Every finding on record at Greenleaf Health Campus

Based on record review and interview, the facility failed to ensure clinical records were accurate and complete related to assessments completed after a change in condition for 1 of 3 residents reviewed for change of condition. (Resident E) Finding includes:The record for Resident E was reviewed on 6/30/26 at 11:35 a.m. Diagnoses included, but were not limited to, anemia (low iron), diabetes, dementia, heart failure, anxiety, delirium, and dysphagia (difficulty swallowing) The 4/17/26 Quarterly Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making, required partial to moderate assistance for eating, and required substantial to maximum assistance for oral hygiene, personal hygiene, and upper body dressing. For all other Activities of Daily Living (ADLs) Resident E was dependent on staff for care. A Nursing Progress Note, dated 6/26/26 at 8:56 a.m., indicated the resident was in bed prior to breakfast and morning medication was attempted to be given. The resident had pocketed the pills, and they were removed from her mouth. The aides had set the resident up in the common area and tried to feed her breakfast while the nurse had crushed her medication. The medication was successfully given with yogurt and water. The staff had called the daughter and had face-timed her and the daughter was unable to get the resident to speak or smile. The daughter requested her mother be put back to bed indicating that maybe she was just tired and needed to sleep. Around 12:00 p.m., crushed medication was attempted to be give and the resident was not able to swallow. The Nurse Practitioner and texted and an order was received to send the Resident out for evaluation. The daughter was called and arrived shortly after the notification and requested the resident be sent out via 911. The record lacked vitals and an assessment at start of change of condition during breakfast.A Nursing Progress Note, dated 6/26/26 at 12:25 p.m., indicated the resident's vitals had been obtained and were as followed: 101/68, heart rate 70, temperature 97.9, and blood sugar was 169. The resident was diaphoretic (sweating profusely) at the time of the assessment.During an interview on 6/30/26 at 1:23 p.m., CNA1 indicated she had gotten the resident up out bed at about 9:30 a.m., on 6/26/2026, because the resident ate with assistance from the restorative aides. She indicated the resident slept a lot and was assisted out of bed around the same time every day. When she had been gotten up that morning, Resident E kept opening her mouth and had acted differently. She thought it was odd and had informed the nurse. CNA 1 indicated she had attempted to feed the resident a little bit of her cream of wheat with little success. She indicated they had called the resident's daughter and Resident E had been assisted back to bed after her daughter requested she be put back to bed. When the nurse had checked on her again later, she appeared worse and that was when the facility had her sent out (to the emergency room). During an interview on 6/30/26 at 2:14 p.m., RN1 indicated she was waiting for Resident E's daughter to arrive because she had assisted her with feeding her her breakfast and giving her her medications. She had had trouble giving her medication in the past. She indicated the resident was not known to her and she had only cared for her four times previously. RN 1 indicated the aides had gotten the resident up and had taken her to the dining room. RN 1 indicated she had started feeding the resident her food and had given her two capsules of medication and the resident was unable to swallow them. RN 1 indicated this had occurred around 9:30 a.m. As the aides had attempted to feed Resident E cream of wheat, she noticed several staff surrounding the resident. The staff had indicated the resident was not swallowing her food. RN 1 indicated she had attempted to feed Resident E yogurt and that had been successful. RN 1 indicated the Employee Experience Manager (EXM) had called the resident's daughter and had face-timed with her. RN 1 indicated she had been mad about that because she was the nurse she should have been the staff member that called the resident's daughter. RN 1 indicated she could have had her sent out then, but the daughter told the EXM to lay her mother back down and that her mother was just sleepy and sometimes she just needed a sleep day. RN 1 indicated the resident had had more medications due at noon, and when she had checked on her, she was unresponsive and her vital signs were lower than when she had taken them at breakfast. RN 1 indicated Resident E's vital signs at breakfast were unremarkable. RN 1 indicated she had then called the Nurse Practitioner and had received an order to send the resident out for an evaluation. The resident's daughter was notified of the order and had agreed to send Resident E out to the hospital. The transporter (of the nonemergent ambulance service that had been initially contacted to transport Resident E) had indicated there was a 20-30-minute transfer wait time. As time went on, the resident became more clammy, with wet skin, and could nott close her mouth. The family was at the bedside and requested the resent be sent out via 911. During an interview on 6/30/36 at 3:13 p.m., the Employee Experience Manager (EXM/CNA) indicated she had called Resident E's daughter because the resident was off and she had wanted to get her daughter on the phone because the resident had not responded very well her (EXM). During an interview on 7/1/26 at 11:01 a.m., the Executive Director indicated she understood the vitals/assessment should have been documented by the nurse at the time of the change of condition. This citation relates to Intake 3062903.410 IAC (Indiana Administrative Code) 16.2-3.1-50(a)(2)

Based on record review and interviews, the facility failed to ensure resident and resident group grievances regarding call lights were answered in a timely manner.During a Resident Council Meeting on 9/23/2025 at 2:08 P.M. 4 of 5 residents indicated call light wait times are 20-30 minutes or more and this happens 3-4 times a week, especially at night. At times they are told by the aide they will be back but never come back. A review of past Resident Council minutes indicated call light response times were a concern on 7/14/2025, 8/15/2025, and 9/5/2025. During an interview on 9/24/2025 at 8:22 P.M., LPN 8 indicated she there were 2 CNAs on the 300 hall, which was normal. During an interview on 9/24/2025 at 8:46 P.M., the ED indicated there was 1 nurse and 1 CNA working the 100 hall and 1 QMA and 2 CNAs on the 200 hall. An audit of call light response time reports on 9/26/2025 at 11:15 A.M. indicated between 8/25 and 9/22/2025 on the 200 hall there were 55 occasions where it took greater than 30 minutes to answer the call light. Of those 55 long response times, 5 were greater than 60 minutes. During an interview on 9/26/2025 at 1:02 P.M., the ED indicated she does have enough staff. Call lights should be answered within 15-20 minutes. The long call light times usually occur during mealtimes, in the morning when getting residents out of bed, and at shift change. The 200 hall tends to be the heaviest as far as care goes and was recruiting for an additional CNA for that hall. A policy for call light response times was requested, on 9/26/2025 at 1:02 P.M., but one was not provided. 3.1-17(a)

Based on record review and interview the facility failed to ensure nursing staff had the competencies to administer medications timely and/or sign off medications immediately after administration for 4 of 5 residents reviewed for medications. ( Residents 3, 10, 37, and 64) This deficient practice involved the following staff: QMA 5, QMA 7, RN 8, RN9, QMA 10, LPN11, RN12, QMA 13, LPN 14, QMA 15, RN 16 and RN 17Findings include:1. A record review for Resident 3 was completed on 9/24/2025 at 9:18 A.M. Diagnoses included, but were not limited to, type 2 diabetes mellitus, dementia without behaviors, generalized anxiety disorder, and atrial fibrillation. Physician Orders for Resident 3 included, but were not limited to: -calcium citrate (supplement) 250 milligram (mg) by mouth twice a day. -carbamazepine (antiseizure) 300 mg by mouth twice a day. -carbamazepine 100 mg by mouth once a day. -vitamin D3 (supplement) 25 micrograms (mcg) by mouth once a day. -duloxetine (antidepressant) 30 mg by mouth once a day. -Eliquis (anticoagulant) 5 mg by mouth twice a day. -furosemide 20 mg by mouth once a day. -lispro insulin (quick acting) sliding scale subcutaneously before meals and at bedtime. -metformin 500 mg by mouth once a day. -pantoprazole (decreases stomach acid production) 40 mg by mouth once a day. -propanol 20 mg (antihypertensive) 20mg by mouth once a day A review of Resident 3's Medication Administration Record (MAR) from August 1st through September 26th, 2025, indicated the following medications had been administered late (30 minutes late or later than prescribed): -calcium citrate 5 times. -carbamazepine 300 mg 5 times. -carbamazepine 100mg 2 times. -vitamin D3 5 times. -duloxetine 4 times. -Eliquis 5 times. -furosemide 4 times. -metformin 5 times. -pantoprazole 6 times. -propranolol 7 times. -sertraline 3 times. The following staff were responsible for administering medications late: QMA 5, RN 8, RN 9, QMA 10, LPN 11, and RN 12. During an interview on 9/25/2025 at 10:45 A.M., the DON indicated there were two ways medications were ordered. If the medication was ordered for a specific time frame, for example, a medication ordered to be administered from 6 A.M. – 10 A.M., the medication would be considered late if it was administered at 10:01 A.M. or later. If the medication was ordered for a specific time, for example, the medication had been ordered for 6 A.M., the medication would be considered late if administered at 7:01 A.M. or later. The DON indicated most medications were administered on time, but the staff had not signed off on the medication administration form until late. The DON indicated medication administration should be signed off in the resident's record as soon as the medication was administered. 2. Resident 10's record review was completed on 9/26/2025 at 8:30 A.M. Diagnoses included, but were not limited to: major depressive disorder, anxiety disorder, dementia, atrial fibrillation and hypertension. Resident 's 10 current Physicians' orders included, but were not limited to: -500 mg acetaminophen (treats pain) once a day -50 mg of metoprolol (treats hypertension) twice a day -150 mg of bupropion (treats depression) once a day -1 tablet B-complex (vitamin b) once a day A review of Resident 10's August and September MARs indicated the following medications had been charted or administered late: (30 minutes late or later) - acetaminophen had been late 15 times - metoprolol had been late 7 times - bupropion had been late 7 times - B-complex had been late 7 times The following staff had been responsible for administering late medications to Resident 64 from 8/1/2025 to 9/26/2025: RN 8, RN 9, QMA 10, QMA 15, RN 16 and RN 17. 3. Resident 37's record review was completed on 9/26/2025 at 9:00 A.M. Diagnoses included, but were not limited to: Alzheimer's disease, dementia, hyperlipidemia, hypertension major depressive disorder, generalized anxiety disorder and gastroesophageal reflux disease (GERD). Resident 37's Physicians' orders from 8/1/2025 to 9/18/2025 included, but were not limited to: -0.5 mg alprazolam (treats anxiety) twice a day -2 mg aripiprazole (treats depression) once a day -cholecalciferol (vitamin D3) once a day -20 mg famotidine (treats GERD) one a day -10 mg lisinopril (treats hypertension) once a day -10 mg memantine (treats Alzheimer's disease and dementia) twice a day -150 mg venlafaxine (treats depression) once a day A review of Resident 37's August and September MARs indicated the following medications had been charted or administered late: (30 minutes late or later) - alprazolam had been late 7 times -aripiprazole had been late 6 times -cholecalciferol had been late 6 times -famotidine had been late 6 times -lisinopril had been late 6 times -memantine had been late 6 times -venlafaxine had been late 6 times The following staff had been responsible for administering late medications to Resident 37 from 8/1/2025 to 9/26/2025: RN 8, RN 9, RN 12, and QMA 15. 4. Resident 64's record review was completed on 9/26/2025 at 9:30 A.M. Diagnoses included, but were not limited to: bipolar disorder, anxiety disorder, chronic obstructive pulmonary disease, splenomegaly and malignant carcinoid tumor of the bronchus and lung. Resident 64's Physicians' orders from 8/1-9/18/2025 included, but were not limited to: -1 puff umeclidinium-vilanterol (inhaler for COPD) once a day -200 mg carbamazepine (treats bipolar disorder) once a day -3.125 mg carvedilol (treats hypertension) twice a day -20 mg furosemide (diuretic) once a day -insulin lispro or aspart (quick acting) sliding scale before meals dependent on resident's before meal blood sugar -18 units insulin lispro or aspart before meals -500 mg methocarbamol (muscle relaxant) three times a day -4 mg ondansetron (treats nausea) every 6 hours -200 mg pregabalin (treats diabetic neuropathy) three times a day -100 mg sertraline (antidepressant) once day A review of Resident 64's August and September MARs indicated the following medications had been charted or administered late: (30 minutes late or later) -umeclidinium-vilanterol had been late 10 times - carbamazepine had been late 6 times -carvedilol had been late 6 times -furosemide had been late 6 times -18 units insulin lispro or aspart before meals had been late 31 times - sliding scale insulin lispro or aspart before meals had been late 13 times -methocarbamol had been late 5 times -ondansetron had been late 23 times -pregabalin had been late 37 times -sertraline had been late 6 times The following staff had been responsible for administering late medications to Resident 64 from 8/1/2025 to 9/26/2025: QMA 5, QMA 7, RN 8, RN 9, LPN 11, RN 12, QMA 13, LPN 14 and QMA 15. During an interview on 9/26/2025 at 10:45 A.M., the DON indicated staff were accessed for skill competency on medication administration times and documenting routine as well as as needed medications during orientation. During an interview on 9/26/2025 at 1:30 P.M., QMA 7 indicated medications had been administered on time for Resident 64, but she had not signed off on all the medications in the record until later in the shift. QMA 7 indicated medications should be signed off in the medical record as soon as the medication had been administered. During an interview on 9/26/2025 at 1:35 P.M., QMA 5 indicated resident's medications should be signed off on in the medical record once the medication had been administered. QMA 5 indicated sometimes she missed a medication sign off during medication administration time frame, but she had put a note in the chart indicating the medication had been administered on time. During an interview on 9/26/2025 at 1:45 P.M., RN 12 indicated medications were late if they had been administered more than one hour after the scheduled time. RN 12 indicated medications had not been administered timely and there had not been a note documented to indicate why the medication had been administered late for Residents 37 and 64. On 9/26/2025 at 1:54 P.M., the Regional Clinical Support Nurse (RCSN) provided checklists titled, Job Specific Orientation and Nurse New Hire. The RCSN indicated all staff had completed their orientation checklists. The Job Specific Orientation and Nurse New Hire checklists indicated QMA 5, QMA 7, RN 8, RN9, QMA 10, LPN11, RN12, QMA 13, LPN 14, QMA 15, RN 16 and RN 17 had been assessed for medication administration and documentation of medication administration. On 9/26/2025 at 1:54 P.M., the RCSN provided an undated policy titled, Guidelines for Administration of Medication and indicated it was the one currently used by the facility. The policy indicated, .24 When administering a medication, the following steps should be followed. b. Make note of the five rights, to assure the proper administration of the medication. v. right time. f. Record the time. 3.1- (b)(5)

Based on observation, interview and record review, the facility failed to maintain oxygen equipment in a sanitary manner related to dating oxygen tubing and cleaning equipment for 3 of 9 residents who were reviewed. (Residents 64, 60 and 21)Findings include:1. During an observation on 9/23/2025 at 10:22 A.M., Resident 64's portable oxygen tank and nasal cannula were hanging in the bathroom.During an observation on 9/25/2025 at 8:45 A.M., Resident 64's portable oxygen tank and nasal cannula were hanging in the bathroom.During an interview on 9/25/2025 at 9:10 A.M., Resident 64 indicated the oxygen tank and nasal cannula she was currently using had been the oxygen tank and nasal cannula from her bathroom.Resident 64's record review was completed on 9/26/2025 at 9:30 A.M. Diagnoses included, but were not limited to: bipolar disorder, anxiety disorder, chronic obstructive pulmonary disease, splenomegaly and malignant carcinoid tumor of the bronchus and lung.Resident 64 had a current Physician's order indicating she was to receive 4 Liters (L) continuous oxygen through a nasal cannula.During an interview on 9/25/2025 at 9:30 A.M., the Director of Nursing (DON) indicated oxygen equipment should not have been stored in the bathroom and if a resident was not using their nasal cannula, the nasal cannula should have been stored in a bag.2. During an observation on 9/23/2025 at 10:46 A.M., Resident 60's continuous positive airway pressure (CPAP) mask was in a bag, dated 9/8/2025, and had a build up of a brown substance on the inside of the mask.During an interview on 9/23/2025 at 10:47 A.M., Resident 60 indicated the brown substance on the inside of her CPAP mask was her make-up. Resident 60 could not recall when her mask had last been cleaned, but indicated it had been at least two weeks ago.During an observation, on 9/25/2025 at 9:33 A.M., of Resident 60's CPAP machine, the DON indicated Resident 60's CPAP mask was dirty and confirmed that the bag storing the CPAP mask was dated 9/8/2025. The DON indicated it was the facility's policy to change the CPAP storage bags weekly.Resident 60's record review was completed on 9/25/2025 at 2:00 P.M. Diagnoses included but were not limited to: respiratory failure with hypoxia, cardiomegaly, anxiety disorder, dementia and chronic fatigue.Resident 60 had a current Physician's order to wash the mask and tubing of the resident's CPAP machine weekly.3. During an observation on 9/23/2025 at 2:10 P.M., Resident 21 was receiving oxygen through a nasal cannula. The nasal cannula tubing was noted dated. The resident's CPAP mask appeared to have a thick build up of a clear substance inside of the mask.During an observation on 9/25/2025 at 9:37 A.M. of Resident 21 and their CPAP machine with the DON, she confirmed Resident 21's CPAP mask was dirty and the nasal cannula Resident 21 was wearing was not dated. The DON indicated it was the facility's policy to change the CPAP storage bags weekly.Resident 21's record review was completed on 9/25/2025 at 2:40 P.M. Diagnoses included, but were not limited to: chronic respiratory failure with hypercapnia and hypoxia, heart failure, dementia, chronic obstructive pulmonary disease and hypertension.Resident 21 had current Physician's orders indicating she was to receive 2 L continuous oxygen through a nasal cannula and staff were to wash her CPAP mask and replace the tubing weekly.On 9/26/2025 at 1:54 P.M., the Regional Clinical Support Nurse (RCSN) provided a policy dated, 12/16/2024 and titled, Administration of Oxygen. The RCSN indicated the policy was the one currently used by the facility. The policy indicated, .1. Verify physician's order for the procedure .14. Date the tubing for the date it was initiated .20. a. Tubing should be changed monthly and PRN .Check the mask, tank humidifying jar to be sure they are in good working order 3.1-18 (a)

Based on interview and record review, the facility failed to have a process for residents to file a grievance anonymously. This had the potential to affect 57 of 57 residents who resided in the facility. Finding includes:During a Resident Council meeting on On 9/23/2025 2:08 P.M., 5 out of 5 residents did not know how to file a grievance without staff assistance. During an interview on 9/23/2025 at 2:21 P.M., the Life Enrichment Director (LED) indicated he helped residents file grievances. If a resident wanted to file a grievance, the LED opened the grievance application (app) on one of the facility's computers and filled out the grievance for the resident. He indicated in order to file a grievance without the help of staff, the resident would need a cell phone and would have had to scan a Quick Response (QR) code (two-dimensional barcode that stores information as a pattern of black and white pixels and is scanned by a smartphone camera to provide instant access to data, such as website links, text, or contact information) to access the grievance forms. On 9/25/2025 10:15 A.M., the Executive Director (ED) indicated the facility used an electronic application (app) to allow residents to file a grievance by scanning a QR code. The app to file a grievance was only accessible to residents who possessed a smartphone and knew how to scan a QR code or by requesting access and assistance from a staff member. On 9/25/2025 at 10:15 A.M., the ED supplied a policy dated, 12/16/2024, and titled, Resident Concern Process. The ED identified the policy as the one currently used by the facility. The policy did not have a provision to ensure the resident or their family had a process to submit a grievance anonymously. 3.1-3(a)

Based on interview and record review the facility failed to ensure staff followed a care plan requiring resident care to be performed in pairs for 1 of 16 residents whose care plans were reviewed. (Resident 1)Finding includes:A record review for Resident 1 was completed on 4/24/2025 at 10:51 A.M. Diagnoses included, but were not limited to, cognitive communication deficit.A Quarterly Minimum Data Set (MDS) assessment, dated 8/15/2025, indicated Resident 1's cognition was intact. he was able to be understood, understood others, had exhibited no behavioral issues and required substantial to maximal assistance for transfers.A Physician's Order, dated 5/13/2025, indicated Resident 1 was to receive care in pairs (two staff members were to assist or be in the room during care).A Care Plan Problem, initiated on 5/2/2024, indicated Resident 1 had made false accusations toward staff and was to receive care in pairs. Another problem, titled Profile Care Guide, indicated that as of 5/2/2025 Resident 1 was to receive care in pairs.A facility reported incident, dated 7/6/2025, indicated Resident 1's family reported a CNA (Certified Nurse Assistant) had spoken rudely to him and told him not to put his call light on again. The investigation indicated the CNAs statement, obtained as part of the investigative process, indicated that Resident 1's call light was on and she had answered the call light and had assisted Resident 1 from the toilet to his wheelchair. The CNA indicated she had not been rude and had said nothing about the call light when she had provided care.During an interview on 9/25/2025 at 9:33 A.M., CNA 2 indicated she knew what care her residents required by looking at the care plan. She indicated three residents on her hall required care in pairs, meaning 2 staff members were needed to provide care, and Resident 1 was one of the residents that required care in pairs. In the July incident ,she had not had another staff member in the room when she transferred Resident 1.During an interview on 9/26/2025 at 9:36 A.M., the ED indicated care in pairs meant that another staff member needs to be present for any care, or interaction with that resident. On 7/6/2025 the CNA did not have another staff member present as stated in the plan of care and task assignment. On 9/26/2025 at 1:54 P.M., the Regional Clinical Support provided a current policy, dated 12/17/2024, and titled, Comprehensive Care Plan Guideline. The policy indicated, .Pertinent care plan approaches are communicated to the nursing staff per the Care Assist profile 3.1-35(d)(1)

Based on observation, interview, and record review, the facility failed to assess a skin condition and notify the physician of a change in condition for 1 of 1 resident reviewed for skin conditions. (Resident 36)Finding includes:During an observation on 9/23/2025 at 10:18 A.M., numerous dark red ecchymotic areas were noted on both of Resident 36's arms. A record review for Resident 36 was completed on 9/24/2025 at 4:16 P.M. Diagnoses included, but were not limited to, atrial fibrillation. A Quarterly Minimum Data Set (MDS) assessment, dated 7/2/2025, indicated Resident 36's cognition was intact; he was dependent on staff for bathing, dressing, and transferring needs; and took daily antiplatelet and anticoagulant medications.09/23/2025 10:18 AM Has numerous dark red ecchymosis areas on his arms; he could not say what happened Physician orders for Resident 36 included, but were not limited to:-6/30/2025 Eliquis (an anticoagulant) 5 milligrams (mg) by mouth twice a day.-6/30/2025 Plavix (an antiplatelet) 75 mg by mouth once a day. A Care Plan Problem initiated on 7/3/2025 indicated Resident 36 was at risk for excessive bleeding and bruising. An intervention included indicated staff were to notify the physician of any abnormal bleeding and/or bruising. During an interview on 9/26/2025 at 9:14 A.M., the DON indicated that the nurse had completed a weekly skin assessment on 9/25/2025 and noted the areas on Resident 36's arms. The DON did not know why the bruising was not noticed between 9/23/2025 and 9/25/2025 but it should have been noted and assessed. During an interview on 9/26/2025 at 9:20 A.M., LPN 3 indicated the CNAs were to report any skin issues or changes in condition they noticed. She indicated the bruises should have been noticed during his showers, which were done on Wednesdays and Saturdays, or during the weekly skin check. She indicated the bruises should have been assessed and the physician notified. The Regional Clinical Support provided a current policy, dated 12/17/2024, and titled, Guidelines For Weekly Skin Observation. The policy indicated, .A full body observation shall be completed weekly by the licensed nurse The Regional Clinical Support provided a current policy, dated 12/17/2025, and titled, Physician-Provider Notification Guidelines. The policy indicated, .Resident assessments for change in condition , suspected injury, event of unknown origin or ordered lab and/or other diagnostic tests should be completed in a timely manner 3.1-37(a)

Based on record review and interview, the facility failed to follow a Pharmacist's recommendation related to obtaining blood laboratory work for 1 of 5 resident's who were reviewed for unnecessary medications. (Resident 64)Finding includes: Resident 64's record review was completed on 9/26/2025 at 9:30 A.M. Diagnoses included, but were not limited to: bipolar disorder, anxiety disorder, chronic obstructive pulmonary disease, splenomegaly and malignant carcinoid tumor of the bronchus and lung. Resident 64 had a current Physician's order indicating she was to receive 400 milligrams (mg) of carbamazepine (anticonvulsant medication used to treat epilepsy, nerve pain, and bipolar disorder) every morning and 600 mg of carbamazepine daily at bedtime. A review of Resident 64's Pharmacist Drug Regimen review, dated12/24/2024, indicated the Pharmacist had recommended monitoring the serum drug level of carbamazepine on the next lab day and every six months after. On 1/8/2025, the facility's Nurse Practitioner (NP) replied to the Pharmacist recommendation that the serum lab of carbamazepine level would be ordered. Resident 64's record lacked the documentation that her serum lab related to carbamazepine had been ordered after 1/8/2025 or before 9/26/2025. During an interview on 9/26/2025 at 11:05 A.M., the Director of Nursing (DON) indicated she had believed the NP had ordered the lab, but it was the her responsibility to be sure the order had been placed. On 9/26/2025 at 1:54 P.M., the Regional Clinical Support Nurse (RCSN) provided a policy dated, 12/16/2024 and titled, Pharmacy Recommendations Standard Operating Procedure. The RCSN indicated the policy was the one currently used by the facility. The policy indicated, .Campus will address pharmacy recommendations by: 2. The medical provider will respond to the recommendation and sign, 3. Campus staff will update the observation in the record and mark it complete, 4. Update orders if appropriate 3.1-25 (i)

Based on observation, record review and interview, the facility failed to store food under sanitary conditions related to foods not tightly sealed, outdated foods and dirty kitchen equipment. In addition, the facility failed to prepare and serve food related to staff members not wearing hair nets as required for 2 of 2 kitchens observed. (Main and Activities kitchen) This issue had the potential to affect 57 of 57 residents who resided in the facility and received food from this dietary kitchen. Finding includes: On [DATE] at 10:09 A.M., a kitchen tour was conducted with the Assistant Director of Food Services. The following was observed in the walk in fridge: - A bag of salad mix not sealed properly. - A container of salad dressing with a use by date of [DATE]. The following was observed in the walk in freezer: - A bag of potatoes not sealed appropriately. The following was observed in the milk fridge: - A bottle of cinnamon yogurt flavoring with no use by date. - A bag of [NAME] jack cheese with a use by date of [DATE]. The following was observed in the juice fridge: - Two bottles of prune juice with use by dates of [DATE] and [DATE]. The following was observed in the dry storage: - A box of pancake mix with a use by date of [DATE]. During an interview, on [DATE] at 10:36 A.M., the Assistant Director of Food Services indicated the foods should have been sealed appropriately and expired foods should have been thrown in the trash. During an observation and interview, on [DATE] at 10:06 A.M., [NAME] 4 was not wearing a hair net. She indicated she should have had one on. On [DATE] at 11:07 A.M., a tour of the activities kitchen was conducted with the Activities Director. The following was observed: - A microwave with dried food on the glass plate, the roof, and all sides. During an interview, on [DATE] at 11:09 A.M., the Activities Director indicated the microwave should have been cleaned. On [DATE] at 10:42 A.M., the Administrator provided the policies titled, Food Safety and Handling, Food Labeling and Dating Policy, and Hair Restraint, dated [DATE] and indicated the policies were the ones currently used by the facility. The policies indicated Prepared leftover food items must be discarded within 3 days. Any food product removed from its original container, has a broken seal, has been processed in any way must have a label that contains the following: 1. Item Name. 2. Date and time the food was labeled. 3. Use by date. 4. Initials of the person labeling the item. 5. Securely cover the food item. All Dining Service employees will be required to wear hair restraints as required by the 2009 Federal Food Code. Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food 3XXX,d+[DATE](h)(3)

Based on observation, interview, and record review, the facility failed to report a fall resulting in major injury to the Indiana Department of Health (IDOH) for a resident requiring hospitalization greater than 23 hours, for one of four residents reviewed for falls. (Resident 46) Finding includes: A Nursing Progress Note, dated 8/22/2024 at 8:00 P.M., indicated Resident 46 was found on the floor in her room. She was lying on her right side with blood coming from her head. Emergency Personnel were called and the resident was sent to the emergency room . A Nursing Progress Note, dated 8/23/2024 at 4:52 A.M., indicated Resident 46 was admitted to the hospital for observation of a large hematoma. A Nursing Progress Note, dated 8/24/2024 at 4:45 P.M., indicated Resident 46 arrived back to the facility with a laceration to the back of her head. The wound had 10 staples and measured 4.5 centimeters (cm) long. A CT (Computed Tomography) scan of Resident 46's brain without contrast, completed at the hospital on 8/22/2024 at 8:50 P.M., indicated the resident had a small intraventricular hemorrhage of the occipital horn and a right posterior scalp hematoma. A record review was completed on 9/10/2024 at 10:00 A.M., for Resident 46. Diagnoses included, but were not limited to: traumatic hemorrhage of cerebrum unspecified with loss of consciousness status unknown, laceration without foreign body of scalp, unspecified fracture of left pubis, subsequent encounter for fracture with routine healing-chronic, unspecified dementia, severe, without behavioral disturbance, psychotic disturbances, mood disturbances and anxiety. During an interview on 9/10/2024 at 1:37 P.M., the Administrator indicated the facility reported a laceration over 5 cm, fractures and subdural hematomas. The resident was not aware that she had an intraventricular hemorrhage and she also misunderstood the portion of the policy referring to phrase of unknown origin or requires hospitalization > 23 hours. On 9/10/2024 at 10:25 A.M., the Administrator provided a policy titled, Reportable Event Guidelines, revised 10/24/2022, and indicated the policy was the one currently used by the facility. The policy indicated .PURPOSE To provide guidelines to ensure reportable occurrences are recorded and monitored in accordance with state and federal guidelines. PROCEDURES 1. iii. Large lacerations or contusions ( of unknown origin or requires hospitalization > 23 hrs . 3.1-28(c)

Based on record review and interview, the facility failed to complete an Annual MDS (Minimum Data Set) assessment timely for 1 of 16 residents. Finding includes: Resident 46's record review was completed on 9/10/2024 at 10:00 A.M. Diagnoses included, but were not limited to dementia, psychotic disturbance, mood disturbance, anxiety, and type 2 diabetes. An Annual MDS assessment was initiated on 8/26/2024 but had not been completed as of 9/13/2024. During an interview on 9/13/2024 at 9:15 A.M., the MDS Coordinator indicated the Annual MDS assessment for Resident 46 was not completed and there was still one section to be completed by the Life and Enrichment staff member. The Annual MDS assessment should have been completed on 9/8/2024. The MDS Coordinator indicated the facility did not have a policy regarding completing MDS assessments but they followed the Resident Assessment Instrument (RAI) manual. During an interview on 9/13/2024 at 9:17 A.M., the MDS Regional Support Specialist indicated Resident 46 should have had an Annual MDS Assessment completed within 14 days from the Assessment Reference Date. 3.1-31(d)(1)

Based on observation, record review and interview, the facility failed to provide ADL (Activities of Daily Living) services related to nail care and facial hair removal for 1 of 3 residents reviewed for ADL care. (Resident 46) Finding includes: During an observation on 9/8/2024 at 2:11 P.M., Resident 46 was in the common area and had facial hair on her chin and dirt under the fingernails. During an observation on 9/09/24 at 10:05 A.M., Resident 46 was seated at a table and had facial hair on her chin and a brown substance under her fingernails. During an observation on 9/10/24 at 9:40 A.M., Resident 46 had facial hair on her chin and a brown substance under her fingernails. During an observation on 9/10/24 at 2:29 P.M., Resident 46 had facial hair on her chin and a brown substance under her nails. During an observation on 9/12/24 at 9:51 A.M., Resident 46 had facial hair on her chin. During an observation on 9/13/24 at 9:43 A.M., Resident 46 had facial hair on her chin and a brown substance under her nails. Resident 46's record review was completed on 9/10/2024 at 10:00 A.M. Her diagnoses included but were not limited to: traumatic hemorrhage of cerebrum unspecified with location, laceration without foreign body of scalp, fracture of left pubic, dementia, psychotic disturbance, mood disturbance, anxiety, and type 2 diabetes. A Quarterly Minimum Data Set (MDS) assessment, dated 5/31/2024, indicated Resident 46 had severe cognitive impairment and required substantial assistance for bathing and moderate assistance for personal hygiene. The current care plan for Resident 46, initiated on 10/11/2023, included a plan related to the resident's impairment of functional status problems. Interventions included: Offer facial shaving on shower days, as needed, and as requested and provide nail care on shower days and as needed. A review of the facility's Shower Book, completed on 9/10/2024 at 10:15 A.M., indicated Resident 46 had received a partial bed bath on 9/5/2024 and bed bath on 9/9/2024. Resident 46's record lacked documentation indicating she had refused to be shaved or have nail care performed by staff. During an interview with CNA 3, completed on 9/12/2024 at 11:39 A.M., she indicated she provided the following care for A.M Care (morning care routine): clean incontinent residents, change them into clean clothes, help with oral care and personal hygiene, give a shower if it is the resident's shower day. CNA 3 indicated a shower would consist of the resident's body and hair being washed, then applying deodorant and dressing the resident. During an interview with CNA 7, completed on 9/12/2024 at 11:45 A.M., she indicated A.M Care included showering the resident if it were the resident's shower day. A shower included washing the residents body and hair, helping them apply deodorant, dressing the resident, assisting the resident during oral care, shaving the resident and cleaning the resident's nails. During an interview with CNA 8, completed on 9/12/2024 at 11:51 A.M., she indicated A.M Care included washing the resident's arm pits, perineal care, oral hygiene, changing the residents clothes, brushing their hair and making sure the resident was clean. If the resident was receiving a shower, the resident would be assisted with washing their body from top to bottom, hair washed, perineal care performed with a clean wash cloth, dried with a towel, dressed and nail care performed. During an interview with CNA 6, completed on 9/12/2024 at 11:55 A.M., she indicated A.M Care included oral care, brushing hair, providing drinks, positioning in bed, toileting the resident or check and changing the resident. During a shower, the resident would be washed from top to bottom, their hair would be washed, oral care would be provided, they would be assisted to dress and taken to breakfast. During an interview with the RCN (Regional Clinical Nurse), completed on 9/13/2024 at 10:00 A.M., she indicated shaving and nail care are performed during A.M and P.M Care (morning and nightly care routine) by the CNAs. Nail care could also be provided by the Activities Department when they painted resident's nails as a scheduled activity. Refusal for nail care and shaving should be documented on the shower sheet or in a Nurse's Progress Notes. A policy for ADL care was requested but the facility indicated they did not have a policy for providing ADL care. 3.1-38 (a)(3)

Based on observation, interview and record review, the facility failed to provide activity programs in the evenings. This had the potential to affect 57 out of 57 residents residing in the facility. Finding includes: During an interview on 9/8/2024 at 10:27 A.M., Resident 7 indicated they have not had any evening activities and she would like to have attended them. A record review was completed on 9/9/2024 at 1:52 P.M., for Resident 7. Diagnoses included, but were not limited to: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, facial weakness following cerebral infarction, unilateral primary osteoarthritis, left hip, low back pain, unspecified, and other chronic pain. An Annual Minimum Data Set (MDS) assessment, dated 11/30/2023, indicated that it was very important to the resident to invite her to group activities. A current Care Plan, titled Activities, initiated on 8/30/2019, indicated that it was important to her to be with groups of people and to invite to activities. The January 2024 Activity schedule provided to the Residents had no activities listed in the evening hours for the month. The August 2024 Activity schedule provided to the Residents only had one special themed dinner listed for the month on 8/22/2024, no other group activity scheduled for the evening hours. The September 2024 Activity calendar provided to the Residents had no evening activities scheduled. During an interview on 9/10/2024 at 9:56 A.M., the Life Enrichment Director indicated the last activity for the day started at 3:00 P.M., then the residents got ready for dinner. He currently did not have anyone working evenings, so he stopped providing activities in the evenings for the past couple of months. He indicated there should have been at least two activities scheduled a week in the evenings. On 9/10/2024 at 10:41 A.M., the Life Enrichment Director, provided a policy titled, Program Components/Standards, dated 6/3/2017, and indicated the policy is the one currently used by the facility. The policy indicated .The Life Enrichment Department designs programs which are meaningful, diverse, stimulating, and consistent with the needs, preferences, and abilities of each individual resident/patient . 3.1-33(c)

Based on observation, interview and record review, the facility failed to ensure the environment was free from accidents and hazards related to medication left unattended on 1 or 2 halls. (200 hall, Resident 7) Finding includes: During an observation on 9/8/2024 at 11:30 A.M., Resident 7 had a tube of Voltaren gel and Biofreeze pain relief cream on her nightstand, and an opened bag of Hall's cough drops on the bedside table. During an observation on 9/9/2024 at 9:19 A.M., Resident 7 had a tube of Voltaren gel and Biofreeze on her nightstand, and an opened bag of Hall's cough drops on the bedside table. A record review was completed on 9/9/24 at 1:52 P.M., for Resident 7. Diagnoses included, but were not limited to: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, facial weakness following cerebral infarction, unilateral primary osteoarthritis, left hip, low back pain, unspecified, and other chronic pain. A review of the Physician Orders, dated September 2024, indicated Resident 7 did not have an order for Voltaren gel, Biofreeze or Hall's cough drops. A review of clinical record assessments indicated there was no self-administration assessment completed for Resident 7. During an interview on 9/9/2024 at 2:13 P.M., RN 11 indicated the facility kept medicated creams in a cart in the medication room. RN 11 indicated the Voltaren gel, Biofreeze, and cough drops should not have been in Resident 7's room and she should have had an order for use of the medication as well as for self-administration of the medications. RN 11 indiated Resident 7 did not self-administer her own medications. In addition, RN 11 indicated there were two cognitively impaired Resident's (43 and 46) housed on the unit that wandered into other residents rooms. On 9/9/2024 at 2:00 P.M., the DON provided a policy titled, Guidelines for Self Administration of Medications, dated 12/31/2023, and indicated the policy was the one currently used by the facility. The policy indicated .Procedures: 1. Residents requesting to self-medicate or self-medications as a part of their plan of care shall be assessed using the observation Trilogy-Self Administration of Medication within the electronic health record. Results of the assessment will be presented to the physician for evaluation and an order for self medication. 3. The medication will be kept in a locked drawer in the residents' room. The resident will maintain the key, as well as, a key will be maintained by the licensed nurse and or QMA. 8. The assessment will be documented in the EHR . 3.1-45(a)1

Based on observation, record review, and interview the facility failed to ensure oxygen tubing and humidifiers were maintained per standards appropriately for 2 of 3 residents observed for respiratory care. (Residents 259 & 36) Findings include: 1. During an observation, on 9/8/2024 at 10:38 A.M., Resident 259's oxygen tubing and humidifier lacked a date to ietntify when they were last changed. During an observation, on 9/9/2024 at 10:11 A.M., the oxygen tubing for Resident 259 had a date of 9/7/2024 and the humidifier still lacked a date. On 9/9/2024 at 2:28 P.M., a record review was completed for Resident 259. Diagnoses included, but were not limited to respiratory failure and bronchitis. A Physician's order, dated 8/26/2024, indicated to change the oxygen tubing monthly, once per day, on the first day of the month. During an observation, on 9/12/2024 at 10:54 A.M., the oxygen humidifier now had a date of 9/12/2024. 44111 2. During an observation on 9/8/2024 at 10:07 A.M., Resident 36 was asleep in her wheelchair wearing oxygen. The respiratory equipment storage bag and oxygen tubing were dated 8/29/2024. The BIPAP tubing was undated and laying on top of the machine uncovered. During an observation on 9/9/2024 at 9:24 A.M., Resident 7 was up in her wheelchair wearing oxygen and the respiratory storage bag and tubing were now dated 9/7 and the BIPAP tubing was undated and laying on top of the machine uncovered. A record review completed on 9/9/2024 at 2:41 P.M., for Resident 36. Diagnoses included, but were not limited to: chronic respiratory failure with hypoxia, acute and chronic respiratory failure with hypercapnia, chronic respiratory failure with hypercapnia, respiratory failure, unspecified with hypercapnia, other disorders of lung note: restrictive lung disease, and chronic obstructive pulmonary disease, unspecified. A Physician Order for Resident 36, dated 5/15/2024, indicated BIPAP 12.5 with 2 liters of oxygen at bedtime and as needed. A Physician Order for Resident 36, dated 5/26/2024, indicated to change oxygen tubing monthly on the 27 th of the month. A Physician Order for Resident 36, dated 4/25/2024, continuous oxygen at 2 liters per nasal cannula. During an interview on 9/12/2024 at 10:48 A.M., LPN 5 indicated the BIPAP tubing should be stored in a bag when not in use. The tubing and mask should be cleaned weekly, and the tubing should be changed out monthly. She could not tell when the BIPAP was cleaned or changed last because she did not have an order for either and the tubing was undated. On 9/10/2024 at 2:53 P.M., the Administrator provided a policy titled. Administration of Oxygen, reviewed 12/31/2023, and indicated the policy was the one currently used by the facility. The policy indicated . SOP DETAILS 14. Date the tubing for the date it was initiated. a. Tubing should be changed monthly and PRN . On 9/12/2024 at 11:40 A.M., the Administrator indicated they did not have a policy for the use and storage of CPAP or BIPAP equipment. 3.1-47(a)(6)

Based on record review and interview, the facility failed to discontinue or obtain a new order for a PRN (as needed) psychotropic medication after 14 days, for 1 of 5 residents whose medications were reviewed. (Resident 44) Finding includes: Resident 44's record review was completed on 9/12/2024 at 2:04 P.M. Her diagnoses included, but were not limited to: bipolar disorder, depression, anxiety disorder. A current Physician's order dated, 8/8/2024, indicated Resident 44 could have 0.5 milligrams of Alprazolam twice a day if needed. Resident 44's record lacked the documentation providing a reason why a PRN psychotropic was used longer than 14 days. During an interview on 9/13/2024 1:57 P.M., the Director of Nursing indicated the facility should have stopped the Alprazolam after 14 days and notified the Nurse Practioner. On 9/13/2024 at 2:25 P.M. the Director of Nursing provided an undated policy titled, Psychotropic Medication Usage and Gradual Dose Reduction, and identified it as the policy currently used by the facility. The policy indicated, .8. PRN order for psychotropic drugs are limited to 14 days. Except as provided if the attending physician or prescriber believes that it is appropriate for PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. 9. PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. 3.1-48 (a)(2)

Based on observation, interview, and record review, the facility failed to promptly notify the ordering physician of laboratory results requiring medical treatment according to policies and procedures for notification and the medical order for 1 of 3 reviewed for antibiotics. (Resident 7) Finding includes: During an interview on 9/8/2024 at 10:34 A.M., Resident 7 indicated she gets frequent urinary tract infections (UTI) but does not recall when she had the last one. A Nursing Progress Note, dated 4/21/2024 at 6:41 A.M., indicated the spouse requested a laboratory test for an UTI due her head being shaky. A physician's order was received. A Physician's Order, dated 4/21/2024, indicated to collect a urinalysis (UA) with culture. A Nursing Progress Note, dated 4/22/2024 at 7:02 P.M., indicated the urine was collected. A laboratory result, with a collection date of 4/22/2024, received date of 4/24/2024 and report date of 4/25/2024 indicated bacterial pathogen detected was Escherichia coli 99.998%. A Nursing Progress Note, dated 5/1/2024 at 4:30 P.M., indicated the urine culture results were reviewed by the Nurse Practitioner and orders were received for Nitrofurantoin, an antibiotic. A Physician Order, dated 5/1/2024, indicated Nitrofurantoin, an antibiotic, 100 mg twice a day for 7 days. A Care Plan, dated 8/30/2023, indicated the had the potential for UTI due to diagnoses of overactive bladder and history of UTI's and incontinence. Interventions included labs as ordered and report abnormal values to the Medical Director. A record review was completed on 9/9/24 at 1:52 P.M., for Resident 7. Diagnoses included, but were not limited to: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, overactive bladder and type 2 diabetes. During an interview, on 9/12/2024 at 9:35 A.M., the Infection Preventionist indicated the lab was notified of the order when it was entered and then the laboratory sends the results back to the facility electronically under the diagnostics section. The nurse was expected to check the EMR each shift after the culture was ordered. She would have expected the nurse to respond within 4 hours after the results were received. May 1, 2024 was the date the laboratory results were followed up on when the follow up should have occurred on 4/25/2024. The NP indicated delay in treating the infection could have resulted in the resident's condition worsening. On 9/12/2024 at 10:59 A.M., the Administrator provided a policy Physician Provider Notification Guidelines, review date 12/31/2023, and indicated the policy was the one currently used by the facility. The policy indicated .PURPOSE: To ensure the resident's physician or practitioner (may include NP, PA, or clinical nurse specialist) is aware of all diagnostic testing results or change in condition in a timely manner to evaluate conation for need of provision of appropriate interventions for care. 1. Resident assessments for change in condition, suspect injury, event of unknown origin or ordered lab and/or other diagnostic tests should be completed in a timely manner. 11. Attempts to notify the physician/provider and their response should be documented in the resident electronic health record . 3.1-49(a)(f)(2)

Based on observation and interview, failed to ensure infection control practices were in place for 1 of 1 resident observed during catheter care. (Resident 259) Findings include: On 9/12/2024 at 1:23 P.M., Resident 259 was observed for catheter care. CNA 3 entered the resident's room. Once in the room, CNA 3 washed her hands prior to putting on a gown and gloves. She removed a disposable wipe from the package and began cleansing the catheter tubing, starting at the insertion site and going down the tube. CNA 3 disposed of the wipe and removed another one from the package and repeated the process. CNA 3 grabbed the residents bed sheets and covered her up, pulled the residents shirt down to cover her abdomen, placed a new bag in the trash, and grabbed the resident's bedside table to move it closer to the. CNA 3 then removed her gown and gloves and washed her hands. On 9/9/2024 at 2:28 P.M., a record review was completed for Resident 259. Diagnoses included, but were not limited to retention of urine. During an interview, on 9/12/2024 at 1:36 P.M., CNA 3 indicated she should have removed her gloves and washed her hands before touching anything else in the room. A current Care Plan, dated 8/27/2024 indicated Resident 259 required enhanced barrier precautions (EBP) during high-contact care related to presence of: an indwelling catheter, infection or colonization of MDRO (Multi drug resistant organism). Interventions included to perform hand hygiene before and after care, per policy, and as required. Utilize gown and gloves per EBP policy during indwelling device care, central lines and urinary catheter care. On 9/12/2024 at 2:08 P.M., the Administrator provided the policy titled, Urinary Catheter Care,undated, and indicated it was the policy currently being used by the facility. The policy indicated, 21. After completion of the procedure: b. Discard disposable items into designated containers. Remove gloves and discard into designated container. Wash hands and dry thoroughly. c. Reposition bed covers. Make the resident comfortable. e. Return the over bed table to its proper position. f. Wash and dry hands thoroughly. 3.1-19(l)

Based on record review and interview, the facility failed to assess a resident's ability to self-administer medication timely for 1 of 1 resident's reviewed for self-administration of medication. (Resident 1) Finding includes: During an observation, on 10/4/2023 at 9:15 A.M., a locked box was sitting on a table next to Resident 1's recliner. During an interview, on 10/4/2023 at 9:16 A.M., Resident 1 indicated she self-administers most of her nightly medications. A record review was completed, on 10/5/2023 at 2:08 P.M. Resident 1's diagnoses included, but were not limited to: atrophy of thyroid, chronic kidney failure stage 4, hyperlipidemia, heart failure, hypertension, and fibromyalgia. A care plan, dated 3/3/2022, indicated the resident may keep medications at bedside and self-administer: all oral medications, powders, eye drops, and creams. Resident 1's current Self-Administration of Medications assessment had been completed on 3/3/2023. During an interview, on 10/6/2023 at 10:03 A.M., the Director of Health Services indicated the Self-Administration of Medications Assessment, dated 3/3/2023 for Resident 1 was the most current. The Director of Health Services indicated there should have been an assessment completed every quarter and was not. ON 10/10/2023 at 9:45 A.M., the Executive Director provided the policy titled,Guidelines for Self-Administration of Medications, dated 12/31/2022, and indicated the policy was the one currently used by the facility. The policy indicated, To ensure the safe administration of medication for residents that request to self-medicate .7. The assessment will be reviewed quarterly, and PRN (as needed) with change of condition. 8. The assessment will be documented in the EHR (Electronic Health Record) 3.1-11

Based on interview, and record review the facility failed to develop a person-centered care plan for 1 of 21 residents whose care plans were reviewed. (Resident 10) Finding includes: During an interview, on 10/2/2023 at 11:07 A.M., Resident 10's daughter indicated that he has issues with constipation and was not sure when he last had a bowel movement. A record review for Resident 10 conducted, on 10/03/2023 at 1:33 P.M., indicated diagnoses that included, but were not limited to: metabolic encephalopathy, urinary tract infection, bacteremia, neuromuscular dysfunction of the bladder, and benign prostatic hypertrophy. An admission MDS (Minimum Data Set) assessment indicated Resident 10's cognition was intact. He required extensive assist of 1 staff for bed mobility, dressing, and toileting, and total dependence of 2 staff for transfers. Resident 10's physician orders included, but were not limited to: -9/6/2023 polyethylene glycol powder 17gm (grams) oral once a day for constipation. -8/30/2023 bisacodyl suppository 10mg (milligrams) 1 suppository rectally once a day as needed for constipation. Resident 10's care plan lacked documentation that addressed constipation. During an interview, on 10/6/2023 at 2:03 P.M., the Director of Health Services indicated that constipation should be addressed in the care plan but was not. A current policy provided by the Executive Director, on 10/6/2023 at 9:45 A.M., titled, Comprehensive Care Plan and Guideline included, but was not limited to: .Problem areas should identify relative concerns .Comprehensive care plans need to remain accurate and current 3.1-35(b)(1)

1. Based on interview and record review, the facility failed to monitor the side effects and respond immediately to a critical lab value for 1 of 4 residents who were receiving an anticoagulant drug. (Resident B) This deficiency resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 1/18/2017 and was identified on 2/10/2017. The Administrator and Director of Nursing were notified of the Immediate Jeopardy on 2/10/2017 at 11:37 A.M. The Immediate Jeopardy was removed on 2/11/17, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. 2. Based on interview and record review, the facility failed to have proper indication and [DIAGNOSES REDACTED].#85 and #27). Findings include: 1. A clinical record review was completed on 02/09/2017 at 10:30 A.M., and indicated Resident B was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. An MDS (minimum data set) assessment, dated 1/18/2017, indicated Resident B had a BIMS (brief interview for mental status) of 14, cognitively intact. A physician's orders [REDACTED].[MEDICATION NAME] ([MEDICATION NAME] - a blood thinner) 3 mg (milligrams) oral once a day A nurses note, dated 1/18/2017, indicated Resident B had a small amount of bloody stool. A physician order, dated 1/24/2017, indicated Resident B was started on [MEDICATION NAME] (an antibiotic) for an upper respiratory infection. A nurses note, dated 1/26/2017, indicated Resident B had an INR (international normalized ratio) of 8 (normal therapeutic range being 1.5 to 3.5) and the physician ordered to hold the [MEDICATION NAME] and recheck the residents INR on 1/27/2017. A lab result, dated 1/27/2017, indicated Resident B's INR was higher than 10 and was considered a critical high level. Resident B's [MEDICATION NAME] surgeon gave orders on the document to hold the [MEDICATION NAME] Friday through Sunday and recheck INR on Monday, to monitor for signs and symptoms of bleeding, and may send to ER (emergency room ) for any complications over the weekend. A nurses note, dated 1/29/2017 at 3:28 A.M., indicated Resident B had a nose bleed from her left nostril, pressure was held for five minutes and it stopped. A nurses note, dated 1/29/17 at 10:34 P.M., indicated Resident B had an episode of nose bleed to left nostril. A nurses note, dated 1/30/2017 at 11:55 A.M., indicated Resident B INR level was 8. A physician order [REDACTED]. A nurses note, dated 1/30/2017, indicated the facility received a critical INR lab result from a local medical foundation at 7:00 P.M. of 11.5. Nurses notes indicated the cardiovascular surgeon was paged and his physician assistant was notified via the phone and the assistant indicated she would consult with the [MEDICATION NAME] surgeon. There was no documentation to show the physician assistant or the [MEDICATION NAME] surgeon called back to give orders. No documentation was noted to show the made any further attempt to contact the [MEDICATION NAME] surgeon regarding the critical INR level. An interdisciplinary team (IDT) note, dated 1/31/2017 at 7:31 A.M., indicated the IDT had reviewed the critical INR level, [MEDICATION NAME] was on hold, and resident was to have a follow up appointment that day with the [MEDICATION NAME] surgeon. A nurses note, dated 1/31/2017 at 10:12 A.M., indicated the facility received a telephone call from the office of the [MEDICATION NAME] surgeon, whom indicated their office had received an INR result from a local medical foundation and it was 11. New orders were received from the [MEDICATION NAME] surgeon for Resident B to receive vitamin K 2.5 milligrams stat (within 5 minutes) and another 2.5 milligrams tomorrow. A nurses note, dated 1/31/2017 at 12:00 P.M., indicated that around 11:30 A.M., Resident B was experiencing lethargy, shortness of breath, and was pale in color. She was then transported to the local emergency room via an ambulance. An assessment, dated 1/31/2017, obtained from the local hospital, indicated Resident B was noted to have lactic acidosis (when the blood becomes too acidic due to a problem with the bodies metabolism), a .very high INR , hypotensive (low blood pressure), and hemoglobin of 6.6 (critically low level of blood cells carrying oxygen throughout the body). The assessment indicated the residents family reported Resident B was having epistaxis (bloody noses) and black stools for the last few days. She was ordered to have a transfusion of 2 units of packed red blood cells and fresh frozen plasma. The assessment indicated that the local hospital's critical care service is being consulted for the management of acute blood loss [MEDICAL CONDITION] and acute hypoxic [MEDICAL CONDITION]. During an interview, on 2/10/2017 at 9:40 A.M., the DON (Director of Nursing) indicated the facilities nurses were expected to call the physician immediately when receiving a critical lab. If no response was obtained from the physician, nurses are expected to attempt contact with the physician every hour until a response is obtained, and the nurses are expected to document that on nurses notes. During an interview, on 2/10/2017 at 10:24 A.M., Resident B's family member indicated, she had visualized the resident experiencing black stools on 1/29/2017 and 1/30/2017. Resident B's daughter indicated she reported the black stools to the residents nurse and the nurse indicated to her that the black stools were caused by the [MEDICATION NAME] the resident had been taking. A policy was provided by the corporate nurse on 2/10/2017 at 10:45 A.M., titled Physician Notification Guidelines, dated 11/28/2016, and indicated this was the policy currently used by the facility. The policy indicated .2. The physician should be notified of critical lab results or an immediate need by phone as soon as the results are known with a response received before the call is completed when possible. If the physician must be paged a call back is expected within 15 minutes to one hour depending on severity of the concern. If unable to reach the primary provider, the campus Medical Director will be notified On 2/13/17 at 9:30 A.M., a policy for monitoring of [MEDICATION NAME] was requested and the Corporate Nurse indicated they did not have one. The Immediate Jeopardy that began on 1/18/17 was removed on 2/11/17, when, through record reviews and interviews, staff had completed education regarding [MEDICATION NAME] and notifying the doctor of a critical lab. This education included side effects of [MEDICATION NAME], normal ranges for PT/INR results, medications that effect a resident's INR level, and the procedure for notifying the doctor of a critical lab result, and if no response, notifying the medical director. Even though the facility's corrective action removed the Immediate Jeopardy, the facility remained out of compliance at a reduced scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because of ongoing monitoring to ensure residents are free from side effects of [MEDICATION NAME]. 2A. A clinical record review was completed on 2/7/17 at 03:53 P.M., and indicated Resident #85 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. A MDS (Minimum Data Set) assessment, dated 1/9/17, indicated Resident #85 was severely cognitively impaired. A physician's orders [REDACTED].[MEDICATION NAME] (an anti-psychotic medication) . 25 mg; Amount to Administer: 3 tabs = 75 mg (milligrams) . Twice a day . Diagnosis . Unspecified dementia with behavioral disturbance A physician's orders [REDACTED].[MEDICATION NAME] . 25 mg . Every 6 hours - PRN (as needed) . Special Instructions . PRN agitation . Diagnosis . unspecified dementia with behavioral disturbance The order was discontinued on 1/26/17. The MAR (Medication Administration Record) indicated a PRN dose was given on 1/14/17. No other doses were recorded. A progress note, dated 1/14/17 at 8:45 A.M., indicated, .IDT (interdisciplinary team) reviewed and verified resident appears to be in distress in relationship to responding to an internal stimuli as observed by facial expression along with mumbling to self that is indictable of understandment with voice changes of appeared distress. Interventions included 1:1 redirection, quiet environment, and assessment of basic needs with no improvement A Behavior Detail Report, dated 1/3/17 through 2/15/17, indicated the resident resists/rejects evaluation of care on 1/5/17 and 1/6/17 with non-pharmacological interventions being effective. The report indicated on 1/15/17 the resident exhibited socially inappropriate behavior but did not indicate if non-pharmacological interventions were attempted. There were no other behaviors noted. During an interview with the Social Service Director on 2/15/17 at 2:26 P.M., she indicated the resident was admitted on [DATE] and was on [MEDICATION NAME] for dementia with combative and aggressive behaviors from home. She indicated the IDT had a behavior meeting on 1/26/17 where the resident's medications were discussed and they discontinued the PRN dose of the [MEDICATION NAME]. She indicated a PRN dose of [MEDICATION NAME] was given on 1/14/17 for the resident's distressed behavior. She indicated dementia was not a proper indication for the use of [MEDICATION NAME]. 2B. A clinical record review was conducted on 02/13/17 at 9:57 A.M., and indicated Resident # 27 was admitted on [DATE]. His [DIAGNOSES REDACTED]. A physician order, dated 01/05/17, indicated [MEDICATION NAME] Sprinkles (medication used for [MEDICAL CONDITION]) 250 milligrams three times per day and 375 milligrams at bedtime, with snack, for [MEDICAL CONDITION] with behavioral disturbance. The order also indicated [MEDICATION NAME] [MEDICATION]) 250 milligrams at bedtime and 25 milligrams after lunch, for [MEDICAL CONDITION] with behavioral disturbances. On 02/16/17 at 2:13 P.M., an interview with the Social Services Director, indicated [MEDICAL CONDITION] in not an appropriate [DIAGNOSES REDACTED]. A policy was provided by administration on 02/16/17 at 2:36 P.M., titled [MEDICAL CONDITION] Medications Usage and Gradual Dose Reduction, dated 05/10/16, and it indicated this was the policy currently used by the facility. The policy indicated .Residents shall receive [MEDICAL CONDITION] medications only if designated medically necessary by the prescriber, with appropriate [DIAGNOSES REDACTED]. The medical necessity will be documented in the resident's medical record and in the care planning process 3.1-48(a)(4) 3.1-48(a)(6)

Based on record review, observation and interview, the facility failed to ensure adequate supervision for a cognitively impaired, dependent resident which resulted in a fall. The resident sustained [REDACTED]. This deficiency affected 1 of 1 dependent residents in a sample of 3 residents who were reviewed for falls. (Resident D) Finding includes: The record of Resident D was reviewed on 06/15/16 at 9:30 a.m. Resident D was admitted to the facility on 02//29/12. The [DIAGNOSES REDACTED]. The most recent Quarterly MDS (Minimum Data Set) assessment, dated 05/06/16, indicated Resident D was not cognitively intact, short term and long term memory were OK, required extensive assistance of 1 for transfers and toileting, and limited assistance of 1 for ambulation and locomotion for movement between locations in the facility. A Progress Note indicated: 06/06/16 11:00 a.m. Outside fall: resident requested to be placed outside to enjoy the weather; call was made to nurse who agreed that resident could go outside. Wheelchair placed outside, brakes locked, and was under supervision from front office staff. Resident was then found on ground apparently attempting to transfer self. The Progress Notes indicated the resident was being treated with antibiotics for a UTI (Urinary Tract Infections). The ER (emergency room ) PHYSICIAN REPORT, dated 06/06/16 11:18 a.m., indicated: .the patient was reportedly was in a wheelchair outside of the nursing home and was unattended (sic) the patient apparently attempted to stand up and fell forward. The patient has abrasions to the face and nose as well as a laceration to her left middle finger Extensive workup here in the emergency department reveals evidence of a urinary tract infection. CT (Computerized Tomography) of the head neck and face bones show no evidence of acute abnormalities left hand x-ray shows no fracture .a 1 cm (centimeter) .of the 3rd middle finger. The patient has excellent flexion and extension. I do not appreciated (sic) any acute tendon injuries. The laceration was closed: .#3 sutures, with 5-0 nylon, running technique. During a facility walk through on 06/15/16 at 10:00 a.m., Resident D was seated in a wheelchair in the 200 Unit common area in front of the TV. The resident's head was bent forward and a healing abrasion, approximately 1.5 inches in width and length was noted on the forehead and no other facial lacerations, bruising or discolorations were visible. During an interview on 06/15/16 at 1:45 p.m., the Business Office Employee (BOE: Front Office) #1 indicated, with permission from the Unit RN (Registered Nurse), Resident D was wheeled outside the facility to the sidewalk to the East of the front lobby window and the brakes were applied to the locked position. BOE #1 indicated Resident D could be observed through the glassed window of the Business Office, across the front lobby through the lobby window to the outside if the BOE raised slightly from her desk chair. The desk of BOE #1 faced West under the Business Office window and the employee had to turn to her left and look South to visualize through the area. BOE #1 indicated she had visualized Resident D several times. During an interview on 06/15/16 at 2:30 p.m., the ED (Executive Director), indicated the fall investigation noted Resident D was seated outside a maximum of 6 minutes prior to a hospice employee entering the building to inform staff the resident was on the sidewalk towards the entry drive. The hospice employee was reported to see the resident change position but did not actually witness the fall. The ED indicated Resident D refuses to sit in the enclosed courtyard and requests sitting outside in the sun and prefers to be left alone. The ED indicated the resident was to be checked by staff every 10 minutes and if she needed assistance, she was to raise her hand. The ED indicated the fall was unwitnessed. During an interview on 06/15/16 at 3:10 p.m., the SSD (Social Service Designee) indicated Resident D, although able to verbalize, prefers to point or shake her head when communicating. The SSD indicated she had tried hard to build rapport with the resident and encouraged Resident D to use words for answering questions during assessment. During interview on 06/15/16 at 3:20 p.m., the MDS Coordinator-RN indicated Resident D fluctuates, most of the time, between being forgetful and lucid. The MDS-RN indicated Resident D could verbalize but needed encouragement to do so. The MDS-RN indicated the resident had the cognitive portion of the MDS completed the morning of 06/15/16 and scored a 10 (moderately impaired). This Federal tag related to Complaint IN 415. 3.1-45(a)(2)