Every finding on record at Hamilton Trace of Fishers

Based on observation, interview, and record review, the facility failed to follow their policies and procedures for infection control, related to hand hygiene during dressing changes for 1 of 3 residents reviewed for infection control. (Resident D) Findings include: During an observation of wound care for Resident D, on 2-10-26 at 10:55 a.m., RN 3 and the Wound Care Nurse explained the procedure they were going to provide to the resident. The resident was to have the staff follow Enhanced Barrier Precautions (EBP- infection control measures for nursing homes, requiring staff to wear gowns and gloves during high-contact care for residents with chronic wounds to prevent germ spread, even when standard contact) for wound care. The RN and Wound Care Nurse removed the resident's wound dressing from the resident's right lower extremity (RLE). Gloves were removed and discarded with new gloves applied without hand hygiene or handwashing being observed. After the treatment to the resident's RLE wound area, both nurses assisted in cleaning up the area. Gloves were removed and discarded with new gloves applied without hand hygiene or handwashing being observed. The resident was re-positioned for care to be provided to the other wound on his sacral area. Both nurses were observed to re-position Resident D onto his left side, at which time Resident D was found to have an incontinent bowel movement, requiring him to be cleaned up prior to continuing the wound care on his sacral area. Both nurses removed and discarded their gloves, without hand hygiene or handwashing being observed. New gloves were donned without hand hygiene or handwashing. RN 3 provided wound care to the resident's sacral wound, removed her gloves, discarded them, and applied new gloves without hand hygiene or handwashing being observed. RN 3 provided wound care to the resident's sacral wound, and both nurses assisted Resident D into a position of comfort and cleaned up the area. Upon completion of this step, both nurses removed and discarded their gloves without hand hygiene or handwashing being observed. After the wound care observation, on 2-10-26, RN 3 indicated she had failed to complete hand hygiene or handwashing between the resident's wound care or after she had assisted cleaning up Resident D's bowel movement. After the wound care observation, on 2-10-26, the Wound Care Nurse indicated hand hygiene or handwashing should have occurred between wounds and after cleaning the resident's bowel movement up and before returning to wound care.An interview, on 2-10-26 at 2:38 p.m., with the Director of Nursing, he indicated RN 3 had recently undergone skills testing, which included a checkoff on wound care with the Corporate Infection Control Nurse and she passed without any problems. On 2-10-26 at 2:40 p.m., he provided a copy of the skills testing for RN 3, dated 1-15-26, and entitled. Licensed Nurse Treatment Skills Validation. The skills validation indicated RN 3 had successfully passed the wounds, section of the skills validation checkoff. This undated skills procedure was the same procedure provided by the facility on 2-10-26 at 1:05 p.m., regarding the facility's infection control policies and procedures related to wound care.This procedure indicated staff were to wash their hands prior to gathering supplies or equipment and prior to explaining the plan of care to the residents. It indicated, once the supplies and equipment are ready, to Wash hands, put on gloves .Remove soiled dressing. Put soiled dressing in plastic bag/waste receptacle. Remove gloves and perform hand hygiene .Open dressings and supplies using clean technique to cleanse the wound. Perform hand hygiene. [sic: does not address removal of gloves prior to performing hand hygiene.] Cleanse wound, clean from least contaminated are to most contaminated [usually from center of wound out.] .When complete, remove gloves and discard them in the waste bag. Perform hand hygiene. Open supplies needed .Perform hand hygiene and re-glove hands. Apply ordered dressing .Once dressing is completed .remove gloves. Discard disposable items into designated containers. Perform hand hygiene and re-glove. Reposition the resident for comfort, provide safety and privacy. Remove gloves, wash hands. Take all waste items and dispose in the soiled utility room. Wash hands. This citation relates to Intake 2737534. 3.1-18(a)3.1-18(l)

Based on interview and record review, the facility failed to ensure a resident with a urinary catheter was provided with catheter care, monitoring, and documenting of urine outputs for 1 of 3 residents reviewed for catheters. (Resident B) Findings include: The clinical record for Resident B was reviewed on 1/30/24 at 2:00 p.m. The diagnoses for Resident B included, but were not limited to, central cord syndrome (spinal cord injury causing weakness without being paralyzed.) and neuromuscular dysfunction of bladder (loss of bladder control). A physician's order, dated 12/20/25, indicated the staff were to bladder scan Resident B for urine retention every shift. If the resident's urine totals in the bladder were greater than 200 milliliters the medical provider was to be contacted. A physician's order, dated 12/29/25, indicated the staff was to remove Resident B's urinary catheter. The January 2026 Medication/Treatment Record (MAR/TAR) indicated on 12/20/25 in the evening shift, the resident's urine residual in his bladder was 855 milliliters. A physician's note, dated 12/20/25, indicated the nursing staff reported that day (12/20/25) Resident B was having urinary retention of 855 milliliters with abdomen firmness. The plan of treatment was to anchor a indwelling catheter and monitor the resident's urine output. The catheter was to be clamped if the resident's urine output was greater than 600 milliliters. Do not remove the indwelling catheter until the resident had been seen by the physician. A nursing note, dated 12/21/25, indicated an order had been given by the on-call provider to anchor the resident's indwelling catheter. The staff were to monitor the resident's urine output and clamp the catheter; if the output was greater than 600 milliliters. The indwelling catheter had been anchored, and Resident B reported he was doing a lot better. The indwelling catheter was not to be removed until the resident was seen by the physician. Resident B's clinical record did not include a physician's order as described in the physician's note, for the resident to have a indwelling catheter, treatment orders for the care of a catheter, or monitoring of urine output. An interview was conducted with the Director of Nursing (DON) on 1/30/26 at 2:16 p.m. He indicated he was unable to locate a physician's order for a indwelling catheter for Resident B. The on-call physician gave the order to the staff during the phone call. The staff was to anchor the indwelling catheter on 12/20/25. The staff did not record urine output amounts unless ordered by the physician to do so. The DON was unaware of the physician's 12/20/25 note indicating the staff were to monitor the resident's urine out. Catheter Care should be provided and documented every shift for residents that have an indwelling catheter. This citation is related to Intake 2711740. 3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to ensure the use of beard restraints by dietary staff, separate storage of a personal lunch bag, ensure coverage of stored frozen food and ready-to-eat dessert, and distribution of food under sanitary conditions. This had the potential to affect 96 of 96 residents in the facility. Findings include: A kitchen tour was conducted, on 5/5/25 at 9:30 a.m., with the [NAME] Supervisor (CS). Dietary Aide (DA) 9 was observed in the kitchen without the use of a beard restraint to cover his facial hair and instead was wearing a surgical mask below his chin. An observation of the walk-in freezer was made during the tour. Four bowls of uncovered chocolate ice cream were observed on a tray. A personal lunch bag was observed sitting on a rack within the freezer. An observation of the main dining room was conducted on 5/5/25 at 12:24 p.m. Plates of dessert cakes were observed uncovered sitting on a cart, partially stacked on top of one another. During an interview with the CS on 5/5/25 at 11:59 a.m., she indicated she was told DA 9 could wear a surgical mask in place of a hair net to cover his facial hair. The CS also indicated that the uncovered ice cream should have been disposed of the day before, and the personal lunch bag contained ice cream samples a vendor had delivered. A Personal Hygiene for Dietary Staff Policy, revised 8/1/24, was provided by the Director of Dining Services (DDS) on 5/9/25 at 12:34 p.m. It indicated . Associates involved in storing, preparing, distributing, and serving food to residents shall: .2. Wear a hair restraint that effectively covers all hair and/or facial hair (mustache, sideburns, and/or beard, to prevent contamination of food, equipment, and utensils . A Food and Non-Food Storage Policy, revised 2012, was provided by the DDS on 5/9/25 at 12:34 p.m. It indicated . All opened foods are covered to protect from contaminates . 3.1-21(i)(3)

Based on interview and record review, the facility failed to promote a dignified environment with not providing care and services timely and ensure a resident was dressed in street clothes while dining in the facility dining room for 14 of 18 residents reviewed for resident council, 3 of 7 residents reviewed for Activities of Daily Living, 1 of 4 residents reviewed for staffing and 2 of 2 residents randomly observed. (Resident D, Resident E, Resident F, Resident G, Resident H, Resident J, Resident K, Resident L, Resident M, Resident N, Resident O, Resident P, Resident Q, Resident R, Resident S, Resident T, Resident X, Resident V, Resident W, Resident Z, Resident DD, Resident EE and Resident C) Findings include: 1. The clinical record for Resident V was reviewed on 5/12/25 at 11:12 a.m. An Admission Minimum Data Set (MDS) assessment, dated 3/21/25, indicated the resident was cognitively intact. On 5/7/25 at 9:53 a.m., Resident V's call light was observed to be on for approximately five minutes. Certified Nurse Aide (CNA) 8 walked past the room and did not go in to answer the call light. Registered Nurse (RN) 5 was at the nurse's station where the call light board was located. On 5/7/25 at 10:13 a.m., Resident V was observed sitting on the edge of her bed with her underwear pulled down to her knees. Her call light was still on. On 5/7/25 at 10:15 a.m., CNA 8 entered Resident V's room and answered her call light. RN 5 was at the nurse's station. 34850 2. The clinical record for Resident L was reviewed on 5/5/25 at 11:40 a.m. The diagnoses included, but were not limited to, chronic kidney disease. A Quarterly MDS assessment, dated 2/10/25, indicated the resident was cognitively intact. An interview was conducted with Resident L on 5/5/25 at 11:31 a.m. She indicated it took up to 45 minutes at times for staff to provide services after pressing her call light to go to the bathroom. 3. The clinical record for Resident M was reviewed on 5/5/25 at 12:00 p.m. The diagnoses included, but were not limited to, hypertension. A Quarterly MDS assessment, dated 2/12/25, indicated the resident was cognitively impaired. An interview was conducted with Resident M on 5/5/25 at 1:22 p.m. She indicated there were delays with call light response times, especially on the weekends. It has taken an hour and a half for the staff to address the needs after pressing her call light. 4. The clinical record for Resident DD was reviewed on 5/6/25 at 11:00 a.m. The diagnoses included, but were not limited to, cellulitis. During an interview with Resident DD on 5/6/25 at 11:03 a.m., she indicated she had to wait over an hour to get her needs met at times after pressing her call light. If it was during meal service; she had been told she would have to wait until meal service was completed before she could receive pain medication. 5. The February 2025, March 2025, and April 2025 resident council minutes were provided by the Executive Director (ED) on 5/6/25 at 1:24 p.m. The attendees in the meetings included, but were not limited to, Resident R, Resident Z, Resident X, Resident F, Resident N, Resident H, Resident T, Resident Q, Resident D, Resident J, Resident G, and Resident O. The resident council had concerns with nursing call light response times for the February 2025, March 2025, and April 2025 resident council meetings. The facility's response and resolution to the resident council concerns were education to the staff. The in-service education provided to the staff included the following: Call light response times, dated 3/4/25, indicated call lights shall be answered within a timely manner. Goal is 10 minutes or less. Nurses are to assist in answering call lights. All staff, including non-clinical staff, shall not pass a room with a call light on. Please answer the call light, acknowledge the need and report to the appropriate staff member . Call light response times, dated 3/25/25, indicated Ensure residents' call lights are answered as soon as possible. If unable to answer due to caring for another resident, please let the resident know you acknowledged their need and will be with them as soon as possible. Nurses, please assist with answering call lights to address resident needs as soon as possible. All staff shall not pass a resident room with a call light on. Anyone can answer a call light. Please enter the room, introduce yourself and ask them what you can do to help. If you are not able to address their needs, please seek someone from the nursing staff . A resident council meeting was conducted on 5/7/25 at 10:07 a.m. The attendees were the following: Resident W, Resident W's Representative, Resident X, Resident N, Resident P, Resident K, Resident H, Resident E, Resident J, Resident EE, and Resident S. During that meeting, 5 of 11 residents voiced concerns regarding the staff not responding to call lights timely. During an interview with the Director of Nursing on 5/9/25 at 10:55 a.m., he indicated there can be delays on answering call lights during high care activity times. 40287 6. The clinical record for Resident C was reviewed on 5/5/25 at 3:18 p.m. The diagnoses included, but were not limited to, cellulitis (infection) of left lower limb and depression. She was admitted to the facility on [DATE]. An Admission MDS assessment, completed 5/7/25, indicated she was cognitively intact. On 5/5/25 at 12:24 p.m., Resident C was observed at a table in the unit dining room. She was sitting in a wheelchair and dressed in a hospital gown. Part of her back was visible above the wheelchair back. On 5/5/25 at 3:18 p.m., Resident C was observed in her room sitting in her wheelchair. She was still dressed in a hospital gown. A suitcase with visible clothing items was on the floor of her room. Resident C indicated she had wanted to get dressed prior to going to therapy that morning. She normally got up and dressed around 5:00 a.m. She had clothes available to wear in her suitcase. A resident rights policy was provided by the Executive Director on 5/9/25 at 8:45 a.m. It indicated, .[Name of Facility Corporation] and its member communities are committed to protecting and promoting the rights of the residents who reside in our communities . 1. a dignified existence . 2. be treated with respect, kindness, and dignity . 37. Receive care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality . This citation relates to Complaint IN00444953. 3.1-3(t)

Based on observation, interview, and record review, the facility failed to ensure food was served at a palatable temperature for 14 of 14 residents reviewed for food. (Residents D, F, G, H, J, N, O, Q, R, T, X, 84, Z, and DD) Findings include: 1. The clinical record for Resident DD was reviewed on 5/6/25 at 11:00 a.m. The diagnoses included, but were not limited to, cellulitis. During an interview with Resident DD on 5/6/25 at 11:03 a.m., she indicated the food was delivered cold. 2. The clinical record for Resident 84 was reviewed on 5/5/25 at 11:15 a.m. The diagnoses included, but were not limited to, hypertension. An interview was conducted with Resident 84 on 5/5/25 at 11:37 a.m. She indicated the food was often served cold. 51750 3. The February 2025, March 2025, and April 2025 resident council minutes were provided by the Executive Director (ED) on 5/6/25 at 1:24 p.m. The attendees in the meetings included, but were not limited to: Resident R, Resident Z, Resident X, Resident F, Resident N, Resident H, Resident T, Resident Q, Resident D, Resident J, Resident G, and Resident O. The resident council had voiced concerns regarding dietary in February 2025 and March 2025. The food was served cold. On 5/8/25 at 12:53 p.m., a test tray was delivered from the serving station on the 600 hall after all residents from the hall received their room trays. The temperatures of the items on the test tray were obtained by the Dietary Resource Manager (DRM). Four slices of pizza were at temperatures of 110 degrees Fahrenheit (F), 127 degrees F, 131 degrees F, and 134.9 degrees F. Two sides of blackberry cobbler were at temperatures of 99.4 degrees F and 110 degrees F. During an interview on 5/8/25 at 12:58 p.m., the DRM indicated holding temperatures should be at least 135 degrees. A Food Preparation and Safety Policy, dated 2012, was provided by the Director of Dining Services on 5/9/25 at 12:34 p.m. It indicated .Trays are delivered promptly to ensure that food is served at a preferable temperature and to preserve the quality of the food . 3.1-21(a)(2)

Based on interview and record review, the facility failed to timely initiate and address a grievance for 1 of 2 residents reviewed for choices (Resident DD). Findings include: The clinical record for Resident DD was reviewed on 5/6/25 at 10:41 a.m. The diagnoses included, but were not limited to, cellulitis (infection) of the right lower limb. She was admitted on [DATE]. A care plan, last reviewed 5/1/25, indicated Resident DD had acute pain related to cellulitis to the right lower extremity and a wound to the right heel. She also had complaints about back pain. She was able to report pain and efficacy of interventions. The goal was for her to have pain levels maintained at a consistent level of comfort while retaining as much function as possible. The interventions were to observe for side effects of treatment interventions, observe for efficacy of interventions, apply non-pharmacological intervention, treatment, and/or removal of the root cause of pain until the issue was resolved, and to monitor vital signs During an interview on 5/6/25 at 10:41 a.m., Resident DD indicated the mattress on her bed was uncomfortable and hurt her back. She had told everyone that the mattress hurt her back. She had asked for a different mattress, but no one had offered to change the mattress for her. After about four hours of lying in bed, she had the staff get her up in her wheelchair because the bed hurt her back so badly. During an interview on 5/7/25 at 9:35 a.m., Resident DD indicated she had been up in her wheelchair most of the night because her back hurt when she was in bed. She had told the staff each day that the mattress made her back hurt. She had been told three different times that a recliner could be provided for her to sleep in, but no one ever brought one. She had slept in a recliner at home in the past. During an interview on 5/8/25 at 3:33 p.m., the Executive Director (ED) indicated there were no grievances for Resident DD. The facility used the Caring Heart's Program to address grievances and concerns. An employee was assigned to each room to check on residents' daily and see if the resident had any concerns. The Admissions Assistant was the employee assigned to Resident DD. During an interview on 5/8/25 at 3:33 p.m., the Director of Nursing (DON) indicated he had not been made aware that Resident DD had requested a recliner or that she had a problem with her mattress. During an interview on 5/8/25 at 3:40 p.m., Resident DD indicated many staff members had stopped during her stay to see how things were going. She had told the Certified Nurse Aides who provided care for her that the bed and mattress hurt her back. She had also told the male nurse who had cared for her about the mattress. Resident DD could not remember a specific staff member that had stopped daily to see if she had any concerns. She was unaware of the Caring Heart program. Earlier in the day, the facility had brought in a recliner for her to use and she was hoping to get some rest soon. During an interview on 5/8/25 at 3:48 p.m., Registered Nurse (RN) 20 and RN 21 indicated they did not believe there were forms available on the unit to use for concerns or grievances. If a resident or resident representative had a concern, RN 20 and RN 21 would attempt to contact the department in charge of the concern or let their Unit Manager know. On 5/7/25 at 1:44 p.m., the ED provided the current Caring Hearts Policy and Procedure which indicated .has implemented the Caring Hearts program to improve our resident's experience and to provide good customer service .When a resident, guest or family member is not satisfied with the resident's room, the service[s] being provided, work done by a department, the environment or any other complaint a 'Grievance Form' .shall be completed. The grievance form should be completed at the time an issue is raised and given to the Administrator/ Executive Director [or delegated associate] immediately .If during an interview or when rounding a grievance is raised by a resident then the 'Grievance Form' .shall be completed immediately . On 5/12/25 at 2:10 p.m., the Clinical Nurse Consultant provided the current Filing Grievances/Complaints policy which indicated .Grievances and/ or complaints may be submitted orally or in writing. Written complaints or grievances must be signed by the resident or the person filing the grievance or complaint on behalf of the resident . Upon receipt of the grievance and/ or complaint . will investigate the allegation and submit a written report of such findings to the Administrator within five [5] working days of receiving the grievance and/ or complaint . 3.1-7(a)(2)

Based on observation, interview, and record review, the facility failed to serve a diet, as ordered by the physician, for 1 of 1 resident randomly observed for dining (Resident 16). Findings include: The clinical record for Resident 16 was reviewed on 5/5/25 at 12:45 p.m. The diagnoses included, but were not limited to, dysphagia (difficulty swallowing). A physician's order, dated 12/20/24, indicated he was to receive a mechanically altered diet with ground meat. A care plan, last reviewed on 4/8/25, indicated he was noted with dysphagia and had the potential for complications. The goal was for him not to demonstrate dysphagia related complications such as weight loss, signs and symptoms of aspiration pneumonia, or dehydration. The interventions included, but were not limited to, providing diet per physician's order with thin liquids. On 5/5/25 at 12:45 p.m., Resident 16 was observed sitting at a table in the dining room waiting for his meal. A staff member set a plate in front of him with a [NAME] sandwich, tossed salad, and root vegetables on the plate. Another staff member came up behind Resident 16 and removed his plate, taking it back to the serving area. At 12:54 p.m., Resident 16 received another plate of food which contained ground meat, root vegetables, and a tossed salad. Resident 16's meal ticket indicated he was to receive a mechanical soft with ground meat diet. During an interview on 5/6/25 at 8:49 a.m., the Director of Dining Services indicated a tossed salad should not have been served to Resident 16, because the lettuce was not shredded. On 5/6/25 at 8:49 a.m., the Director of Dining Services provided the Mechanical or Dental Soft Diet guidelines which indicated .Foods not allowed .raw vegetables except shredded lettuce . 3.1-21(a)(3)

Based on observation, interview, and record review, the facility failed to ensure staff donned a gown prior to administering medication using a nasogastric tube (nasal feeding tube), and prior to urinary catheter and colostomy care for residents on enhanced barrier precautions (EBP) for 1 of 1 resident reviewed for tube feedings and 1 of 1 resident randomly observed during care. (Resident 54 and Resident 210). Findings include: 1. The clinical record for Resident 210 was reviewed on 5/7/25 at 9:30 a.m. The diagnoses included, but were not limited to, dysphagia (difficulty swallowing) and pressure ulcer. On 5/9/25 at 1:57 p.m., Licensed Practical Nurse (LPN) 3 was observed administering medication to Resident 210. LPN 3 prepared the medication at the medication cart and entered the room. She performed hand hygiene and donned disposable gloves, attached the syringe to the nasogastric tube, and administered the medication. LPN 3 then flushed the nasogastric tube with 20 milliliters of water and reconnected the nasogastric tube to the tube feeding. She did not don a gown prior to administering the medication through the nasogastric tube. During an interview on 5/9/25 at 2:09 p.m., LPN 3 indicated she was unsure if she needed to wear a gown while administering medications through a nasogastric tube. 52119 2. The clinical record for Resident 54 was reviewed on 5/12/25 at 10:19 a.m. Diagnoses included, but were not limited to, diverticulosis (small pouches which form in the intestines), neuromuscular dysfunction of bladder, and urinary tract infection. A Quarterly Minimum Data Set (MDS) assessment, dated 3/11/25, indicated Resident 54 was cognitively intact and had an indwelling urinary catheter and an ostomy (external bag to collect liquid stool from the intestines). A physician order, dated 2/28/25, indicated Resident 54 was on enhanced barrier precautions. A care plan, created 11/5/24 and revised 3/30/25, indicated Resident 54 required enhanced barrier precautions related to her indwelling medical device (i.e. catheter). An interview was conducted with Resident 54 on 5/5/25 at 11:38 a.m. She indicated staff always wore gloves when performing her personal care but had never seen them put on a gown. A red Enhanced Barrier Precaution sign was observed on the wall outside the resident's bathroom. A resident representative was interviewed on 5/5/25 at 11:40 a.m. She indicated she had never seen staff put on a gown when assisting Resident 54. An observation of catheter and colostomy care was conducted with Certified Nurse Aide (CNA) 7 on 5/7/25 at 9:21 a.m. CNA 7 did hand hygiene and donned gloves prior to emptying Resident 54's colostomy bag but did not don a gown. She removed her gloves prior to leaving the room to retrieve perineal (genital area) cleaner spray. When she returned to the room, she put on a new pair of gloves but did not don a gown. She then emptied Resident 54's urine catheter bag and performed catheter care on the resident. An interview was conducted with CNA 7 on 5/7/25 at 9:45 a.m. She indicated she needed to don gloves only when doing perineal or catheter care. If a resident was in enhanced isolation, a cart with gowns, masks, and face shields would be outside the resident's door. The Executive Director (ED) provided a policy titled Enhanced Barrier Precautions Policy and Procedure, created 10/2017 and revised 4/2024, on 5/12/25 at 10:21 a.m. It indicated Enhanced Barrier Precautions [EBP] refers to an infection control intervention designed to reduce transmission of Multidrug-resistant Organisms [MDROs]. EBP employs targeted gown and glove use during high contact resident care activities. EBP is used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .For residents for whom EBP are indicated, EBP is employed when performing high contact, bundled Resident care activities such as dressing, bathing/showering/transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, wound care. 3.1-18(b)(2)

Based on interview and record review, the facility failed to ensure a resident's medical record was kept private and confidential by giving a resident the wrong medical record in error at discharge for 1 of 3 residents reviewed for discharge. (Resident B and Resident E) Findings include: A. The clinical record for Resident B was reviewed on 5/7/25 at 9:35 a.m. The diagnoses included, but were not limited to, stroke. The resident was discharged from the facility on 10/10/24. B. The clinical record for Resident E was reviewed on 5/12/25 at 12:27 p.m. The diagnoses included, but were not limited to, pain. The resident was discharged from the facility on 10/10/24. During a Confidential Interview, Resident B was given Resident E's medical record at the time of discharge. It was not recognized until 24 hours after discharge from the facility. Resident B had gone to the emergency room with the medical chart that had been given to her by the facility at discharge. At that time, the hospital staff recognized Resident B had been given the wrong resident's medical chart and notified the facility. An interview was conducted with the Executive Director (ED) and the Director of Nursing (DON) on 5/7/25 at 2:22 p.m. The ED indicated Resident B had received Resident E's medical record at the time of discharge by error. Both residents were discharged on the same day, 10/10/24. The medical records were placed in folders sitting on top of the nurse's station. The nurse gave Resident E's medical chart to Resident B by error. A resident rights policy was provided by the ED on 5/9/25 at 8:45 a.m. It indicated .[Name of Facility Corporation] and its member communities are committed to protecting and promoting the rights of the residents who reside in our communities . 17. Access personal and medical records pertaining to him or herself . 20. Privacy and confidentiality . This citation is related to Complaint IN00444953. 3.1-3(o)

Based on observation, interview, and record review, the facility failed to determine a root cause analysis of falls and to implement fall interventions, as care planned, for 3 of 5 residents reviewed for falls. (Residents' F, 33 and 68) Findings include: 1. The clinical record for Resident 33 was reviewed on 5/5/25 at 1:02 p.m. The diagnoses included but were not limited to Alzheimer's disease. A Quarterly Minimum Data Set (MDS) assessment, completed on 1/29/25, indicated severe cognitive impairment. A progress note, dated 2/24/25 at 3:26 p.m., indicated Resident 33 was seen walking into the television room. She fell after attempting to get onto the weight station. An event report, dated 2/24/25, indicated Resident 33 was fully clothed with her shoes on at the time of the fall, and was incontinent of urine. The clinical record did not contain an Interdisciplinary Team (IDT) note for the 2/24/25 fall. A Significant Change MDS assessment, completed on 2/27/25, indicated she was sometimes able to make herself understood and sometimes able to understand what was said to her. She had moderate visual impairment, and poor decision-making skills. She was frequently incontinent of bowel and blader, and dependent on toileting. She was able to walk 150 feet with supervision/touching assistance of staff. She had a history of two falls with no injuries and one fall with an injury since her prior MDS assessment. A progress note, dated 3/29/25 at 4:50 p.m., indicated Resident 33 was found lying on the floor of another resident's room sleeping. An event report, dated 3/29/25, indicated she was fully dressed and not incontinent. An IDT note, dated 3/31/25, indicated root cause analysis of the fall was resident was found lying on the floor sleeping in another resident room. Resident was unable to provide details of events r/t [related to] cognition. Resident self ambulates/wanders throughout unit with staff monitoring. Immediate intervention: Resident was assessed by unit nurse; vs [vital signs] and neuro [neurological] monitoring initiated; no injuries noted at the time of assessment. The resident was assisted from the floor by two staff members and provided with ADL [Activities of Daily Living] assistance. Heightened monitoring by staff. Intervention initiated by IDT: Staff to offer resident to take nap in between meals as she allows. A progress note, dated 4/27/25 at 12:47 p.m., indicated Resident 33 was found lying supine (on her back). An event report, dated 4/27/25, indicated Resident 33 was ambulating near the nurses' station fully clothed, shoes were on, and she was not incontinent. An IDT note, dated 4/28/25, indicated Root cause analysis the resident had an unwitnessed fall. Floor nurse heard resident and went to where resident was walking/wandering and found resident lying in a supine position on the floor. The resident stated that she 'didn't see it,' Resident is a memory care resident and is not cognitively intact. Immediate intervention: Neuros initiated and within normal limits. VS [vital signs] taken, the resident was assisted x2 [times two] staff off the floor and brought out the nurse's station for further monitoring. Resident stated she did not hit her head. All vitals were checked again and WNL [within normal limits]. Ice was placed for 20 min on and off per hospice. Intervention initiated by IDT: Assess [Resident 33's] footwear for proper fitting. A progress note, dated 5/1/25 at 8:46 a.m., indicated Resident 33 was found lying on the floor of the activities room after an unwitnessed fall. An event report, dated 5/1/25, indicated the resident was fully clothed with shoes on and was incontinent of urine and bowel. An IDT note, dated 5/2/25, indicated .Root cause analysis: Resident ambulating on unit when fall occurred. Resident stands and ambulates at will. Noted with impaired safety awareness secondary to dementia, resident difficult to redirect at times. Immediate intervention: resident was assessed by unit nurse; vs and neuro monitoring initiated; no injuries noted at the time of assessment. resident [sic] was assisted from floor by staff and provided with ADL assistance. heightened [sic] monitoring and resident education provided. Intervention initiated by IDT: resident care planned for injury prevention, Care plan reviewed, continue with current plan of care. During an interview on 5/8/25 at 10:51 a.m., the Memory Care Coordinator (MCC) indicated Resident 33 would pace the unit most days. When Resident 33 appeared to be tired, staff attempted to lay her down for a nap. Some days Resident 33 would take a nap and other days she would get up and start pacing the unit again. During an interview on 5/8/25 at 12:48 p.m., the Director of Nursing (DON) indicated during IDT meetings the team looked at what Resident 33 was doing at the time of the falls. He indicated Resident 33 was impulsive and had impaired safety awareness. The DON indicated the IDT did look at root cause analysis for all falls. During an interview on 5/12/25 at 2:29 p.m., the DON and Corporate Nurse Consultant (CNC) both indicated the IDT notes were the root cause analysis of the falls. The DON indicated Resident 33 was not interviewable, and he did not feel the IDT team could speculate on what had occurred between the last time she was seen by staff and when she was found after an unwitnessed fall. The root cause analysis in the IDT notes for Resident 33 reflected the way Resident 33 was found after her fall events. A policy titled Clinical- Fall Prevention Policy and Procedure, dated May 2016, was provided by the Executive Director (ED) on 5/7/25 at 1:36 p.m. The policy indicated .Purpose: The purpose of this policy is to provide [Name of Corporation] communities with best practices and evidence-based approaches to prevent falls and protect residents who are at risk for falling .Procedure: This section describes the process for the prevention of falls and accurate documentation when there is a fall. Accurate documentation of fall risks and falls provided a clinical picture of a resident and in utilized in developing their plan of care. It is the responsibility of the interdisciplinary team to document falls prevention, when a fall occurs, and interventions to avoid future falls . Step Two: Fall Event Assessment: The fall event assessment will be completed by the charge nurse if a patient experiences a fall. This data will be utilized by the community to thoroughly investigate the root cause for each fall and ensure effective interventions are put into place to prevent additional falls .Step Three: Strategies of Prevention .Each fall risk factor is unique for every resident .Step Five: Interdisciplinary Guidelines: If a fall occurs, the interdisciplinary team [IDT] will meet collectively and examine the fall using the following criteria . An IDT member/designee will physically visit the place of the fall to verify the post fall assessment and investigate for any for any additional information that could be useful in preventing a reoccurrence; iii. A root cause analysis will be performed utilizing the 5 Whys [NAME] process; iv. A member/designee of the IDT will assist the team and update the care plan and the nurse aide assignment sheets to ensure accuracy of fall preventions vi. A narrative IDT note will include: a. Root cause explanation with new intervention strategy to prevent reoccurrence . A policy titled 5 whys Policy, dated February 2015, was provided by the ED on 5/9/25 at 12:42 p.m. The policy indicated Purpose: The 5 Whys is a system that is utilized to help determine the root cause of a problem. It is used to discover if a relationship exists between more than one variable and the proper use of the 5 Whys will help the user implement meaningful changes to permanently correct an identified problem. How to use 5 Whys . 2. Complete the header questions with the resident name and identified problem being addressed. 3. Answer the first question 'why did the problem happen' and answer down below in the appropriate box. 4. Repeat step three (3) consecutively until the root cause of the problem is effectively identified . 52119 2. The clinical record for Resident F was reviewed on 5/8/25 at 9:06 a.m. The diagnoses included, but were not limited to, Parkinson's disease, repeated falls, syncope (fainting) and collapse, orthostatic hypotension (a form of low blood pressure that happens when standing up from sitting or lying down), and osteoporosis (brittle bones). An Admission MDS assessment, dated 12/17/24, indicated the resident had multiple falls in the six months prior to admission, including a fall one month prior to admission to the facility. A Quarterly MDS assessment, dated 4/8/25, indicated the resident was cognitively intact. A falls care plan, dated 12/16/24, indicated Resident F was at risk for falling and fall related injuries related to requiring assistance from staff for transfers, history of falls, incontinence, using a wheelchair and walker, receiving blood pressure medication, antidepressants, syncope and collapse, and orthostatic hypotension. A physician order, dated 4/11/25, indicated the staff should encourage the resident to wear hip protectors daily as she allows. Staff were to document the completion of this task in the morning and at bedtime. The Director of Nursing (DON) provided fall event reports on 5/12/25 at 11:50 a.m. They indicated the following: Resident F had an unwitnessed fall, on 4/10/25, which resulted in a bloody abrasion (scrape) to her nose. A care plan approach, initiated on 4/11/25, indicated [Resident] to don hip protectors as she allows. Resident F had an unwitnessed fall, on 4/25/25, which resulted in a hematoma (collection of blood similar to a bruise) on her right forehead. A care plan approach, initiated on 4/28/25, indicated Continue with plan of care. No new interventions were initiated. Resident F had an unwitnessed fall, on 5/10/25, which resulted in an abrasion and bruise to the middle of her back. The care plan approach [Resident] to don hip protectors as she allows was edited, on 5/6/25, to read [Resident] to don hip protectors as she allows-refuses often. Resident F was interviewed in the physical therapy room on 5/8/25 at 10:26 a.m. She indicated she remembered seeing hip protectors in a package when she returned to her room one day. No one had put them on her before, and she had not tried them. She was observed to not be wearing hip protectors. The Unit Manager (UM) was interviewed in Resident F's room on 5/8/25 at 10:31 a.m. She was not sure where the hip protectors were and was not sure if Resident F was wearing any. She located a pair of hip protectors in plastic packaging on the floor in the resident's closet. She was going to go see if Resident F had any on. The UM was interviewed on 5/8/25 at 10:40 a.m. She indicated she had asked Resident F if she would wear the hip protectors, and the resident refused. As of 5/8/25 at 12:11 p.m., there was no documentation regarding Resident F's refusal to wear the hip protectors within the electronic health record, including but not limited to, the progress notes, event charting, observation charting, medication administration records, and/or treatment administration records. 3. The clinical record for Resident 68 was reviewed on 5/7/25 at 10:31 a.m. The diagnoses included, but were not limited to, cerebral infarction (stroke), speech/language deficits following stroke, memory deficit following cerebral infarction, and unsteadiness. An Admission MDS assessment, dated 3/7/25, indicated Resident 68 was dependent on staff for help with rolling left and right, sitting up, and transferring. A care plan, initiated on 3/6/25, indicated Resident 68 was at risk for falling and fall related injuries related to: requires assistance from staff for transfers, utilizes a wheelchair and may use walker with therapy, history of falls, incontinence, catheter in place, controls bed height and puts bed in high position despite staff explanation of risks and benefits, receives routine hypoglycemic (medicine to lower blood sugar), and PRN (as needed) narcotic use. A Post Fall Assessment note, dated 4/29/25, indicated Resident 68 had an unwitnessed fall at 12:12 a.m. The following approaches were added to Resident 68's care plan, on 4/29/25, after his fall: resident sent out to emergency room for further evaluation, encourage him to leave bed height in low position that was often refused, and add bed bolsters to bed for tactile edge. Resident 68 was observed in bed on 5/5/25 at 10:38 a.m. No bed bolsters were observed on the resident's bed. Resident 68 was observed in bed on 5/7/25 at 1:36 p.m. No bed bolsters were observed in the resident's bed. There was no documentation of Resident 68 refusing the bed bolsters in his electronic health record. An interview with Registered Nurse (RN) 5 was conducted on 5/7/25 at 1:49 p.m. She indicated bed bolsters had been ordered but had not been delivered yet. An interview with the UM was conducted on 5/7/25 at 1:56 p.m. She indicated the bed bolsters had been ordered and received but Resident 68 refused them. The refusal was documented on his care plan. The care plan approach titled add bed bolsters to bed for tactile edge was edited, on 5/7/25, to read add bed bolsters to bed for tactile edge-resident refused bed bolster. An interview with Resident 68's Representative was conducted on 5/8/25 at 10:44 a.m. He indicated the UM ordered the bed bolsters the day after the resident's fall. Staff came in once to put them on the bed, but Resident 68 was in pain and vomiting, so they said they would come back later. No one ever came back with the bed bolsters, and he thought they were simply forgotten. To his knowledge, Resident 68 had not refused the bed bolsters. On 5/7/25 at 1:36 p.m., the Executive Director (ED) provided a policy titled Fall Prevention Policy and Procedure, dated May 2016. It indicated The Community must take reasonable steps to ensure it implements best practices and evidence-based approaches to prevent falls and protect residents who are at risk for falling. Due to the risks associated with falls for older adults living in long-term care facilities, compliance with this policy is essential .It is the responsibility of the interdisciplinary team to document falls prevention, when a fall occurs, and interventions to avoid future falls .Every resident will be considered a high risk for falls during their stay and individual interventions will be introduced as needed for these patients .Fall risk care plans will be kept current by the IDT and other associates within each community. Individualized interventions on the fall care plan will be duplicated onto care sheets to ensure care plan strategies are integrated into the health system. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to trim a resident's nails and assist a resident with transferring timely for 2 of 7 residents reviewed for activities of daily living (ADL) care. (Resident 200 and Resident 253) Findings include: 1. The clinical record for Resident 200 was reviewed on 5/5/25 at 3:18 p.m. The diagnoses included, but were not limited to, cellulitis (infection) of the left lower limb and depression. She was admitted to the facility on [DATE]. An Admission Minimum Data Set assessment, completed 5/7/25, indicated she was cognitively intact. During an interview on 5/5/25 at 3:18 p.m., Resident 200 indicated her nails were long and needed to be trimmed. Resident 200's nails were observed to extend well past the tips of her fingers and have worn green polish on them. On 5/7/25 at 9:54 a.m., the Executive Director provided the shower sheets for Resident 200, which indicated she had a bed bath on 5/6/25. The shower sheet did not indicate if Resident 200's fingernails had been trimmed and did not indicate refusal of such care. During an interview on 5/7/25 at 1:38 p.m., Resident 200 indicated she had received a bed bath the night before. On 5/8/25 at 11:15 a.m., Resident 200 was observed sitting in her wheelchair dressed in street clothes. Her nails were long and there was worn green polish present on them. Resident 200 indicated her nails still needed trimmed. During an interview on 5/8/25 at 11:20 a.m., Certified Nurse Aide (CNA) 2 indicated that residents nails should be trimmed on shower days and as needed. 51750 2. The clinical record for Resident 253 was reviewed on 5/5/25 at 11:30 a.m. The diagnoses included, but were not limited, paraplegia (a condition causing partial or complete paralysis of the lower body) and repeated falls. An Annual Minimum Data Set (MDS) assessment, completed 5/4/25, indicated Resident 253 was cognitively intact. A care plan, created 5/6/25, indicated Resident 253 was at risk for falling and fall related injuries and required assistance from staff for transfers. The goal for Resident 253 was to minimize the risk of falls and fall related injuries. The interventions, created 5/6/25, included, but were not limited to, were to assist with ADLs. During an observation on 5/5/25 at 12:30 p.m., Resident 253's call light indicator was illuminated. On 5/5/25 at 12:56 p.m., Resident 253's call light indicator was illuminated. The resident was observed grimacing while sitting in a wheelchair in her room. She indicated she had been sitting in her wheelchair for an hour and a half and needed to get back to bed because she was in pain from the wounds on her backside. Resident 253 indicated she had asked staff to transfer her back to her bed and was told staff had to pass lunch first. During an interview on 5/6/25 at 11:45 a.m., Resident 253's Representative indicated the resident had to wait for assistance during mealtimes. On 5/6/25 at 11:48 a.m., CNA 4 was observed, indicating to Resident 253 at that point in time, this would be her only opportunity to lay the resident down before lunchtime and then she would be in the dining room; otherwise, the resident would have to wait until after lunch to lay down. Resident 253 chose to lay down instead of going to the dining room for lunch. During an interview on 5/9/25 at 10:55 a.m., the Director of Nursing (DON) indicated during high care times there can be delays in care. An ADL Supporting Policy, revised March 2018, was provided by the DON on 5/12/25 at 11:27 a.m. It indicated .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: .b. Mobility (transfer and ambulation, including walking) . 3.1-38(a)(2)(B) 3.1-38(a)(3)(E)

Based on interview and record review, the facility failed to ensure a resident received a discharge summary at the time of discharge for 1 of 3 residents reviewed for discharge. (Resident B) Findings include: A. The clinical record for Resident B was reviewed on 5/7/25 at 9:35 a.m. The diagnoses included, but were not limited to, stroke. The resident was discharged from the facility on 10/10/24. During a Confidential Interview, Resident B was given Resident E's medical record at the time of discharge. She did not receive any of Resident B's medical or discharge information. An interview was conducted with the Executive Director (ED) and the Director of Nursing (DON) on 5/7/25 at 2:22 p.m. The ED indicated Resident B had received Resident E's medical record at the time of discharge by error. Both residents were discharged on the same day, 10/10/24. The medical records were placed in folders sitting on top of the nurse's station. The nurse gave Resident E's medical chart to Resident B by error. A discharge planning policy was provided by the ED on 5/7/25 at 1:36 p.m. It indicated .[Name of Facility Corporation] and its member communities are committed to ensuring a resident discharge process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions .I. When the community anticipates a resident's discharge to a private residence . a discharge summary and a post discharge plan will be developed which will assist the resident to adjust to his or her living environment. II. The discharge summary will include a recapitulation of the resident's stay at this community and a final summary of the resident's status at that time of the discharge in accordance with established regulations governing release information and as permitted by the resident. The discharge summary shall include a description of the resident's: a. current diagnoses; b. medical history (including any history of mental disorders and intellectual disabilities) . c. course of illness, treatment and/or therapy since entering the facility . d. current laboratory, radiology, consultation, and diagnostic test results . e. physical and mental functional status . f. ability to perform activities of daily living . XIII. A copy of the following will be provided to the resident and any receiving provider and a copy will be filed in the resident's medical records: a. an evaluation of the resident's discharge needs . b. The post-discharge plan . and c. The discharge summary . This citation is related to Complaint IN00444953. 3.1-36(a)(1) 3.1-36(a)(2) 3.1-36(a)(3)

Based on interview and record review, the facility failed to ensure a resident had a rationale for indication of use and ongoing administration of a prophylactic antibiotic for the prevention of urinary tract infections for 1 of 2 residents reviewed for antibiotic medications and 2 of 5 residents reviewed for unnecessary medications. (Resident 16, Resident L, and Resident 39) Findings include: 1. The clinical record for Resident L was reviewed on 5/5/25 at 11:40 a.m. The diagnoses included, but were not limited to, chronic kidney disease. A care plan, dated 12/16/24, indicated Resident L had a history of urinary tract infections. A nursing note, dated 2/13/25, indicated Resident L's Representative had requested for a prophylactic antibiotic to be given due to the resident's recurrent and history of chronic urinary tract infections. A physician order, dated 2/14/25, indicated the resident was to receive 100 milligrams of Macrobid once a day as a prophylactic for urinary tract infections. A prophylactic antibiotic care plan, dated 2/14/25, indicated the following approaches: staff were to administer antibiotic as ordered, observe for adverse reactions, and notify medical doctor if adverse reactions were observed. The February 2025, March 2025, April 2025 Medication Administration Records (MAR) indicated the staff administered the 100 milligrams of Macrobid daily as ordered. A nursing note, dated 4/10/25, indicated the medical provider ordered a urine specimen. A nursing note, dated 4/14/25, indicated the resident's urine culture results were 10,000-50,000 klebsiella pneumoniae (bacterial infection in the urinary tract). The medical provider did not issue new orders. A nursing note, dated 4/15/25, indicated the resident was observed with increased confusion and pain. The medical provider was aware, and the staff was awaiting new orders. A nursing note, dated 4/16/25, indicated the medical provider ordered the resident to receive 400 milligrams-80 milligrams of Bactrim (antibiotic medication) twice a day for three days. A medical provider note, dated 4/16/25, indicated the resident had complaints of urinary discomfort. The staff was to administer Bactrim due to the resident being symptomatic. A physician order, dated 4/16/25, indicated the resident was to receive 400 milligrams-80 milligrams of Bactrim twice a day until 4/18/25. The April 2025 MAR indicated Resident L had received the 400 milligrams-80 milligrams of Bactrim twice a day and 100 mg of Macrobid daily as ordered, simultaneously. There was no documentation in Resident L's electronic health record regarding the rationale for continuation and ongoing use for the prophylactic antibiotic. An interview was conducted with the Director of Nursing on 5/12/25 at 8:37 a.m. He indicated the medical provider had ordered the prophylactic antibiotic for Resident L due to her chronic urinary tract infections. The medical provider did not order to stop the prophylactic antibiotic while on the Bactrim antibiotic. The staff administered the antibiotics as ordered. 51984 2. The clinical record for Resident 39 was reviewed on 5/9/25 at 11:30 a.m. The diagnoses included, but were not limited to, Alzheimer's disease and a history of urinary tract infections (UTIs). A Significant Change Minimum Data Set (MDS) assessment, dated 4/14/25, indicated severe cognitive impairment. An Acute Care Hospital After Visit Summary, dated 7/1/23, indicated Resident 39 was to start taking Macrobid (an antibiotic used to treat urinary tract infections) 100 milligrams (mg) once a day in the morning, for UTI symptoms. Resident 39 had continued to receive Macrobid 100 mg daily, since 7/1/23, for a history of frequent UTIs. There was no documentation in Resident 39's electronic health record regarding the rationale for continuation and ongoing use for the prophylactic antibiotic. During an interview on 5/9/25 at 12:39 p.m., the Infection Preventionist (IP) indicated that prophylactic antibiotics were tracked for the first month only in the Antibiotic Stewardship binder. The IP indicated antibiotics were continued as prescribed when a resident was admitted /readmitted to the facility. The IP indicated no conversation has occurred with the Medical Doctor (MD) about prophylactic antibiotic use for this resident. 52119 3. The clinical record for Resident 16 was reviewed on 5/8/25 at 2:48 p.m. Diagnoses included, but were not limited to, benign prostatic hyperplasia (enlarged prostate gland) without urinary tract symptoms. Resident 16 was discharged from the facility's assisted living and admitted to the long-term care portion of the facility on 9/30/24. A care plan, created 10/1/24 and revised on 4/8/25, indicated [Resident] has history of urinary tract infections. potential for recurrence. The care plan approaches indicated the following obtain UA and C/S [urinalysis and culture/screen, two tests for urinary infection] per order . report symptoms of UTI; concentrated and/or foul smelling urine, abdominal and/or flank pain, dysuria, fever, change in mental status . encourage fluid intake . assist with incontinence care as needed . A care plan, created on 10/1/24 and revised on 4/8/25, indicated [Resident] is receiving antibiotic prophylactically. potential for complications. The care plan approaches indicated the following: .notify MD/NP should adverse reactions occur .be alert for adverse reactions. nausea, vomiting, diarrhea, dizziness, nosebleed, insomnia .administer antibiotic per order . The assisted living discharge paperwork, dated 9/30/24, indicated the resident had been prescribed Macrobid (an antibiotic used to treat urinary tract infections) prophylactically (preventatively) since 8/3/2022. A physician's order, dated 9/30/24, indicated Resident 16 was to take Macrobid 100 milligrams (mg) daily. The order had no end date. A physician admission note, dated 10/1/24, indicated the following: Res [resident] has [Benign Prostatic Hyperplasia] BPH [enlarged prostate] with history of recurrent UTI [urinary tract infection] chronically on Macrobid 100 mg daily .Benign prostatic hyperplasia, unspecified whether lower urinary tract symptoms present .Denies difficulty emptying his bladder with history of recurrent UTI chronically on Macrobid . A note titled Infection Tracker with McGeer's Criteria was written on 10/1/24 at 9:10 a.m. It indicated admitted on ppx abx [prophylactic antibiotic] for recurrent UTIs. A review of the provider's notes from 10/1/24 to present indicated there was no rationale documented for continuing the antibiotic. The Infection Preventionist (IP) was interviewed on 5/9/25 at 12:39 p.m. She indicated they list the month a resident starts an antibiotic in their antibiotic stewardship binder but do not track residents who are on a prophylactic antibiotic. They only monitor antibiotics for new infections. The Director of Nursing was interviewed on 5/9/25 at 12:41 p.m. He indicated the provider made all decisions regarding prophylactic antibiotics and the rationale was based on their judgment. They do not give any education to their providers regarding antibiotic stewardship necessarily, but they did have an informational binder with training in it. He did not know who originally prescribed Resident 16's Macrobid. They don't always receive that information from the hospital or prior facility. They don't track antibiotic side effects, indications, etc., because that was up to the doctor's judgment and it would be documented in their notes. The ED provided a policy titled Infection Prevention and Control Program on 5/9/25 at 12:42 p.m. It indicated Antibiotic Stewardship. A. Culture reports, sensitivity data, and antibiotic usage reviews are included in surveillance activities. B. Medical criteria and standardized definition of infections are used to help recognize and manage infections. C. Antibiotic usage is evaluated, and practitioners are provided feedback on reviews. 3.1-48(a)(1) 3.1-48(a)(3) 3.1-48(a)(4)

Based on interview and record review, the facility failed to ensure a timely Level I and Level II screening was obtained for 1 of 1 resident reviewed for Pre-Admission Screening and Resident Review (PASRR). (Resident 16) Findings include: The clinical record for Resident 16 was reviewed on [DATE] at 2:13 p.m. The resident was admitted on [DATE]. Diagnoses included, but were not limited to, dementia, bipolar disorder (a mood disorder characterized by episodes of mania and depression), and depression. A facility Social Services Admission Screening, dated [DATE], indicated the resident did have diagnoses which may impact adjustment, such as dementia or bipolar disorder. The Executive Director provided a Level I PASRR screen on [DATE] at 1:36 p.m. It indicated the facility completed the screening on [DATE]. The screening also indicated Reason for screening: This nursing facility resident has never had a PASRR Level I screen. The Social Services Director (SSD) was interviewed on [DATE] at 4:28 p.m. She indicated there was no other screening done. She wasn't sure if the resident had admitted with one already completed. She was not sure how long after admission, a Level I was supposed to be done. She would have to ask the previous director. The Director of Nursing (DON) was interviewed on [DATE] at 1:50 p.m. He indicated they did not have a PASRR policy. The ED provided a printed PASRR entry report on [DATE] at 1:45 p.m. It indicated the following: -A Level I screen draft was started, but was withdrawn, on [DATE]. -A Level I screen was started, but expired, on [DATE], [DATE], and [DATE]. -A Level I screen was completed and referred for a Level II screening on [DATE]. 3XXX,d+[DATE](d)(1)(A) 3XXX,d+[DATE](d)(1)(B)

Based on observation, interview, and record review, the facility failed to have the most recent survey results available in the survey binder with the potential to affect 97 of 97 residents currently residing at the facility. Findings include: On 5/7/25 at 10:07 a.m., a resident council meeting was conducted at the facility. During the resident council meeting, a family member indicated they had attempted to read the most recent survey results in the Facility Survey Binder, located by the front entrance. They were unable to view the most recent facility survey. The binder contained survey information from 2022. On 5/7/25 at 10:50 a.m., the Facility Survey Binder was observed with the Executive Director. The most recent survey present in the binder was from December 2022. The Executive Director indicated the Annual Recertification Survey, conducted March 2024, should have been included in the State Survey Binder. He was unsure as to why it was not there. 3.1-3(b)(1)

3. The clinical record for Resident D was reviewed on 3/8/24 at 3:10 p.m. Resident D's diagnoses included, but not limited to, fracture of lower end of right femur, major depressive disorder, and lymphadema. A Brief Interview for Mental Status (BIMS) assessment conducted on 3/7/24 indicated, Resident D was cognitively intact. An observation and interview with Resident D conducted on 3/6/24 at 10:09 a.m. indicated, Resident D was lying in bed with the right leg immobilizer on her leg. When asked about having her heels floated while in bed, she indicated, no one had educated her on why she should have her heels floated while in bed nor did she know how to float her heels. She further indicated, it was difficult for her to turn herself independently while in bed. Resident D was unable to bend her right knee related to the brace/immobilizer on her leg. A physician's order dated 3/3/24 indicated, to Elevate/Offload heels while in bed as tolerated. Every Shift: Days, Nights. Resident D's care plan dated 3/5/24 indicated, Resident D was at risk for skin breakdown related to not being independent for bed mobility, having incontinence at times, and wearing a brace to her right lower extremity. Interventions included, but not limited to, Elevate/Float Heels when in bed and Apply Skin Prep to bilateral heels at bedtime. Another care plan with the same date indicated, Resident D was unable to independently perform late loss ADLs[sic, Activities of Daily Living] R/T[sic related to] R[sic, right] distal femur fracture and requires partial to substantial assist for bed mobility, transfers, toileting . One intervention included to Provide assistance and encouragement for bed mobility, eating, toileting, and transfers. An interview with Resident D conducted on 3/8/24 at 1:20 p.m. indicated, when asked if the facility was applying skin prep to her heels since she was admitted to the facility, she indicated no, no one has even washed my feet since I was admitted to the facility. Resident D's MAR/TAR (medication administration record/treatment administration record) for March 2024 was reviewed and indicated, neither the floating of the heels nor application of skin prep to the heels was recorded in the clinical record. An interview with DON (Director of Nursing) conducted on 3/8/24 at 2:49 p.m. indicated, the floating of heels when in bed and the application of skin prep to Resident D's heels were nursing interventions to be used for the prevention of skin breakdown and do not require a physician's order. He indicated, the care plans and interventions are created by another department and should have been showing up on Resident D's MAR for nursing to complete. An interview with DON conducted on 3/8/24 at 3:08 p.m. indicated, the facility did not have a care plan policy but rather follows the RAI (Resident Assessment Instrument) handbook/policy. On 3/8/23 at 2:55 p.m., the Director of Nursing provided the current Medication Administration: General Policies & Procedures which read .Medications are administered as prescribed in accordance with good nursing principles and practices . CMS ' s (Centers for Medicare and Medicaid) RAI Version 3.0 Manual CH 1: Resident Assessment Instrument (RAI) October 2023 Page 1-2 CHAPTER 1: RESIDENT ASSESSMENT INSTRUMENT (RAI) Overview: The RAI helps nursing home staff gather definitive information on a resident ' s strengths and needs, which must be addressed in an individualized care plan. It also assists staff with evaluating goal achievement and revising care plans accordingly by enabling the nursing home to track changes in the resident ' s status. As the process of problem identification is integrated with sound clinical interventions, the care plan becomes each resident ' s unique path toward achieving or maintaining their highest practical level of well-being. 3.1-32(a) 3.1-35(a) 3.1-35(b) This Federal tag relates to Complaint IN00424343. Based on interview and record review, the facility failed to timely administer an antibiotic, as ordered by the physician, to ensure physician orders were followed regarding administration of duplicate medication therapy for an antidepressant, and to implement a resident's care plan for floating heels when in bed and applying skin prep to bilateral heels daily for 2 of 6 residents reviewed for unnecessary medications and 1 of 1 resident reviewed for positioning (Resident B, C, and D). Findings include: 1. The clinical record for Resident B was reviewed on 3/5/24 at 2:53 p.m. The Resident's diagnosis included, but were not limited to, diabetes and urinary tract infection. She was admitted to the rehab unit of the facility on 12/15/23. A care plan, initiated 12/18/23, indicated Resident B had a urinary tract infection. The goal was for her not to exhibit signs of urinary tract infection upon completion of antibiotics. The interventions included, but were not limited to, administer antibiotic per order, initiated 12/18/23, and assist with incontinence care, initiated 12/28/23. A physician's order, dated 12/15/23, indicated she was to receive linezolid (antibiotic) 600 mg (milligram) 1 tablet every 12 hours. The order was discontinued on 12/18/23. A physician's order, dated 12/18/23, indicated she was to receive linezolid 600 mg 1 tablet every 12 hours. The order was discontinued on 12/19/23. A physician's order, dated 12/19/23, indicated she was to receive linezolid 600 mg 1 tablet every 12 hours through 12/21/23. The December 2023 MAR (Medication Administration Record) indicated that the linezolid 600 mg, ordered 12/15/23, was not administered on 12/15/23 due to pharmacy delivery, 12/16/23 due to being unavailable, 12/17/23 due to allergy and drug unavailable, and 12/18/23 the medication was discontinued. The linezolid was reordered on 12/18/23 and was documented as given on 12/18/23 at 1:00 p.m., and as not given due to being unavailable on 12/19/23 at 1:00 a.m. The linezolid, ordered 12/19/23 was documented as administered as ordered from 12/19/23 at 6:00 a.m. through 12/21/23 at 6:00 a.m. During an interview on 3/7/24 1:45 p.m., FM (Family Member) 5 indicated that Resident B did not receive her antibiotics timely after being admitted to the rehab unit. Resident B was admitted to the rehab unit on Friday 12/15/23 with an order to receive an antibiotic. Resident B did not receive the antibiotic until Monday 12/18/23. FM 5 had been told it was due to an allergy that was listed in Resident B's record. The facility had not contacted FM 5 about the delay in Resident B receiving her antibiotic until 12/18/23, when FM 5 informed the facility that Resident B had tolerated the linezolid in the past and it was not an allergy. During an interview on 3/8/24 at 10:53 a.m., Pharmacy Tech 6 indicated the pharmacy had received an order for Resident B to receive linezolid on 12/15/23. Resident B had an allergy for linezolid list in her medical record and a drug regimen review had been sent to clarify the order. The linezolid would not have been sent by the pharmacy until the order was clarified. The linezolid 600 mg had been dispensed on 12/18/23. During an interview on 3/8/24 at 11:03 a.m., the Director of Nursing indicated Resident B had been admitted on a Friday evening. Linezolid was listed as an allergy, but she had tolerated the medication in the past, so the pharmacy was contacted the following Monday. FM 5 had been informed about the allergy on Monday 12/18/23. 2. The clinical record for Resident C was reviewed on 3/7/24 at 3:20 p.m. The diagnoses included, but were not limited to, chronic kidney disease, anxiety disorder, and depression. A physician order, dated 10/2/23, was noted for Wellbutrin SR (sustained release) tablet; 100 milligrams; twice a day from 10/2/23 to 10/6/23. A physician order, dated 10/3/23, was noted for bupropion (generic name for Wellbutrin) tablet; 100 milligrams; twice a day from 10/3/23 to 10/11/23. A pharmacy recommendation, dated 10/6/23, indicated a duplication of therapy and the recommendation to discontinue the order for bupropion tablet 100 milligrams or Wellbutrin tablet 100 milligrams. The electronic medication administration record (EMAR) for October of 2023, indicated the bupropion and Wellbutrin 100 milligrams were administered, as duplicate therapy, on 10/3/23 in the evening, 10/4/23 in the morning and evening, 10/5/23 in the evening, and 10/6/23 in the morning.

Based on interview and record review, the facility failed to timely administer an antibiotic, as ordered by the physician, to ensure physician orders were followed regarding administration of duplicate medication therapy for an antidepressant for 2 of 6 residents reviewed for unnecessary medications (Resident B and C). Findings include: 1. The clinical record for Resident B was reviewed on 3/5/24 at 2:53 p.m. The Resident's diagnosis included, but were not limited to, diabetes and urinary tract infection. She was admitted to the rehab unit of the facility on 12/15/23. A care plan, initiated 12/18/23, indicated Resident B had a urinary tract infection. The goal was for her not to exhibit signs of urinary tract infection upon completion of antibiotics. The interventions included, but were not limited to, administer antibiotic per order, initiated 12/18/23, and assist with incontinence care, initiated 12/28/23. A physician's order, dated 12/15/23, indicated she was to receive linezolid (antibiotic) 600 mg (milligram) 1 tablet every 12 hours. The order was discontinued on 12/18/23. A physician's order, dated 12/18/23, indicated she was to receive linezolid 600 mg 1 tablet every 12 hours. The order was discontinued on 12/19/23. A physician's order, dated 12/19/23, indicated she was to receive linezolid 600 mg 1 tablet every 12 hours through 12/21/23. The December 2023 MAR (Medication Administration Record) indicated that the linezolid 600 mg, ordered 12/15/23, was not administered on 12/15/23 due to pharmacy delivery, 12/16/23 due to being unavailable, 12/17/23 due to allergy and drug unavailable, and 12/18/23 the medication was discontinued. The linezolid was reordered on 12/18/23 and was documented as given on 12/18/23 at 1:00 p.m., and as not given due to being unavailable on 12/19/23 at 1:00 a.m. The linezolid, ordered 12/19/23 was documented as administered as ordered from 12/19/23 at 6:00 a.m. through 12/21/23 at 6:00 a.m. During an interview on 3/7/24 1:45 p.m., FM (Family Member) 5 indicated that Resident B did not receive her antibiotics timely after being admitted to the rehab unit. Resident B was admitted to the rehab unit on Friday 12/15/23 with an order to receive an antibiotic. Resident B did not receive the antibiotic until Monday 12/18/23. FM 5 had been told it was due to an allergy that was listed in Resident B's record. The facility had not contacted FM 5 about the delay in Resident B receiving her antibiotic until 12/18/23, when FM 5 informed the facility that Resident B had tolerated the linezolid in the past and it was not an allergy. During an interview on 3/8/24 at 10:53 a.m., Pharmacy Tech 6 indicated the pharmacy had received an order for Resident B to receive linezolid on 12/15/23. Resident B had an allergy for linezolid list in her medical record and a drug regimen review had been sent to clarify the order. The linezolid would not have been sent by the pharmacy until the order was clarified. The linezolid 600 mg had been dispensed on 12/18/23. During an interview on 3/8/24 at 11:03 a.m., the Director of Nursing indicated Resident B had been admitted on a Friday evening. Linezolid was listed as an allergy, but she had tolerated the medication in the past, so the pharmacy was contacted the following Monday. FM 5 had been informed about the allergy on Monday 12/18/23. 36942 2. The clinical record for Resident C was reviewed on 3/7/24 at 3:20 p.m. The diagnoses included, but were not limited to, chronic kidney disease, anxiety disorder, and depression. A physician order, dated 10/2/23, was noted for Wellbutrin SR (sustained release) tablet; 100 milligrams; twice a day from 10/2/23 to 10/6/23. A physician order, dated 10/3/23, was noted for bupropion (generic name for Wellbutrin) tablet; 100 milligrams; twice a day from 10/3/23 to 10/11/23. A pharmacy recommendation, dated 10/6/23, indicated a duplication of therapy and the recommendation to discontinue the order for bupropion tablet 100 milligrams or Wellbutrin tablet 100 milligrams. The electronic medication administration record (EMAR) for October of 2023, indicated the bupropion and Wellbutrin 100 milligrams were administered, as duplicate therapy, on 10/3/23 in the evening, 10/4/23 in the morning and evening, 10/5/23 in the evening, and 10/6/23 in the morning. 41129 On 3/8/23 at 2:55 p.m., the Director of Nursing provided the current Medication Administration: General Policies & Procedures which read .Medications are administered as prescribed in accordance with good nursing principles and practices . 3.1-32(a) 3.1-35(a) 3.1-35(b) This Federal tag relates to Complaint IN00424343.

Based on observation, interview, and record review, the facility failed to ensure a gait belt was utilized during resident transfers and fall prevention measures were implemented during a residents' transfer that led to them being lowered to the ground for 1 of 6 residents reviewed for ADL (Activities of Daily Living) and 1 of 3 residents reviewed for accidents. (Resident 2 and 97) Findings include: 1. The clinical record for Resident 97 was reviewed on 3/7/24 at 11:43 a.m. The diagnoses included, but were not limited to, spinal stenosis, anemia, dysphagia, weakness, lack of coordination, and mixed receptive-expressive language disorder. An Admission Minimum Data Set (MDS) assessment, dated 1/16/24, indicated he was cognitively intact, had impairment to one side of the upper extremities, partial/moderate assistance with sit to standing, and partial/moderate assistance with chair/bed-to-chair transfer. An interview conducted with Resident 97, on 3/7/24 at 10:15 a.m., indicated he had fallen a couple of days prior to the interview. The CNA (Certified Nursing Aide) came in and they didn't utilize a gait belt. A gait belt was observed to be folded and located on top of the air conditioning/heat unit in his room. Resident 97 indicated that gait belt had not been utilized in over a month. The CNA held underneath his right arm while he stood upwards. His wheelchair was not locked on one side and when he attempted to sit down the wheelchair moved back while he attempted to sit down. He also had no footwear on and indicated the floor was slippery when he doesn't wear any non-skid footwear due to callouses on his feet. He was then lowered to the floor by the nursing staff. An event report, dated 3/3/24, indicated Resident 97 fell next to his bed, wheelchair was in use, and the fall was assisted. A progress note, dated 3/3/24 at 11:00 a.m., indicated the following, .summoned to resident room via CNA on duty. Upon entering, resident was noted sitting on floor next to bed. CNA on duty stated she had to guide resident to the floor as he became unsteady during transfer from bed to w/c [wheelchair] A fall care plan, edited 3/5/24, indicated Resident 97 was at risk for falling and fall related injuries related to required assistance from staff for transfers, utilized wheelchair, history of falls, and had an indwelling catheter in place. The approaches included, but were not limited to, assist of 1-2 staff with transfers, assistance with activities of daily living (ADLs) to meet needs, and encourage resident to wear gripper socks when out of bed if shoes are not worn (added on 3/8/24). An interview with the Director of Nursing (DON), on 3/7/24 at 10:20 a.m., indicated he believed there were students in Resident 97's room at the time of the fall event and they did not have the items in place when transferring Resident 97. An interview with the DON, on 3/8/24 at 11:00 a.m., indicated he added gripper socks to Resident 97's plan of care. An interview with the DON, on 3/8/24 at 12:22 p.m., indicated there was no facility policy on the utilization of a gait belt. 40287 2. The clinical record for Resident 2 was reviewed on 3/6/24 at 10:50 a.m. The Resident's diagnosis included, but were not limited to, multiple sclerosis and dementia. A care plan, initiated 11/17/22, indicated that Resident 2 was at risk for falls related to needing assistance of staff with transfers. The goal was for the risk for falls and fall related injuries to be minimized. The interventions included, but were not limited to, assist with ADLs to meet needs, initiated 11/17/23, observe for and report any functional changes, initiated 11/17/23, and call don't fall sign added to the room, initiated 12/5/23. On 3/6/24 at 10:50 a.m., Resident 2 was observed being transferred from her wheelchair to her recliner chair in her room. CNA (Certified Nursing Assistant) 3 positioned the wheelchair close to the recliner. CNA 3 then put her hands on either side of Resident 2 just under her armpits and lifted Resident 2, pivoting with her and sat Resident 2 into her recliner chair. No gait belt was used. Resident 2 had a slight grimace on her face during the transfer. A sign was observed posted by Resident 2's door which read Helping [Resident 2] move lift with gait belt not arms or shoulders to standing use walker. She pivots with walker, lower to next seat with gait belt. A gait belt was hanging on a hook behind the door. Resident 2 indicated that the staff sometimes used the gait belt. During an interview on 3/08/24 at 1:43 p.m., the TM (Therapy Manager) indicated that Resident 2 had decreased range of motion in her shoulder. A gait belt was important to use for safety when transferring residents, especially with Resident 2. The Indiana State Department of Health Nurse Aide Curriculum, revised November 19, 2015, indicated the following, .PROCEDURE #24: USING A GAIT BELT TO ASSIST WITH AMBULATION .3. Place belt around resident's waist with the buckle in front and adjust to a snug fit ensuring that you can get your hands under the belt .4. Assist the resident to stand on count of three .6. Stand to side and slightly behind resident while continuing to hold onto belt .PROCEDURE #26: TRANSFER TO WHEELCHAIR .2. Place wheelchair on resident's unaffected side .4. Stand in front of resident and apply gait belt around the resident's abdomen 3.1-45(a)(2)

Based on interview and record review the facility failed to ensure accuracy of Minimum Data Set (MDS) assessments regarding restraint use and discharge location for 1 of 1 residents reviewed for Restraint use and 1 of 1 resident received for hospitalization . (Resident 5 and 106) Findings include: 1. The clinical record for Resident 5 was reviewed on 3/8/24 at 11:05 a.m. The diagnoses included, but were not limited to, dementia, impaired mobility, and cerebrovascular accident (CVA). A Quarterly MDS assessment, dated 2/15/24, indicated the chair prevents rising under the restraint section and it was utilized less than daily. There were no care plans for restraint use and/or physician orders for the utilization of a restraint. An Occupational Therapy (OT) note, dated 11/1/23, indicated the utilization of a pommel cushion but no restraint. An interview conducted with the Director of Nursing (DON), on 3/7/24 at 10:00 a.m., indicated the MDS for Resident 5 was miscoded and it was corrected. Resident 5 does not utilize any restraints. 34850 2. The clinical record for Resident 106 was reviewed on 3/7/24 at 9:00 a.m. The diagnosis for Resident 106 included, but was not limited to, thoracic vertebra (middle of spine) fracture. The discharge MDS assessment completed on 1/17/24 indicated the resident was discharged to an acute hospital. A nursing progress note dated 1/17/24 indicated Resident 106 was discharged home. An interview was conducted with the MDS Coordinator on 3/7/24 at 10:36 a.m. She indicated the discharge MDS assessment completed on 1/17/24 for Resident 106 was coded in error. It should have been marked as discharged to home. An interview was conducted with the Director of Nursing on 3/8/24 at 8:50 a.m. He indicated the facility did not have a policy regarding MDS accuracy. The facility follows the RAI (Resident Assessment Instrument) manual.

Based on observation and record review, the facility failed to maintain an infection prevention and control program by not ensuring a urinary catheter's tubing was off of the floor for 1 of 2 residents reviewed for a urinary catheter. (Resident 89) Findings include: The clinical record for Resident 89 was reviewed on 3/7/24 at 9:58 a.m. Resident 89's diagnoses included, but not limited to, urinary tract infection, atrial fibrillation (irregular heartbeat), sacral pressure ulcer stage III, and obstructive and reflux uropathy (difficulties in urination). A Brief Interview for Mental Status (BIMS) assessment completed on 3/6/24 indicated Resident 89 was cognitively intact. An observation of Resident 89 on 3/5/24 at 11:30 a.m. found Resident 89 asleep in his bed and his urinary bag and tubing were lying on the floor. An observation on 3/7/24 at 1:38 p.m. found Resident 89 asleep in his bed with his Foley catheter bag and tubing lying on the floor. Resident 89's care plan dated 1/9/24 indicated, Resident 89 required an indwelling urinary catheter related to obstructive uropathy. One of the interventions indicated, Do not allow tubing or any part of the drainage system to touch the floor. A Catheterizing The Urinary Bladder with an Indwelling Catheter Skills Validation received on 3/7/24 at 3:42 p.m. indicated, For a Male Residents .18. Position the drainage bag below the level of the bladder at the side of the bed *no tubing must touch the floor. 3.1-18(a) 3.1-18(b)

Based on observation, interview and record review, the facility failed to recognize a severe weight loss and implement prevention interventions in a timely manner to prevent a resident from experiencing a 30.6% severe weight loss for 1 of 4 residents reviewed for nutrition (Resident #107) and failed to provide weight loss interventions to 1 of 4 residents reviewed for nutrition. (Resident B). These deficiencies impacted 2 of 4 residents reviewed for nutrition and weight loss. Findings include: 1. Resident #107's record was reviewed on 2/6/15 at 10:49 a.m. [DIAGNOSES REDACTED]., vitamin deficiency, diabetes mellitus type II, and [MEDICAL CONDITION]. On 2/5/15 at 12:25 p.m., Resident #107 received meatloaf, green beans and potatoes, mashed potatoes and brown gravy, bread and butter and he had 2 chocolate covered strawberries on a plate in front of him with a glass of nectar thickened juice for lunch. He was eating with his left hand in the main assist area dining room with his fingers, then he picked up his fork and used it for a minute. His meatloaf was not cut up into pieces at that time, so he tore pieces of meatloaf off the slice of meatloaf with his fingers. He picked up his fork and attempted to cut a piece of the meatloaf off the slice, but when he could not do that, he went back to picking the meatloaf up with his fingers. He was observed cutting the slice of meatloaf into pieces with only his left hand. He was observed having trouble getting food onto his fork at times. He would lean forward in his wheelchair for awhile, then he would lean back against the back of the wheelchair and try to eat his lunch. At that time when he was leaning forward in his wheelchair was the time he had the most trouble getting the food onto his fork. He closed his eyes and had facial grimacing with furrowed brows when he swallowed bites of food or his NTL juice. He ate 75% of his meal and drank 4 ounces of his juice and pushed himself away from the table. No staff was present to assist the resident finishing his meal after he had finished eating. A lunch meal ticket dated 2/5/15, indicated the following food items were circled: 2 ounces (oz) meatloaf-LS (Low Sodium) with 1 oz NTL brown gravy-LS, 4 oz green beans and potatoes-LS, 4 oz steamed broccoli-LS, 1 slice bread and 1 iced sugar cookie. The resident's lunch meal lacked the steamed broccoli and the iced cookie. On 2/5/15 at 5:24 p.m., Resident #107 was observed receiving baked chicken, baked beans, coleslaw, dinner roll, pudding parfait and an 8 oz glass of nectar thickened juice for his dinner meal. An unidentified CNA assisted the resident with his chicken and cut the chicken into large pieces. He was eating with his left hand in the main assist area dining room. He was observed to chew a piece of chicken multiple times before he swallowed it. He had a lump of food on the right side of his cheek and placed more food in his mouth and chewed that food multiple times before he swallowed. The resident was observed taking a piece of chicken out of his mouth and he placed it on his plate, while he continued to chew the food he had in his mouth. He was observed taking a large piece of chicken out of his mouth and placed it on his plate, then the large lump in the right cheek area was gone. The resident ate 75% of his meal, while only 15% of that 75% he ate was his baked chicken. He drank 4 oz of the NTL juice. No staff was present to assist him to finish his meal after he had finished eating. A dinner meal ticket dated 2/5/15, indicated the following food items were circled: 8 oz NTL Pureed vegetable soup, 2 oz each piece baked chicken-LS, 1 piece corn on the cob-LS, #10 scoop creamy coleslaw-LS, dinner roll and #8 scoop pudding parfait. The resident's dinner meal lacked the pureed vegetable soup and the corn on the cob. On 2/6/15 at 8:03 a.m., Resident #107 was observed eating a breakfast meal with a banana cut into slices, a small bowl of oatmeal and scrambled eggs with an 8 oz glass of NTL water and NTL cup of coffee to drink. He was observed eating the banana with his fingers. He ate 50% of his breakfast and drank 4 oz of his water and 2 oz of his coffee. His toast did not have butter or jelly on it and he only took one bite of the dry toast. No staff was present to assist him to finish his meal after he had finished eating. On 2/6/15 at 1:25 p.m., the resident was observed laying in bed with his lunch tray in front of him eating corn with a fork out of a 1/2 filled bowl of corn,. He ate a 1/2 a hamburger on a bun and he had ate his salad and his dessert. He had a full glass of NTL water sitting on his lunch tray and he took a drink of the water. On 2/6/15 at 1:32 p.m., CNA #6 was observed picking up the resident's tray. The resident's Medication Administration History dated February 2015, included, but were not limited to, the following orders: 1/18/15--Offer bedtime snack 1/21/15--Magic cups (a supplement) twice daily between meals at 10:30 a.m. and 2:30 p.m. 2/4/15--2 gram Na (Sodium) diet with NTL. The resident's weights taken from the computer under the "Vitals" tab from the last 180 days were as follows: 08/02/14--175 09/01/14--173 09/19/14--170 09/22/14--172 10/01/14--174 11/03/14--175 12/04/14--169 12/29/14--138 01/05/15--134 01/12/15--134 01/13/15--137 01/14/15--137 01/19/15--131 01/21/15--134 01/28/15--134 02/01/15--135 The resident's weights taken from the Medication Administration History documentation dated August 2014 thru January 16, 2015, for the last 180 days included, but were not limited to the following: 08/02/14--175 09/01/14--159 09/19/14--not documented 10/01/14--148 11/03/14--149 12/04/14--146 12/29/14--not documented 01/05/15--not documented 01/12/15--134 01/13/15--134 01/14/15--137 The resident's annual MDS (Minimum Data Set) assessment dated [DATE], indicated he required supervision with setup of his meal tray during mealtime. He did not have any swallowing disorders, his weight was 173 and he had not had any weight loss. The CAA (Care Area Assessment) summary for Nutritional Status dated 9/17/14, for the annual MDS assessment dated [DATE], indicated "Resident receiving a regular diet with adequate intakes. BMI (Body Mass Index) is slightly in overweight category. Registered Dietitian reviews as needed. Will continue to monitor." The resident's significant change MDS assessment dated [DATE], indicated he required extensive assist with one person physical assist with eating. He did not have any swallowing disorders, his weight was 134, and he was on a therapeutic diet. The CAA summary for Nutritional Status dated 2/9/15, for the significant change MDS assessment dated [DATE], indicated "resident remains at risk for altered nutritional and weight status related to need for therapeutic diet prescribed due to hx (history) of [MEDICAL CONDITIONS]. resident with significant weight loss at this time. Interventions per IDT (Interdisciplinary Team) and RD (Registered Dietitian) recommendations." An "IDT Clinically At Risk Review" note dated 1/7/15 at 4:18 p.m., indicated the note was a weekly review and Resident #107 was an ongoing risk for skin and wound issues and weight loss. The root cause indicated the resident's weight loss was possibly related to flu like symptoms, [MEDICAL CONDITION] and [DIAGNOSES REDACTED]. The current status indicated he had a 3.7 pound weight loss in the last week. He had been on antibiotic therapy for flu like symptoms and wry neck. He was to be seen by the Gastrointestinal Physician related to visible blood in his stool and a low hemoglobin. The interventions the IDT had in place were obtain weight as ordered, complete labs as ordered by the Physician, administer the resident's medications, treatments and diet as ordered. An "IDT Clinically at Risk Review" note dated 2/4/15 at 4:23 p.m., indicated the note was an initial review and Resident #107 was a new risk for weight loss. The root cause indicated he had experienced weight loss related to dysphagia and poor food intake. The resident's current status indicated his weight had increased 0.8 pounds the last 4 days. The interventions the IDT had in place was weekly weights, MVI with minerals, a regular diet with NTL, fortified cereal with breakfast, a magic cup twice a day between meals, a 2 gram Na diet and a snack at bedtime. A "Nutritional Assessment Comprehensive" dated 9/22/14 at 8:39 a.m., indicated the assessment was for a readmission. He was on a 2 gm Na diet. He ate in the area dining room and weight 173 lbs. His UBW (usual body weight) was 170-180 lbs and his IBW (ideal body weight) was 128-156. His body mass index (BMI) was 27.9. He had not lost 5% or more in a month or >10% in 6 months. He consumed an average of 50-75% of his food at meals. His total calories, total protein required to meet his estimated needs were 60-80 grams of protein /day. His weight status was BMI <18.5 or >24.9. His oral/nutritional intake of food met 25-75% of his estimated needs. The RD Summary indicated he was on a regular 2 gm Na diet order. He remained at risk for altered nutritional/weight status related to being on a regular 2 gram Na diet. The interventions indicated no new recommendations at that time. A "Nutritional Assessment Short Form" dated 11/12/14 at 1:05 p.m., indicated the resident did not have any swallowing disorders. He weighed 175 pounds. His BMI was 28 and he was on a therapeutic diet. His diet order was 2 gram Na and he received routine snacks. He consumed an average of 76-100% of his meals. The summary indicated "resident continues to receive therapeutic diet with adequate intakes. BMI is slightly in the overweight category...." A "Nutritional Assessment Comprehensive" dated 1/18/15 at 7:56 p.m. indicated the assessment was for a readmission. The diet order was 2 gm NA. The resident ate his meals in the area dining room and he weighed 137 pounds. His IBW should be 133-163. His BMI was 21.4. He had lost 5% or more in the last month or 10% or more in the last 6 months and he was not on a prescribed weight loss regimen. His average food intake at meals was 50-100%. His total protein required to meet his estimated needs was 62-80 grams of protein/day. His weight status was BMI 18.5 to 24.9. He had a less than 7.5% weight change in 90 days and a less than 10% weight change in 6 months. His oral/nutritional intake met 76-100% of his estimated needs and met 26-75% of his estimated needs. The RD Summary indicated The Interventions were he was to follow a 2 gram Na diet order, MVI with iron and the weekly weights monitored. The note indicated because of his history of weight loss the RD suggested fortified cereal with breakfast, magic cup twice daily between meals. Additional Observations indicated the resident had about a 21% weight loss over 164 days. A Therapy Screen note dated 1/20/15 at 11:52 a.m., indicated the screen date was 1/20/15 and the facility referral was because the resident had increased dehydration/malnutrition. The ST (Speech Therapy) services warranted at that time was to monitor safe oral intake with LRD (Larygopharyngeal Reflux Disease) (the backup of gastric content into the larynx and pharynx). His swallowing function was poor. There was a recent weight loss or diet change. The evaluation recommendation was for Speech therapy. A Speech Therapy (ST) progress note dated 1/22/15 at 12:57 p.m., indicated "recommended diet at this time is regular diet with NECTAR THICK LIQUID. Medication consumed via NTL consistency. Pt (patient) to upright 90 degrees for all meals or in dining room with supervision. compensatory safe swallow strategies Include: small sips, small bites, complete oral hygiene prior to meals, be sure dentures are in place prior to oral intake, upright following meal for 20-30 minutes." A physician progress notes [REDACTED]. 01/28/2015 10:49 AM Weight 134.4 lbs... 01/21/2015 5:04 PM Weight 134.0 lbs... 01/19/2015 2:21 PM Weight 130.8 lbs... Acceptable Range: 5 percent change in weight in 30 days. 01/14/2015 11:19 AM Weight 137.0 lbs... 01/14/2015 9:48 AM Weight 137 lbs... 01/13/2015 11:19 AM Weight 136.6 lbs... 01/12/2015 11:19 AM Weight 134.2 lbs... 01/05/2015 4:18 PM Weight 134.4 lbs...12/29/2015 11:21 AM Weight 138.0 lbs... Assessment: 1. Weight loss. Plan: Weight loss <10%, Continue nursing and dietary interventions, Will not intervene with appetite stimulation meds until 10% weight loss...." The resident's record was reviewed from 8/1/14 to 2/11/15, and the record lacked documentation that the Physician was notified of a severe weight loss of 30.6% in 180 days. A RD progress note dated 2/9/15 at 12:59 p.m., indicated "Resident with weight loss and stage 1 PU (pressure ulcer). current weight of 135 lb (pounds) reflects a BMI WNL (within normal limits) at 21.7. Weights past few weeks have ranged around 134 +/-2-5 lb. Diet remains regular 2 g Na with intakes averaged at ~ (about) 50%...Nutrition interventions in place include MVI w (with)/minerals, fortified cereal with breakfast, Magic Cup BID (twice daily) b/w (between) meals...weights monitored...." A ST progress progress note dated 2/9/15 at 2:55 p.m., indicated "Pt to be upright 90 degrees for all oral intake with supervision to encourage hydration/nutrition and increased PO (by mouth) intake...." The resident had a Care Plan dated 1/19/15, that addressed the problem he was at risk for weight loss related to [MEDICAL CONDITION], poor food intakes and he removed his dentures and sat them on the table. The approaches included, but were not limited to, "1/21/15--Fortified cereal with breakfast, Magic cup BID (twice daily) between meals...supplements as needed." The resident had a Care Plan dated 1/22/15, that addressed the problem he had dysphagia and a potential for complications related to nectar thick liquids. The approaches included, but were not limited to, "...1/22/15--Monitor and record intake, Observe resident for difficulty swallowing, coughing, watering eyes during meals, and/or aspiration...." The resident had a Care Plan dated 2/4/15, that addressed the problem he was experiencing weight loss related to dysphagia and inconsistent po intake. The approaches included, but were not limited to, "2/5/15--Encourage res to feed himself as much of meal as res can and offer assistance with remainder of meal. 2/4/15--diet as ordered, fortified cereal with breakfast, HS snack, Magic cup BID between meals...." The resident's meal intakes were reviewed from 8/1/14 to 1/31/15 and he averaged these intakes for the following meals: Breakfast-51-75% Lunch-51-75% Dinner-51-75% The resident's supplement intakes were reviewed for the following times and months and he averaged these intakes: 1/22/15 thru 1/31/15 10:30 a.m.-0-50% 2:30 p.m.-25-50% 2/1/15 thru 2/6/15 10:30 a.m.-50-100% (2/3/15-resident was unavailable) 2:30 p.m.-0-50% During an interview on 2/09/15 at 1:18 p.m., the RD, Director of Dining Services (DDS), Dietary Manager (DM), Director of Nursing (DON) and Clinical Nurse Consultant (CNC) were present. The RD indicated she was going to look at his fluids and at his diuretic use in regards to his weight loss. She indicated he had not had MedPass or house shakes as far as she knew as a supplement since he had the severe weight loss. She indicated if residents with weight losses had meal intakes above 50% they did not routinely get Medpass, boost or house shake as a supplement. She indicated the resident was not to eat alone in his room due to he had dysphagia and required supervision during meals. The Director of Dietary Services (DDS) indicated at that time if food items were circled on a meal ticket, the resident had chosen those food items as his meal preferences for that particular meal. She indicated if the resident was unable to fill the meal ticket out himself and did not have family to assist him, the CNA's would assist him in circling his food item preferences for his meals. The DDS indicated the resident should have gotten the food items that were circled on his meal ticket. She indicated he would have gotten the main meal for breakfast if he did not have any food items circled on his meal ticket or Dietary Aide #10 would have asked him what he wanted before she started serving his meal. The DM indicated at that time Resident #107 received fortified cereal and a banana with breakfast and a magic cup between meals as interventions to prevent him from losing weight and to try to maintain his weight. The CNC indicated at that time the resident's monthly weights were not documented accurately and she believed that a previous Unit Manager (UM) that worked at the facility was putting the wrong weights in the computer for this resident. She indicated the previous Unit Manager was documenting monthly and weekly weights in the computer that were not the same weights as the daily weights the nurses caring for the resident were documenting in the Electronic Medication Administration Record. During an interview on 2/10/15 at 8:40 a.m., the Administrator indicated she had not seen corn on the cob served at the facility and she was surprised to see it listed as a food item selection on Resident #107's dinner meal ticket. During an interview on 2/10/15 at 9:30 a.m., the DON indicated the resident did not get any supplements started until 1/21/15, because the UM of the unit the resident resided on did not accurately document his weight each week and month. She indicated the monthly and weekly weights the UM documented in the computer did not match up to the daily weights that were being documented in the computer by the floor nurses and she did not realize he had a significant weight loss until December. She indicated when she noticed the weight inaccuracies the IDT started him on supplements. She indicated they implemented interventions as soon as they caught the significant weight loss and the resident was starting to gain weight then. She indicated the supplements were started on 1/21/15, not in December when the inaccuracies were discovered. During an interview on 2/11/15 at 12:15 p.m., Speech Therapist (ST) #11 indicated the resident was on Speech Therapy for silent aspirating thin liquids (ingesting fluids into the lungs without coughing to protect the lungs). She indicated he got fatigued easily while eating and he did not have much of an appetite because he ate three to four bites when she was with him, then he did not want anymore to eat. She indicated on 2/6/15, she was with him until 1:00 p.m. supervising his meal, then she had left his meal tray in his room. After leaving his room she went to inform the nurse that he was done eating and he was complaining of groin pain and she did not re-enter his room. She indicated she talked with the DM on 2/10/15, regarding the resident's decreased appetite and if he was on an appetite stimulant. She indicated the DM indicated she did not think he was on an appetite stimulant, but she was going to inquire about getting one for him. 2. Resident B's record was reviewed on 2/5/15 at 4:06 p.m. [DIAGNOSES REDACTED]. On 2/05/15 at 12:19 p.m., the resident was observed receiving meatloaf, broccoli, mashed potatoes and gravy, bread and butter, peaches, a sugar cookie and an 8 oz glass of prune juice. He was in a family member's room eating with her. A lunch meal ticket dated 2/5/15, indicated the following food items were circled: 2 ounces (oz) meatloaf with 1 oz brown gravy, #10 scoop mashed potatoes and 1 oz gravy, 4 oz steamed broccoli, 1 serving fruit of the day and 1 iced sugar cookie. The resident had a diamond symbol next to #8 scoop fortified pudding and 8 fluid oz whole milk. On 2/05/15 12:57 p.m., the resident ate 75% of his meal and his family member's fruit and cookie. He drank his prune juice. His meal tray lacked the fortified pudding and whole milk when he received it and he did not receive either one by the time he had left his family member's room to go back to his room after lunch at that time. On 2/05/15 5:59 p.m., Resident B was observed receiving a dinner tray in a family members room with baked BBQ chicken, coleslaw, baked beans, parfait pudding, an 8 oz glass of water and an 8 oz glass of milk. The resident did not drink any of his milk. He ate 50% of his meal. He ate his family member's apricots and he did not eat his own dessert. He drank 6 oz of his water. A dinner meal ticket dated 2/5/15, indicated the following food items were circled: #10 scoop baked beans, #10 scoop creamy coleslaw, #8 pudding parfait and thigh was written above the 2 oz each piece BBQ chicken. The resident had a diamond symbol next to 8 fluid oz whole milk. At that time, the resident indicated he did not usually get milk on his tray for meals except for at breakfast and he only used it for his cereal. He indicated he had not been getting milk with his meals until this meal. He indicated he did not drink milk. On 2/06/15 8:05 a.m., the resident received an 8 oz glass of milk and a 4 oz glass of milk, a bowl of oatmeal, a banana and a bowl of corn flakes. He received a cup of coffee to drink. He ate 75% of his breakfast. At that time, Resident B's family member indicated he was never a big breakfast eater and all he ate for breakfast was a bowl of hot cereal and a bowl of cold cereal. She indicated that was why that was all he ate at the facility because he did not eat a traditional breakfast of eggs and breakfast meat when he was at home. The resident's Physicians Orders dated February 2015, included, but were not limited to the following orders: 7/21/14--Whole milk three times a day with meals. 8/31/14--Fortified cereal with breakfast daily. 10/5/13--Regular diet. 1/9/15--Offer resident bedtime snack. 1/17/15--MedPass (a supplement) 120 ml by mouth three times a day at 8:30 a.m., 11:30 a.m. and 4:30 p.m. (Discontinued 2/10/15) The resident had a Care Plan dated 1/7/15, which addressed the problem he was experiencing weight loss related to decreased appetite and poor food intake. The approaches included, but were not limited to, "2/5/14-Fortified pudding at lunch. 1/16/14--Med pass 120 ml TID (three times daily). 1/7/15--Cont (continue) fortified cereal with breakfast, cont whole milk TID with meals, diet as ordered...." The resident's meal intakes were reviewed from 9/1/14 to 2/10/15 and he averaged these intakes for the following meals: Breakfast--76-100% Lunch--50-100% Dinner--50-100% The resident's weights taken from the computer under the "Vitals" tab from the last 180 days were as follows: 08/05/14--146 09/03/14--146 09/08/14--146 10/04/14--141 10/28/14--135 11/03/14--133 11/10/14--135 11/17/14--136 11/24/14--137 12/01/14--140 01/05/15--131 01/14/15--134 01/19/15--134 01/26/15--133 02/04/15--135 A "Nutritional Assessment Comprehensive" note for an annual review dated 8/25/14 at 8:37 a.m., indicated his weight was 146. His BMI was 19.8. His BMI was lower for his age at 19. The resident remains at risk for altered nutritional/weight status related to regular diet order, history of weight loss (not significant) lower BMI for his age at 19. A RD progress note dated 11/3/14 at 12:51 p.m., indicated "current weight of 134 lb (pound) reflects a 4.5% decline x ~ (about) 1 month from weight of 141 lb and 12.5% x 176 days from weight 152 lb. BMI is lower for age of 18.7. Intakes on regular diet are averaged at 50-100%...." An "IDT Clinically At Risk Review" note dated on 11/5/14 at 2:17 p.m., indicated the resident was a new risk for skin and wound issues. The root cause was he had a weight loss related to decreased appetite. His current status was he had an 8.8% weight loss during the last 2 months. A "Nutritional Assessment Short Form" note dated 11/24/14 at 7:55 p.m., indicated he weighed 137 pounds. His BMI was 18.6. He had not lost 5% or more in the last month or 10% or more in the last 6 months. He consumed an average of 51-100% of his meals. The summary indicated "... however had weight loss in October 2014...." An "IDT Clinically At Risk Review" noted dated on 1/7/15 at 1:44 p.m., indicated the resident was a new risk for weight loss. The root cause was poor appetite and food intake. The current status was the resident had an 8 lb weight loss within the last 30 days. A RD progress note dated 1/12/15 at 3:17 p.m., indicated "resident's current weight of 131 lb (pound) reflects a 6.2% decline x 35 days and 12.1% x 160 days. BMI is low at 17.1. Diet is regular with fluctuating PO (by mouth) intakes ~ (about)50-75%...." An "IDT Clinically At Risk Review" noted dated on 1/21/15 at 12:59 p.m., indicated the resident was an ongoing risk for weight loss. The root cause was poor appetite and food intake. The current status was he had a 0.4% weight loss during this week. A nursing progress note dated 2/5/15 at 2:30 p.m., indicated "Noticed at end of afternoon meal pass, fortified pudding was not on meal tray but in refrigerator. Offered fortified pudding and whole milk as afternoon snack. Resident refused both. Staff encouraged res (resident) to eat pudding and drink milk. continued to refused (sic) but allowed staff to leave in room at bedside in case res changes his mind." A nursing progress note dated 2/5/15 at 4:12 p.m., indicated "Resident consumed 50% of fortified pudding but continued to refuse the whole milk. Asked writer to get rid of it." During an interview on 2/9/15 at 1:18 p.m., the Director of Dining Services indicated if the resident had a diamond symbol next to a food item on his meal ticket that symbolized the resident was to receive that food item at that meal. During an Interview on 2/09/2015 2:08 p.m., the Dietary Manager indicated she noticed when the kitchen was being cleaned up that there was a fortified pudding left in the refrigerator and that Resident B did not get his fortified pudding and his whole milk at lunch, so she took it down to his room. She indicated she tried to give the fortified pudding and whole milk to him, but he did not want either one. She indicated she left the pudding and milk in the resident's room on his bedside table and told the nurses that she left them for him. During an interview on 2/09/15 2:12 p.m., the Clinical Nurse Consultant indicated on 2/5/14, there was documentation that the resident was offered his whole milk and fortified pudding after the staff realized he did not receive it with his lunch tray and it was documented at 2:30 p.m. During an interview on 2/11/15 4:52 p.m., the DON indicated she was unable to locate any [MEDICATION NAME], pre-[MEDICATION NAME] or total protein laboratory tests for either of these residents in the last year since [DATE]. A current policy titled "Nutrition & Hydration At Risk Program" undated, provided by the DON on 2/9/15 at 10:35 a.m., indicated "Residents at nutrition and/or hydration risk will be identified through the interdisciplinary process. Residents who are found to be at risk are placed on a Nutritional/Hydration Risk Program. Residents are reviewed through the Interdisciplinary Nutrition at Risk (NAR) meeting bi-monthly...Residents who develop conditions/needs as listed below may be placed in the nutrition/hydration at risk monitoring program: Residents with weight loss of 5% in one month and 10% in 6 months which was not desired or expected...The RD is responsive for recommending nutritional interventions... If there is a significant weight loss, the licensed nurse will add the resident to the bi-weekly weight list and the nutrition at risk program...." A current policy titled "Nutritional and Weight Monitoring" undated, provided by the DON on 2/9/15 at 10:35 a.m., indicated "...Weights are collected and reviewed monthly (or bi-monthly if on NAR (Nutrition at Risk); or weekly for 4 weeks if the resident is a new admission) and recorded on the resident's weight record. Significant weight loss is defined as: 5% in 1 month, 7.5% in 3 months, 10% in 6 months... Once the weight loss is verified, nursing will notify the RD/CDM (Registered Dietitian/Certified Dietary Manager) in writing. The licensed nurse will also notify the resident's physician and the resident's responsible party of the significant weight loss. The RD/CDM is responsible for reviewing each resident with unplanned weight loss, recommending the appropriate intervention and documenting in the resident's clinical record...." 3/1-46(a)(1)

Based on observation, record review and interview the facility failed to ensure the hydration needs of dependent residents, in that when residents required the facility nursing staff to provide sufficient fluids to meet hydration needs the facility failed to ensure adequate hydration. A resident ("A") was transported to a local area hospital due to a change in condition where it was determined the resident had elevated electrolytes due to dehydration which required intravenous fluids to be administered. This deficient practice effected 3 of 3 sampled residents reviewed with [DIAGNOSES REDACTED]. (Residents "A", "B" and "E"). Findings include: 1. The record for Resident "A" was reviewed on 01-13-15 at 11:00 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. Prior to admission, the "New Admit Communication Form," from the facility clinical liaison indicated the following:"Acute [MEDICAL CONDITION] with frequent falls and UTI (urinary tract infection), [MEDICAL CONDITIONS] and elevated blood pressure." A notation at the bottom of the form indicated, "Pt. (patient) admitted with acute [MEDICAL CONDITION]. They checked her for UTI but it was mild. Pt. had some diarrhea so she is also dehydrated. Needs assistance with eating." A review of the resident's hospital "discharge summary," dated 10-09-14, indicated discharge [DIAGNOSES REDACTED]." A review of the "Nutritional Assessment - Comprehensive," dated 10-12-14, indicated the resident received a regular diet and consumed 1590 ml (milliliters) of fluids daily and an average daily meal consumption of 51 - 75 %. The dietician indicated the resident "was at risk for altered nutritional/weight status, r/t (related to) regular diet order AEB (as evident by) hx. (history) [MEDICAL CONDITION](hypertension), [MEDICAL CONDITION], skin alterations. Initiate Plan of Care." A review of the nursing admission assessment, dated 10-15-14, indicated the resident had no visual impairments, was alert, had no memory problems, had diarrhea, presented with moist oral mucosa, with no clinical signs or symptoms of dehydration. The nurse determined there was no need to proceed with a plan of care as the resident was not at risk for dehydration. The assessment indicated the resident weighed 115 lbs at the time of admission. A plan of care was developed, dated 10-15-14, and indicated a short term goal included, "Resident will remain well hydrated." Interventions included "encourage fluid intake, obtain and monitor lab work PRN (as needed)." In addition, the resident had complaints of loose stools on 10-15-14 and the physician ordered [MEDICATION NAME] two times a day for two weeks to aide in the resident's diarrhea/loose stools. The 14 day nursing assessment, dated 10-21-14 indicated the resident had "cognitive impairment, which prevents communicating needs or obtaining fluids independently. Functional impairment which prevents independent access to fluids. At risk for dehydration - proceed to care plan." The plan of care was not updated after this assessment. On 10-18-14 the resident was found with a "skin tear to the right lower leg." The resident was unable to inform the staff how the skin tear occurred, but the "change of condition event report," dated 10-18-14, indicated the area measured 1 centimeter by 1 centimeter with no complaints of pain by the resident. A progress note dated 10-21-14 at 10:25 a.m., indicated the area measured 1.2 centimeters by 1.4 centimeters. On 10-21-14 at 6:00 p.m., the progress note indicated "noted by other nurse that resident's RLE (right lower extremity) has turned red, warm to touch, and [MEDICAL CONDITION]." The physician was notified and instructed the nursing staff to administer Keflex 500 mg (milligrams) one tablet three times a day for 7 days. The 10-22-14 progress note indicated the resident was "nauseated by the antibiotic" and the physician was notified. The nursing staff received additional medication orders to aide in the resident's nausea. The 10-22-14 Nurse Practitioner notation indicated the resident had "chronic [MEDICAL CONDITION], a skin tear on RLE with "some withering from loss of fluid, there is some warmth, no tenderness and no [MEDICAL CONDITION]." The 10-24-14 Nurse Practitioner notation indicated the resident was evaluated for "vomiting and early dehydration, positive for nausea and vomiting. N/V (nausea /vomiting cause undetermined - [MEDICATION NAME] (a medication for nausea) ordered for treatment, monitor." The Nurse Practitioner also ordered [MEDICATION NAME] (a diuretic) 40 mg by mouth for three days. The resident continued to complain of nausea on 10-23-14, 10-24-14, 10-25-14, and 10-26-14 with some emesis noted. By 10-25-14 the resident began to refuse her medications. The 10-25-14 nurses progress note indicated a concerned family member requested the antibiotic to be administered intramuscularly as the resident began to refuse medications, and also requested intervenous fluids started due to the resident's decreased ability to consume food or fluids due to nausea and vomiting. The notes indicated the Nurse Practitioner was notified of the request but denied the family request as the Nurse Practitioner "stated that resident is not showing signs or symptoms of dehydration and that vomiting is not an indicator of intravenous fluids." During an interview on 01-13-15 at 2:50 p.m., a concerned family member indicated the family was aware the resident had a history of [REDACTED]. "She (the resident) had trouble swallowing and then she would vomit. The nurse said she called the doctor and was told 'no.' When we asked the nurse to ask the doctor why that decision was made, the nurse stated, "because he's the doctor and that's why." "I don't know who the nurse spoke with, but we spoke to the doctor and he said he was on vacation and had no idea the problems (resident) was having." A 10-26-14 at 9:43 a.m., the nurses progress note indicated, "Resident would not take any medications this a.m. d/t (due to) feeling 'nauseated.' Resident also refused to take any anti-nausea meds. (medications). Lying in bed with empty emesis basin at bedside." A review of the food intake record indicated the resident's appetite began to decline with food consumption diminishing from an average of 50 - 75 % to 1 -25 % at breakfast, lunch and dinner. Fluid intake diminished to 930 c.c. (cubic centimeters) on 10-22-14, 1220 c.c. on 10-23-14, 1620 c.c. on 10-24-14, 1740 c.c. on 10-25-14, 1560 on 10-26-14 and 840 c.c. on 10-27-14. The resident had a change of condition on 10-27-14 and was transported to the local area hospital via emergent transport 911. A review of the hospital record on 01-12-15 at 1:00 p.m., indicated the emergency documentation acknowledged the resident "per family member" had not been eating or drinking much and has had vomiting times 4 days." The hospital physician notation dated 10-27-14 indicated , "Impression: elevated BP (blood pressure), dehydration, AKI (acute kidney injury), dementia, leukocytosis and [MEDICAL CONDITION]. Plan: Dehydration: [MEDICAL CONDITION]. Secondary to lack of PO (by mouth) intake and N/V. On IVF (intravenous fluids). AKI: secondary to dehydration Cr. (Creatinine) 2.52 Baseline around 1.0. Generous IVF. [MEDICAL CONDITION]: likely hypovolemic [MEDICAL CONDITION] secondary to dehydration. History of present illness: She is a poor historian and is not able to give much information but does c/o (complain of) abdominal pain and nausea that she has had times 4 days. She has also had diarrhea. She also has had decreased appetite and fluid intake for the past several days. Of note, she was being treated for [REDACTED]. Review of Systems: Positive for nausea, vomiting, abdominal pain. Has had diarrhea in the past week. Mucous membranes are dry, lower abdominal tenderness." The resident received [MEDICATION NAME] 5% with 0.9 % of sodium KCL at 100 ml per hour. The hospital laboratory results included a Na+ (sodium) of 133 (normal range of 136 - 145), BUN 36 (normal range of 10-20), Creatinine of 2.52 (normal range of .7 - 1.2) and WBC (white blood cell count) 21.8. In addition the hospital tested the resident's lactic acid level (a test that measures the level of lactic acid made in the body which can be elevated due to infection), with a result of 0.9 (normal range .5 - 2.2) and subsequently diagnosed with [REDACTED]." 2. The record for Resident "B" was reviewed on 01-14-15 at 10:30 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. A review of the "New Admit Communication Form," indicated the resident had a history of [REDACTED]. does not talk but can follow some commands, has mild oral dysphagia, musculoskeletal weakness - bilaterally upper and lower extremities, acute [MEDICAL CONDITION] but now back to baseline. Pt. with extensive history of dementia and admitted to the hospital with [REDACTED]." The hospital discharge summary, dated 12-31-14, indicated the resident had mild oral dysphagia and dementia which was "impacting swallowing," and also while at the hospital the resident had an elevated BUN of 31 on 12-27-14 with a creatinine of 1.77 and needed to be "hydrated." Further review of the record indicated that on 12-30-14, after hydration the resident's BUN was 18, prior to admission to the facility. At the time the resident was admitted to the facility the resident weighed 210 lbs. (pounds) and had physician orders for [MEDICATION NAME] 20 mg every day. A review of the initial plan of care, dated 01-08-15, indicated the resident was at risk for dehydration due to cognitive impairment. Interventions to this plan of care included "encourage fluid intake, obtain and monitor laboratory work as needed and dehydration assessment per policy." A review of the 14 day assessment, dated 01-14-15 indicated the resident "rarely/never understands others, vision was moderately impaired, always incontinent of bowel and bladder," and risk factors for dehydration included "cognitive impairment which prevents communicating needs or obtaining fluids aindependently, functional impairment which prevents independent access to fluids and had the use of diuretics and/or laxatives." Resident is at risk for dehydration - proceed to care plan." Further review of the plan of care lacked any additional interventions. A review of a laboratory result, dated 01-12-15 indicated the resident's BUN was elevated at 30 (normal range 8 - 21), and Creatinine 1.37 (normal range of .64 - 1.27). A handwritten notation on this report instructed the nursing staff to "push fluids." In addition the resident had a change in condition, which required transportation to the local area hospital due to a laceration to the lip/mouth which continued to bleed and needed physician intervention. While at the hospital, the resident had blood work drawn and the laboratory results included a BUN of 34 "H" (high), Creatinine of 1.43 "H", and Sodium of 147 "H". Approximate fluid needs for this resident, based on a weight of 210 lbs, indicated the resident required approximately 2863 c.c. daily, (210 lbs divided by 2.2 kilograms per pound times 30 c.c. of fluids = approximate amount of daily fluid needs) . A review of the Total Intake of fluids in cubic centimeters (c.c.) for this resident from 12-31-14 thru 01-14-15 were as follows: 12-31-14 = 600 01-01-15 = 1081 01-02-15 = 630 01-03-15 = 1500 01-04-15 = 1500 01-05-15 = 1980 01-06-15 = 1140 01-07-15 = 1440 01-08-15 = 1980 01-09-15 = 2400 01-10-15 = 1600 01-11-15 = 1080 01-12-15 = 2400 01-13-15 = 1950 01-14-15 = 1680 The fluids needs of this dependent resident were not met. During an interview on 01-15-15 at 10:00 a.m., the corporate nurse consultant verified the dietician had not estimated the fluid needs for the resident. 3. The record for Resident "E" was reviewed on 01-13-14 at 2:00 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. At the time of the complaint survey the resident was identified by Licensed Nurse #3 as "in contact isolation due to [MEDICAL CONDITION]. ([MEDICAL CONDITION])." The resident had current physician orders for [MEDICATION NAME] 20 mg every day. The resident had a current plan of care, originally dated 04-14-14 which indicated the resident was "at risk for dehydration." Interventions to this plan of care included "Assess for dehydration (dizziness on sitting/standing, change in mental status, decreased urine output, concentrated urine, poor skin turgor, dry, cracked lips, dry mucus membranes, sunken eyes, constipation, fever, infection ,electrolyte imbalance). Assess risk factor for dehydration, Keep fluids accessible, monitor lab work and report abnormal's." A review of the current laboratory results in the resident's record indicated the resident BUN on 10-22-14 was 29, and Sodium 141. A subsequent laboratory result, dated 12-02-14 indicated the resident's BUN was 20, Sodium 147 (normal range 135 - 145) and WBC's (white blood cell count) was 14.89. This laboratory result identified the resident with [MEDICAL CONDITION]. The record indicated on 01-11-15 the resident continued with "Loose stools." The record indicated the resident weighed 146 lbs. on 12-04-14. Fluids needs for this resident were approximately 1990 c.c. daily, (146 lbs divided by 2.2 kilograms per pound times 30 c.c. of fluids = approximate amount of daily fluid needs) . A review of the fluid intake in cubic centimeters (c.c.) from 12-04-14 thru 12-04-14 indicated the following consumption: 12-04-14 = 1680 12-06-14 = 1690 12-07-14 = 1050 12-08-14 = 1800 12-09-14 = 1320 12-10-14 = 1790 12-11-14 = 1560 12-12-14 = 1800 12-13-14 = 1800 12-15-14 = 1980 12-16-14 = 1570 12-17-14 = 1680 12-18-14 = 1460 12-19-14 = 1460 12-20-14 = 780 12-21-14 = 1880 12-22-14 = 1680 12-23-14 = 1572 12-25-14 = 1770 12-26-14 = 1680 12-28-14 = 1740 12-29-14 = 1330 12-30-14 = 870 12-31-14 = 840 The record indicated the resident weighed 138.6 lbs on 01-05-15. Fluid needs for this resident were approximately 1890 c.c. daily. A review of the fluid intake from 01-01-15 thru 01-13-15 indicated the following fluid consumption: 01-01-15 = 1560 01-02-15 = 1680 01-03-15 = 1650 01-04-15 = 1560 01-05-15 = 2277 01-06-15 = 840 01-07-15 = 1730 01-08-15 = 2360 01-09-15 = 2010 01-10-15 = 2400 01-11-15 = 1920 01-12-15 = 840 01-13-15 = 1650 The record indicated on 01-11-15 the resident continued with "Loose stools." During an observation on 01-14-15 at 8:45 a.m., the resident was observed sitting up in bed. The resident's breakfast tray was on the overbed table in front of the resident. The only fluid observed on the tray was orange juice. The water pitcher was out of the resident's reach. During interview, the resident stated, "I ate my cereal, but I only got juice and no coffee." 4. A review of the facility policy on 01-15-14 at 9:00 a.m., dated as "revised" 11/12, titled "Hydration Monitoring," indicated the following: "Purpose" To aid each resident in receiving sufficient fluid intake to maintain hydration in accordance with calculated fluid needs." "Policy: It is the policy of this facility to monitor the resident's fluid balance in accordance assessed needs or problems." "Examples of resident problems or needs which may (underscored) required hydration monitoring: 1. Significant weight variances or identified nutritional risk. 2. diagnosed with [REDACTED]. 3. Functional impairments which prevent independent access to fluids. ... 5. Signs and symptoms of dehydration: weight loss, unusually dry skin, dry mucous membranes, dry cracked tongue, cracked lips, poor skin turgor, excessive thirst, fever, malaise, abnormal lab values (elevated Hbg (hemoglobin), K+ (potassium), Cl (chloride), Na+ (sodium), [MEDICATION NAME], transferrin, BUN (blood urea nitrogen) or urine specific gravity), abnormally low urinary output, highly concentrated urine. ... 7. Vomiting or diarrhea resulting in fluid loss." "Procedure: At the time of admission and periodically thereafter, the licensed nurse will assess the resident's need for hydration monitoring. Fluids needs will be calculated by the Dietary manager or the Registered Dietician. Fluids will be provided on meal trays, with between meal nourishments, medication administration, during activities programming, and offered frequently during care and resident contact. A minimum of 60% of the residents daily fluid needs will be provided on the resident's meal trays within a 24 hour period. A dehydration assessment will be completed upon admission and with significant changes in condition to assist in identifying risk factors and development of the plan of care. A plan of care shell be developed to address any hydration concerns. This plan of care will be developed utilizing the clinical conditions and risk factors identified, taking into account the estimated fluid needs of the resident. When indicated, shift and 24 hour fluid intake totals shall be calculated and analyzed by a licensed nurse. ... The attending physician shall be notified of significant hydration concerns." 5. A subsequent policy reviewed on 01-14-15 at 10:00 a.m., titled "Nutrition Hydration at risk Program," undated, indicated the following: "Resident's at nutrition and/or hydration risk will be identified through the interdisciplinary process. Residents who are found to be at risk are placed on a Nutritional/Hydration Risk Program." "Fluid intake will be documented on all residents for the 1st seven days of the resident's admission to asses in hydration monitoring." "The nutritional assessment completed on all residents by the RD (Registered Dietician) or the CDM (Certified Dietary Manager) will assist in determining those residents which are at an increased risk based upon [DIAGNOSES REDACTED]., Infection, Dehydration, constipation/Diarrhea, Dysphagia/chewing and swallowing problems, edentulous or ill-fitting dentures, totally dependent for eating, Abnormal lab values associated with malnutrition ([MEDICATION NAME], plasma transferrin, magnesium, hct/hbg (hemoglobin/hematocrit), BUN/creatinine ratio, potassium, cholesterol), use of medications such as diuretics, laxatives and cardiovascular agents." "The facility's interdisciplinary nutrition at risk committee will review the residents who are on the program on a bi-monthly basis. This review will include monitoring of the food intake and fluid intake records, the weight flow records, the clinical documentation, and the overall plan of care. The RD is responsible for recommending nutritional interventions." "A licensed nurse is responsible for analyzing the nutritional consumption documentation as it appears on the food intake record, and notifying the RD/CDM and the physician when there are nutritional concerns." This Federal tag relates to Complaint IN 111. 3.1-46(b)