secretions, mucous membranes, specimens, resident equipment. 3.1-18(l)

Based on observation, interview, and record review, the facility failed to monitor a resident's wound for 1 of 1 resident reviewed for skin conditions and ensure priming of 2 units of insulin prior to administration of insulin dosage utilizing an insulin flex pen for 2 of 2 residents observed during insulin administrations. (Resident 16, Resident 28 and Resident 51) Findings include: 1. The clinical record for Resident 28 was reviewed on 11/19/25 at 10:30 a.m. The diagnoses for Resident 28 included, but were not limited to, type 2 diabetes mellitus. A physician order, dated 7/15/25, indicated Resident 28 was to receive the following Humalog insulin sliding scale twice a day: blood sugar reading of 150 – 199 = 2 units of insulin, blood sugar reading of 200 – 249 = 4 units of insulin, blood sugar reading of 250 – 299 = 6 units of insulin, blood sugar reading of 300 – 349 = 8 units of insulin, and blood sugar reading of 400 or greater the staff was to call the medical provider. An observation was made of an insulin administration with Registered Nurse (RN) 10 on 11/20/25 at 11:38 a.m. RN 10 was observed pulling a Humalog flex pen for Resident 28 from her medication cart. She indicated the resident's blood sugar reading was 164. The resident would receive 2 units of insulin. RN 10 dialed up 2 units of insulin. She then went to the resident's room and administered the 2 units of insulin in the resident's abdomen. There was no observation of 2 units of priming of the insulin flex pen prior to dialing up the insulin administration units. 2. The clinical record for Resident 51 was reviewed on 11/19/25 at 11:30 a.m. The diagnoses for Resident 51 included, but were not limited to, morbid obesity. A physician order, dated 11/9/25, indicated the resident was to receive the following NovoLog insulin sliding scale before meals: blood sugar reading of 180 – 200 = 2 units of insulin, blood sugar reading of 201 – 220 = 4 units of insulin, blood sugar reading of 221 – 240 = 6 units of insulin, blood sugar reading of 241 – 260 = 8 units of insulin, blood sugar reading of 261 – 280 = 10 units of insulin, and blood sugar reading of greater than 300 the staff was to call the medical provider. An observation was made of an insulin administration with RN 10 on 11/20/25 at 11:42 a.m. RN 10 was observed pulling a NovoLog insulin flex pen from the medication cart. During that time, she indicated Resident 51's blood sugar reading was 267. The resident was going to receive 8 units of NovoLog insulin. RN 10 dialed up 8 units of insulin. After, she entered the resident's room and administered the 8 units of insulin in his abdomen. There was no observation of 2 units of priming of the insulin flex pen prior to dialing up the insulin administration dosage. An interview was conducted with the Nurse Consultant on 11/21/25 at 9:09 a.m. She indicated the staff should be following standard protocol for the insulin administration. A NovoLog insulin flex pen manufacture instructions were provided by the NC on 11/21/25 at 1:51 p.m. It indicated, .Giving the air shot before each injection. Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: E. Turn dose selector to select 2 units.F. Hold your novolog flex pen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge.G. Keep the needle pointing upwards, press the push-button all the way in.The dose selector returns to 0. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than 6 times. 3. The clinical record for Resident 16 was reviewed on 11/19/25 at 10:37 a.m. The resident's diagnosis included, but was not limited to, dementia. A care plan, initiated 7/23/25, indicated she was at risk for skin breakdown related to weakness, impaired mobility, and incontinence. The goal was for her skin to remain intact. The interventions included to conduct weekly skin assessments and avoid shearing skin during positioning, turning,and transferring. A Quarterly Minimum Data Set (MDS) Assessment, completed 9/17/25, indicated she had severe cognitive impairment. A progress note, dated 10/09/25 at 7:30 p.m., indicated during a transfer, Resident 16 had received a laceration to her left lower leg. She was sent to an acute care hospital to have the laceration assessed. A progress note, dated 10/9/25 at 11:33 p.m., indicated she had sutures to the laceration to her left lower leg which was to be treated with bacitracin and wrapped with a dressing. The sutures were to be removed in seven to ten days. A progress note, dated 10/20/25 at 4:09 p.m., indicated the stitches were removed from Resident 16's left, lower leg. Some drainage was present and steri-strips (thin bandages to keep a cut closed) were applied. A physician's order, dated 11/3/25, indicated to cleanse wound on left lower leg, with wound cleanser, pat dry, and apply collagen (type of wound dressing) to wound bed and cover with border dressing daily. The clinical record did not contain a description or measurements of Resident 16's left lower leg wound. On 11/20/25 at 2:18 p.m., the Wound Nurse (WN) was observed changing the dressing on Resident 16's left lower leg. The WN removed the old dressing and cleansed the wound. She measured the wound to be 3 centimeters (cm) in length and 1.9 cm in width. The wound was observed to have 50 percent granulation (new) tissue and 50 percent slough (yellow non-viable) tissue. She applied collagen and a foam dressing. During an interview on 11/20/25 at 2:30 p.m., the WN indicated the wound on Resident 16's left lower leg had started as a laceration. There were no measurements of the wound until she measured it during the observed treatment. On 11/20/25, the DNS (Director of Nursing Services) provided the Guidelines for General Wound and Skin Care policy, approved 5/10/2017, that read .20. Document type of wound, location, stage [if applicable], length, width, depth in centimeters, base, drainage, periwound tissue, and treatment of the wound weekly using the wound/skin treatment flow sheet . 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure fall interventions were in place for a resident, prior to experiencing a fall in the bathroom for 1 of 2 residents reviewed for accidents. (Resident 53)The clinical record for Resident 53 was reviewed on 11/18/25 at 2:30 p.m. Her diagnoses included, but were not limited to, spinal stenosis and heart disease. She was admitted to the facility on [DATE] after a hospitalization for surgery on her back. The admission MDS (Minimum Data Set) assessment, dated 11/11/25, indicated she required substantial assistance with bathing, toileting, and taking on/taking off footwear. The fall care plan, dated 11/6/25, indicated the resident was at risk for falling related to weakness and impaired mobility. Interventions were to ensure the floor was free of liquids and foreign objects, starting 11/6/25, and to provide non-skid footwear, starting 11/6/25. An interview was conducted with Resident 53 on 11/18/25 at 2:40 p.m. She was sitting in a chair in her room. Family Member 20 was also present in the room during the interview. The resident indicated she fell in the bathroom yesterday morning, with an aide present, in her previous room. The aide, CRCA (Certified Resident Care Assistant) Student 21, was going to assist her with a shower. She was naked on the commode, barefoot, while CRCA Student 21 was running the water in the shower to warm it. Resident 53 mentioned being barefoot to CRCA Student 21. CRCA Student 21 informed her she'd be going immediately into the shower. Resident 53 informed CRCA Student 21 that there was water running all over the floor as the shower floor was even with the rest of the bathroom floor, and there was no towel on the floor. CRCA Student 21 informed her she would wipe the floor once she assisted her into the shower. Resident 53 stood up from the commode, holding onto the grab bar by the commode and, I started going down. When she stood up, she went down. CRCA Student 21 started grabbing towels right away and wiped up the water from the floor, before anyone else came into the room. They pressed the call light for assistance, but no one came, so CRCA Student 21 left to get help. Two staff members came to assist with getting her up from the floor. Resident 53 was quite sore the previous day. Staff placed ice packs on her back and used a cream to soothe the pain. She obtained a cut on her backside from the fall. The resident who lived in that room with her had many things of her own in the bathroom, including a plastic cabinet, and when she fell, she cut her back on the edge of the plastic cabinet. She had a bandage over it now. An interview was conducted with Family Member 20, on 11/18/25 at 2:40 p.m., in the presence of Resident 53. The family member indicated he didn't understand why Student 21 began running the water in the shower while Resident 53 was still on the commode and barefoot. These things led to an increased chance of her falling. Staff knew she was unstable. The nurse's note, dated 11/17/25 at 7:30 a.m., indicated Resident had witnessed fall in bathroom. Resident was preparing to transfer to wheelchair, and then get into shower. Since resident was about to get into shower, resident was not wearing footwear. CRCA Student states that resident's foot slid out from underneath her as she was about to get into wheelchair, and fell to the floor. Education provided to student to have non-skid socks on resident during any transfer. Student voices understanding. Resident did not hit her head. New laceration/abrasion on right buttock (see occurrence note). Denies any new pain. Son aware. DHS [Director of Health Services] aware. Note in MD folder. The Fall Event, dated 11/17/25, indicated she had a fall in the bathroom on 11/17/25 at 7:20 a.m., witnessed by CRCA Student 21. She was not wearing any footwear at the time of the fall. There was a laceration to her right buttock, caused by hitting a plastic shelf during the fall. The wound management entry, dated 11/17/25, indicated the resident had an abrasion to the upper, right buttock that measured 2.5 x 9 cm. The site was red. A dry dressing was applied over the site. An interview was conducted with Resident 53 in her room on 11/21/25 at 11:24 a.m. She indicated she was feeling pretty good, but she was sore across her back. When she fell on [DATE] in the bathroom of her previous room, she started out in bed and was not wearing any socks or shoes. CRCA 21 assisted her out of bed and into her wheelchair and pushed her into the bathroom. After they got into the bathroom, she questioned not wearing any socks, and that was when CRCA 21 informed her it was okay, because she was going immediately into the shower. Resident 53 should have insisted she wanted to wear socks, but didn't. There were no towels down on the floor either, while the shower water was running and she was still on the commode. CRCA 21 did not put any towels down until after she fell. She had another shower yesterday and it went well. They didn't turn the water on until after she got into the shower and it only took a minute for it to warm up. The other room had an adjustable shower head in the shower too, just like her current shower, so staff could have pointed the water away from her to let it warm up, like they did for yesterday's shower. She was leery during yesterday's shower, but it went fine. An observation of Resident 53's shower and bathroom were made on 11/21/25 at 11:24 a.m. during the above interview. The shower head was removable. An interview was conducted with CRCA Student 21 on 11/20/25 at 2:36 p.m. She indicated she'd been a student at the facility since 10/10/25. During Resident 53's fall, she assisted Resident 53 from the commode and into her wheelchair to get into the shower. It looked like Resident 53 got her feet caught, and she went down. They had gotten her undressed already, and CRCA Student 21 thought she was still wearing her socks, but she noticed afterwards she was not. This was CRCA 21's first time assisting Resident 53. She was educated afterwards about ensuring there was a towel down, that the resident was wearing socks, and waiting for the nurse to come after a fall. The Fall Management Program Guidelines policy was provided by the Nurse Consultant on 11/21/25 at 9:24 a.m. It indicated, The purpose of this policy is to: [Name of facility] strives to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures. [Name of facility] recognizes even the most vigilant efforts may not prevent all falls and injuries. In those cases, intensive efforts will be directed toward minimizing or preventing injury.Care plan interventions should be implemented that address the resident's risk factors.3.1-45(a)(1)3.1-45(a)(2)

Based on interview and record review, the facility failed to timely develop a behavior plan of care and track behaviors for a resident who displayed verbal agitation and cursing at staff and other residents for 1 of 2 reviewed for hospitalizations. (Resident 10)Findings include: The clinical record for Resident 10 was reviewed on 11/18/25 at 9:52 a.m. The resident's diagnosis included, but were not limited to, major depressive disorder with psychotic symptoms. A care plan, dated 11/15/2022, indicated Resident 10 had a diagnosis of depression and was at risk for demonstrating signs and symptoms of depression, including: Verbalizations of distress, refusals to get out of bed, refusals of care, tearfulness, exhibiting self-hate, refusing to attend favorite activities, poor motivation, and self-care deficits. The goal was for him to be free from persistent, distressing signs and symptoms of depression. A Quarterly Minimum Data Set (MDS) Assessment, dated 8/15/25, indicated he was cognitively intact and displayed no behaviors.A progress note, dated 9/20/25 at 9:58 p.m., indicated Resident 10 had become angry and yelled at the nurse when she asked him if he wanted MiraLAX (medication to treat constipation) during the evening medication pass. Resident 10 had called the nurse a dumb***. Resident 10 had told the nurse it was always horrible when they worked and then continued to berate the nurse and his roommate. Resident 10 had indicated his roommate was a dumb*** as well. The nurse had left the room to deescalate the situation. A progress note, dated 10/04/25 at 12:09 p.m., indicated Resident 10 was overheard from the hallway cursing at his roommate. Resident 10 had stated is that right you stupid [expletive] and [expletive] you . Resident 10 consistently raises the volume of his television so that the roommate cannot hear his own television. The televisions could be heard from the nurse's station. A progress note, dated 10/04/25 at 12:27 p.m., indicated attempts to redirect Resident 10's behavior frustrated him more. Resident 10 became very angry. Management and family were notified.A progress note, dated 10/13/25 at 8:00 a.m., indicated Resident 10 was in the dining room waiting for breakfast. He thought that breakfast was taking too long and became angry, yelling at the kitchen staff and slamming his plate of food on the side of the table. He became upset that he did not get the food he had requested. Staff attempted to talk with Resident 10, and he headed back to his room yell at staff members better do something with those kitchen people. He continued to yell in the hallway. A progress note, dated 10/13/25 at 10:48 a.m., indicated the Executive Director and Social Services had been spoken to about Resident 10's behavior that started in the morning. Resident 10 continues to try to argue with roommate and was yelling out at staff members. The physician had been notified. A social services progress note, dated 10/13/25 at 11:45 a.m., indicated Resident 10's sister had been notified of recent behaviors including verbal aggression toward staff. His sister was in agreement to send Resident 10 to an inpatient psychiatric hospital for evaluation. The clinical record did not contain a physician's order or an order set to track or record Resident 10's verbal agitation or aggression toward staff or other residents. The clinical record did not include a care plan addressing Resident 10's verbal agitation or aggression toward staff or other residents. Resident 10 returned to the facility on [DATE].During an interview ow 11/19/25 at 3:00 p.m., Certified Resident Care Assistant (CRCA) 25 indicated Resident 10 would mumble under his breath and glare at staff if they entered the room wrong to care for his roommate. Resident 10 would become agitated a couple of time a week. The behavior had happened for quite some time prior to his hospitalization. During an interview on 11/19/25 at 3:02 p.m., Registered Nurse (RN) 26 indicated behaviors were to be tracked on the Medication Administration Record. During an interview on 11/21/25 at 9:44 p.m., RN 27 indicated Resident 10 would lash out at others and get very angry. He would lash out at whoever was around. Resident 10 would lash out and yell at his roommate. The staff would leave his room and re-approach at a later time. Resident 10 would calm down and act as if nothing had happened. Resident 10 had displayed these behaviors prior to his hospitalization, but not often. The nurses were to chart about behaviors episodes in the progress notes. On 11/20/25 at 2:08 p.m., the Nurse Consultant provided the Guidelines for Mental Health Wellness Program, reviewed 12/17/24, that read . Purpose To develop a Mental Health Wellness/ Behavior Management plan through the identification and elimination of causative factors and implementation of non-pharmacological interventions. Positive outcomes will be measured by behaviors being reduces, managed or eliminated thereby resulting in improved quality of life for each resident .10. The Mental Health Wellness/ Behavior Management Program shall consist of: a. A care plan initiated or updated with realistic, effective interventions which complements the resident's cognitive status, and incorporates their total care. i. Interventions are considered to be a form of preventative measures. Interventions may include structuring the environment and honoring prior life patterns. Communication to Social Services Director and Physician alerting them to new, exacerbated behaviors, current status, intervention effectiveness . 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure Resident 9 had fresh ice water available at the bedside for 1 of 1 resident reviewed for hydration. Findings include: The clinical record for Resident 9 was reviewed on 8/9/2024 at 12:40 p.m. The medical diagnosis included heart failure. The Minimum Data Set assessment, dated 7/15/2024, indicated Resident 9 was cognitively impaired but was not dehydrated. A diuretic care plan, dated 10/30/2023, indicated Resident 9 was at risk for medication complications related to the use of diuretics. An intervention, dated 10/30/2023, indicated to encourage fluids throughout the day if not contraindicated. During an interview and observation, on 8/7/2024 at 11:32 a.m., Resident 9 indicated ice water was rarely passed to the resident's room. The cup of water in the room was room temperature and had no ice in it. During an interview and observation, on 8/9/2024 at 1:30 p.m., Resident 9 indicated the staff rarely passed ice water to the resident's room. There were three containers of water in the room. First was a Styrofoam cup, dated 8/8/2024, which Resident 9 stated was hot and stale, the second was a clear cup with no date which Resident 9 stated was warm and from breakfast yesterday, and the third was metal container personal glass which had no water in it. Resident 9 indicated outside of meals and medication pass, no one had given any additional fluids, and no staff had refreshed the water in the room since yesterday, 8/8/2024. An interview with CNA 1, on 8/9/2024 at 1:35 p.m., indicated staff were to pass ice water every shift, but ice water had not been passed yet because CNA 1 did not have time to complete the task yet. An interview with the Director of Health Services, on 8/12/2024 at 2:05 p.m., indicated any staff member can pass ice water, but it was primarily the responsibility of the direct care staff to pass ice at least every shift unless medically contraindicated. An interview with the Regional Nurse Consultant, on 8/12/2024 at 2:40 p.m., indicated that the facility did not have a policy for passing ice water to residents. 3.1-3(v)(1)

Based on interview and record review, the facility failed to follow their grievance policy regarding a resident's missing clothing for 1 of 1 resident reviewed for personal property. (Resident 39) Findings include: The clinical record for Resident 39 was reviewed on 8/8/24 at 11:40 a.m. The diagnoses included, but were not limited to, anxiety. She was admitted to the facility on [DATE]. The 6/17/24 Admission MDS (Minimum Data Set) assessment indicated Resident 39 was cognitively intact. An interview was conducted with Resident 39 on 8/8/24 at 11:20 a.m. She indicated she was missing two shirts and a pair of jean pedal pushers. The two tops went missing a couple weeks after she was admitted to the facility, and the jeans went missing about two weeks ago. She informed staff, including some of the CNAs (Certified Nursing Assistants) and laundry staff, of the missing items, and they informed her they'd keep an eye out. An interview was conducted with the ED (Executive Director) on 8/12/24 at 1:50 p.m. She indicated when a resident voiced they were missing clothing, they typically took the resident into the laundry room to identify the clothing and/or contacted laundry staff to look for the clothing. If the clothing was unable to be located, the facility replaced it. They also filled out a resident concern form and documented follow-up with the resident. She did not recall a concern for Resident 39 regarding missing clothing. On 8/12/24 at 10:30 a.m., the ED provided the Resident Concerns Log for the past month. There were no concerns regarding missing clothing for Resident 39. An interview was conducted with ESA (Environmental Services Assistant) 2 in the laundry room of the facility on 8/12/24 at 1:57 p.m. She indicated Resident 39 informed her and some of the CNAs of her missing jean pedal pushers and two shirts a few weeks ago. ESA 2 looked for the items but was unable to locate them. ESA 2 did not fill out a resident concern form, as many residents complained of missing items. She informed staff they could bring Resident 39 into the laundry room to look for her items, but no one ever did. The Resident Concern Process policy was provided by the ED on 8/12/24 at 2:04 p.m. It read, Purpose: To provide a process for handling, tracking and resolving customer concerns to provide excellence in customer service. Procedures: .5. Enter the concern using the desktop icon labeled 'Resident Concern Form.' All concerns should be entered electronically, however Environmental and Dining departments may use a paper Resident Concern form, submitting to their supervisor who will enter 6. Concerns are reviewed in morning meeting, noting new entries and assigning them for follow up and resolution. 7. Follow up from the department leader will occur within 24-48 [sic] with resolution entered in KeyStats. 8. The Executive Director will review and manage the follow up of the concerns. 9. The department leader will investigate and discuss the concerns with the team and will implement, or educate to prevent further concerns. 10. The department leader will document the resolution on the concerns form using an addendum when needed and will follow up with the person reporting the concern to explain the resolution. 3.1-7(b)

Based on observation, interview and record review the facility failed to implement a sling for a resident with impaired range of motion (ROM) for 1 of 1 resident reviewed for ROM (Resident 16). Findings include: During an observation and interview on 8/07/24 at 1:43 p.m., Resident 16 was sitting in a wheelchair outside. The resident's right hand was curved inward. Resident 16 indicated he was unable to move his right arm and right hand. The resident took his left hand and picked up his right arm and hand and they were flaccid (hanging loosely/limp). The resident indicated he had a sling to wear, and it was in his room. During an observation and interview on 8/08/24 at 10:31 a.m., Resident 16 was sitting in a wheelchair outside with no sling in place. The resident's right arm and hand was laying on his lap. During an observation on 8/09/24 at 10:57 a.m., Resident 16 was sitting in a wheelchair outside with no sling in place. The resident's right arm and hand was laying on his lap. During an observation on 8/12/24 at 10:20 a.m., Resident 16 was sitting in a wheelchair outside with no sling in place. The resident's right arm and hand was laying on his lap. During an observation and interview on 8/12/24 at 1:53 p.m., Resident 16 was sitting outside with a sling in place to the right arm and hand. The resident indicated the sling was in a drawer in his room and the staff helped him put it on. He indicated his right arm and hand felt better supported in the sling. During an interview with the Director of Health Services (DHS) on 8/12/24 at 1:58 p.m., indicated she found Resident 16's sling in a drawer in his bedroom. The DHS indicated she talked with the resident, and he wanted to wear the sling for comfort. The clinical record for Resident 16 was reviewed on 8/9/24 at 11:00 a.m. The diagnoses included, but were not limited to, hemiplegia (paralysis) and hemiparesis (weakness) affecting the right dominant side and cerebral vascular accident (CVA). The face sheet for Resident 16 provided from the discharging facility, dated 6/3/24, had a picture of the resident with a sling present on the right arm. The physician progress note from the discharging facility for Resident 16, dated 6/3/24, indicated the resident denied any pain or increased weakness to right side and right hand was in the sling. The resident reported pain control was adequate. The resident had right sided hemiplegia and right lower extremity decreased ROM. The resident had a mild contracture of the right upper extremity and limited use of the right hand. The resident was up in a wheelchair with a sling. The admission Minimum Data Set (MDS) assessment for Resident 16, dated 6/18/24, indicated the resident had the ability to make himself understood and was able to understand others. The resident had limited function in range of motion and had impairment on one side of the upper and lower extremities. The resident required substantial assistance with upper body dressing (helper does more than half of the effort). The resident was admitted to the facility on [DATE]. The plan of care for Resident 16, dated 6/25/24, indicated the resident had impairment in functional status related to a cerebral vascular accident (CVA) with hemiplegia. The interventions included, but were not limited to, encourage resident to be as independent safely as possible, medications as ordered, provide assistance as needed with self-care and mobility, and therapy evaluation/treatment as needed. The plan of care did not address the utilization of a sling. The plan of care for Resident 16, dated 6/25/24, indicated the resident had a diagnosis of cerebrovascular accident with hemiparesis/hemiplegia and required assistance with activities of daily living. During an interview with the Executive Director (ED) on 8/13/24 at 11:05 a.m., they indicated the facility had no policy for ROM, splints, or contractures. 3.1-42(a)(2)

Based on observation, interview, and record review the facility failed to provide fortified food and fortified shakes as recommended by the Registered Dietician (RD) and as ordered by the physician for a resident who had experienced significant weight loss for 1 of 2 residents reviewed for nutrition (Resident 34). Findings include: The clinical record for Resident 34 was reviewed on 8/9/24 at 11:20 a.m. The diagnoses included, but were not limited to, hemiplegia (paralysis), hemiparesis (one-sided muscle weakness), ataxia (loss of muscle control), polyosteoarthritis, pulmonary fibrosis, and hypothyroidism. The clinical record for Resident 34 was reviewed on 8/9/24 at 11:30 a.m. The following weights were noted: 6/1/24 of 131.8 pounds, 7/2/24 of 129.8 pounds, and 8/2/24 of 122.6 pounds. This indicated the resident lost 6.98 % body weight in two months and lost 5.5 % body weight in one month. The quarterly Minimum Data (MDS) assessment for Resident 34, dated 7/26/24, indicated the resident was severely impaired for daily decision making. A physician order for Resident 34, dated 8/8/24, indicated the resident was ordered fortified food with puree texture. The plan of care for Resident 34, dated 8/8/24 indicated the resident had experienced a significant weight loss. The interventions included, but were not limited to, provide diet and supplements. The RD assessment for Resident 34, dated 8/8/24, indicated the resident had a 5% weight loss in one month that was not physician prescribed. The recommendation was for the resident to receive fortified foods and include fortified shakes with meals to promote protein and calorie intake and reweigh the resident. During an observation on 8/9/24 at 12:29 p.m., Resident 34 did not have a shake with her meal. She had tea and water. During an observation on 8/12/24 at 12:17 p.m., Resident 34 was in the assisted dining room. She had a pureed diet with a divided plate. The resident had eaten approximately a quarter of her food. The resident did not have a fortified shake. She had tea and water. During an interview with the Dietary Manager on 8/12/24 at 2:14 p.m., they indicated when a resident was ordered fortified food and fortified shake the dietary department would get a diet order from nursing for a diet change. The Dietary Manager indicated he was not aware Resident 34 was supposed to be provided fortified food and fortified shake. The Dietary Manager indicated Resident 34 had not been receiving fortified foods or fortified shakes. During an interview with the Director of Health Services (DHS) on 8/12/24 at 2:32 p.m., they indicated nurses were responsible for printing out Resident 34's diet order and provide it too dietary. The DHS indicated the nursing staff were responsible to reweigh as recommended by the RD and it was not completed. The weight policy provided by the DHS, on 8/13/24 at 10:48 a.m., indicated the purpose was to ensure resident weight was monitored for weight loss to prevent complications arising from compromised nutrition. 3.1-46(a)(2)

Based on observation, interview and record review the facility failed to provide a dignity bag to cover catheters for 2 of 4 reviewed for catheters (Resident 30 and Resident 50). Findings include: 1.) During an observation on 6/08/23 at 4:26 p.m., Resident 30 was laying in bed. The resident had a catheter with no dignity bag covering. During an observation on 6/12/23 at 1:11 p.m., Resident 30 laying in bed with no dignity bag covering the catheter. Review of the record of Resident 30 on 6/14/23 at 2:40 p.m., indicated the resident's diagnoses included, but were not limited to, acute respiratory disease, diabetes, depression, bipolar disorder, urinary retention and history of urinary tract infection. The plan of care for Resident 30, dated 6/23/21, indicated the resident used a Foley catheter. The interventions included, but were not limited to, maintain closed system with urinary bag below the resident's bladder and cover. The physician order for Resident 30, dated 6/9/23, indicated the resident was ordered to have indwelling Foley catheter for obstructive uropathy and reflux uropathy. 2.) During an observation on 6/13/23 at 11:05 a.m., Resident 50 in therapy gym with no dignity bag covering her Foley catheter. Review of the record of record of Resident 50 on 6/13/23 at 12:20 p.m., indicated the resident's diagnoses included, but were not limited to, urinary tract infection, cerebrovascular disease, non inflammatory disorder of the vagina, dehydration, non inflammatory disorder of the vulva, urinary retention, acute kidney failure and hypertension. The plan of care for Resident 50, dated 5/18/23, indicated the resident uses a Foley catheter for a diagnoses of vaginal cyst, labial adhesions and adnexal cyst. The interventions included, but were not limited to, cover urinary bag. The physician order for Resident 50, dated 6/9/23, indicated the resident was to have a Foley catheter for vaginal cyst impeding bladder. During an interview with the Director of Health Services on 6/13/23 at 11:55 a.m., indicated the CNA's and nurses were responsible to ensure residents with catheters had dignity bags covering the catheter. During an interview with the Executive Director on 6/14/23 at 11:17 a.m.,indicated the facilities expectation was that dignity bags would be used for residents catheter. 3.1-3(t)

Based on interview, observations, and record review, the facility failed to ensure the call light was in reach for 1 of 3 residents reviewed for accommodation of needs. (Resident 2) Findings include: The clinical record Resident 2 was reviewed on 6/15/2023 at 11:45 a.m. The medical diagnoses included dementia and right-hand contracture. A Quarterly Minimum Data Set Assessment, dated for 5/10/2023, indicated that Resident 2 was cognitively impaired and had impairment on one upper extremity. A fall care plan, dated for 11/12/2021, indicated for Resident 2 to have a call light within reach. An observation on 6/8/2023 at 4:47 p.m. indicated Resident 2 was in her room at this time. She was sitting in her wheelchair, facing towards a television on the wall with her call light out of reach. An observation on 6/12/2023 at 11:35 a.m., indicated Resident 2 was in her room at this time. She was sitting in her wheelchair, facing towards a television on the wall with her call light out of reach. CRCA 1 verified that Resident 2 could not reach her call light. CRCA 1 indicated she had not seen Resident 2 use her call light in the last couple months. When the call light was placed within reach, the resident was unable to press the button call light. A nursing progress note, dated for 6/13/2023, indicated that the button call light was replaced with a soft touch call light. A policy entitled, Guidelines for Answering Call Lights, was provided my Clinical Support RN on 6/15/2023 at 12:20 p.m. The policy indicated, .Ensure the call light is plugged in security to the outlet and in reach of the resident .Adaptive call lights are available if needed . 3.1-3(v)(1)

Based on observation, interview, and record review, the facility failed to ensure a resident had an ongoing activity program. This affected 1 of 3 residents reviewed for activities. (Resident 9) Findings include: During an interview, on 6/08/23 at 2:03 p.m., Resident 9 indicated she chooses not to go to activities. On 6/12/23, at 2:30 p.m., Resident 9 was observed asleep in her recliner, her TV was not on. On 6/13/23, at 9:39 a.m., Resident 9 was observed laying on her bed, eyes closed, her TV was not on. On 06/13/23, at 2:58 p.m., Resident 9 was observed asleep in her recliner, her TV was off but her roommate's TV was on. On 06/14/23, at 3:02 p.m., Resident 9 was observed asleep on her bed. On 6/15/23, at 11:10 a.m., Resident 9 indicated activities are lax right now. She said no one comes in and talks to her for a one on one activity every day. She was sitting in her chair and her TV was not on. Resident 9's clinical record was reviewed on 6/13/23 at 2:05 p.m. The clinical record indicated Resident 9 had diagnoses that included, but were not limited to, dementia, difficulty swallowing, chronic obstructive pulmonary disease, generalized muscle weakness, depression, macular degeneration, legal blindness, and chronic pain. An Annual Minimum Data Set assessment, dated 11/11/2022, indicated Resident 9 was cognitively intact, and activities were music and her favorite activities. A care plan, last reviewed 4/18/23, indicated While in the campus, I may not engage in activities that are meaningful to me because of: I am dx (diagnosed ) with Blindness, and dementia. I enjoy listening to Wild Cat games on my TV, visiting with such as mindful mornings. Long Term Goal Target Date: 07/18/2023 I will accept and/or utilize adaptations and modifications to enable participation in activities that are meaningful to me. Approach Start Date: 12/07/2022 Please engage me in Mindful moment activities to help me manage my dementia at least once a week .Provide me with one to one visits, daily. A Live Enrichment Progress note, dated 4/13/23, indicated accommodations utilized for successful participation were: 1:1 settings, verbal instructions and hand under cueing/guidance to support visual impairment, use of her wheelchair, verbal prompts, and supplies placed within reach. The programming participation responses were: her participation level was active, type of participation was independent, large groups, small groups and one to one, participates in activities of expressed importance of pets and favorite activities of listening to KY Wild Cat. The specific programming participation this quarter was mindful moments, theme dinner, celebrated birthday and happy hour. The frequency of visitors indicated daily visits. Her independent activities of interest in which resident participates was watching TV and visits with others. Also she was not interested in changing activity pursuits or trying activities, she was satisfied with current activities. Review of May, 2023 activity logs indicated she had 2 one to one visits, she listened to her TV every day, and she had six visits by family, friends, clergy, or pets. She also had her nails done once, had one mindful morning, and had her mail read to her one time by staff. Review of June activity logs from June 1 through June 13, 2023, indicated she listened to her TV every day, she participated in the traveling garden, had 3 visits by family, friends, clergy, or pets, and had one staff one to one visit. The activity logs failed to indicate she had mindful moment activities weekly or daily one to one visits as addressed in her care plan. In an interview, on 06/15/23, at 12:05 p.m., the Life Enrichment Director indicated Resident 9 has a lot of one on ones because she is blind and likes to stay in her room. The activity girls see her twice a week and she sees the therapy dogs. She will go to mindful moments if she is up, and staff read her mail to her. She indicated they need to document it better. Life Enrichment Assistant 8 indicated she likes the traveling garden and mindful mornings, and she uses her other senses like smelling and feeling, because she can't see. On 6/16/23 at 11:42 a.m., the Executive Director indicated they don't have a specific policy for activities, they follow the regulations. 3.1-33(a)

Based on interview, observation, and record review the facility failed to obtain orders for a preventive dressing to a non-pressure skin area for Resident 18, failed to obtain treatment orders for a non-pressure skin area for Resident 13, and failed to follow call parameters for Resident 11 for 3 of 14 residents reviewed for compliance for physician orders. Findings include: 1. The clinical record for Resident 18 was reviewed on 6/14/2023 at 2:06 p.m. The medical diagnoses included chronic obstructive pulmonary disease and dementia. An Admission Minimum Data Set Assessment, dated for 4/25/2023, indicated Resident 18 was cognitively intact and was at risk for skin impairments. An observation on 6/8/2023 at 3:18 p.m. indicated that Resident 18 was sitting in her wheelchair. She had a pink foam dressing applied to the left lower leg without a date or initial upon the dressing. An observation on 6/13/2023 at 2:50 p.m. indicated Resident 18 sitting in her wheelchair. She had a pink foam dressing applied to the left lower leg without a date or initials. RN 2 came to resident's room and verified the pink dressing was in place without an indication of date of application. Resident 18 indicated the dressing had been in place forever. When asked to clarify, she said about a week or so. The dressing was changed to reveal multiple scabbed areas and a scant amount of drainage on the dressing. RN 2 indicated that Resident 18's skin was very fragile and the dressing was more a preventative measure. Review of the medical record indicated Resident 18 did not have an order for dressings to the left lower leg on 6/8/2023 or 6/13/2023. 2. The clinical record for Resident 13 was reviewed on 6/14/2023 at 2:49 p.m. The medical diagnoses included stroke and edema. An Admission Minimum Data Set Assessment, dated for 4/26/2023, indicated that Resident 13 was cognitively intact, was at risk for skin impairments, and had pressure areas and skin tear(s). An observations on 6/8/2023 at 2:01 p.m. indicated Resident 13 sitting in her wheelchair. She had a pink foam dressing applied to the left knee with no date and had no dressing to the right knee with visible open areas. A scant amount of drainage was noted on her pants. A nursing note, dated 6/11/2023, indicated that dressings were changed to Resident 13's knees. An observations on 6/12/2023 at 12:59 p.m. indicated that Resident 13 was in bed. She had two pink foam dressings on her knees without any date or initials on the dressing. No dressings orders for Resident 13's bilateral knees were on the physician orders. A policy entitled, Guidelines for General Wound and Skin Care, was provided by the Executive Director on 6/14/2023 at 10:00 a.m. The policy indicated, .Date, time, and initial all dressings at the time of applications . 3. The clinical record for Resident 11 was reviewed on 6/12/2023 at 11:00 a.m. The medical diagnoses included chronic kidney failure and heart failure. A Quarterly Minimum Data Set Assessment, dated 6/4/2023, indicated Resident 11 had a mild cognitively impairment. A care plan, dated for 1/26/2023, indicated for Resident 11 to have weights as ordered. A physician order, dated 1/6/2023, indicated for Resident 11 to have daily weights and to call the physician for a three-pound weight gain in 24 hours and/or a five-pound weight gain in five days. Review of the medical record indicated that between 1/6/2023 and 4/19/2023, Resident 11 had 14 instances of a weight gain of three pounds, or more, in a 24-hour period. Of these instances, the physician was notified five times. An interview with Clinical Support RN, on 6/14/2023 at 3:30 p.m. indicated that the staff should follow physician orders as written, including those to obtain weights and call parameters. 3.1-37(a)

Based on observation, interview and record review the facility failed to follow up with the physician related to a pressure ulcer with increased odor, failed to implement a pressure relieving cushion and failed to complete a thorough and accurate skin assessment for 2 of 6 residents reviewed for pressure ulcers (Resident 36 and Resident 155). Findings include: 1.) Review of the record of Resident 36 on 6/12/23 at 11:00 a.m., indicated the resident's diagnoses included, but were not limited to, osteomyelitis of vertebra, sacral and sacrococcygeal, stage four pressure ulcer, hypertension, colon cancer and altered mental status. The local hospital note for Resident 36, dated 3/27/23, indicated the resident had a pressure ulcer on the sacrum that was red, blanchable and not open. The resident was discharged to the facility on [DATE]. The Admission observation assessment for Resident 36, dated 3/30/23 at 11:16 a.m., indicated the resident had skin impairment (no location or description of wound documented), at high risk for developing pressure ulcers and offloading was the intervention implemented. There was no wound event documented for this skin impairment. The Admission Minimum Data Set (MDS) assessment for Resident 36, dated 4/4/2023, indicated the resident was severely cognitively impaired. The resident did not have behavior of rejecting care. The resident required extensive assistance of two people for bed mobility and transfers. The resident did not ambulate. The resident was at risk of developing pressure and had one unhealed pressure ulcer. The wound assessment for Resident 36, dated 4/4/23, indicated the resident had a unstageable (slough/eschar) on the coccyx measuring 2.5 centimeters (cm) by 1.4 cm. The plan of care for Resident 36, dated 4/5/23, indicated the resident was at risk for skin breakdown. The interventions included, but were not limited to, pressure reducing cushion to chair. The progress note for Resident 36, dated 4/10/23 at 5:51 a.m., indicated the resident had a strong odor noted from wound. The fax to the physician for Resident 36, dated 4/10/23, indicated the resident had increased odor to wound. Please advise. The progress note for Resident 36, dated 4/15/23 at 1:49 p.m., indicated the resident's wound had a foul odor. The progress note for Resident 36, dated 4/17/23 at 10:28 a.m , indicated the resident's wound had a foul odor. The progress note for Resident 36, dated 4/19/23 at 10:35 a.m., indicated the resident was out to the wound center. The wound center called and stated the physician wanted to admit the resident resident for wound care and observation. The local hospital note for Resident 36, dated 4/19/23, indicated the assessment of the resident was stage 4 pressure ulcer (full thickness loss with exposed bone, tendon or muscle) and osteomyelitis (infection of the bone). During an observation on 6/13/23 at 2:50 p.m., Resident 36 was sitting in her wheelchair on a pillow, there was no pressure relieving cushion under the pillow. During an interview with the Nurse Consultant on 6/15/23 at 10:42 a.m., indicated Resident 36 had a stage one pressure ulcer (skin intact with redness and non blanchable) on admission from the hospital and there was no wound event completed for the stage one pressure ulcer. The facility would not necessarily complete a wound event for stage one pressure ulcer. During an interview the Director Of Health Services (DHS) on 6/15/23 at 1:35 p.m., indicated the physician did not respond to the fax sent on 4/10/23 related to Resident 36's wound having an increase in odor and the physician did not evaluate the resident's wound. During an interview with the DHS on 6/15/23 at 1:40 p.m., indicated the nurses were responsible to follow up with the physician when there was no response from the 4/10/23 fax about resident 36's wound with an increase in odor. The facility would expect a response from a fax to the physician within 1 to 2 days. 2.) Review of the record of Resident 155 on 6/13/23 at 2:01 p.m., indicated the resident's diagnoses included, but were not limited, acute respiratory failure with hypoxia, pleural effusion, chronic obstructive pulmonary, dementia and chronic kidney disease. The Admission Minimum Data Set (MDS) assessment for Resident 155, dated 6/5/23, indicated the resident was severely impaired for daily decision making. The resident was extensive assistance of two staff for bed mobility, transfers and did not ambulate. The resident was at risk of developing a pressure ulcer and had an unhealed pressure ulcer. The resident was admitted to the facility on [DATE]. The progress note for Resident 155, dated 6/7/23 at 10:07 a.m., indicated the resident was complaining of right ankle pain and upon assessment found a douderm dressing dated 5/29/23, which was prior to admission to the facility. The area looked like a stage two pressure ulcer, with redness and edema, very tender to touch. Cleaned area and applied a new dressing. The ankle was wrapped and an ice pack placed for pain and swelling. The progress note for Resident 155, dated 6/7/23 at 11:54 a.m., indicated the resident had a wound on the right lateral ankle over bone measuring 0.5 cm by 0.7 cm. The area was yellow/pink. The margins white/soft in appearance, light serous drainage noted to old dressing. A foam dressing was applied. The wound assessment for Resident 155, dated 6/7/23, indicated the resident had an unspecified ulcer of the right lateral ankle. Wound bed pale yellow/pink. Margins white/soft. Periwound reddened; blanches. Foam dressing applied over site. Measuring 0.5 centimeter (cm) by 0.7 cm. During an interview with DHS on 6/15/23 at 2:20 p.m., indicated it was the admitting nurse who was responsible to complete a thorough and accurate skin assessment and initiate a treatment for Resident 155. The notification of change in condition provided by the Executive Director on 6/15/23 at 10:40 a.m., indicated the purpose was to ensure appropriate individuals are notified of change in condition. The facility must inform the resident's physician when there was a significant change in the resident's physical status or a need to alter treatment significantly. Sample reasons to notify the physician immediately included, but were not limited to, a deterioration in health status in either life threatening conditions or clinical complications and a need to alter treatment significantly. The pressure ulcer policy provided by the Nurse Consultant on 6/15/23 at 12:20 p.m., indicated appropriate wound event is completed by a nurse in the electronic health record for each impaired skin area with measurements, color, odor, wound margins, surrounding tissue, exudate and tunneling. The purpose was to provide weekly documentation of wound measurements and condition. 3.1-40(a)(2)

Based on observation, interview and record review the facility failed to maintain an nebulizer machine in sanitary manner, failed to change the tubing monthly and failed to have oxygen tubing dated for 3 of 7 residents reviewed for respiratory care (Resident 15, Resident 37 and Resident 3). Findings include: 1.) During an observation on 6/08/23 at 3:54 p.m., Resident 15 nebulizer tubing was dated 4/17/23, the oxygen tubing did not have a date on it. During an observation and interview with Resident 15 on 6/12/23 at 1:56 p.m., the resident's nebulizer mask was laying on the bedside table, Resident 15 indicated she did not know where the bag was to store it in. The resident searched for a bag to store it in, but was unable to locate one. Review of the record of Resident 15 on 6/12/23 at 2:20 p.m., indicated the resident's diagnoses included, but were not limited to, Chronic respiratory failure with hypoxia, Chronic obstructive pulmonary disease with (acute) exacerbation, Unspecified fall, osteoarthritis, Unsteadiness on feet, repeated falls, dependence on supplemental oxygen and difficulty in walking. The physician order for Resident 15, dated 4/12/23, indicated the resident was ordered Albuterol sulfate solution for nebulization three times a day. The physician order for Resident 15, dated 6/14/23, indicated the resident was ordered oxygen at 2.5 liters nasal cannula continuous. During an interview with the Director of Health Services (DHS) on 6/13/23 at 12:00 p.m., the nurse on night shift was suppose to change oxygen tubing weekly on Sundays and are responsible to date oxygen tubing and keep nebulizer in a mask. The facility policy says monthly, but the DHS preferred it be done weekly. During an interview with the Executive Director on 6/14/23 at 1:25 p.m., Resident 15 did not have an order for oxygen until today, she should of had an order. The resident had went to the hospital and when she came back the facility did not get an order. 45291 2. The clinical record for Resident 3 was reviewed on 6/14/2023 at 2:14 p.m. The medical diagnoses included respiratory failure and heart failure. A Quarterly Minimum Data Set Assessment, dated 5/15/2023, indicated that Resident 3 was cognitively intact and utilized oxygen therapy. An observation on 6/8/2023 indicated Resident 3 sitting in his motorized chair utilizing portable oxygen. He had a nasal cannula in place. No date was on the nasal cannula, nor a storage bag noted for the portable oxygen tubing. An observation on 6/12/2023 at 4:05 p.m. indicated Resident 3 was sitting in his motorized chair utilizing portable oxygen. He had a nasal cannula in place. No date was on the nasal cannula, nor a storage back noted for the portable oxygen tubing. 3. The clinical record for Resident 37 was reviewed on 6/15/2023 at 10:55 a.m. The medical diagnoses included respiratory failure and pneumonia. A Quarterly Minimum Data Set Assessment, dated 5/12/2023, indicated that Resident 37 was cognitively impaired and utilized oxygen therapy. An observations on 6/9/2023 at 12:26 p.m. indicated that the portable oxygen nasal cannula tubing did not have a date, but a bag on the back of the Geri chair was dated for 4/17. An observation on 6/12/2023 indicated that Resident 37 was sitting in her Geri chair. She had her portable oxygen therapy in place. The nasal cannula did not have a date, but an oxygen storage bag was on the back off the chair dated 4/17. CRCA 1 verified no date on the tubing, but the date of 4/17 on the storage bag. She immediately changed the oxygen set up and tubing. A policy entitled, Administration of Oxygen, was provided by the Executive Director on 6/13/2023 at 2:15 p.m. The policy indicated, .Date the tubing for the date it was initiated .Tubing should be changed monthly and PRN [as needed] . 3.1-47(a)(6)

Based on interview, observation, and record review, the facility failed to ensure Resident 18 did not have medications at bedside for 1 of 6 residents reviewed for medication administration. Findings include: The clinical record for Resident 18 was reviewed on 6/14/2023 at 2:06 p.m. The medical diagnoses included chronic obstructive pulmonary disease and dementia. An Admission Minimum Data Set Assessment, dated for 4/25/2023, indicated Resident 18 was cognitively intact and was at risk for skin impairments. The clinical record did not indicate that Resident 18 could self-administer medications. Review of the medical record indicated that Resident 18 did not have an order for Systane or Refresh eye drops. A physician order, dated 6/8/2023, indicated for Resident 18 to utilize a Spiriva inhaler 2 puffs daily. An observation on 6/12/2023 at 11:30 a.m. indicated that Resident 18 had a Spiriva inhaler, a bottle of Systane eye drops, and a bottle of Refresh eye drops on her beside table. An observation on 6/12/2023 at 1:45 p.m. indicated that Resident 18 had a Spiriva inhaler, a bottle of Systane eye drops, and a bottle of Refresh eye drops on her beside table. An observation on 6/13/2023 at 3:02 p.m. indicated that she Systane eye drops, and Refresh eye drops on her beside table. She indicated her family had brought in the eye drops awhile back, but she does not use them that often. She indicated the nurses bring in her inhaler and usually leave it for her to take as she gets up then will pick it up at the end of their shift. An interview with RN 2 on 6/13/2023 at 3:06 p.m. indicated she did not believe Resident 18 could self-administer her inhaler or eye drops. She told Resident 18 was going to place the eye drops in the medication cart. An interview with the Director of Health Services on 6/15/2023 at 2:55 p.m. indicated that Resident 18 does not self-administer medications and medications should not be let at the bedside. Review of the medical record indicated that Resident 18 did not have an order for Systane or Refresh eye drops. A policy entitled, Medication Storage in the Facility, was provided by the Executive Director on 6/16/2023 at 11:40 a.m. The policy indicated, .medications intended for internal use are storage in a medical cart or other designated area . 3.1-25(m)

Based on interview and record review, the facility failed to complete to complete an inventory sheet for Resident 11 for 1 of 3 reviewed for inventory sheets. Findings included: The clinical record for Resident 11 was reviewed on 6/12/2023 at 11:00 a.m. The medical diagnoses included chronic kidney failure and heart failure. A Quarterly Minimum Data Set Assessment, dated 6/4/2023, indicated Resident 11 had a mild cognitively impairment, was moderately hard of hearing, and utilized assistive devices for hearing. An interview with Resident 11's Power of Attorney (POA), indicated that Resident 11 had hearing aids when she was admitted to the facility. The POA indicated that Resident 11 has lost her hearing aids and they have not been replaced yet, but she would like Resident 11 to see audiology services. A review of Resident 11 record indicated that no inventory sheet was completed at admission. An interview with the Executive Director on 6/14/2023 at 3:35 p.m. indicated that no inventory sheet was completed for Resident 11. The facility does not have a policy for inventory sheets, but it is the expectation that these are completed at the time of admission. 3.1-50(a)(1)

Based on observation, interview and record review, the facility failed to ensure proper food storage related to expired and undated food in the main refrigerator and the nutrition pantry. This had the potential to affect all 52 residents that reside in the facility. Findings include: 1. A tour was conducted of the kitchen on [DATE] at 11:30 a.m. The main refrigerator was noted with the following: - Cream of chicken soup with a use by date of [DATE], - Chicken gravy with a use by date of [DATE], - Ham salad with a use by date of [DATE], - Left over soup with a use by date of [DATE], - Chicken salad with a use by date of [DATE], - Green vegetables with a use by date of [DATE], - Pureed sweet potatoes with no date, - Pasta salad with a use by date of [DATE], & - Package of 4 limes that appeared to be brown and soft. There was a muffin pan than contained 10 muffins that was located on top of a clean rack with clean pots and pans located on and underneath. An interview conducted with the Assistant Director of Food Services, on [DATE] at 11:45 a.m., indicated the muffin pan shouldn't be located on the clean dish rack and the food should have been dated and discarded before the use by date. 2. An observation was conducted of the nutrition pantry by the nurses' station on [DATE] at 10:35 a.m. The following was noted in the refrigerator: Buttermilk with a best by date of [DATE], Prune juice with a use by date of [DATE], Prune juice with a use by date of [DATE], & Yogurt with a best by date of [DATE]. The same concerns were noted on [DATE] at 2:40 p.m. A policy titled Storage was provided by the Executive Director, on [DATE] at 12:00 p.m. The policy indicated the following, .Food and supplies shall be properly stored to keep foods safe and preserve flavor, nutritive value, and appearance .Refrigerated Storage .5. Food is covered, dated and stored loosely to permit air circulation .7. Prepared perishables such as salads, puddings, milk, etc., are stored in a refrigerator and covered, labeled, and dated until used 3.,d+[DATE](i)(3)

Based on observation, interview and record review the facility failed to thoroughly investigate the root cause analysis of a fall and failed to use a gait belt during ambulation with a resident who was at high risk for falls resulting in a fall with a left ankle fracture, causing pain for 1 of 3 residents reviewed for falls of 3 who met the criteria for accidents (Resident #47). Finding include: Interview with Resident #47 on 7/16/14 at 10:01 a.m., indicated she had discomfort and pain without relief. Resident #47 indicated she had fell and messed up her left ankle. Resident #47 indicated the facility gave her pain medicine for her left ankle pain and sometimes it helped and sometimes it did not help. Resident #47 was sitting in a wheelchair with a pink cast on her left leg and foot. Interview with LPN #9 on 7/16/14 at 11:41 a.m., indicated Resident #47 had fell and sustained a left ankle fracture in last 30 days. Review of the record of Resident #47 on 7/17/14 at 1:30 p.m., indicated the resident's [DIAGNOSES REDACTED]. The "assessment review and considerations" for Resident #47 dated 5/10/14 (no time), indicated the resident was at risk for falls due to cognitive impairment. The nursing safety assessment for Resident #47 dated 5/10/14 (no time), indicated the resident required an assistive device of a walker and a wheelchair. The safety plan of care for Resident #47 dated 5/10/14 (no time), indicated the interventions included, but were not limited to, "implement enabler to assist with fall prevention" and "provide assistive devise and ensure it is accessible". The safety plan of care did not indicate what type of enabler or assistive device needed to be used to assist the resident with safety. The Admission Minimum Data set (MDS) assessment for Resident #47 dated 5/17/14, indicated the following: walk in room- extensive assistance of one person, walk in corridor- limited assistance of one person, locomotion on the unit- extensive assistance of one person, toilet use-extensive assistance of one person, walking- not steady, only able to stabilize with staff assistance, functional range of motion-no impairment of the upper or lower extremities, pain or hurting in the last five days-no and received scheduled, as needed or non medication interventions for pain in the past five days-no. The "profile history report" for Resident #47 dated 6/6/14, indicated the resident was at risk for falls. The interventions were "place my bed at an appropriate level for my body height to facilitate safe transfers, lock the brakes, keep my call light and frequently used items with easy reach to prevent me from overstretching, ensure my environment is appropriately lit for the time of day and my pathway are free of clutter." "My goal is to have no falls or at least no injuries from falls." The profile history report did not indicate any revision or update until 6/20/14 with the intervention to encourage to ask for help. The "Rehabilitation screening" for Resident #47 dated 6/16/14, indicated the resident staff reported the resident was ambulating with a front wheeled walker from the dining room with an abnormal gait. The resident was observed during this screen to have poor posture, rigidity in bilateral leg extremities and ambulating with a wider base of support increasing the risk for falls. The resident may benefit from physical therapy skilled services for abnormal gait pattern. The Physical therapy plan of care for Resident #47 dated 6/18/14, indicated the resident presented to therapy with a decline in Activities of Daily Living of ambulation with a front wheeled walker due to an abnormal gait pattern and poor cognition deficits. The nursing staff had noticed a decrease with the ability to ambulate, resulting in decreased safety and an increase need for assistance and risk of falls. The resident's current level of functioning was ambulated on a level surface and on carpet requiring contact guard assist, the resident required contact due to unsteadiness with the front wheeled walker. The fall circumstance assessment and intervention for Resident #47 dated 6/20/14, indicated the resident had a witnessed fall and hit her head. The resident had signs and symptoms of a left ankle fracture. The prevention intervention update was orient to environment, nonskid footwear, use a wheelchair and encourage to ask for help. The Interdisciplinary (IDT) review located on the bottom of the document dated 6/23/14, indicated no root cause, no intervention update appropriate or change of intervention. All areas of the review were blank. The IDT review was signed by the Assistant Director of Health services (ADHS). The change in condition form for Resident #47 dated 6/20/14, indicated the resident fell in her room onto her knees and then fell back and hit her head on a chair. The resident had no complaints at first and now was complaining of pain to the left ankle. The physician ordered an x-ray of the left ankle. The resident was not able to bear weight on the left ankle. The radiology report for Resident #47 dated 6/20/14, indicated the resident had an oblique (at an angle) fracture of the left distal fibula (the bone on the outside of the lower leg attached to the ankle) with associated soft tissue swelling. The pain circumstance assessment for Resident #47 dated 6/21/14, indicated the resident had acute pain from a fall with a left ankle fracture. The resident's pain was very severe. The careplan update was tramadol 50 milligrams one by mouth every fours hours as needed. The orthopedic initial fracture care for Resident #47 dated 6/24/14, indicated the resident had a left ankle fracture as a result of a fall. The resident described her pain as aching, discomforting and throbbing. The symptoms occurred intermittently and was aggravated by movement. The symptoms had been acute and traumatic. The resident also was experiencing bruising, decreased mobility, joint tenderness, swelling and weakness. The resident had a splint placed to allow for swelling and will been seen in two weeks for a cast and was to be non weight bearing. The orthopedic note for Resident #47 dated 7/8/14, indicated the resident reported the her symptoms were intermittently and were mild to moderate. The symptoms were relieved by rest and elevation. The resident indicated she mostly sat in her chair. The resident had a short leg cast placed and was to continue to be non weight bearing. The physical therapy note for Resident #47 dated 6/24/14, indicated the resident had a fall on 6/20/14 resulting in a left lower leg fracture. The resident was too anxious to continue therapy services at this time. Interview with the ADHS on 7/17/14 at 1:35 p.m., indicated she did the investigation of Resident #47's fall on 6/20/14. The ADHS indicated the resident was with CNA #1, the resident fell to her knees and then fell backward. The ADHS indicated she did not know where the resident was going at the time of the fall or if the CNA was using a gait belt or if the resident was using her walker. Interview with Resident #47 on 7/17/14 at 1:43 p.m., indicated she did not remember what happened the day she fell . The resident indicated she did not know if she had her walker or if staff were with her when she fell . The resident indicated she remembered she did not feel well the day she fell . Interview with CNA #1 on 7/17/14 at 2:03 p.m., indicated she was with Resident #47 on 6/20/14 when she fell . CNA #1 indicated she was walking with the resident from the dining room to the resident's bedroom because the resident needed to use the restroom. CNA #1 indicated the resident was using a walker. CNA #1 indicated the resident was dragging her left leg while she ambulated from the dining room. CNA #1 indicated when they got to the resident's bedroom the resident's legs began shaking and she dropped to her knees and fell back and hit her head. CNA #1 indicated she and a nurse got the resident up and the resident did not complain of pain. CNA #1 indicated she then took the resident to the bathroom and the resident started complaining that her left ankle hurt really bad. CNA #1 indicated the resident did not have a gait belt on while she was ambulating from the dining room to her bedroom. Interview with Physical Therapist (PT) #4 on 7/18/14 at 11:15 a.m., indicated she did the assessment and evaluation for Resident #47 on 6/18/14. PT #4 indicated the resident had a lot of stiffness in her legs and required contact guard assist with ambulation. PT #4 indicated the resident was at high risk for falls and required a gait belt during ambulation with the assistance of staff because the resident had a rigid spastic gait. PT #4 indicated she had verbally communicated to the nursing staff Resident #47 needed to be held onto with a gait belt and use a walker during ambulation. PT #4 indicated the distance from the dining room to Resident #47's bedroom was between 150 to 200 feet. Interview with the Director of Health Services (DHS) on 7/18/14 at 1:00 p.m. indicated therapy recommendations for ambulation were communicated to the facility staff by the profile history report. During observation on 7/18/14 at 1:20 p.m., CNA #2 and CNA #3 transferred Resident #47 from her wheelchair to her bed to use a bedpan, a hoyer lift was used for the transfer. CNA #2 indicated before the resident fractured her ankle she walked to the toilet. CNA #2 indicated now that the resident had to use a hoyer lift for transfers and had to use a bedpan for toileting needs because the hoyer lift would not fit in the bathroom. Resident #47 indicated it was uncomfortable for her to use a bedpan. CNA #2 left the room to look for a bedside commode. Resident #47 used the bedpan before CNA #2 returned due to the resident could not wait to use the restroom. Interview with the DHS on 7/18/14 at 2:12 p.m. indicated Resident #47 profile history report was not updated with therapy recommendations for ambulation on 6-18-14. The fall management program provided by DHS on 7/18/14 at 2:15 p.m., indicated the facility strived to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures. Care plan interventions should be implemented that address the resident's risk factors. Should a resident experience a fall the attending nurse shall complete the fall circumstance form. The form includes an investigation of the circumstances surrounding the fall to determine the cause of the episode, a reassessment to identify possible contributing factors, interventions to reduce risk of repeat episode and a review by the IDT to evaluate thoroughness of the investigation and appropriateness of the interventions. 3.1-45(a)(2)