Every finding on record at Glenbrook Rehabilitation & Skilled Nursing Center

Based on interview and record review the facility failed to ensure 3 of 3 residents were free of misappropriation of medications (Resident B, Resident C, Resident D).Findings include:A report, dated 7/10/26, indicated Registered Nurse 4 (RN) was allegedly taking discontinued medications from Resident B, Resident C, Resident D.In an interview, on 8/4/26 at 9:10 AM, the Administrator indicated an Administrator from another facility notified her RN 4 had possession of Resident B, Resident C, and Resident D's medications in her home. The Administrator indicated a police report was made, the officer confirmed the medications were in the home, labelled for Resident B, Resident C and Resident D and did not belong to RN 4. The Administrator indicated the officer retrieved the medications from RN 4's home.In an interview, on 8/4/26 at 10:41 AM, the police department indicated Officer 5 received notification from an Administrator of resident medications in RN 4's home, Officer 5 searched the home on 7/9/26 and retrieved the medications. The police department indicated Officer 5 confirmed the medications had Resident B, Resident C and Resident D information on them and did not belong to RN 4.In an interview, on 8/4/26 at 9:36 AM, RN 2 indicated discontinued medications are taken out of the medication cart and handed to the Director of Nursing (DON) for disposition or pharmacy return. RN 2 indicated staff never took resident medications home with them.In an interview, on 8/4/26 at 9:45 AM, Licensed Practical Nurse (LPN) 3 indicated discontinued medications are taken out of the medication cart and handed to the DON for disposition or pharmacy return. LPN 3 indicated staff never took resident medications home with them.Resident B's record was reviewed on 8/4/26 at 10 AM. Diagnoses included major depressive disorder and panic disorder.A discontinued order, dated 5/5/26 - 5/8/26, indicated to administer Sertraline (antidepressant) 50 mg 1x day.The Medication Administration Record (MAR), dated 5/1/26 - 5/30/26, indicated Resident B received 4 doses with 26 capsules of discontinued doses left over.A discontinued order, dated 5/5/26 - 5/8/26, indicated to administer cephalexin (antibiotic) 500 mg x 17 doses every eight hours for a urinary tract infection.The MAR, dated 5/1/26 - 5/30/26, indicated the medication was administered as prescribed with 7 capsules of discontinued doses left over.2. Resident C's record was reviewed on 8/4/26 at 10:27 AM. Diagnoses include chronic obstructive pulmonary disease and respiratory failure.A discontinued order, dated 4/23/26 - 4/23/26, indicated to administer 2- 20 mg tablets (40 mg) 1x daily for 1 dose of prednisone (corticosteroid).The MAR, dated 4/1/26-4/30/26, indicated Resident B had taken 2 doses with 8 discontinued doses left over.3. Resident D's record was reviewed on 8/4/26 at 10:33 AM. Diagnoses include depression, anxiety disorder and cellulitis to left lower limb.A discontinued order, dated 4/1/26-4/2/26, indicated to administer 100 mg every 12 hours for 4 doses of doxycycline hyclate (antibiotic) 100 mg.The MAR, dated 4/1/26 - 4/30/26, indicated Resident D received 2 doses with 2 discontinued doses left over.In an interview, on 8/4/26 at 10:14 AM, the DON indicated there were no disposition or pharmacy return forms completed for Resident B, Resident C or Resident D's discontinued medications. The DON indicated per her audit on 7/10/26, RN 4 took the following medications from the following residents:Resident B: 7 doses of cephalexin, 26 doses of sertralineResident C: 8 doses of prednisoneResident D: 2 doses of doxycycline hyclateA current policy, last revised June 2023, titled Abuse Prohibition, Reporting and Investigation was provided by the Administrator on 8/4/26 at 11:40 AM. The policy indicated residents would remain free from misappropriation of property, including items taken without consent from the resident.This finding relates to Intake 3090304.410 IAC (Indiana Administrative Code) 16.2 - 3.1-28(a)

Based on observation, interview, and record review the facility failed to ensure staff followed physician orders for 3 of 3 residents reviewed. (Resident B, Resident C, and Resident D)Findings include: 1. A record review for Resident B began on 11/18/25 at 11:45 AM. Diagnoses included type 2 diabetes, atherosclerosis of the left leg, and right-sided below the knee amputation.A review of Resident B's current quarterly MDS, dated [DATE], indicated their BIMS (Basic Interview for Mental Status) score was 14. (cognitively intact). The MDS indicated the resident received insulin injections 7 days a week. A review of physician orders, dated 9/10/25, indicated 8 units of Humalog insulin was to be administered three times a day with meals. If the blood glucose was less than 150, the insulin dose was not to be given.A review of physician orders, dated 9/2/25, indicated blood glucose was to be measured and recorded four times a day, before meals and at bedtime.A review of the Medication Administration Record (MAR), dated 9/1/25-9/30/25, indicated Resident B was given 8 units of insulin on 9/11/25 at 6:00 PM for a blood sugar less than 150 and 9/17/25 at noon for a blood sugar less than 150. A review of physician orders, dated 10/3/25, indicated 8 units of the insulin Lispro was to be given three times a day. If the blood glucose was less than 150, the insulin dose was not to be given.A review of physician orders, dated 10/13/25, indicated 42 units of Lantus insulin were to be given to Resident B every evening at bedtime.A review of the MAR dated, 10/1/25-10/31/25, indicated Resident B was given 8 units of insulin on 10/9/25 at 6:00 PM for a blood sugar of 102, 10/12/25 at 6 pm for a blood sugar of 147, 10/18/25 at 6:00 PM for a blood sugar of 134, 10/25/25 at 6:00 PM for a blood sugar of 119. No documentation of insulin administration was found on 10/15/25 at 6:00 PM for a blood glucose measuring 221 or on 10/20/25 at 6:00 PM for a blood glucose measuring 167. On 10/30/25, a blood glucose of 159 was recorded at 8:00 AM, the site of administration was documented with the letter N. 42 units of Lantus was not documented as given on 10/27/25.A review of the MAR notes on 10/30/25 indicated there were no notes the resident received the insulin dose or if they did not. N is not a documented abbreviation for a subcutaneous insulin injection site.A review of progress notes, dated 9/1/25 to 11/1/25, indicated no explanations or documentation regarding the missing insulin doses, or documentation for giving the insulin without an order from the physician.2. A record review for Resident C, began on 11/18/25 at 1:30 PM. Diagnoses included type 2 diabetes with diabetic polyneuropathy, peripheral vascular disease, congestive heart failure, atherosclerotic heart disease, and chronic kidney disease.A review of physician orders, dated 6/9/25-9/11/25, indicated blood glucose was to be measured three times a day.A review of physician orders, dated 6/9/25-9/11/25, indicated 3 units of insulin Lispro was to be administered if blood glucose was above 200.A review of physician orders, dated 6/10/25-9/8/25, indicated 42 units of Lantus was to be given every evening, at bedtime.A review of physician orders, dated 8/18/25-8/25/25, indicated 7.5-325 mg of hydrocodone-acetaminophen was to be given to Resident C four times a day.A review of physician orders, dated 8/25/25-9/11/25, indicated 7.5-325 mg of hydrocodone-acetaminophen was to be given to Resident C four times a day.A review of the MAR, dated 8/1/25-8/31/25, indicated Lantus insulin was not documented as given or refused on 8/1/25 and 8/10/25. Blood glucose was not recorded on 8/31/25 at 6 pm. No documentation of Lispro administration was found on 8/1/25 at 6:00 PM for a glucose of 272, 8/4/25 at noon for a glucose of 255. No administration or refusal of Lispro was indicated on 8/31/25. 42 units of Lantus were given between 7:00 PM and 10:00 PM without a recorded blood glucose measurement. No documentation of hydrocodone-acetaminophen administration or refusal was indicated on 8/21/25 at 12:00 AM. 3. A record review for Resident D began on 11/19/25 at 9:35 AM. Diagnoses included type 2 diabetes with diabetic peripheral angiopathy with gangrene and chronic kidney disease, right leg below the knee amputation. Resident D routinely leaves the facility for dialysis on Mondays, Wednesdays, and Fridays.A review of Resident D's current quarterly MDS, dated [DATE], indicated their BIMS (Basic Interview for Mental Status) score was 14. (cognitively intact). The MDS indicated the resident received insulin injections 5 days a week during the previous week of the assessment.A review of physician orders, dated 9/18/25-10/20/25, indicated blood glucose was to be measured four times a day.A review of physician orders, dated 9/18/25-10/6/25, indicated 18 units of insulin glargine was to be given once a day. The order did not provide parameters to hold insulin or to hold on dialysis appointments.A review of physician orders, dated 10/6/25, indicated 18 units of Rezvoglar Kwik Pen insulin glargine was to be given once a day. The order did not provide parameters to hold insulin or to hold on dialysis appointments.A review of the MAR, dated 10/1/25-10/31/25, indicated blood glucose was not documented as completed or refused on Sunday 8/5/25 at 8:00 AM, Tuesday 10/7/25 at 5:00 PM, and Tuesday 10/14/25 at 8:00 AM. The 8:00 AM of 18 units of insulin glargine was held by facility staff, without physician parameters, on 10/6/25 for glucose of 120, 10/10/25 for a glucose of 93, 10/12/25 for a glucose of 132, 10/13/25 for a glucose of 121, 10/14/25 a note indicated the glucose was not measured prior to Resident D leaving the facility for a procedure, 10/22/25 a note indicated the resident was going to dialysis, 10/23/25 for a glucose of 124, 10/26/25 for a glucose of 100, 10/28/25 for a glucose of 95, and 10/30/25 for a glucose of 108. The MAR indicated, 18 units Resvoglar insulin was routinely not given to Resident D on Mondays, Wednesdays, and Fridays (dialysis days), except for Monday 10/27/25 prior to dialysis. In an interview, on 11/19/25 at 3:02 PM, LPN 4 indicated staff routinely obtained a blood sugar measurement within an hour before meals and bedtime. When insulin was required, within the parameters ordered, a Qualified Medical Assistant would need to have a nurse administer the insulin dose. Documentation was required on the MAR. When a resident was not in the building, staff would document the resident was not available or LOA.A current procedure, dated 2/2010, provided by the Administrator, indicated medications held or refused will be documented in the MAR. Medication administration will be documented on the MAR after the medication has been given. Insulin type, units to be given should be checked against the physician order at least 3 times for accuracy prior to administration.A current policy, dated 2/2003, provided by the Administrator, indicated staff was to administer medications and meals before or after dialysis as ordered.This citation is related to intake 2649663 and 2626035.3.1-30(a)

Based on observation, interview and record review the facility failed to ensure behavior was identified, tracked and interventions initiated for 1 of 3 residents reviewed. Findings include:On 9/15/25 at 1:45 PM, Resident 63 was observed in the hallway sitting in their wheelchair. Resident 63's face and head were covered with scarves, only their eyes were visible. Resident 63 was holding 2 foam toy guns. Resident 63 fired a foam bullet, striking a passerby with a foam bullet. Resident 63 then propelled their wheelchair away quickly.On 9/16/25 at 2:40 PM, Resident 63 was observed in their wheelchair in the hallway. Resident 63 was holding 2 foam toy guns. Resident 63 stood briefly and pointed their toy guns at a passerby. 2 staff members were present in the hallway but did not intervene.In an interview, on 9/16/25 at 9:30 AM, Resident 5 indicated some residents were afraid of Resident 63. Resident 5 indicated Resident 63 did whatever they want, and the staff would not intervene.In an interview, on 9/16/25 at 9:31 AM, Resident 13 indicated Resident 63 vaped and screamed in the hallways. Resident 13 indicated Resident 63 blared loud music. Resident 13 indicated the staff would not intervene. Resident 13 indicated Resident 63 had an active arrest warrant.In an interview, on 9/18/25 at 10:42 AM, the Administrator indicated they had asked Resident 63 to put away their foam guns on the day the resident was admitted . The Administrator indicated they had asked the resident not to vape in the hallways, and the resident had complied. The Administrator indicated Resident 63 had not been observed pointing their foam guns at other residents. The Administrator indicated they were aware of one resident having reported Resident 63 blaring loud music at 4 in the morning.1.Resident 5's record was reviewed on 9/18/25 at 9:50 AM. Resident 5's admission Minimum Data Set, (MDS) dated [DATE], indicated Resident 5's Brief Interview for Mental Status (BIMS) score was 15 (no cognitive loss).2.Resident 13's record was reviewed on 9/18/25 at 10:10 AM. Resident 13's Quarterly Minimum Data Set, (MDS) dated [DATE], indicated Resident 13's Brief Interview for Mental Status (BIMS) score was 15 (no cognitive loss).3.Resident 63's record was reviewed on 9/15/25 at 2:30 PM. Diagnoses included anxiety, insomnia, pain disorder, post traumatic stress disorder (PTSD) and schizophrenia.Resident 63's care plan, dated 9/5/25, indicated Resident 63 had chosen to smoke.Resident 63's care plan, dated 9/8/25, indicated Resident 63 had a history of substance use disorder.Resident 63's care plan, dated 9/8/25, indicated Resident 63 was at risk for anxiety.Resident 63's care plan, dated 9/9/25, indicated the resident had PTSD due to poor family support, childhood abuse and had survived being shot during an attempted murder. The care plan indicated the resident had received special education services while in school. The care plan indicated Resident 63 had been incarcerated.Resident 63's care plan did not indicate they had disruptive behaviors of screaming, blaring loud music or vaping in the hallways.Resident 63's care plan did not indicate they had attempted to shoot people with foam guns.Resident 63's care plan summary for direct care staff (profile) indicated the resident had diagnoses of schizophrenia, anxiety, epilepsy, insomnia and a history of noncompliance.Resident 63's profile did not indicate the resident had disruptive behaviors of screaming and playing loud music. The profile did not indicate Resident 63 had foam guns in the hallways. The profile did not indicate any interventions to address Resident 63's behavior.Resident 63's Medication Administration Record (MAR), dated August 2025, did not include any tracking or interventions related to Resident 63's behaviors. In an interview, on 9/18/25 at 12:18 PM, the Social Services Director indicated she had nothing to add. She indicated there was no identification and no tracking unless it was on the MAR.A current facility policy, dated 10/2022, indicated staff would be educated in regard to resident specific interventions for behavioral issues.3.1-43(a)(1)

Based on observation, interview, and record review the facility failed to ensure monitoring of refrigerated medications in accordance with manufacturer guidelines in 1 of 1 refrigerated storage units reviewed. (Resident 4, Resident 50 and Resident 23)During an observation on 9/19/25 at 11:00 AM, the medication storage room had a freezer and refrigerator log missing internal temperature measurements for 9/17/25, 9/18/25, and 9/19/25. On 9/16/25, the refrigerator temperature was last recorded as 37 degrees Fahrenheit (F). Inside the refrigerator, the thermometer measured 20 degrees F and felt cold. Licensed Practical Nurse (LPN) 8 observed the thermometer and confirmed it was 20 degrees. A basket of medication pens was found on the second shelf. The medications included Lantus, Ozempic, Rezvoglar, Tresiba, and a vial of Aplisol tuberculin.In an interview, on 9/19/25 at 11:27 AM, LPN 8 indicated refrigerator temperatures are recorded at the end of the day shift, between 2:15 PM- 3:00 PM. LPN 8 indicated the thermometer should be exchanged. LPN 8 notified the Director of Nursing, (DON) the refrigerator were temperatures out of range.A review of the medications in the refrigerator included, 1 Ozempic pen and 4 Degludec insulin pens for Resident 4, 1 Rezvoglar pen for Resident 50, 1 Lispro insulin pen for Resident 23, and a vial of Aplisol tuberculin labeled House Stock. A review of Novo Nordisk manufacturer instructions indicated Degludec and Ozempic should be refrigerated between 36 F to 46 F. The instructions indicated to not use if Ozempic had been frozen. The manufacturer did not include the freezing temperature of Ozempic.A review of [NAME] Lilly manufacturer instructions indicated Rezvoglar and Lispro should be refrigerated between 36 to 46 F until opened. There were no further instructions regarding use. A review of Par Sterile Products manufacturer instructions indicated Aplisol should be refrigerated between 36 to 46 F. There were no further instructions regarding use. In an observation, on 9/19/2025 at 11:36 AM, a different thermometer indicated the internal refrigerator temperature was 40 degrees F. A current policy, dated 11/2024, provided by the DON, indicated medications would be stored in the refrigerator between 36-46 degrees F. The policy indicated the facility should monitor the refrigerator at least once daily.3.1-25(m)

Based on observation, interview and record review, the facility failed to ensure protective smoking equipment was provided and a electronic cigarette vapor free indoor room environment was provided for 2 of 20 residents reviewed (Resident 40 and Resident 17).Findings included:1) During an observation, on 09/15/2025 at 9:39 AM, Resident 40 was in the smoking area outdoors smoking a cigarette and was not wearing a smoking apron. During an observation, on 09/16/2025 at 1:32 PM, the Assistant Culinary Manager (ACM) lit a cigarette for Resident 40 in the outdoor smoking area. Resident 40 was not wearing a smoking apron. The ACM, approached Resident 36, assisted him in putting on a smoking apron and lit Resident 36's cigarette. The ACM continued giving out and lighting cigarettes for several other residents in the smoking area with his back turned to Resident 40. During an observation, on 09/16/2025 at 1:34 PM, the Administrator entered the smoking area and asked another staff member to get an apron for Resident 40. Resident 40 indicated to the Administrator he was not going to wear the apron. No additional conversation regarding encouragement or risks occurred. The Administrator returned to the building. Resident 40 requested an additional cigarette from the ACM. The ACM gave him another cigarette, lit it and observed Resident 40 until he finished the cigarette, disposed of the cigarette and assisted Resident 40 back to the building. Resident 40's record was reviewed on 09/16/2025 at 1:36 PM. Diagnoses included vascular dementia with behavioral disturbance, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side, diabetes mellitus due to underlying condition with diabetic neuropathy and nicotine dependance. A review of Resident 40's current annual Minimum Data Set (MDS) assessment, dated 8/7/2025, indicated his Basic Interview for Mental Status (BIMS) score was 13 (cognitively intact). A current smoking assessment, dated 8/7/2025, indicated Resident 40 had been observed having careless smoking with a potential to drop his cigarette. The assessment indicated the resident should have a smoking apron. A document listing smoking times and names of persons who smoked, provided by the Administrator on 09/15/2025 at 11:12 AM, indicated Resident 40 should use a smoking apron while smoking. A current care plan, revised 08/16/25, titled Resident currently uses tobacco, indicated Resident 40 smoked cigarettes with a potential for non-compliance, with a goal date of 11/16/2025. The care plan indicated Resident 40 should be provided with a smoking apron and supervised while smoking. The care plan indicated the smoking policy should be explained to Resident 40 with reminders as needed. During an interview, on 09/16/2025 at 2:33 PM, the ACM indicated he told the Activity Director Resident 40 refused his apron while inside the building, prior to going out to the smoking area. He indicated he lit Resident 40's cigarette prior to the Administrator arriving in the smoking area to talk to Resident 40. During an interview, on 09/16/2025 at 2:39 PM, the Administrator indicated the smoking policy did not address what staff should do when a resident refused his smoking apron. She indicated the staff member should not have lit the cigarette until the Administrator addressed the refusal. A current policy titled Smoking Policy, dated 09/2024, provided by the Administrator on 09/16/2025 at 01:15 PM indicated a smoking assessment must be completed upon admission, quarterly and with a significant change for all residents wishing to smoke. The policy indicated the smoking assessment determined the amount of safety equipment required for each resident. Safety equipment requirements should be care planned and communicated to staff monitoring smoking. The policy indicated residents found to be non-compliant with the policy should have an immediate meeting with facility staff to discuss all options for safety reasons. 2) During an interview, on 09/16/2025 at 10:36 AM, Resident 13 indicated she was allowed to maintain her vaping supplies herself in her room She indicated she was allowed to vape in her room or outside in the smoking area during her assigned smoking times. She indicated her roommate was present in the room when she vaped Resident 13 indicated she shared a room with Resident 17 and Resident 17 did not care if she vaped in the room. During an observation, on 09/16/2025 at 1:43 PM, Resident 13 was observed removing a vape cartridge from her handbag and using it in the facility smoking area outdoors. Resident 13's record was reviewed on 9/16/2025 10:36 AM. Diagnoses included anxiety disorder and nicotine dependence. A review of Resident 13's current quarterly Minimum Data Set (MDS) assessment, dated 8/20/25, indicated she had a Basic Interview for Mental Status (BIMS) score of 15 (cognitively intact). A current care plan, dated 8/25/2025, indicated Resident 13 had a problem of use of an electronic cigarette with a goal date of 11/24/2025. The care plan had a goal of maintaining safety with an approach of reviewing the electronic cigarette policy upon admission and as needed. 3) Resident 17's record was reviewed on 09/19/25 9:48 AM. Diagnoses included anxiety disorder, Bipolar disorder, and psychotic disorder. A review of Resident 17's current quarterly Minimum Data Set (MDS) assessment, dated 8/12/25, indicated she had a Basic Interview for Mental Status (BIMS) score of 7 (cognitively impaired) The MDS indicated Resident 17 displayed disorganized thinking and difficulty focusing in conversation. During an interview, on 09/19/2025 at 9:57 AM, the Director of Nursing indicated Resident 17, a cognitively impaired resident with difficulty focusing and disorganized thinking was unable to give consent to another resident vaping in their room She indicated smoking status did not imply consent to vape in the room. During an interview, on 09/19/2025 at 12:16 PM, the Administrator indicated the facility followed the city ordinance exceptions in regard to indoor electronic cigarette use. A City ordinance, dated indicated private or semi private rooms, in Nursing Homes where resident both smoked and had requested to be placed in a room where smoking was permitted were allowed electronic vaping provided the vapor did not infiltrate into other areas of the facility. A current policy, titled Electronic Cigarettes, dated 7/2017, provided by the Administrator on 09/16/2025 1:15 PM, indicted the IDT team should meet to determine if a resident is appropriate for use of an electronic cigarette based on cognitive ability and eye hand coordination. Prior to the use of the electronic cigarette, the resident's roommate should be consulted as to comfort with the use of the electronic cigarette in their room.3.1-45(a)

Based on observation, interview, and record review the facility failed to ensure respiratory care was consistent with professional standards of practice for 1 of 3 residents reviewed. (Resident 42)During a continuous observation on 9/18/2025 from 2:33 PM to 2:52 PM, Certified Nursing Assistant (CNA) 6 replaced the water container for Resident 42's oxygen humidity. Water in the container entered the nasal cannula tubing. When CNA 6 connected the water container to the oxygen, the water rose up the nasal cannula to the resident's nose and dripped large water droplets. CNA 6 removed the nasal cannula from Resident 42, placed the tubing in the bag attached to the oxygen concentrator, and turned off the oxygen flow. CNA 6 verbalized the intention to notify the nurse and left the room. At 2:51 PM, LPN 7 entered Resident 42's room. Resident 42's oxygen saturation measured 88% on room air. A new nasal cannula was applied and oxygen flow was started by LPN 7 at 2:52 PM. In an interview, on 09/18/2025 at 2:55 PM, LPN 7 indicated that CNAs are allowed to change the oxygen water humidifier. LPN 7 indicated she was told Resident 42 was out of water, not that the resident was without oxygen. A record review for Resident 42's began on 9/18/2025 9:28 AM. Diagnoses included chronic obstructive pulmonary disease (COPD), asthma, anemia, heart failure, and Alzheimer's.A review of Resident 42's current quarterly MDS, dated [DATE], indicated their BIMS (Basic Interview for Mental Status) score was 6 (severe cognitive impairment). The MDS indicated the resident required oxygen therapy for chronic respiratory failure with hypoxia (low oxygen saturation).A review of physician orders, dated 5/29/25, indicated oxygen delivery should be at 3 liters per minute (lpm). A review of physician orders, dated 9/19/25, indicated oxygen delivery should be at 2 liters per minute, but may increase to 4 lpm to keep oxygen saturation above 90%.A current undated policy, provided by the Director of Nursing on 9/19/2025 at 8:56 AM, indicated the water humidifier was to be attached, the oxygen flow adjusted, then attach the oxygen tubing to the port and fit the nasal cannula to the resident.A review of the Indiana State Department of Health, Nurse Aide Curriculum dated 9/19/2015 indicated nursing assistants never stop, adjust, or initiate the use of oxygen.A review of the CNA Procedure titled Nasal Cannula Care, provided by the Regional Nurse Administrator, on 9/19/25 at 12:56 PM, indicated the nursing assistant could remove the nasal cannula, clean the skin around the nose, and reapply the nasal cannula before removing gloves, and leaving the room.The procedure did not indicate the CNA could remove or turn off the oxygen3.1-47(a)(6)

Based on interview and record review, the facility failed to the ensure residents were free from misappropriation of property for 1 of 5 residents reviewed (Resident B). Findings include: Resident B's record was reviewed on 4/10/25 at 12:45 PM. Resident B no longer resided in the facility. A report, dated 3/24/25, provided by the Administrator on 4/10/25 at 12:42 PM indicated Certified Nurse Aide (CNA) 3 was suspected of theft. A file was provided by the Administrator on 4/10/25 at 12:42 PM. The file included the following statements: Housekeeping Supervisor's statement, dated 3/25/25, indicated Housekeeping Aide 4 reported an allegation of theft on 3/23/25. The statement indicated Housekeeping Aide 4, on 3/19/25, observed CNA 3 search the pockets of Resident B's clothes, found his wallet and removed $27 of cash. Housekeeping Aide 4's statement, dated 3/24/25, indicated she observed CNA 3 search the pockets of Resident B's clothes, found a wallet with $27 of cash. Housekeeping Aide 4 indicated CNA 3 asked if there were any cameras in the laundry room. Housekeeping Aide 4 indicated she was unaware of any cameras. Housekeeping Aide 4 then indicated CNA 3 indicated I can use this money for gas, then observed CNA 3 put the $27 cash in her pocket. An Administrator and Housekeeper Supervisor statement, dated 3/24/25, indicated CNA 3 was interviewed by the Administrator and the Housekeeping Supervisor on 3/24/25. The statement indicated CNA 3 searched the pockets of Resident B's clothes but denied the allegation of taking Resident B's money out of his wallet. In an interview, on 4/10/25 at 12:38 PM, CNA 2 indicated personal items, including money should be not taken from a resident. CNA 2 indicated when stealing was observed, she reported the incident to the Director of Nursing (DON) and/or the Administrator. CNA 2 indicated if neither the DON or Administrator were available, she would report to the Charge Nurse. A policy, undated, titled Abuse: Zero Tolerance, was provided by the Administrator on 4/10/25 at 12:42 PM. The policy indicated taking or borrowing money from a resident was considered a form of abuse. The policy indicated the facility had a zero tolerance of any form of abuse. This finding relates to Complaint IN00456068. 3.1-28(a)

Based on interview and record review, the facility failed to ensure proper assessments and to maintain consistent communication with the dialysis team for 1 of 2 residents reviewed (Resident 10). Findings include: Resident 10's record was reviewed on 10/10/24 at 10:21 AM. Diagnoses included end stage kidney disease, diabetes and heart failure. Resident 10's Quarterly Minimum Data Set (MDS) dated [DATE], indicated Resident 10's Brief Interview for Mental Status (BIMS) was 15 (no cognitive impairment). The MDS indicated Resident 10 required dialysis treatments. A physician order, dated 10/27/17, indicated Resident 10 was to receive dialysis every Tuesday, Thursday and Saturday. Resident 10's weight was to be obtained every day upon return from dialysis. A physician order, dated 9/3/24, indicated the nursing staff was to include documentation using a Dialysis Event form upon Resident 10's return from dialysis every Tuesday, Thursday and Saturday. The physician order included special instructions for the form to be complete. The form was to include Resident 10's blood pressure and their dialysis assessment. Resident 10's Care Plan, dated 8/8/16, indicated Resident 10 was at risk for fluid overload, bleeding and infection due to receiving hemodialysis. The target goal was Resident 10 would not have complications related to hemodialysis through 12/18/24. Interventions included monitoring Resident 10's fluid intake and blood pressure. Other interventions included monitoring for symptoms of excess fluid volume such as weight gain, shortness of breath and high blood pressure. A Dialysis Center Communication Tool, dated 9/3/24, indicated Resident 10's pre dialysis weight was 325 pounds. The post dialysis weight section was blank. A Dialysis Center Communication Tool, dated 9/5/24, indicated Resident 10's post dialysis weight was 372.9 pounds. The pre dialysis weight section was blank. A Dialysis Center Communication Tool, dated 9/10/24, indicated Resident 10's pre dialysis weight was 322 pounds. The post dialysis weight section was blank. A Dialysis Center Communication Tool, dated 9/12/24, indicated Resident 10's pre dialysis weight was 319 pounds. Resident 10's post dialysis weight was 312.4 pounds. A Dialysis Center Communication Tool, dated 9/17/24, indicated Resident 10's pre dialysis weight was 320.5 pounds. Resident 10's post dialysis weight was 312.4 pounds. A Dialysis Event, dated 9/24/24 at 9:47 PM, indicated appropriate paperwork was sent with the Resident 10 to dialysis. The event indicated return paperwork was not reviewed. A progress note, dated 9/24/24 at 9:49 PM, indicated Resident 10 had returned from dialysis. Resident 10 had been transferred to bed with a mechanical lift. Resident 10's dressing to their left arm was dry and intact. Resident 10 had taken their medications and were on 2 liters of oxygen. The note did not indicate Resident 10 had been weighed. A Dialysis Event, dated 9/26/24 at 10:53 AM, indicated appropriate paperwork had been sent with Resident 10 to dialysis. The event indicated return paperwork had been reviewed for new orders and any required follow-up. Resident 10's record did not include return paperwork, or a Dialysis Center Communication Tool dated 9/26/24. Resident 10's record did not include a progress note dated 9/26/24. Resident 10's record did not include a pre or post dialysis assessment dated [DATE]. A Dialysis Event, dated 9/28/24 at 2:26 PM, indicated appropriate paperwork had been sent with Resident 10 to dialysis. The event indicated return paperwork was not reviewed. Resident 10's record did not include return paperwork, or a Dialysis Center Communication Tool dated 9/28/24. Resident 10's record did not include a progress note dated 9/28/24. Resident 10's record did not include a pre or post dialysis assessment dated [DATE]. A Dialysis Event, dated 10/1/24 at 2:26 PM, indicated appropriate paperwork had been sent with Resident 10 to dialysis. The event indicated return paperwork had been reviewed for new orders and any required follow-up. Resident 10's record did not include return paperwork, or a Dialysis Center Communication Tool dated 10/1/24. Resident 10's record did not include a progress note dated 10/1/24. Handwritten documentation, dated 10/1/24, noted at the bottom of a Dialysis Center Communication Tool, dated 9/17/24, indicated Resident 10's pre dialysis weight had been 319 pounds, and their post dialysis weight had been 312.4 pounds. Resident 10's record did not include a Dialysis Event dated 10/5/24. Resident 10's record did not include a Dialysis Center Communication Tool dated 10/5/24. Resident 10's record did not include a progress note dated 10/5/24. Resident 10's record did not include a pre or post dialysis assessment dated [DATE]. A progress note, dated 10/7/24 at 4:46 PM, indicated Resident 10 had reported a productive cough. The resident was on 2 liters of oxygen and their oxygen level was 90 percent (90 to 100 is normal). Wheezes were heard throughout Resident 10's lungs. Resident 10's Covid-19 test had been negative. A progress note, dated 10/7/24 at 4:53 PM, indicated Resident 10's physician ordered a chest x-ray, breathing treatments and cough syrup. A progress note, dated 10/8/24 at 9:35 AM, indicated Resident 10's oxygen levels had been decreasing and they had been transferred to the emergency department for slightly labored breathing. A progress note, dated 10/9/24 at 8:00 AM, indicated Resident 10 had been admitted to the hospital due to fluid overload and was currently intubated (a tube placed in the airway to provide mechanical breaths). In an interview on 10/10/24 at 2:15 PM, the Regional Nurse Consultant indicated a pre and post dialysis assessment should be obtained for each dialysis treatment. The Regional Nurse Consultant indicated the dialysis treatment center performed post dialysis assessments. The Regional Nurse Consultant indicated the facility was responsible for communication with the dialysis treatment center. The Regional Nurse Consultant indicated the facility should have requested documentation from the dialysis treatment center. A current facility policy, dated 11/17, provided by the Administrator, on 10/10/24 at 2:10 PM, indicated the facility would provide ongoing assessment and monitoring for complications before and after dialysis. The policy indicated the facility would maintain ongoing collaboration and communication with the dialysis treatment center. The policy indicated the facility recommended dialysis residents should be kept on alert charting to monitor complications such as signs of fluid overload, pain, change in condition and access site. 3.1-37(a)

Based on record review and interviews, the facility failed to ensure safety of intermittent self-catheterization for 1 of 1 resident reviewed (Resident 31). Findings include: In an interview on 10/7/24 at 10:33 AM, Resident 31 indicated she had difficulty getting supplies to perform self-catheterization. Resident 31 indicated she was receiving the catheters from the purchasing person who shared an office with the activity director. Resident 31 indicated due to her difficulty getting catheters as needed she was washing them out with bleach or vinegar and then rinsing them several times and using them up to seven times in one day. She indicaated sometimes she would reuse them again the next day as well. Resident 31 indicated she used the same 14fr (French) 5-inch catheter 5 to 7 times per day since March of 2024 to perform self-catheterization when her bladder was full. Resident 31 indicated prior to the intermittent self-catheterization she had an anchored foley catheter. Resident 31 indicated the facility did not offer or ask her to demonstrate her ability to perform self-catheterization. Resident 31 indicated the facility was aware of her performing intermittent self-catheterization as they were the ones inconsistently providing the catheters. Resident 31 indicated the facility was aware of the frustration of running out of catheters and need for a more ready supply. Resident 31's record review began on 10/8/24 at 12:28PM. Resident 31 was admitted on [DATE]. Resident 31's diagnoses included lung disease, below the knee amputation, and neuromuscular dysfunction of the bladder. Resident 31's MDS (Minimum Data Set) assessment dated [DATE] was as follows: Section C-Cognitive Function BIMS (Brief Interview of Mental Status) score was 15 on 9/24/24. A score of 15 indicated intact mental status. Section E-Behavior indicated no behavioral symptoms were exhibited. Section H-Bladder and Bowel indicated there were no indwelling or intermittant self-catheterizations. This assessment further indicated occasional incontinence of bowel and bladder without a toileting program in place. Resident 31 had physician orders for a foley catheter 16fr from 2/23/24 to 3/31/24. Resident 31 had care orders for the foley catheter as well. There were no orders for straight catheter between 4/1/24 and 10/8/24. Resident 31's current undated care plan did not indicated a problem for intermittent self-catheterization. Resident 31's record did not include any teaching or assessment for intermittant self-catheterization documented between 4/1/24 and 10/8/24. A physician progress note, dated 9/25/24 at 7:42 AM, with a review of systems did not include intermittent self-catheterization. A formal grievance was filed by Resident 31 dated 6/12/24 with the nature of concern stated as inability to get small briefs and catheters as required. The review and action taken indicated the DON spoke with Resident 31 to explain the facility did not have orders for intermittent self-catheterization therefore catheters were not ordered, and Resident 31 was to use the toilet independently. Comments indicated Resident 31 was happy the facility would provide catheters and briefs and supplies were given. The grievance was signed as resolved by the Administrator. There were no follow up orders or notes in Resident 31's medical record related to self-catheterization. A formal grievance was filed by Resident 31 dated 9/14/24 with the nature of concern stated as the inability to have the correct size of briefs and catheters as needed. The review and action taken was discussed in morning meeting with consensus to have the scheduler order specific briefs and catheters for Resident 31. A discussion was held with Resident 31 to determine exactly the brief and catheter she preferred. Comments indicated Social Services confirmed the scheduler ordered briefs and informed the resident the facility would follow up when the catheter and brief supplies were delivered. Concern and grievance were resolved was checked off by the Administrator on 9/18/24. There was no order for intermitted self-cauterization in Resident 31's medical record. No teaching or assessment of ability to perform self-catheterization. There was no indication the acting physician was aware of resident performing intermittent self-catheterization. In an interview on, 10/8/24 at 2:38 PM, the Director of Nursing (DON) indicated Resident 31 was admitted with an indwelling catheter and had been performing intermittent self-catheterization since the indwelling catheter was discontinued at a doctor's appointment in March. The DON was unable to determine when the resident last saw a urologist or had an assessment to ensure proper technique or teaching to understand the importance of care. The DON was unaware Resident 31 was cleaning catheters with bleach and reusing the catheter. In an interview, on 10/9/24 at 9:38 AM, the DON indicated she discussed with Resident 31 the need to use a new catheter each time she performed self- catheterization. Resident 31 purchased the bleach she was using on an outing. The DON discussed with Resident 31 her preference of catheter, technique, and the need to for recording of output. The DON offered and the resident refused a urology appointment. The DON completed a Self-Administration assessment related to intermittent self-catheterization for Resident 31 dated 10/8/24. The DON indicated she was last seen by Lutheran urology in 2022.The DON care planned and obtained a physician's order for Resident 31 to perform intermittent self-catheterization. The DON provided an in-service log, dated 10/8/24, instructing Certified Nursing Assistants ( CNA ) and housekeeping to remove any cleaning products from residents' rooms when seen and discuss with management immediately. There was no policy provided regarding intermittent self-catheterization, reusing catheters, or cleaning catheters between uses. A policy titled, Indwelling Urinary Catheter detailing sterile technique was provided by the Administrator on 10/9/24 at 1:45PM. 3.1-41(a)(1)

Based on interview and record review, the facility failed to ensure services were effectively provided a resident admitted without pressure-related skin impairment and identified to be risk to develop pressure injuries to prevent the development of a pressure injury for 1 of 1 resident reviewed for pressure injuries. (Resident M) This deficient practice resulted in Resident M developing a facility-acquired stage two pressure injury on the left buttock that deteriorated to an unstageable pressure injury with infection that required debridement twice, and facility-acquired stage two pressure injuries on the coccyx and right buttock, and a facility-acquired stage one pressure injuries on the right hip. The resident required acute care treatment for wound infection and a new facility-acquired unstageable pressure ulcer was identified on the left upper buttock by hospital staff upon admission. Findings include: On 7/29/24 at 1:17 P.M., Resident M's record was reviewed. Diagnoses included, but were not limited to, hemiplegia on the right side, memory deficits, chronic obstructive pulmonary disease, dementia, and chronic smoker of cigarettes. A quarterly MDS, dated [DATE], indicated Resident M was independent with mobility in his wheelchair and had no pressure areas. An untimed Occupational Therapy (OT) Discharge Summary, dated 4/3/24, indicated the resident had received therapy from 1/11/24 to 4/3/24 for assessment of upper extremity strength, functions, wheelchair mobility and propulsion. At discharge, the resident was able to propel his wheelchair with modified supervision for short distances at a time, he required extra time for verbal cues, and encouragements and prompts to correctly use both upper extremities to propel the wheelchair. He was able to utilize hallway rails as needed to assist in wheelchair mobility. He had no issues with sliding or falling out of the wheelchair and was being discharged from OT due to reaching his maximal potential with skilled services. A nurse progress note, dated 4/5/24 at 3:44 p.m., indicated a referral was sent to therapy due to the resident requiring assistance of three staff members to transfer from his wheelchair to bed, inability to use a stand-up lift for transfers, and slouching forward to the right side when up in his wheelchair. There was no care plan revision implemented to address the need for assistance with positioning. No re-assessment of pressure risk was completed. There were no progress notes between 4/3 and 4/8 to indicate a reason for the change in transfer abilities or positioning, any intervention revisions, or interventions initiated. On 4/8/24 at 10:02 a.m., a physician order was obtained for use of a Broda Chair (a chair able to be tipped back to prevent slouching and leaning which required staff assistance to propel). There were no progress notes between 4/8 and 4/11 to indicate the facility had addressed the PI risk or begun monitoring for pressure injury. A therapy screen, dated 4/11/2024 at 8:42 a.m., indicated Resident M had a functional change condition and would be evaluated for Physical Therapy related to transfers and lower extremity strengthening. The clinical record did not include was no documentation the therapy screen had been completed between 4/11/24 and 6/10/24. A Wound Management report, completed by the facility wound nurse and dated 4/16/24 at 12:14 p.m., indicated Resident M had a pressure ulcer observed on his left buttock (wound 1) identified on 4/16/24. The wound measured 1.6 cm (centimeters) by 0.8 cm by a depth of 0.1 cm. There was a light amount of serous (clear) drainage and the wound tissue was covered with 100% epithelial tissue (cells that line the external surface of the body). An undated IDT (Interdisciplinary Team) progress note indicated the resident had a Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising) pressure ulcer to his left buttock. He had no pain or signs of infection. Contributing factors to the wound development were pressure, moisture, and an increase in incontinence. A treatment order was obtained on 4/16/2024 for the left buttock wound to be cleansed with soap and water, patted dry, Medihoney applied and covered with a bordered gauze. Woundsource.com defined Medihoney as a wound dressing designed to remove necrotic (dead) tissue and an aid to wound healing for pressure areas with partial to full thickness tissue involvement. The National Pressure Injury Advisory Panel (NPIAP) website (npiap.com) indicated Stage II pressure injuries are partial thickness injuries with exposed dermal layer (middle layer of skin between the epidermis and other tissue layers), granulation is not present. Stage III pressure injuries are full thickness skin injuries, adipose (fat), granulation (new skin cells) tissues are often present, and the area may have necrotic tissue present. Woundsource.com defined Medihoney as a wound dressing designed to remove necrotic (dead) tissue and an aid to wound healing for pressure areas with partial to full thickness tissue involvement. There was no documentation in the clinical record to indicate an assessment for further pressure injury risk was completed, a care plan developed, or interventions were initiated in response to the discovery of the wound between 4/16/2024 and 4/21/2024. A Wound Management report, dated 4/22/24 at 12:49 p.m., indicated wound on his left buttock continued with no change in measurements. The IDT progress note indicated the resident's wound was stable and staff were to continue to encourage him to lie down between meals. He had no complaints of pain and no changes were made to the treatment of the wound. The report did not include documentation of specific characteristics of the wound bed. There was no documentation in the clinical record to indicate an assessment for further pressure injury risk was completed, a care plan developed, or interventions were initiated related to the facility-acquired pressure injury on the left buttock between 4/22/2024 and 4/29/2024. A Wound Management report, dated Monday 4/29/24 at 1:42 p.m., indicated the resident refused to lie down to have his wound assessed. There was no documentation to indicate further attempts were made to assess the wound. The care plan was not updated with the resident's refusal of care. The April 2024 Treatment Administration Record (TAR) indicated the treatment for the left buttock wound was not administered in accordance with the physician order on 10 of 16 day shifts between 4/16/24 and 4/30/24. There was no indication in the documentation the resident had been reapproached to attempt wound care during the missed times. The progress notes, dated 4/16/24 through 4/30/24, did not indicate documentation of any attempts made to complete treatments at a different time, nor attempts made to determine cause of the refusals. Resident M was visited by the medical NP on 4/22/24. Progress notes were completed without mention of the resident's wound to his left buttock or refusals of care. A physician visit progress note, dated 5/2/24 at 7:36 a.m., indicated the resident was seen for a chronic care visit. The note indicated the resident had no recent falls, blood pressure was elevated, and should be re-checked by nursing. The resident's weight was stable; and he appeared comfortable with mild chronic pain to his right foot/ankle. The note didn't indicate the resident had a pressure wound to his left buttock nor refusals of treatment by the resident. A Wound Assessment Report by the Wound NP, dated Friday 5/3/24 at 7:21 a.m., indicated the resident was being seen for a new skin and wound consult. He had a stage II wound to his left ischium/buttock (curved bone forming the base of each half of the pelvis). It measured 4 cm by 2 cm by depth of 0.1 cm and had 100% epithelial tissue covering it with a scant amount of serous drainage. There were no changes made to the treatment. Preventative Measures were to continue pressure reduction and turning and repositioning precautions. The resident was incontinent of bowel and bladder and staff were to use barrier creams after providing thorough skin care for each incontinent episode as well as briefs to manage moisture. The report didn't indicate the wound NP had been notified or aware of the resident's refusals nor his unavailability for wound care on the day shift. A Wound Management report, dated Monday 5/6/24 at 4:27 p.m., indicated the wound on Resident M's left buttock measured 4 cm by 2 cm by 0.1 cm. Contributing factors related to the wound decline were the resident seated in the chair for extended periods of time. Staff were to encourage him to turn and reposition every two hours and a request was made to therapy for a different cushion to his chair. He had no complaints of pain and no changes were made to the treatment of the wound. Resident M's refusals of care were not noted in the report. A Wound Management report, dated Monday 5/13/24 at 2:26 p.m., indicated the assessment had not been completed due to resident's refusal and not wanting to lie down. There were no changes made to the care plan between 4/16/24 and 5/3/24 to assess the resident's refusal of wound care, changes to timing of wound care per his preferences, pain related to the wound and with treatments, or effects of use of Broda chair such as dependency on staff for ambulation and increased need for assistance with shifting his weight while up in the chair. There were no request/referral documentation for therapy to provide a different cushion for his Broda chair. There were no interventions or descriptions of the wound documented in the clinical record between 5/6/24 and 5/13/24. A Wound Assessment Report by the Wound NP, dated Friday 5/17/24 at 10:02 a.m., indicated the resident's wound was unable to be evaluated on this day due to the resident not being in his room at the time of the visit. There was no indication the resident was reapproached or aware the wound NP was there to see him. There were no interventions or descriptions of the wound documented in the clinical record between 5/13/24 and 5/16/24. A Wound Management report, dated Monday 5/20/24 at 8:30 a.m., indicated the resident's wound was unable to be evaluated on this day due to the resident not being in his room at the time of the visit. A Registered Dietician review, dated 5/20/24 at 9:44 a.m., indicated the resident received a regular diet and was eating and drinking well. He had an open area to his left buttock, was provided a multi-vitamin, double eggs and meat for breakfast and a protein snack at bedtime. He was meeting his nutritional needs with interventions in place. His weight had been down the past 3 months but was not a significant weight change. His BMI was within normal range for his age. A medical NP progress note, dated 5/20/24 at 10:34 a.m., indicated the resident was seen for pain management and reported his pain was well controlled with his current pain medication Xtampza (an extended release opioid given the resident every 12 hours routinely for pain). The medication appeared to be effective in controlling his chronic pain and would continue on the medication. There was no documentation regarding the resident's wound or refusals of wound treatment. A Care Plan Summary form, dated 5/22/24 at 8:51 a.m., indicated the resident's care and care plan was reviewed following a significant change MDS assessment. Neither Resident M nor his POA were at the meeting. There was no documentation the resident or POA were invited or had any concerns. The goal for the resident was to remain within the facility, utilizing a Broda chair. The Care Plan Summary form did not indicate the resident had a new pressure wound to the left buttock, had any refusals of wound treatments or pressure reducing interventions such as lying down between meals. The May 2024 TAR indicated the treatment for the left buttock wound was not administered in accordance with the physician order on 12 of 24 day shifts and on 1 of 24 night shifts between 5/1/24 and 5/24/24. There was no indication in the documentation the resident had been reapproached to attempt wound care during the missed times. A significant change MDS (Minimum Data Set) assessment, dated 5/10/24, indicated the resident had severely impaired cognition. He had several mood indicators, present nearly every day. This included: little interest or pleasure in doing things, feeling down, depressed, or hopeless, trouble falling or staying asleep, and poor appetite. The MDS indicated he had no refusals of care, was dependent on two staff for mechanical lift transfers in and out of bed and was dependent on 1 staff for mobility in his wheelchair, and he was always incontinent of bowel and bladder. The MDS indicated the resident had a new facility acquired stage II wound on the left buttock. Care plans, reviewed and revised on 5/22/24, indicated the following: -Impaired skin integrity: the resident had an open area to the left buttock with contributing factors of incontinence, stroke with right side hemiplegia, shearing, behaviors, and non-compliant with wound care/medications. The goal was for the wound to heal and be free from signs of complications. Interventions were: assess for pain/treat as ordered and notify MD (Medical Doctor) of worsening/unrelieved pain, assess wound weekly documenting measurements and description, encourage resident to eat at least 75%, labs as ordered, notify MD of worsening or no change in wound or signs of infection, observe for signs of infection: redness, pain, drainage, malodorous drainage, fever, increase in size/depth of wound, pressure reducing cushion to chair, pressure reducing mattress on bed, RD (Registered Dietician) to assess routinely, supplements as ordered, turn and reposition every 2 hours, and wound healing vitamins and treatment as ordered. The care plan did not address the resident's noncompliance or provide interventions to prevent pressure ulcer development, deterioration or provide pressure relief to the left buttock. -At risk for further skin breakdown in the current pressure area on the left buttock due to hemiplegia, dementia, and chronic pain. The care plan indicated he was at moderate risk, according to the Braden Scale for Predicting Pressure Sore Risk, due to a slighted limited ability to respond to pressure related discomfort, occasionally moist skin, being chairfast and only able to make occasional slight changes in body position, nutrition probably inadequate, only occasional acceptance of a dietary supplement when offered, and potential problem with friction and shear when being assisted to reposition. The goal was to be free from skin breakdown. Interventions included: assess and document skin condition weekly, as needed and house barrier cream to be used as needed. The care plan did not address the resident's increased risk due to noncompliance or provide interventions to prevent pressure ulcer development, deterioration or provide pressure relief to the left buttock. -Nutritional status: at risk for altered nutrition and unintentional weight change due to varied meal intakes, chronic disease, and pressure area to left buttock. The goal was for the resident to maintain his current weight without significant weight changes although gradual long-term weight loss to his UBWR (usual body weight range) was acceptable (UBWR=175-180 pounds). Interventions included: provide diet as ordered-regular, double eggs and meat with breakfast. -The resident required assistance with his ADL's (activities of daily living) bed mobility, transfers, eating and toileting. Interventions included: Assist with ambulation as needed utilizing a Broda chair. The care plan did not address the increased risk of pressure area related to the Broda chair or provide interventions to prevent pressure ulcer development, deterioration or provide pressure relief to the left buttock. A Wound Assessment Report by the Wound NP, dated Friday 5/24/24 at 7:11 a.m., indicated the resident was seen for continued evaluation of a wound on his left buttock. The wound had worsened and was unstageable (Pressure ulcers that have eschar [tan, black, or brown] or slough [yellow, tan, gray, green or brown] tissue present such that the anatomic depth of soft tissue damage cannot be visualized or palpated in the wound bed). The wound measured 2 cm by 1.5 cm by 0.1 cm. The wound base was covered with 25% slough and 75% eschar, the wound edges were attached, periwound had scarring, and there was no drainage. Treatment orders were changed to applying Santyl (chemical removal of dead tissue) followed by bordered gauze, then change daily. The resident's risk for complications was moderate due to decreased mobility, disease comorbidities, incontinence of urine and stool, and impaired nutrition. The Wound NP report didn't indicate the resident missed wound treatments at times due to being unavailable or refusing treatment. A physician order, dated 5/24/24, was for the left buttock wound to be cleansed with soap and water, patted dry and Santyl (a wound dressing designed to remove necrotic tissue) applied and covered with bordered gauze 2 times per day which were scheduled to be done between 2:00 p.m. - 10:00 p.m. and again, between 10:00 p.m. - 6:00 a.m. The May 2024 TAR indicated the treatment for the left buttock was not administered in accordance with physician order on 4 of 24 day shifts and on 2 of 24 night shifts between 5/2/24 and 5/31/24. There was no indication in the documentation the resident had been reapproached to attempt wound care during the missed times. The clinical record did not include documentation, between 4/16/24 and 5/24/24, to indicate the facility-acquired pressure wound bed included necrotic tissue. There were no further assessments, progress notes or care plans regarding the left buttock wound between 5/22/24 and 5/24/24. A Wound Management report, dated Monday 5/27/24, indicated the residents facility-acquired unstageable pressure wound had worsened in size; now measured 2 cm by 1.5 cm by 0.1 cm and the wound bed was covered with necrotic tissue. Contributing factors related to wound worsening were pressure and the resident refusing to lay down between meals. The new intervention was a change in the wound treatment. There were no new interventions to provide pressure relief to the left buttock added to the care plan. On 5/30/24 at 9:57 a.m., the resident was seen by the medical NP for chronic care management with a left buttock wound and chronic pain. The resident had a left buttock wound with treatment currently in place. Staff were to reposition the resident to alleviate pressure and potentially reduce pain. Wound care would be provided to promote healing and prevent infection. His nutritional status would be monitored to ensure adequate intake for wound healing. The note didn't indicate the medical NP had been notified of the resident's refusal of care or his being unavailable for wound treatments to be completed as ordered. A Wound Assessment Report by the Wound NP, dated Friday 5/31/24 at 6:49 a.m., indicated the resident was seen for the pressure wound on his left ischium. The wound measured 2.2 cm by 3 cm by 0.1 cm and was unstageable. The wound bed was covered with 75% slough, 25% eschar and had a scant amount of serous drainage. The wound was mechanically debrided (physical removal of necrotic tissue) with use of a scalpel and forceps. 100% of the wound was debrided of necrotic tissue. New recommendations were to continue to treat the wound with Santyl, obtain low air loss mattress, and cushion for the wheelchair. His risk for complications remained moderate. The note didn't indicate the wound NP had been notified of the resident's refusal of care or of his being unavailable for wound treatments to be completed as ordered. There were no new interventions added to the care plan to provide pressure relief to the left buttock after deterioration was identified. A TAR, dated June 2024, indicated physician orders, dated 5/24/24 and discontinued 6/10/24, were for the left buttock wound to be cleansed with soap and water, patted dry and Santyl applied and covered with bordered gauze 2 times per day which were scheduled to be done between 2:00 p.m. - 10:00 p.m. and again, between 10:00 p.m. - 6:00 a.m. The TAR indicated the treatments had not been completed as ordered between 2:00 p.m. - 10:00 p.m. on 6/1 and 6/2/24. There was no indication in the documentation the resident was reapproached to attempt wound care during the missed times. A Wound Management report, dated Monday 6/3/24 at 7:09 p.m., indicated the residents wound measured 2.2 cm by 3 cm by 0.1 cm. It was unstageable due to slough and eschar and had light serous drainage. There was no IDT note completed or new interventions put in place. There were no interventions or descriptions of the wound documented in the clinical record between 5/27/24 and 6/3/24. A Wound Assessment Report by the Wound NP, dated Friday 6/7/24 at 7:30 a.m., indicated the resident was seen for follow up care to his pressure wound to his left ischium (wound 1). Santyl for enzymatic debridement had been used, revealed more depth and necrotic tissue to the wound. The report indicated the Wound NP was still unable to get the true depth of the wound. The wound was unstageable and measured 2.2 cm by 3.6 cm by depth of 3.1 cm with a moderate amount of serosanguineous (blood and liquid) drainage. The wound bed was covered with 75% slough and 25% eschar with scarring at the periwound. The wound was mechanically debrided with use of a scalpel and forceps. 100% of the wound was debrided of necrotic tissue. Nursing staff were given detailed ulcer care instructions and asked to monitor the ulcer for signs or symptoms of prolonged bleeding and debridement intolerance. The plan was to cleanse the wound with 0.125% Dakins solution (topical antiseptic to treat and prevent infections in wounds); apply Santyl and Dakins moistened fluffed gauze to base of the wound; secure with a bordered gauze dressing and change daily. Recommendations were to continue ongoing pressure reduction and turning/repositioning precautions per protocol. All prevention measures were discussed with the staff at the time of the visit. Resident M's risk for complications remained moderate. The note didn't indicate the wound NP had been notified of the resident's refusal of care or pressure reducing interventions. There were no other assessments between 4/16/24 and 6/7/24 to show the facility re-assessed the resident's risk to develop additional pressure wounds. A Wound Management report, dated Friday 6/7/24 at 10:36 a.m., indicated Resident M had new wounds observed. He had a stage II pressure ulcer on his coccyx (wound 2) which measured 2 cm by 1.5 cm by 0.1 cm with light serous drainage. He had a stage II wound to his right buttock (wound 3) which measured 2 cm by 2.5 cm by 0.1 cm and had serous drainage. A third unstaged pressure wound (wound 4) was observed on his right hip which measured 5.5 cm by 6.5 cm with no depth and was red in color. There was no documentation in progress notes or management reports completed to indicate the physician, medical NP, wound NP, or family had been notified of the new wounds or treatment orders obtained when the wounds were observed on 6/7, nor any follow up on 7/8 or 6/9/24. There was no documentation completed on the resident's wounds, pain, or adherence to implementation of pressure reducing interventions on 6/8 or 6/9/24. The TAR, dated June 2024, did not indicate the wound treatment ordered by the wound NP on 6/7/24 to cleanse the wound with 0.125% Dakins solution followed by Santyl and Dakins moistened fluffed gauze to base of the wound, secure with a bordered gauze dressing and change daily was initiated between 6/7/24 and 6/10/24 to show the treatment was completed as ordered. A nurse progress note, dated 6/10/24 at 11:24 a.m., indicated Resident M had been transported to the hospital per EMS at family request due to pressure areas. Hospital emergency room records, dated 6/10/24 at 12:11 p.m., indicated the resident was seen in the emergency room for multiple pressure ulcers and evaluation of two pressure ulcers which had worsened. EMS reported the resident had increased pain and upon arrival in ER. The coccyx ulcer (wound 2) on the left showed full skin and tissue loss with possible tunneling and eschar over the wound base with potential surrounding cellulitis. He was started on intravenous antibiotics, blood work was obtained and a CAT (X rays using a computer to define bones and soft tissues) scan ordered. He had no signs of secondary infection at the time of assessment. A hospital CAT scan, completed on 6/10/24 at 4:05 p.m. indicated the resident had a large soft tissue ulcer along his left posterior soft tissues with overlying edema (swelling) and a questionable midline ulcer over his coccyx. The CAT scan could not rule out a bone infection where the ulcers were located and MRI was to be considered for further evaluation but not done due to presence of metal in his body from an old injury. Wound Physician assessment indicated complete healing of the wounds could be attempted with routine follow up but potential to heal was poor. Factors which likely contribute to non-healing included lack of adequate off-loading when seated and supine, recurrent infection, repeated unintentional trauma, lack of adequate nutrition, dementia, and inability to offload with contractures present. Pressure wounds, documented on 6/10/24 with photographs and measurements, observed in the emergency room , were further evaluated on 6/11/24 by the wound care consultant. The left ischium (wound 1) pressure wound-last documented on and measured by the facility wound NP on 6/7/24-measured 3 cm by 4 cm with unknown depth due to the wound being open but covered with eschar. A pressure injury to the mid-sacral/coccyx (wound 3) area-identified at the facility on 6/7/24 with no treatment ordered and measuring 2 cm by 1.5 cm by 0.1 cm-was a stage II wound which was moist, open and measured 1.5 cm by 1 cm by depth of 0.3 cm with a small amount of tan drainage with a faint odor. A pressure injury to his lateral right hip (wound 4) wound -identified at the facility on 6/7/24, as an abrasion which measured 5.5 cm by 6.5 cm-presented as a stage II wound that measured 6.7 cm by 7.5 cm. The wound was open with slough and moderate tan/brown drainage which had a faint foul odor. An unstageable pressure injury to the residents left upper buttock (wound 5), which was present upon admission but not identified by the facility, measured 0.5 cm by 1 cm and was dry and covered with eschar. The resident remained in the hospital for 9 days and was discharged to a long term care facility located nearer to family. The Hospital note did not include sufficient information to determine wound 3 on the right buttock was assessed. An Indiana Department of Health complaint intake, dated 7/16/2024, indicated Resident M had been neglected and subsequently developed multiple pressure ulcers. This resulted in hospitalization of treatment of his wounds. On 7/29/24 at 10:29 A.M., Resident M's POA (Power of Attorney) was interviewed. They indicated the resident had been hospitalized 9 days for treatment of his pressure ulcers developed at the facility. Following hospitalization , the resident was moved to a different nursing home closer to the POA. On 7/29/24 at 2:21 P.M., Nurse 2 was interviewed. She indicated when residents refused a wound treatment, she would ask why they were refusing, ask if there was a better time for the treatment to be done, reapproach them, ask about pain, hunger, thirst, or try and have another nurse complete the treatment. -At 2:24 P.M., Nurse 3 was interviewed. The TAR indicated Resident M usually refused to have wound treatment completed by Nurse 3. The nurse indicated she asked residents three times and when they refused a treatment, she documented it in the nurse progress notes and let the Director of Nursing Services (DNS) know. There was no documentation available for review regarding Resident M's refusals or the notification of the DNS. -At 2:26 P.M., the DNS indicated staff should reapproach a resident later when they refuse a treatment and notify the physician for continued refusals. When asked about the physical therapy evaluation, on 4/11/24, and new order for the Broda chair, the DNS indicated the physical therapy referral had not been completed as recommended. No reason was given related to the therapy assessment of the Broda chair. On 7/30/24 at 10:53 A.M., the DNS, Administrator, and RDCS (Regional Director of Clinical Services) were interviewed. The DNS indicated the resident resided in the facility since 2019 and never had any wounds/pressure areas. She indicated the resident had been declining with weight loss and little appetite. Resident M frequently refused care and preferred to stay in his chair all day so he could smoke during smoke times. When asked, the DNS indicated the POA was aware of the resident's refusals of care though there wasn't documentation completed about the refusals. There was no documentation to indicate attempts were made to offer different times for wound care according to his preferences. The DNS, Administrator, and RDCS agreed the POA hadn't been notified of the residents new wounds identified on 6/7/24, but the NP had been made aware despite lack of documentation. The DNS indicated the resident's care plan indicated the resident had a pressure ulcer and was non-compliant with wound care/medications; however, there were no interventions put in place to address his refusals. There was no documentation to indicate attempts had been made to alter the times his treatments were scheduled so he would agree to lie down between meals and gotten back up for smoke breaks. There was no documentation the POA or resident had been notified of the consequences of refusing wound care and potential for further skin breakdown to occur. On 7/30/24 at 11:11 A.M., the SSD (Social Service Director) was interviewed. She indicated refusal of care, was documented in the progress notes or on forms titled new and worsening behaviors and communication forms which were available in the record for staff to complete. She indicated she would get involved with refusals of care when it became a problem but provided no further clarification on what was considered a problem. She reviewed progress notes, new and worsening behavior forms and communication forms for April, May, and June 2024 and indicated there had been no documentation of the resident refusing care. She indicated she wasn't aware of the resident's refusals which had impacted his wound care. On 7/30/24 at 11:22 A.M., the wound care nurse was interviewed. She indicated managers reviewed wounds in their daily morning meetings including the progress of wound healing. She would complete wound measurements and observations on Fridays with the Wound NP as she did her rounds, then would document the visit, wound measurements, and interventions on the Monday following the Friday visit. When asked, she was unsure why the order for Dakins solution, ordered on 6/7/24, hadn't been documented on the TAR and started immediately. The wound nurse indicated she wrote down the assessment of the Wound NP to complete her documentation. A current facility policy, titled Skin Management Program, was provided on 7/30/24 at 10:53 A.M., which stated: It's the facility policy to ensure . a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing .Procedure for Alteration in Skin Integrity-Pressure and Non-Pressure: Alterations in skin integrity will be reported to the MD/NP, the resident and/or resident representative as well as to direct care staff. Treatment order will be obtained from MD/NP .A plan of care will be initiated to include resident specific risk factors and contributing factors with a[TRUNCATED]

Based on observation, interview and record review the facility failed to monitor behaviors, assure staff awareness of behaviors and revise the care plan for behaviors for 1 of 2 residents reviewed. (Resident 33). Findings include: In an interview on 10/5/23 at 11:16 AM Resident 33 indicated they were not interested in the facility's organized activities. Resident 33 made a sexually inappropriate gesture during the interview. Resident 33's record was reviewed on 10/5/23 at 2:39 PM. Diagnoses included diabetes, malnutrition, left lower leg amputation, a wound to the sacrum, chronic pain syndrome, and insomnia. A review of Resident 33's current quarterly Minimum Data Set (MDS dated [DATE]) indicated their Basic Interview for Mental Status (BIMS) score was 12 (cognitively intact). Resident 33's current care plan for trauma dated 5/3/23 with a goal date of 9/20/23 indicated the resident had a risk for traumatization due to childhood sexual trauma. Interventions included encouragement to meet with a counselor, establishment of open communication and resident/family input in development and revision of the resident's care plan. Resident 33's care plan for behaviors dated 10/3/23 with a goal date of 1/3/24 indicated the resident would masturbate while staff was performing care. Interventions included notification of behaviors to all staff and behavioral health providers, resident education related to inappropriate behaviors and completion of a new and/or worsening behavior assessment. A psychiatry progress note dated 9/27/23 indicated Resident 33 had been evaluated for chronic insomnia. The progress note indicated Resident 33 made sexually inappropriate comments and gestures towards the Psychiatric Nurse Practitioner (NP). The progress note indicated the NP notified the facility staff of Resident 33's inappropriate behavior. The progress note indicated the resident's family history had been reviewed and there had been no contributing family history to the resident's current presentation. The progress note did not indicate the NP had been aware of Resident's history of childhood sexual trauma. A psychotherapy progress note date 8/11/23 indicated Resident 33 was referred to psychotherapy services due to symptoms of depression. The progress note indicated the resident displayed symptoms of grief, loss, sadness and social isolation. The progress note indicated the resident's family history had been reviewed and there had been no contributing family history to the resident's current presentation. The progress note did not indicate the NP had been aware of Resident 33's history of childhood sexual trauma. A psychotherapy progress note date 10/5/23 indicated Resident 33 was referred to psychotherapy services due to symptoms of depression. The progress note indicated the resident displayed symptoms of anxiety and inappropriate verbal boundaries. The progress note indicated the resident's family history had been reviewed and there had been no contributing family history to the resident's current presentation. The progress note did not indicate the provider had been aware of Resident 33's history of childhood sexual trauma. The progress note did not indicate the provider had been aware of the resident's new onset of sexually inappropriate behaviors. In an interview on 10/6/23 at 3:04 PM Social Service Director (SSD) 7 indicated Resident 33's inappropriate sexual behavior was new. The SSD 7 indicated Resident 33 had denied traumatic events and did not present any signs of trauma at the time of admission. SSD 7 indicated Resident 33 was evaluated by the psychiatric NP on 10/5/23. SSD 7 indicated they had been unable to locate the psychiatric NP's visit note for 10/5/23. SSD 7 indicated Resident 33 had been speaking with a counselor for the last couple of weeks, but no behavior monitoring or tracking for prebehavior triggers had been initiated. SSD 7 indicated they were unaware of any events that could have prompted the counselor visits. SSD 7 indicated they were unaware of any triggers that would lead to Resident 33 presenting with inappropriate sexual behaviors. SSD 7 indicated the resident's care plan entry on 5/3/23 related to trauma had been prompted by the resident's sister having stated the resident had been sexually abused as a child. In an interview on 10/10/23 at 2:15 PM the Administrator indicated Resident 33's sexually inappropriate behavior on 9/27/23 was thought to be a single episode. The Administrator indicated Resident 33 had denied traumatic events upon admission. The Administrator indicated the loss of a limb and living in a vehicle could be traumatic. In an interview on 10/10/23 at 2:17 PM SSD 6 indicated the resident's root cause for sexual behavior had been determined to be boredom. SSD 6 indicated the facility was addressing Resident 33's sexually inappropriate behavior by allowing the psychiatric NP to evaluate and identify further root causes for the new behavior. SSD 6 indicated there were no clear interventions due to Resident 33's inappropriate behaviors having been so recent. SSD 6 indicated the psychiatric NP believed the inappropriate behavior was an isolated event. The SSD 6 indicated child sexual abuse could be a possible cause for Resident 33's display of inappropriate sexual behavior. In an interview on 10/10/23 at 10/10/23 at 3:20 PM Licensed Practical Nurse (LPN) 2 indicated the behavior binder contained safety check forms and individual resident behaviors to be aware of. LPN 2 indicated there were no behavior tracking forms in the binder for Resident 33. LPN 2 indicated a verbal report of behaviors was relayed to the nursing staff. Review of the behavior binder on 10/10/23 at 3:23 PM indicated the binder contained behavior care plans that included mental illnesses, abnormal behaviors and histories of trauma. The binder did not contain Resident 33's behavior care plan for a history of trauma or inappropriate sexual behavior. In an interview on 10/10/23 at 3:23 PM an anonymous Certified Nurse Aide (CNA) indicated they referred to the behavior binder to determine if behaviors were new or established behaviors. The CNA indicated they were familiar with Resident 33. The CNA indicated they were not aware of Resident 33's display of behaviors. The CNA indicated they did not have access to the resident's care plans in the computer. In an interview on 10/10/23 at 3:30 PM RN 3 indicated the CNAs referred to the behavior binders to make themselves aware of behaviors that were being monitored. RN 3 indicated Resident 33 had been exhibiting inappropriate behaviors for approximately 2 weeks. RN 3 was unable to locate Resident 33's behavior sheet in the binder. RN 3 indicated SSD 7 generally placed the behavior care plans in the binder. In an interview on 10/11/23 at 10:28 AM the Administrator indicated Resident 33's trauma history had been added to the care plan. The Administrator indicated the staff could refer to the resident's care plans. A current policy dated 10/2022 provided by the Administrator indicated the plan of care would be routinely evaluated and revised. 3.1-43(a)(1)

Based on interview and record review the facility failed to ensure resident assessment was completed after a change in statusfor 1 of 2 residents reviewed. (Resident 3). Findings include: Resident 3's record was reviewed on 10/10/23 at 10:53 am. Diagnoses included cerebral palsy, neurogenic bladder, obstruction of the bladder and reflux of urine. Resident 3 had been admitted to the hospital on 9/24/23 and returned to the facility on [DATE]. Resident 3's current quarterly Minimum Data Set (MDS) dated [DATE] indicated their Basic Interview for Mental Status (BIMS) score was 8 (cognitively impaired). The MDS indicated the resident did not exhibit signs of pain. The MDS indicated Resident 3 had not been administered pain medication. The MDS indicated Resident 3 had a urinary catheter. Resident 3's current care plan for an indwelling urinary catheter dated 6/21/21 with a goal date of 11/2/23 indicated the resident had a risk of infection due to catheter usage. Interventions included monitoring and reporting nausea, vomiting, abdominal pain and low back pain. A progress note dated 9/18/23 at 6:01 AM indicated Resident 3 felt constipated. The resident's abdomen was soft and non-tender. A progress note dated 9/19/23 at 10:12 AM indicated Resident 3 had vomited on 9/18/23. There was no note of the characteristics or an assessment of the resident's abdomen. A physician order dated 9/20/23 indicated Resident 3 was to have an x-ray of their kidneys, ureter and bladder (KUB). A physician order dated 9/20/23 indicated Resident 3 was to have blood collected for a complete blood count (CBC) and a basic metabolic panel (BMP). A progress note dated 9/20/23 at 11:33 AM indicated Resident 3 was to have a KUB completed STAT (urgently). A progress note dated 9/20/23 at 3:15 PM indicated Resident 3 had been moaning and was medicated for pain. The progress note indicated the resident's urinary catheter was irrigated with 60 milliliters (ml) of acetic acid and was draining. The progress note indicated Resident 3 was awaiting IV placement and a KUB. The progress note did not indicate where the resident's pain was located. The progress note did not include an assessment of thier abdomen or note the characteristics of the urine. Resident 3's vital sign record for September 2023 indicated the resident's vital signs had been assessed on 9/14/23 and 9/21/23. There were no vital signs documented related to the residents complaints of pain or vomiting episode. Resident 3's Medication Administration Record (MAR) dated September 2023 indicated on 9/20/23 at 6:33 the resident had not been administered their medications due to severe abdominal pain. The MAR indicated on 9/20/23 at 6:34 PM the resident had not received an evening snack due to severe abdominal pain. The MAR indicated Resident 3 had been medicated for pain on 9/17/23. The MAR indicated Resident 3 had been medicated for back pain on 9/18/23 at 7:59 PM. The MAR indicated Resident 3 had been medicated for nausea on 9/18/23 at 10:44 PM. Resident 3's record did not indicate an assessment was completed for the resident's episodes of pain or nausea. A physician order dated 9/21/23 indicated Resident 3 was to have an intravenous (IV) catheter placed for hydration. A progress note dated 9/22/23 at 3:10 PM indicated a significant change in Resident 3's condition had been identified. The progress note did not include a resident assessment of theri pain, abdominal status or the characteristics of thier urine. A progress note dated 9/22/23 at 10:07 PM indicated Resident 3's urinary catheter had been irrigated and was draining. There was no documentation of the characteristics of the resident's urine. A progress note dated 9/23/23 at 3:05 PM indicated Resident 3 had vomited that morning when taking their medications. The progress note did not include a resident assessment of abdominal status or pain. A progress note dated 9/24/23 at 4:25 PM indicated Resident 3 reported they had vomited blood. The progress note indicated the resident was nauseated, had abdominal distension, severe abdominal pain and kidney pain. The progress note indicated Resident 3 was transferred to the hospital. A progress note dated 9/25/23 at 3:42 PM indicated the Nurse Practitioner (NP) reviewed Resident 3's KUB, CBC and BMP results. A progress note dated 10/5/23 at 3:36 PM indicated Resident 3 had been hospitalized due to a urinary tract infection and constipation. A hospital laboratory report dated 9/24/23 at 10:01 PM indicated Resident 3's urine was turbid (cloudy). The laboratory report indicated the resident's urine contained 2+ bacteria, 31-50 white blood cells and 3+ leukocyte esterase. The presence of bacteria, white blood cells and leukocyte esterase in a catheter urine sample are indicative of a UTI ([NAME] et. al., 2022). Resident 3's hospital discharge summary dated 10/5/23 at 2:53 PM indicated while hospitalized , the resident had completed a course of antibiotics for a UTI. In an interview on 10/10/23 at 2:45 PM Registered Nurse (RN) 4 indicated symptoms of a urinary tract infection could include nausea, vomiting, abdominal pain and kidney pain. RN 4 indicated a urine test could have been analyzed at the facility. RN 4 indicated an assessment should be completed upon a resident who had vomited. RN 4 indicated a resident assessment should include vital signs and general condition. RN 4 indicated the facility did not have a policy related to when a resident assessment is necessary or when an assessment should be reported to the physician. In an interview on 10/11/23 at 9:41 AM the Director of Nursing (DON) indicated Resident 3's IV had been placed to assist the resident in having a bowel movement. The DON indicated the reference to a significant change in the progress note dated 9/22/23 at 3:10 PM had been entered by the MDS team but a significant change assessment could not be located. The DON indicated they were unaware of when the NP was notified of the resident's STAT x-ray results or blood tests due to the NP notification log had been shredded. The DON indicated there would be no reason to call the NP for negative results. The DON indicated they were aware the resident had continued to have symptoms. The DON indicated Resident 3's symptoms were not constant as there had been progress notes reflective of the resident's comfort. The DON indicated a urine test had not been performed due to the resident having had clear yellow urine. The DON indicated nausea, vomiting, back pain and abdominal pain could be signs of a UTI. The DON indicated a resident assessment should be completed when a resident experienced vomiting. The DON indicated the assessment should include the resident's vital signs. The DON indicated Resident 3's urinary catheter had been routinely flushed with acetic acid due to sediment and mucous in the urine. The DON indicated the presence of a urinary catheter and frequent catheter irrigations could have increased Resident 3's risk of contracting a UTI. The DON indicated Resident 3 had not been diagnosed with a UTI at the hospital. The DON indicated Resident 3 had been treated with an antibiotic at the hospital as a precautionary measure and a UTI had been ruled out. In an interview on 10/11/23 at 10:11 AM RN 3 indicated the facility did not have a policy for urine testing. RN 3 indicated physician order for urine tests were requested based on a resident's assessment and signs of a UTI. RN 3 indicated a resident assessment should include vital signs, general condition and the presence or absence of pain. RN 3 indicated nausea, vomiting, abdominal pain and back pain could be signs of a UTI. RN 3 indicated the presence of a urinary catheter could increase a resident's risk of UTI. A current policy dated 11/2018 provided by RN 4 indicated the licensed nurse would document all symptoms and unusual signs in the medical record and promptly notify the attending physician. The policy indicated the licensed nurse would continue assessment and documentation every shift until the resident's condition had stabilized. 3.1-37

Based on observation, interview, and record review, the facility failed to ensure staff were educated regarding cervical collar care for 1 of 1 resident reviewed (Resident 311). Findings include: During an observation on 11/28/22 at 11:43 AM, Resident 311 was observed lying in bed with a cervical collar over her mouth. Resident 311's nose was about one centimeter above the chin plate of the cervical collar. During an interview on 11/28/22 at 11:45 AM, Licensed Practical Nurse (LPN) 2, indicated she was not trained on use and adjustment of the cervical collar, was not sure how to adjust the collar, but would get therapy to assist. During an interview on 11/28/22 at 11:45 AM, Registered Nurse (RN) 4 indicated she did not have any training on cervical collar application, but she would attempt to help. Occupational Therapist (OT) 3 came into the room on 11/28/22 at 11:50 AM. OT 3 indicated the resident was not on his caseload and he does not know her. He said he would check with a nurse. OT 3 did not provide any verbal or physical assistance to RN 4 and LPN 2 as they adjusted the collar. On 11/28/22 at 11:55 AM when RN 4 and LPN 2 finished, the collar was observed angled to the right. LPN 2 indicated that was the best she could do but she understood the chin should rest evenly on the chin plate. During an observation on 11/28/22 at 1:41 PM, Resident 311 was observed with her chin beneath the chin plate of the cervical collar. Nurse Consultant 5 came into the room and indicated he would adjust the collar. A record review on 11/28/22 at 2:10 PM indicated Resident 311 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) dated [DATE] indicated Resident 311 was cognitively impaired and unable to be interviewed. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 11/28/22 at 3:04 PM, the Administrator indicated no training specific to cervical collar application had been done. He indicated there was no specific policy for cervical collar application.

Based on observation, interview and record review, the facility failed to ensure oxygen tubing was changed in 2 of 2 residents reviewed (Resident 51 and Resident 54). Findings include: 1. During an interview with Resident 51 on 11/28/22 at 9:44 AM, Resident 51 indicated a staff member came in and changed the oxygen tubing attached to his bedside concentrator that morning, but it had been a long time since the tubing attached to portable tanks had been changed. Resident 51 indicated he had lived in the facility for 6 months and this was the third time any of his tubing had been changed since admission. The nasal cannula attached to his bedside oxygen concentrator was dated 11/28/22. The tubing attached to his portable oxygen tank attached to his chair was not dated. The tubing attached to a green cylinder tank was not dated. During a record review conducted on 11/28/22 at 10:31 AM a Minimum Data Set (MDS) dated [DATE] indicated Resident 51 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated Resident 51 had a Brief Interview for Mental Status (BIMS) score of 15/15. He was cognitively intact and able to be interviewed. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. During an observation on 11/28/22 at 02:18 PM, Resident 54 was observed seated in her wheelchair in the hallway with a nasal cannula in place attached to a portable oxygen tank. The nasal cannula attached to the portable oxygen tank for Resident 54 was not dated. During an observation on 11/29/22 at 9:10 AM, the nasal cannula attached to Resident 54's portable tank was not dated. During an observation on 11/30/22 at 10:12 AM, the nasal cannula attached to Resident 54's portable tank was not dated. During a record review on 11/30/22 at 11:16 AM, an MDS dated [DATE] indicated Resident 54 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated Resident 54 was rarely able to make herself understood and was not interviewable. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with Licensed Practical Nurse (LPN) 2 on 11/28/22 at 9:56 AM, she indicated tubing should be replaced weekly and as needed and it should be dated when changed. She indicated she was unable to tell how long the undated tubing had been in place as it was not dated. A current policy, undated, title Oxygen Therapy and Devices indicated a nasal cannula used for oxygen delivery should be changed weekly and as needed. 3.1-47(a)(6)

Based on observation, interview, and record review the facility failed to implement treatments as ordered for 2 of 2 residents reviewed. (Residents 35 and 311). Findings include: 1. On 11/30/22 at 11:50 AM, Resident 35 was observed ambulating in the hall without an assistive device. The resident walked with a shuffling gait. He had swelling to both feet and ankles. The resident was not wearing compression wraps. A record review on 11/30/22 at 9:45 AM indicated the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had no cognitive deficit. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's care plan indicated the resident was at risk for ineffective tissue perfusion related to hypertension. A goal dated 5/16/22 indicated the resident was to maintain adequate tissue perfusion as evidenced by no [CONDITION(S)]. An intervention dated 5/16/22 indicated the resident was to be observed for [CONDITION(S)] and the presence of [CONDITION(S)] was to be documented. The resident's care plan did not include compression wraps to his lower legs as an intervention to control [CONDITION(S)]. A medication administration record (MAR) dated 11/1/11 through 11/30/22 indicated compression wraps had been applied to the resident's lower legs daily. During an interview on 12/1/22 at 12:12 PM Resident 35 indicated he did not recall compression wraps being utilized recently. During an interview on 12/1/22 at 3:09 PM Licensed Practical Nurse (LPN) 1 indicated the nurse was responsible for applying compression wraps. She indicated the resident often refuses the compression wraps. She viewed the MAR and indicated she had signed the compression wraps before applying. She indicated the MAR should not be signed until the wraps were applied. During an interview on 12/2/22 at 9:24 AM, the Health Facility Administrator (HFA) indicated the resident frequently removed the compression wraps. During an interview on 12/2/22 at 9:31 AM, the Director of Nursing indicated she was aware LPN 1 had signed the MAR prior to applying the resident's compression wraps. She indicated the MAR should be signed after the application was completed. She indicated the resident often refused the compression wraps. She indicated she was aware no refusals were being documented in the MAR. During an interview on 12/2/22 at 11:26 AM, the HFA indicated the facility did not have a policy for compression wraps. A current policy titled Resident Refusal of Medications/Treatments provided by the HFA on 12/2/22 at 11:26 am indicated refusal of treatments would be documented in the MAR. 2. During an observation on 11/28/22 at 11:43 AM, Resident 311 was observed lying in bed with a cervical collar over her mouth. Resident 311's nose was about one centimeter above the chin plate of the cervical collar. During an interview on 11/28/22 at 11:45 AM, Licensed Practical Nurse (LPN) 2, indicated she was not sure how to adjust the collar and would get therapy to assist. Occupational Therapist (OT) 3 came into the room on 11/28/22 at 11:50 AM and indicated the resident was not on his caseload and he did not know her. He indicated he would check with a facility nurse. Registered Nurse (RN) 4 assisted LPN 2 to adjust the collar. After the adjustment, the collar was angled to the right. LPN 2 indicated Resident 311's chin should rest evenly on the chin plate, and she was unable to achieve that position completely. During an observation on 11/28/22 at 1:41 PM, Resident 311 was observed with her chin below the chin plate of the collar. Nurse Consultant 5 came into the room and indicated he would adjust the collar. During an interview on 11/28/22 at 3:04 PM, the Administrator indicated no specific training on cervical collar application had been done. A record review conducted on 11/28/22 at 2:10 PM indicated Resident 311 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) dated [DATE] indicated Resident 311 was cognitively impaired and unable to be interviewed. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . No records reviewed indicated refusal of cervical collar care. No facility policy specific to cervical collar application was available for review. 3.1-37

Based on interview and record review, the facility failed to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident C, and Resident F) Findings include: 1. On 2-11-22 at 12:20 PM, the record of Resident C was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the BIMS (Brief Interview of Mental Status) indicated a score of 15 of 15. This indicated Resident C was interviewable. A list of residents that could be interviewed was provided by the Administrator on 2-11-22 at 12:22 PM. The list included Resident C. A review of Resident C's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR reflected the medication was to be given at 6:00 AM, 2:00 PM, and 10:00 PM. A review of Resident C's controlled substance record for the medication [MEDICATION(S)] 10 mg every 8 hours, quantity, date, time, amount given, quantity remain, and signature, indicated on 11-24-21 Resident C received [MEDICATION(S)] 10 mg at 5:00 AM, 2:00 PM and 8:00 PM. The medication was given 2 hours before scheduled. A review of Resident C's MAR (medication administration record) indicated on 11-24-21 the resident received [MEDICATION(S)] 10 mg at 6:00 AM, 2:00 PM and 10:00 PM. There was no other documentation to indicate why there was a discrepancy in administration times. A review of Resident C's MAR indicated on 11-25-21 Resident C received [MEDICATION(S)] 10 mg at 6:00 AM, 2:00 PM and 10:00 PM. A review of Resident C's controlled substances record indicated on 11-25-21 Resident C received [MEDICATION(S)] 10 mg at 6:00 AM, 2:00 PM and 8:00 PM. The medication was given 2 hours before scheduled. There was no other documentation to indicate why there was a discrepancy in administration times. A review of Resident C's MAR indicated on 11-28-21 Resident C received [MEDICATION(S)] 10 mg at 6:00 am, 2:00 PM and 10:00 PM. A review of Resident C's controlled substances record indicated on 11-28-21 Resident C received [MEDICATION(S)] 10 mg at 5:00 AM and 9:00 PM. The medication was not documented as given at 2:00 PM. There was no other documentation to indicate why there was a discrepancy in administration times. A review of Resident C's MAR indicated on 12-11-21 Resident C received [MEDICATION(S)] 10 mg at 6:00 AM, 2:00 PM and 10:00 PM. A review of Resident C's controlled substance record indicated on 12-11-21 Resident C received [MEDICATION(S)] 10 mg at 6:00 AM, 12:00 PM, 8:00 PM and 10:00 PM. The documentation indicated Resident C received the medication early at 12:00 PM 2 hours before scheduled and received an 1 extra dose at 8:00 PM. There was no other documentation to indicate why there was a discrepancy in administration times. A review of Resident C's MAR indicated on 12-14-21 Resident C received [MEDICATION(S)] 10 mg at 6:00 AM, 2:00 PM, and 10:00 PM. A review of Resident C's controlled substance record indicated on 12-14-21 Resident C received [MEDICATION(S)] 10 mg at 5:00 AM, 2:00 PM and 8:00 PM. The medication was given 2 hours before scheduled at 10:00 PM. There was no other documentation to indicate why there was a discrepancy in administration times. A review of Resident C's MAR indicated on 12-15-21 Resident C received [MEDICATION(S)] 10 mg at 6:00 AM, 2:00 PM and 10:00 PM. A review of Resident C's controlled substance record indicated on 12-15-21 Resident C received [MEDICATION(S)] 10 mg at 6:00 AM, 2:00 PM and 8:00 PM. The medication was given 2 hours before scheduled at 10:00 PM. There was no other documentation to indicate why there was a discrepancy in administration times. A review of Resident C's MAR indicated on on 12-24-21 Resident C received [MEDICATION(S)] 10 mg at 6:00 AM, and 2:00 PM. The medication was not documented at 10:00 PM as given. A review of Resident C's controlled substance record indicated on 12-24-21 the resident received [MEDICATION(S)] 10 mg at 6:00 AM and 2:00 PM. The medication was not documented as given at 10:00 PM. A review of Resident C's MAR indicated on 12-25-21 Resident C received [MEDICATION(S)] 10 mg at 6:00 AM, 2:00 PM and 10:00 PM. A review of Resident C's controlled substance record indicated on 12-25-21 Resident C received [MEDICATION(S)] 10 mg at 5:45 AM and 2:00 PM. The medication was not documented as given at 10:00 PM. There was no other documentation to indicate why there was a discrepancy in administration times. A review of Resident C's MAR indicated on 12-29-21 Resident C received [MEDICATION(S)] 10 mg at 6:00 AM and 2:00 PM. The medication was not documented at 10:00 PM as given. A review of Resident C's controlled substance record indicated on 12-29-21 Resident C received [MEDICATION(S)] 10 mg at 6:00 AM and 2:00 PM. The medication was not documented as given at 10:00 PM. A review of Resident C's MAR indicated on 1-5-22 Resident C received the medication [MEDICATION(S)] 10 mg at 6:00 AM, 2:00 PM, and 10:00 PM. A review of Resident C's controlled substance record indicated on 1-5-22 Resident C received [MEDICATION(S)] 10 mg at 6:00 AM and 9:00 PM. The medication was not documented as given at 2:00 PM. A review of Resident C's MAR indicated on 1-10-22 Resident C received [MEDICATION(S)] 10 mg at 6:00 AM, 2:00 PM and 10:00 PM. A review of Resident C's controlled substance record indicated on 1-10-22 Resident C received [MEDICATION(S)] 10 mg at 5:50 AM, 2:00 PM, and 6:00 PM. The medication was given 4 hours before the scheduled time. A review of Resident C's MAR indicated on 1-21-22 Resident C received [MEDICATION(S)] 10 mg at 5:00 AM, 1:00 PM, and 9:00 PM. A review of Resident C's controlled substance record indicated on 1-21-22 Resident C received [MEDICATION(S)] 10 mg at 6:00 AM, 2:00 PM, and 6:00 PM. The medication was documented as given 4 hours before the scheduled time. A review of Resident C's MAR indicated on 1-22-22 Resident C received [MEDICATION(S)] 10 mg at 5:00 AM and 9:00 PM. The medication was not documented as given at 1:00 PM. A review of Resident C's controlled substance record indicated on 1-22-22 Resident C received [MEDICATION(S)] 10 mg at 8:45 AM and 2:15 PM. The medication was not documented as given at 9:00 PM. There was no other documentation to indicate why there was a discrepancy in administration times. A review of Resident C's MAR indicated on 1-24-22 Resident C received [MEDICATION(S)] 10 mg at 5:00 AM, 1:00 PM, and 9:00 PM. A review of Resident C's controlled substance record indicated on 1-24-22 Resident 3 received [MEDICATION(S)] 10 mg at 12:00 AM, 5:00 AM, 1:00 PM and 9:00 PM. Resident C received 1 extra dose of [MEDICATION(S)]. There was no other documentation to indicate why there was a discrepancy in administration times. A review of Resident C's MAR indicated on 1-27-22 Resident C received [MEDICATION(S)] 10 mg at 5:00 AM and 1:00 PM. The medication was not documented as given at 9:00 PM. A review of Resident C's controlled substance record indicated on 1-27-22 Resident C received [MEDICATION(S)] 10 mg at 5:00 AM, 1:00 PM, and 5:00 PM. The medication was given 5 hours before the scheduled time. There was no other documentation to indicate why there was a discrepancy in administration times. On 2-11-22 at 2:30 PM, in an interview, the DON ( Director of Nursing) indicated there should have been a progress note to reflect why the resident did not get medication as ordered. She indicated medication times were changed for Resident C from 6 AM, 2 PM, and 10 PM to 5 AM, 1 PM and 9 PM, but there was not a progress note to indicate Resident C had been informed. Medications may be given 1 hour before and 1 hour after the scheduled time according to policy. When the staff try to give medication earlier, the system will alert them to document why they are giving the medication early. The MAR and the controlled substance record should reflect each other for medication administration. 2. On 2-14-22 at 9:10 AM, the record of Resident F was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the BIMS indicated a score of 14 of 15.This indicated Resident C was interviewable. A list of residents that could be interviewed was provided by the Administrator on 2-11-22 at 12:22 PM. The list included Resident F. A review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident F's MAR indicated on 12-13-21 Resident F received [MEDICATION(S)]-acet 10-325 mg at 12:00 AM, 12:00 PM and 6:00 PM. The medication was not documented as given at 6:00 AM. A review of Resident F's controlled substance record indicated on 12-13-21 Resident F received [MEDICATION(S)]-acet 10-325 mg at 12:00 AM, 6:00 AM, 10:00 AM, 2:00 PM and 6:00 PM. Resident 6 was given 1 extra dose of the medication.There was no other documentation to indicate why there was a discrepancy in administration times. A review of Resident F's MAR indicated on 1-19-22 Resident F received [MEDICATION(S)]-acet 10-325 mg at 12:00 AM, 6:00 AM, and 6:00 PM. The medication was not documented at 12:00 PM as given. A review of Resident F's controlled substance record indicated on 1-19-22 Resident F received [MEDICATION(S)]-acet 10-325 mg 12:00 AM, 6:00 AM, and 5:00 PM. The medication was not documented as given at 12:00 PM. There was no other documentation to indicate why there was a discrepancy in administration times. A review of Resident F's MAR indicated on 1-22-22 Resident F received [MEDICATION(S)]-acet 10-325 mg at 6:00 AM and 12:00 PM. The medication was not documented as given at 12:00 AM and 6:00 PM . A review of Resident F's controlled substance record indicated 1-22-22 Resident F received [MEDICATION(S)]-acet 10-325 mg at 8:45 AM and 12:03 PM. The medication was not documented as given at 12:00 AM and 6:00 PM. There was no other documentation to indicate why there was a discrepancy in administration times. A review of Resident F's MAR indicated on 1-23-22 Resident 6 received [MEDICATION(S)]-acet 10-325 mg at 12:00 AM, 12:00 PM, and 6:00 PM. The medication was not documented as given at 6:00 AM. A review of Resident F's controlled substance record indicated on 1-23-22 Resident F received [MEDICATION(S)]-acet 10-325 mg at 12:12 AM, 6:00 AM, and 6:00 PM. The medication was not documented as given at 12:00 PM. There was no other documentation to indicate why there was a discrepancy in administration times. A review of Resident F's MAR indicated on 1-30-22 Resident F received [MEDICATION(S)]-acet 10-325 mg at 6:00 AM, 12:00 PM, and 6:00 PM. The medication was not documented as given at 12:00 AM. A review of Resident F's controlled substance record indicated on 1-30-22 Resident F received [MEDICATION(S)]-acet 10-325 mg 6:00 AM, 1:00 PM, and 6:00 PM. The medication was not documented as given at 12:00 AM. There was no other documentation to indicate why there was a discrepancy in administration times. A review of Resident F's MAR indicated on 1-31-22 Resident F received [MEDICATION(S)]-acet 10-325 mg at 6:00 AM, 12:00 PM, and 6:00 PM. The medication was not documented at 12:00 AM as given. A review of Resident F's controlled substance record indicated on 1-31-22 Resident F received [MEDICATION(S)]-acet 10-325 mg 6:00 AM, 1:00 PM, and 6:00 PM. The medication was not documented as given at 12:00 AM. There was no other documentation to indicate why there was a discrepancy in administration times. On 2-14-22 at 11:53 AM, in an interview, the DON indicated there should have been a progress note to reflect why the Resident F did not get the medication. A current facility policy, Medication Administration Times, dated 5-1-10, was provided by the DON on 2-14-22 at 10:02 AM. The policy indicated .Facility should commence medication administration within sixty (60) minutes before the designated times of administration and should be completed by sixty (60) after the designated times of administration A current facility policy, General Dose Preparation and Medication Administration, dated 1-1-13, was provided by the DON on 2-14-22 at 10:02 AM. The policy indicated . 4.1.1 Verify each time a medication is administered that is the correct medication, at the correct dose, correct route, at the correct rate, at the correct time, for the correct resident .4.1.2 Confirm that the MAR reflects the most recent medication order .5.4 Administer medications within timeframes specified by facility policy .5.5 Document the administration of controlled substances in accordance with applicable law .6.1 Document necessary medication administration/treatment information (e.g., when medication are opened, when medications are given, injections site of medication, if medications are refused. PRN medications, application site) on appropriate forms This Federal citation is related to Complaint IN 047. 3.1-37

Based on observation, interview and record review, the facility failed to properly prevent transmission of COVID-19 for 1 of 1 observations made (Employee 3, Resident 18) and for 9 employee and 51 visitor screenings. This had the potential to affect all residents residing in the facility. Findings include: 1. A continuous observation was made on 10/5/21 at 10:13 AM. Employee 3 exited Resident 13's room with an isolation gown, gloves and laundry in a plastic bag. Employee 3 walked down the hall to the laundry room, and entered the laundry room. At 10:22 AM, Employee 3 exited the laundry room without the isolation gown, gloves or laundry. Employee 3 was interviewed on 10/5/21 at 10:22 AM. Employee 3 indicated he had exited Resident 13's room, who was on transmission based precautions, and brought the resident's laundry to the laundry room. Employee 3 indicated he should have taken the isolation gown and gloves off before exiting the resident's room. An observation was made on 10/5/21 at 10:28 AM. Signage on Resident 13's door indicated the resident was on transmission based precautions. The Administrator was interviewed on 10/5/21 at 12:42 PM, the Administrator indicated when entering a transmission based precaution room, staff should first put on full personal protective equipment: an isolation gown, gloves, face shield and face masks. Then, before exiting the room, the staff member should take off the personal protective equipment. The Administrator also indicated the facility did not have a specific policy pertaining to personal protective equipment and transmission based precaution rooms but indicated the facility followed Indiana Department of Health guidance. 2. Employee 4 was interviewed on 10/5/21 at 10:13 AM. Employee 4 indicated she would arrive at work around 6 AM and would screen herself for signs and symptoms of COVID-19 due to no staff available to do the screenings. Employee 3 was interviewed on 10/5/21 at 10:22 AM. Employee 3 indicated he would arrive at work around 5:30 AM and would screen himself for signs and symptoms of COVID-19 due to no staff available to do the screenings. Employee 2 was interviewed on 10/5/21 at 10:51 AM. Employee 2 indicated she would arrive at work around 6 AM and would screen staff for signs and symptoms of COVID-19. Employee 2 also indicated she would screen herself for signs and symptoms of COVID-19 when she arrived to work becuse there was [NAME] else available to do so. Employee Screening logs, dated 9/2/21- 10/5/21, were provided by the Director of Nursing (DON) on 10/5/21 at 1 PM. The Employee Screening logs indicated 9 employees had screened themselves. Visitor Screening logs, dated 8/11/21-9/16/21, were provided by the DON on 10/5/21 at 1 PM. The Visitor Screening logs indicated 51 visitors had screened themselves. The Administrator was interviewed on 10/5/21 at 12:42 PM. The Administrator indicated staff and visitors should be screened by someone other than themselves. 3.1-18(b)(2) 3.1-18(b)(1)(a)

Based on interview and record review the facility failed to provide catheter care for 1 of 1 residents reviewed. (Resident 3). Findings include: 1. Resident 3 was interviewed on 9/21/21 at 11:54 AM. She indicated she had not received catheter care as ordered. A record review was completed on 9/22/21 at 1:20 PM. Resident 3's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 3's care plan, dated 5/5/21, indicated to monitor urinary output and staff were to record urinary output in ml. An order, dated 5/6/2021, indicated the following catheter orders concerning foley catheter care. The nurse was to record catheter output every shift (6 AM, 2 PM, 10 PM). The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Employee 3 was interviewed on 9/23/21 at 10:43 AM. Employee 3 indicated a Certified Nursing Assistant (CNA) or nurse should empty a resident's catheter. When a resident had an order related to catheter output, the CNA would let the nurse know the amount and the nurse would document the amount of output in the MAR. Employee 1 was interviewed on 9/23/21 at 11:47 AM. Employee 1 indicated CNAs could empty and tell the nurse the output so the output would be documented. Employee 1 also indicated CNAs would provide peri-care to all catheter residents when the resident was getting up or was cleaned up throughout the day. On 9/24/21 at 2:12 PM., Resident 3 refused to allow the surveyor to observe catheter care. A lab report, dated 6/3/21, was provided by the Director of Nursing (DON) on 9/24/21 at 3:21 PM. The report indicated Resident 3 had a urinary tract infection. The Director of Nursing (DON) was interviewed on 9/24/21 at 9 AM. The DON indicated the CNA and/or nurse was responsible for emptying catheters and the nurse should document the output on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] A policy, dated 12/2012, titled Indwelling Catheter Care, Emptying Drainage bag and catheter removal was provided by the DON on 9/24/21 at 3:21 PM. The policy indicated emptying urinary catheter bag document pertinent information. 3.1-41(a)(1)

Based on observation, interview, and record review the facility failed to ensure pharmaceutical procedures were followed for medication storage, medication labeling and discarding medication for 2 of 4 medication carts observed. (Resident 5, Resident 41 and Resident 44) Findings include: During an observation on 9/22/21 at 1:09 P.M., with Licensed Practical Nurse 4 (LPN) in the top drawer200-hall medication cart of the medication cart, was a medication of [MEDICATION(S)] ([MEDICATION(S)] injection pen) 100 unit/ milliliters (ml) with an open date of 8/19/21. The medication was labeled for Resident 44. LPN 4 indicated the insulin was good for 28 days after open. The clinical record for Resident 44 was reviewed 9/23/21 at 10:56 A.M. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M.-10:00 P.M. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M.-10:00 P.M. During an observation on 9/22/21 at 1:21 P.M., with Director of Nursing (DON), in the top drawer of the 100-hall medication cart, was a medication of Wixela 250-50 INHUB with an open date of 7/29/21. The medication was labeled for Resident 41. Observation of the locked narcotic box in the medication cart indicated there was a vial of Testosteron Cyp 1,000 milligrams (mg)/ 10 ml. The medication was labeled for Resident 5. On the bottle there was no opened date, the dispensed date indicated the medication had been sent from the pharmacy on 5/15/21. In the same locked narcotic box was another un-opened bottle of the Testosteron Cyp 1,000 mg/10 ml labeled for Resident 5. In an interview, the DON indicated she did not know how long they kept aerosol medications after being opened but would find out from the pharmacy. The record for Resident 41 was reviewed on 9/23/21 at 10:58 A.M. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M.-11:00 A.M and 5:00 P.M.-10:00 P.M. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M.-11:00 A.M. and 5:00 P.M.- 10:00 P.M. The record for Resident 5 was reviewed on 9/23/21 at 10:57 A.M. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M., on July 1, 8, 15, 22, and 29 2021 at 8:00 P.M., on August 5, 12, 19, and 26 2021 at 8:00 P.M., and on September 2, 9, and 16 2021 at 8:00 P.M. During an interview on 9/22/21 at 4:15 P.M. the DON indicated the medication of Wixela and Testerone were both good for only 30 days after opening. A current facility policy, Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, dated 4/5/19, was provided by the DON on 9/23/21 at 11:21 A.M. The policy indicated .Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has shortened expiration date once opened . 3.1-25(j)(m) and (n)

Based on interview and record review the facility failed to provide assistance with showers for 1 of 1 residents reviewed. (Resident 3). Findings include: Resident 3 was interviewed on 9/21/21 at 11:54 AM. She indicated she had not received showers based on her preferences. A record review was completed on 9/22/21 at 1:20 PM. Resident 3's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 3's care plan, dated 5/5/21, indicated to assist with bathing as needed per resident preference. Offer showers two times per week with partial bath in between. A Minimum Date Set (MDS) assessment dated [DATE] indicated Resident 3 required 2 person physical assistance with bathing. Employee 1 was interviewed on 9/23/21 at 11:47 AM. They indicated residents receive showers 2 times a week or based on request. All residents have an option for shower, partial bed bath or complete bed bath. Employee 1 indicated when a resident refuses a shower, the nurse should offer a bed bath before the shower sheet is signed off. A complete bed bath can replace a shower if the resident prefered. Employee 1 also indicated Resident 3 required total assistance with bathing. Employee 3 was interviewed on 9/24/21 at 12:18 PM. They indicated a shower would be a complete head to toe wash in the shower room. A complete bed bath would be a complete head to toe wash including hair washing in the resident's room. Employee 3 also indicated a partial bed bath would be a washed face, underarms and peri-care. A point of care history report, dated 7/12/21-9/23/21, was provided by the Director of Nursing (DON) on 9/24/21 at 9:40 AM. The report indicated from 7/12/21-9/9/21 Resident 3 received a partial bed bath daily. The DON provided shower sheets for Resident 3, indicated Resident 3 refused 3 showers and received one complete bed bath from 7/12/21-9/23/21. The DON was interviewed on 9/24/21 at 1:15 PM. The DON indicated residents should be offered 2 showers a week, when a resident refused, staff should document. The DON also indicated Resident 3 should receive partial bed baths in between showers per care plan. The DON indicated the facility follows Indiana Department of Health guidance. 3.1-3(u)(1)

Based on interview and record review, the facility failed to provide catheter supplies for 1 of 1 residents reviewed with [MEDICAL CONDITION]. This resulted in a urinary tract infection secondary to the residnet being unable to completely empty his baldder. (Resident F). Findings include: On 3/2/18 at 11:40 A.M., Resident F's record was reviewed. [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment, dated 12/13/18, indicated Resident F had a BIMS (Brief Interview Mental Status) score of 15 which signified the resident had no cognitive impairment. The assessment indicated the resident required intermittent urinary catheterization. A Plan of Care, dated 5/9/16, indicated Resident F required intermittent catheterizations (done per self) related to [MEDICAL CONDITION] bladder. Interventions included, but were not limited to, may self straight cath self per choice and use catheter per physician order. On 3/2/18 at 10:00 A.M., Resident F was interviewed. During the interview, he indicated he performed self catheterization approximately 6-8 times per day. He stated that he had been out of catheters approximately two weeks ago. He indicated on 2/18/18, he ran out of catheters and had told numerous nurses and CNA's that he did not have any catheters. The resident indicated he was without catheters and unable to perform self catheterization for 5 days which resulted in retention of urine and a urinary tract infection. Review of physician orders [REDACTED]. 5/10/16 Cath orders: straight catheter: (brand of catheter). Indication: Resident straight cath's self. 2/25/18 [MEDICATION NAME] tablet 875-125 mg; oral twice a day for UTI (urinary tract infection). A physician progress notes [REDACTED]. The note indicated the resident stated he was able to urinate some but usually self cathed himself approximately 6 times a day and usually gets 200-300 milliliters of urine at each catheterization. The resident reports he has been out of self cath supplies for a few days now. Reports some abdominal tenderness. On 3/2/18 at 12:11 P.M., the ADON (Assistant Director of Nursing) was interviewed. During the interview, she indicated Resident F was never out of catheters. She indicated she was made aware the resident needed catheters so she directed a nursing staff member to go to another company facility and obtain the needed catheters. The ADON indicated she did not remember which day she was made aware of the need for catheters or which nursing staff member was directed to obtain the catheters. On 3/2/18 at 12:28 P.M., during a confidential interview, Employee 1 indicated it was reported to nursing staff that Resident F was out of catheters. Employee 1 indicated this was reported during the week of 2/18/18 through 2/22/18. Employee 1 further indicated there had been another instance when Resident F had been out of catheters. The employee indicated this had occurred (MONTH) (YEAR) and the facility had to borrow catheters from another facility at that time. On 3/2/18 at 12:50 P.M., during a confidential interview, Employee 3 indicated Resident F had been out of catheters on 2/18/18 and Administrative Nursing staff had been notified, but was unsure why the catheters had not been available to the resident. On 3/2/18 at 4:25 P.M., Employee 5 was interviewed. During the interview, Employee 5 indicated Resident F had been very upset when he was out of catheters which occurred 2/18/18 to 2/22/18. Employee 5 indicated being assigned to care for the resident during the week of 2/18/18 to 2/22/18. Resident F would put his call light on several times throughout the shift, about every 15 minutes for assistance with the urinal. Employee 5 indicated the resident complained of having to urinate but being unable to completely empty his bladder. The employee indicated Resident F had numerous incontinent episodes. Employee 5 indicated the nurses were notified the resident was out of catheters and was having problems emptying his bladder, but no catheters were available for the resident. This Federal tag relates to Complaint IN 870. 3.1-41(a)(2)