Every finding on record at Harbour Manor Health & Living Community

Based on record review and interview, the facility failed to develop and implement a process to ensure the identity and competency of agency staff. This deficient practice had the potential to affect 122 of 122 residents in the facility. Findings include:During a confidential interview, on 5/18/26 at 11:43 a.m., it was indicated they were advised of a situation where CNA 8 was discovered to be working in more than one facility on the same date at the same time. They were able to contact both facilities and were provided with photographic evidence of CNA 8 and another employee, CNA 9, in different locations during this time frame. During an internal investigation, it was discovered that CNA 8 and CNA 9 had shared a staffing agency account and a banking account.A facility reported incident, provided by the Administrator on 5/18/26 at 11:45 a.m., indicated the following: On 5/8/26, a corporate payroll accounting discovered CNA 8 had worked the 2:00 p.m. - 10:00 p.m. shift on 5/3/26 at one facility through an agency contract while also working the 6:00 a.m. - 10:00 p.m. shift on 5/3/26 through her weekend option employment with another facility.A review of the facility investigation file, provided by the Administrator on 5/18/26 at 11:45 a.m., included the following:A copy of the facility reported incident page.An e-mailed internal investigation, from the staffing agency, indicating the following was discovered: CNA 8 was working at one facility from 6:00 a.m. - 10:00 p.m. CNA 9 had accepted a posted open shift at another facility while logged into CNA 8's agency account. CNA 9 worked a 2:00 p.m. - 10:00 p.m. shift at the other facility acting as CNA 8. Both facilities provided photographic evidence of each CNA working in their facilities. CNA 8 and CNA 9 had shared an agency account and a bank account which was against the agency's policies.A facility list of residents on CNA 9's assignment.Progress notes for each of the residents on CNA 9's assignment. Skin assessments, pain assessments, and psychosocial assessments were completed without concerns.A 5/8/26, in-service sign-in sheet related to education of the new process for verification of agency staff members. The sign-in sheet contained 7 facility employee names.A 5/11/26, current open shift listing for the staffing agency with the new instructions.During an interview, on 5/18/26 at 11:30 a.m., the Facility Scheduler indicated she posted detailed descriptions of each shift and its role on the agency website. The agency staff accepted the open shifts on the agency app. The facility had access to the agency staff licensure and profiles only. The open shift descriptions contained instructions for the agency staff members to report to the [NAME] nurse station, locate their name in the assignment log and report to the unit for hand off report and to relieve the outgoing staff member. These instructions were changed recently due to the events that occurred on 5/3/26. The current instructions indicated the agency staff member must report to the [NAME] nurse station and provide a photo identification (ID) to a nurse. A review of the schedules dated 5/4/26 - 5/17/26, provided by the ADON on 5/18/26 at 11:20 a.m., indicated the following: Two sets of initials beside each date an agency CNA had an assignment. (5/8/26, 5/9/26, 5/10/26, 5/11/26, 5/12/26, 5/15/26, 5/16/26, & 5/17/26)An online review of the professional licensing agency website, on 5/18/26 at 1:04 p.m., indicated the following:CNA 8 had an active CNA licensure and CNA 9 had an active CNA licensure.Resident B's clinical record was reviewed on 5/18/26 at 1:36 p.m. Diagnosis included Neuromyelitis optica (an autoimmune disorder), hypokalemia, and stage 3 pressure ulcer (full-thickness skin loss) of the sacral region. A 2/9/26, quarterly, Minimum Data Set (MDS) assessment indicated Resident B was dependent on staff assistance for toileting hygiene, personal hygiene, and transfers. Resident C's clinical record was reviewed on 5/19/26 at 11:21 a.m. Diagnosis included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, hypertension, and major depressive disorder. A 2/27/26, quarterly MDS assessment indicated Resident C was dependent on staff assistance for toileting hygiene, lower body dressing, and transfers. Resident D's clinical record was reviewed on 5/19/26 at 11:40 a.m. Diagnosis included Parkinson's disease, Alzheimer's disease, and peripheral vascular disease. A 2/25/26, quarterly MDS assessment indicated Resident D required substantial assistance from staff for toileting hygiene, personal hygiene, and transfers. During a telephone interview, on 5/19/26 at 9:40 a.m., CNA 8 indicated she was contacted by the facility corporate office and told she was found to be logged in working at two different facilities on 5/3/26 at the same time. On 5/3/26, she had been working at her weekend option job location and had worked a double shift from 6:00 a.m. - 10:00 p.m. A few days later another representative from the corporate office contacted her and showed her a photo of the other staff member. CNA 8 recognized the employee and identified her to the corporate office representative as CNA 9. CNA 8 and CNA 9 had a personal connection and relationship outside of work. CNA 8 had utilized CNA 9's cell phone to accept a different shift through the staffing agency app. CNA 8 thought she had logged out of her account, but it's possible she did not. CNA 9 was unable to obtain her own bank account and CNA 8 had allowed her to share her banking information. CNA 8 indicated she spoke with the agency to ensure documentation that the banking information was being used by two separate employees. CNA 8 indicated she thought CNA 9 made a mistake and was logged into the wrong account when she accepted the shift. CNA 8 indicated she had assisted in all investigations related to this incident.CNA 9 was unable to be contacted during the survey time period.A review of the agency identification folder, provided by the DON on 5/19/26 at 10:21 a.m., contained the following: Twenty-six (26) photocopied identification cards and/or passports. Some of the copies were labeled with the shift worked. The folder was kept in DON's office.A review of the agency education binder, located at the [NAME] nurse station, on 5/19/26 at 11:00 a.m. contained the following: Copies of the following policies and procedures - Resident Rights, Abuse, Standard Precautions, Spills, Hand hygiene, Respiratory etiquette, and Contact Isolation. The current sign-in sheet started on 5/8/26. During an interview, on 5/19/26 at 11:01 a.m., RN 6 indicated there was now a new process when an agency CNA arrived to the facility. The agency staff member must take a photo ID to the [NAME] nurse station. There, a facility nurse would make a copy of the ID and give it to the DON. The facility nurse and agency CNA both initialed the schedule to confirm that the verification took place. The agency CNA then reviewed the education binder and signed on the sign-in sheet. Once those steps were completed, the agency CNA reported to their assignment, received a tour of the unit, and got hand-off report. On 5/19/26 at 11:03 a.m., LPN 10 indicated all agency CNAs followed the instructions on the agency app. On 5/19/26 at 12:23 p.m., the DON indicated the situation was discovered on 5/8/26 when the corporate office was reviewing timecards. It was discovered that CNA 8 was working at two separate facilities at the same time on 5/3/26. The facility management started an investigation and interviewed the facility staff members to see which agency staff members they worked with on that day. The facility employees indicated the agency staff member identified herself as CNA 8. The management reviewed photographic evidence from the 5/3/26 shift. CNA 9 was seen on the photographic evidence. The facility staff interviewed all the residents on the affected assignment and found no concerns. Skin assessments, pain assessments, and psychosocial questions were completed for all affected residents without findings. On 5/19/26 at 12:35 p.m., the Administrator indicated the corporate office had reviewed timecards and discovered that CNA 8 had worked in two facilities at the same time on 5/3/26. Once he was made aware of the situation, he started an investigation and contacted the other facility and asked them to interview CNA 8. He asked the staffing agency to explore any other options that could cause this type of discrepancy. Through his investigation, communication with the secondary facility, and the staffing agency, it was discovered that CNA 8 was not the staff member working on 5/3/26 at this facility. CNA 9 was working under the account of CNA 8. The facility staff working on 5/3/26 indicated in interviews that they worked with an agency staff member who identified themselves as CNA 8. The facility interviewed the residents living on the affected assignment and there were no concerns. The facility completed skin assessments, pain assessments, and psychosocial follow-up on the resident living on the affected assignment and no concerns were noted. The facility had no specific agency staffing policies or procedures. They had a contract with the staffing agency who verified the agency staff members' identity and licensure. This citation relates to Intake 3011813 and Intake 3009363.410 IAC (Indiana Administrative Code) 16.2-3.1-14(i)

Based on observation, interview, and record review, the facility failed to post current and accurate nursing staff information daily for residents, resident representatives, and/or visitors. Findings include:During an observation, on 5/18/26 at 9:00 a.m., the facility nurse staffing, dated 5/15/26 was posted on the wall across from the receptionist desk in the front lobby. The nursing staff posting, dated 5/15/26, included the following:Census: 116 Number of Registered Nurses (RN): Day shift hours: 24.00, Evening shift hours: 12.00, and Night shift hours: 16.00.Number of Licensed Practical Nurses (LPN): Day shift hours: 48.00, Evening shift hours: 36.00, and Night shift hours: 24.00. Number of Qualified Medication Aides (QMA): Day shift hours: 8.00, Evening shift hours: 16.00, and Night shift hours: 0.00.Number of Certified Nursing Assistant (CNA): Day shift hours: 80.00, Evening shift hours: 64.00, and Night shift hours: 48.00.During an observation, on 5/18/26 at 9:34 a.m., the facility nurse staffing posting was updated. The updated staff post was dated 5/18/26 and included the following:Census: 122Number of RN: Day shift hours: 24.00, Evening shift hours: 24.00, and Night shift hours: 0.00.Number of LPN: Day shift hours: 32.00, Evening shift hours: 48.00, and Night shift hours: 32.00. Number of QMA: Day shift hours: 16.00, Evening shift hours: 8.00, and Night shift hours: 8.00.Number of CNA: Day shift hours: 72.00, Evening shift hours: 64.00, and Night shift hours: 48.00.During an interview, on 5/18/26 at 11:00 a.m., the Facility Scheduler indicated she updated the facility nurse staff posting every morning when she arrived at work. This was usually between 8:00 a.m. and 8:30 a.m., expect on Mondays since she had other duties to complete first thing. The posting on Mondays was completed around 9:00 a.m. She utilized the daily schedules to populate the posting information. She indicated there was not a staff member over the weekends to complete this task. She didn't prepopulate the weekend staff posting information due to daily changes to the schedule, such as call-ins. The staff posting was to be completed daily at the start of each day and contain accurate staffing information.During an interview, on 5/19/26 at 12:35 p.m., the Administrator indicated the facility nurse staff posting was to be updated daily and posted at the beginning of each shift. The facility needed a process in place to ensure the nurse staff posting was updated appropriately over the weekends. A current facility policy, dated 6/16/19, titled, Staffing Policy, provided by the Administrator on 5/19/26 at 10:00 a.m., indicated the following: . 5. Direct care staffing information is posted each day pursuant to CMS Requirements of Participation.

Based on observation, interview, and record review, the facility failed to store drugs and biologicals in a safe and secure manner for 18 of 18 residents' treatments stored in the Rehab Hall treatment cart. Findings include:During a walk-through observation, on 5/18/26 at 9:45 a.m., the medication treatment cart on the Rehab unit was unlocked and unattended.During a continuous observation on 5/18/26 from 9:45 a.m. to 9:51 a.m., the medication treatment cart remained unlocked. During this time frame, the following were observed near the unlocked and unattended medication treatment cart: a housekeeping staff member, a laundry staff member and a Certified Nursing Assistant (CNA).During a medication storage observation of the Rehab treatment cart, accompanied by LPN 5, on 5/18/26 at 9:51 a.m., following medications were observed:Two (2) tubes of zinc oxide (to protect skin) ointment,Four (4) tubes of 1% diclofenac sodium (to treat joint pain) gel,Two (2) tubes of nystatin (an antifungal) 100,000 units cream,One tube of 2% miconazole (an antifungal) cream,One bottle of 0.05% fluocinonide (a corticosteroid) eye drops,Two (2) tubes of 0.05% clobetasol (a super-high-potency topical steroid) cream,Two (2) tubes of 12% ammonium lactate (to treat dry skin) cream,One tube of bacitracin (an antibiotic) gel,One bottle of antifungal (to treat fungal infections) powder,One tube of menthol (to treat pain) gel, And one container of hemorrhoid medipads (premoistened) wipes. During an interview, at the time of the observation, LPN 5 indicated there were 18 treatment medications kept on the Rehab treatment cart. The treatment cart should remain locked to prevent access to medications and ensure the safety of residents and visitors. During an interview, on 5/18/26 at 9:57 a.m., RN 6 indicated the treatment medication carts should remain locked when unattended. This was done to ensure patient safety and to protect residents. On 5/18/26 at 10:40 a.m., the Unit Manager indicated the treatment medication carts needed to remain locked to protect the residents and visitors. An unlocked cart could pose a risk to residents' safety. On 5/19/26 at 12:23 p.m., the DON indicated treatment cart should remain locked when not in use. This protects residents, staff, and visitors as the treatment carts contain prescription medications with resident identifiers. An undated facility policy, titled, Drug Storage, provided by the Administrator on 5/19/26 at 10:01 a.m., indicated the following: . Drugs shall be stored in an orderly manner in cabinets, drawers, or carts of sufficient size to prevent crowding. All medications and other drugs, including treatment items, need to be stored in a locked cabinet or room, inaccessible to residents and visitors.410 IAC (Indiana Administrative Code) 16.2-3.1-25(j)410 IAC 16.2-3.1-25(k)

Based on record review and interview, the facility failed to initiate and conduct a 72-hour care plan meeting for a resident following admission to ensure the development of a person-centered care plan addressing the resident's immediate needs. This deficient practice had the potential to affect the resident by delaying the identification and coordination of care needs, and increased the risk for unmet needs, decline in condition, and lack of interdisciplinary oversight. (Resident B)Findings include:Resident B's clinical record was reviewed on 2/12/26 at 11:00 a.m. Diagnoses included fracture of unspecified neck of right femur post-surgical repair, signs and symptoms involving cognitive functions following a cerebrovascular accident, repeated falls, hypertension, conversion disorder with seizures or convulsions, osteoporosis, and chronic pain.Resident B was admitted to the facility on [DATE]. The clinical record lacked documentation that a 72-hour care plan meeting was initiated or conducted within the required timeframe. Review of the most current admission MDS (Minimum Data Set) assessment, dated 1/6/26, indicated the resident had moderate cognitive impairment, used a wheelchair for mobility, was frequently incontinent of bladder, occasionally incontinent of bowel and was impaired on one side of her lower extremities.Review of the clinical record indicated the initial care conference for Resident B took place on 1/9/26, nine days after Resident B was admitted to the facility.During an interview with the Social Service Director on 2/13/26 at 9:52 a.m., she indicated she called resident representatives the day after the admission date to set up a care conference. It was usually 24 to 48 hours after admission when she contacted the representative(s). Generally, she would not document if she were unable to reach a resident's representative. During a care conference, social services, therapy, and nursing were present to discuss care provided by the facility, including any discharge plan(s). Care was planned in coordination with the residents and their families. Such documentation would be located under Care Conference Summary in the electronic health record.During an interview with the admission Coordinator on 2/13/26 at 12:15 p.m., she indicated Resident B's representative was contacted on 1/5/26 at 4:05 p.m. via phone. She left a voice mail requesting a return call from the representative. Resident B was admitted to the facility on [DATE]. Since it was a holiday, 1/5/26 was the first opportunity she had to contact Resident B's representative.During an interview with the Transitional Care Nurse on 2/13/26 at 3:42 p.m., she indicated the Unit Manager (UM) completed the initial assessment for a new resident. If the UM was not available, the floor nurse would perform the assessment and enter new orders. Orders were then discussed during the morning meeting the following day. Care plans were found in the electronic health record and staff used those as a means of knowing how to provide care for residents. The Transitional Care Nurse knew Resident B's care conference was delayed and had been scheduled to accommodate the representative's schedule. Resident B's representative wanted to be present during the care conference. Initial care conferences usually took place 48 to 72 hours after admission. The facility did their best to accommodate representatives' preferences when scheduling the initial care conferences.A current facility policy, titled Resident Care Planning - Resident Summary Policy, provided by the DON on 1/12/26 at 3:25 p.m., indicated the following: .The Community must take reasonable steps to ensure the development of the person-centered, baseline care plan within 48 hours of a new resident's admission, providing a written summary of the baseline care plan to the resident and/or representative. The baseline care plan includes resident medications, dietary instructions, services, treatments and pertinent updates by the date of the initial Interdisciplinary Team (IDT) care conference.This citation relates to Intake 2740980.

Based on observation, record review, and interview, the facility failed to ensure controlled substance inventory was accurately documented on individual narcotic record sheets per facility policy to mitigate risk for drug diversion for 6 of 6 residents reviewed during a medication storage observation. (Residents J, K, L, M, N, and O)Findings include:During an observation of the [NAME] 1 medication cart, accompanied by LPN 10 and LPN 11, on 2/12/26 at 1:49 p.m., LPN 11 indicated she did not document the removal of the controlled medications she administered that morning on the individual controlled medication inventory record sheets. Review of the individual narcotic sheets indicated the documentation had not been completed. LPN 11 indicated the [NAME] 1 medication cart contained medications for 18 residents, six of which received controlled medications from the cart. LPN 11 indicated she administered Resident J's pregabalin (anticonvulsant) 50 mg and hydrocodone acetaminophen (opioid pain medication) 5-325 mg the morning of 2/12/26.An observation during the interview indicated the controlled medication binder indicated the following concerns:Resident J had 25 remaining pregabalin 50 mg pills. The pregabalin blister card had 24 pills remaining. The controlled medication binder indicated Resident J had 29 remaining hydrocodone acetaminophen 5-325 mg pills. The hydrocodone acetaminophen 5-325 blister card had 28 pills remaining.LPN 11 indicated she administered Resident K's tramadol (opiate pain medication) 50 mg the morning of 2/12/26. An observation during the interview indicated the controlled medication documentation for Resident K had nine remaining tramadol 50 mg pills. The tramadol 50 mg blister card had eight pills remaining.LPN 11 indicated she administered Resident L's lorazepam (anti-anxiety medication) 0.5 mg the morning of 2/12/26. The controlled medication binder indicated Resident L had 37 remaining lorazepam 0.5 mg pills. The lorazepam 0.5 mg blister card had 36 pills remaining.LPN 11 indicated she administered Resident M's tramadol 50 mg the morning of 2/12/26. The controlled medication binder indicated Resident M had 20 remaining tramadol 50 mg pills. The tramadol 50 mg blister card had 19 pills remaining.LPN 11 indicated she administered Resident N's hydrocodone acetaminophen 7.5-325 mg the morning of 2/12/26. The controlled medication binder indicated Resident N had two remaining hydrocodone acetaminophen 7.5-325 mg pills. The hydrocodone acetaminophen 7.5-325 mg blister card had one pill remaining.LPN 11 indicated she administered Resident O's clonazepam (anti-anxiety medication) 0.5 mg and pregabalin 75 mg the morning of 2/12/26. The controlled medication binder indicated Resident O had 16 remaining clonazepam 0.5 mg pills. The clonazepam 0.5 blister card had 15 pills remaining. The controlled medication binder indicated Resident O had 15 remaining pregabalin 75 mg pills. The pregabalin 75 mg blister card had 14 pills remaining.Resident J's clinical record was reviewed on 2/12/26 at 2:04 p.m. Resident J was severely cognitively impaired. Diagnoses included hyperlipidemia, hemiplegia, seizure disorder, depression, and a history of cerebrovascular accident.Resident K's clinical record was reviewed on 2/12/26 at 2:10 p.m. Resident K was cognitively intact. Diagnoses included anemia, hypertension, and chronic obstructive pulmonary disease.Resident L's clinical record was reviewed on 2/12/26 at 2:22 p.m. Resident L was cognitively intact. Diagnoses included anemia, neurogenic bladder, hyperlipidemia, and chronic obstructive pulmonary disease.Resident M's clinical record was reviewed on 2/12/26 at 2:36 p.m. Resident M was severely cognitively impaired. Diagnoses included coronary artery disease, hypertension, hyperlipidemia, and Parkinson's disease.Resident N's clinical record was reviewed on 2/12/26 at 3:12 p.m. Diagnoses included type 2 diabetes mellitus, pain - unspecified, a history of cerebrovascular accident, hypertension, and cardiomyopathy.During an interview with the Unit Manager, on 2/12/26 at 2:00 p.m., she indicated LPN 11 should have documented in the controlled medication binder each time she removed a controlled medication to show how many pills had been removed and what time they were removed.During an interview with the Director of Nursing (DON) on 2/13/26 at 4:58 p.m., she indicated the expectation was for nurses to sign out controlled medications as soon as they pulled them, before administering to the residents. There was the potential for the controlled medication count to be incorrect, and the nurse would not know what time the medication was administered.A current facility policy, titled Managing Controlled Substances, provided by the DON on 2/13/26 at 1:23 p.m., indicated the following: .Drugs with high abuse potential are subject to special handling, storage, disposal, and record keeping.7) Immediate after a dose of a controlled drug is administered, the licensed nurse administering the drug is to enter all of the following information on the proof-of-use record: a) Date and time of administration. b) Dose administered. c) Signature of the nurse administering the dose. d) Remaining doses.This citation relates to Intake 2740980.3.1-25(3)(e)(2)

Based on interview and record review, the facility failed to protect the safety of a cognitively impaired resident from potential harm by not providing supervision at an outside appointment for 1 out of 3 residents reviewed to accidents. (Resident B) Findings include:Resident B's clinical record was reviewed on 2/12/26 at 11:00 a.m. Diagnoses included fracture of unspecified part of neck of right femur post-surgical repair, symptoms and signs involving cognitive functions following other cerebrovascular disease, repeated falls, hypertension, conversion disorder with seizures or convulsions, osteoporosis, and chronic pain. Review of the most current admission MDS (Minimum Data Set) assessment, dated 1/6/26, indicated the resident had moderate cognitive impairment, used a wheelchair for mobility, was frequently incontinent of bladder, occasionally incontinent of bowel and was impaired on one side in the lower extremities.Review of the hospital discharge orders, dated 12/31/25, indicated a follow up appointment with the orthopedic surgeon on 1/12/26.Review of the clinical record indicated the following orders:Appointment 1/19/26 at 2:15 p.m. (physician name, location and telephone number). Start date: 1/18/26. Discontinued date: 1/19/26.Appointment 1/19/26 at 2:15 p.m. (physician name, location and telephone number). Start date: 1/18/26. Discontinued date: 1/13/26.Review of a progress note, dated 1/5/26 at 1:36 p.m., indicated Resident B had a fall on 1/4/26. The root cause of the fall was determined to be the resident had poor safety awareness. The resident was incontinent at time of the fall.Review of a progress note dated 1/11/26 at 11:14 p.m., the resident was found on the floor next to the bathroom. The resident indicated she was trying to get up and couldn't. Resident denied need to use the bathroom.Review of a progress note, dated 1/12/26 at 2:52 p.m., indicated Resident B was taken to a follow up orthopedic appointment as scheduled per hospital discharge. Transportation reported they were called to pick up the resident because the resident did not have an appointment this date. The resident was without supervision for approximately 2.5 hours. The appointment was rescheduled for 1/19/26 at 2:15pm. Transport was requested.Review of an Interdisciplinary Team (IDT) post fall assessment, dated 1/12/26 at 3:17 p.m., indicated the resident was found on the floor in the bathroom on 1/11/26. The Resident was not incontinent at the time of the fall. The root cause was determined to be due to safety awareness. Review of a physician's note, dated 1/11/26 at 10:50 p.m., indicated the reason for visit was due to fall without injury. The noted indicated the resident had confusion and a poor historian.During an interview on 2/12/26 at 11:39 a.m., the Orthopedic office front desk receptionist indicated, on 1/12/26 at 1:00 p.m., Resident B arrived at the office at 12:30 p.m. The resident was confused and agitated and asked the receptionist to call her family. The office chart indicated the resident was to be accompanied by a caregiver for appointments. The receptionist called the family and informed them the resident was in the office without an appointment and unsupervised. The receptionist indicated they sat with the resident for 1-1.5 hours while they waited for the facility to pick the resident up.During an interview on 2/13/26 at 1:12 p.m., Unit Manager 1 indicated the facility received the 1/12/26 appointment in the hospital discharge orders. The facility did not call the family to ask about transportation arrangements. The appointment was sent to transportation through the facility. The resident arrived at the scheduled appointment on 1/12/26 but it had been cancelled. There had been a communication breakdown, and the facility had not been aware the appointment had been cancelled. The resident had periods of confusion after surgery and was not safe to be unsupervised.During an interview on 2/13/26 at 3:33 p.m., the transportation driver indicated, on 1/12/26, he transported the resident to a scheduled physician appointment. After they arrived at the physician's office, they were informed the resident did not have an appointment, but the office would be able to see the resident. He left the resident at the physician's office and went to get something to eat. Approximately 45 minutes later, he received a call instructing him to return the resident to the facility. When he arrived to pick up the resident, he was informed she had not been seen by the physician. He indicated he did not call the facility to confirm the appointment or inform them of the mishap.During an interview on 2/13/26 at 3:33 p.m. the Clinical Support Consultant indicated the facility did not have a policy related to transportation and/or conduct for the transportation of residents. During an interview on 2/13/26 at 3:42 p.m., the Transitional Care Nurse indicated transportation arrangements to and from appointments for Resident B were not discussed during the initial care conference. The initial care conference usually took place 48-72 hours after admission. The facility did their best to accommodate the families' schedules when scheduling the initial care conference.Review of the clinical record indicated the initial care conference for Resident B took place on 1/9/26. Attendees included the resident's Power of Attorney (POA).This citation relates to Intake 2740980. 3.1-45(a)(2)

Based on record review and interview, the facility failed to provide a notice of transfer/discharge and a bed hold policy notification to the resident or resident representative for 2 of 3 residents reviewed for hospitalizations. (Residents 5 and 15) Findings include:1. Resident 5's clinical record was reviewed on 12/4/24 at 9:27 a.m. Diagnoses included dysphagia following other cerebrovascular disease with a risk for malnutrition, iron deficiency anemia, other vitamin B12 deficiencies, and abdominal distention.A 8/27/25, annual Minimum Data Set (MDS) assessment indicated the resident was cognitively intact.A 4/22/25 progress note indicated Resident 5 had experienced multiple episodes of coffee ground-like emesis (vomit) and requested to be sent out to the emergency room.A 4/22/25, Resident Transfer Form observation note indicated the resident was transferred to the hospital for nausea, vomiting, and diarrhea. The observation note was unsigned.A 4/22/25, discharge MDS indicated the resident discharged with a return anticipated.The clinical record lacked documentation that the resident or resident's representative was provided with a copy of the bed hold policy and notice of transfer.A 7/23/25 progress note indicated Resident 5 had experienced three (3) episodes of coffee ground-like emesis and requested to be sent out to the emergency room.A 7/23/25, discharge MDS indicated the resident discharged with a return anticipated.A 7/23/25, Resident Transfer Form observation note indicated the resident was transferred to the hospital for nausea and vomiting. The observation note was unsigned.The clinical record lacked documentation that the resident or resident's representative was provided with a copy of the bed hold policy and notice of transfer.2. Resident 15's clinical record was reviewed on 12/3/25 at 12:55 p.m. Diagnoses included malignant neoplasm of middle lobe, bronchus or lung-stage IV, unspecified neuromuscular dysfunction of bladder, and chronic kidney disease, stage 4.A 10/7/25, significant change MDS assessment indicated the resident had severe cognitive impairment.A 9/24/25 progress note indicated the resident was lethargic and unable to be woken up with verbal stimuli. The resident's blood pressure was 94/65 mmHg (millimeters of mercury). The Nurse Practitioner (NP) was called and provided an order to send the resident to the emergency room. A voice mail was left for the resident's family.A 9/24/25 discharge MDS indicated the resident discharged with a return anticipated.A 9/24/25 Resident Transfer Form observation note indicated the resident was transferred to the hospital for hematuria and lethargy. The observation note was unsigned.The clinical record lacked documentation that the resident or resident's representative was provided with a copy of the bed hold policy and notice of transfer.During an interview, on 12/4/25 at 2:58 p.m., the RN Support indicated the Resident Transfer Form observation had a check box on page four (4) that indicated the following documents were sent with the resident: Medication Sheet, CCD Document, Notice of Transfer, Request for Hearing, Bed Hold Policy, and a copy of the Transfer Observation. During a follow-up interview, on 12/4/25 at 3:05 p.m., the RN Support confirmed the check box previously mentioned did not indicate who had received the documents. She indicated the facility's normal practice would not include providing documents to residents who were cognitively impaired.On 12/4/25 at 4:51 p.m., the RN Support indicated she was unable to locate the notice of transfer or bed hold policies provided to either Resident 5 or 15.On 12/5/25 at 10:03 a.m., LPN 4 indicated when a resident required transfer to the hospital she would ensure there was an order from the physician, open the Discharge Event in the electronic medical record (EMAR), monitor the resident's vital signs, call the facility DON and Administrator, and contact the resident's family. LPN 4 would also call for transportation, call report into the hospital, print the residents' Continuity of Care Document (CCD) and face sheet and provide these papers to the Emergency Medical Services (EMS) drivers. She would document all her actions in the Discharge Event and progress notes sections of the resident's clinical record. On 12/5/25 at 10:12 a.m., LPN 5 indicated when a resident needed to be sent out to the hospital, she would immediately obtain an order from the physician or NP. She would print out any necessary documents such as the residents' CCD form and face sheet, the transfer form, and a bed hold policy. She would call for transportation, remain with the residents and give reports to the hospital. She prints up three (3) copies of the documents and gives two (2) sets of the documents to the EMS drivers. She notified the family and documents all her actions in the residents' progress notes and observations. On 12/5/25 at 10:23 a.m., LPN 6 indicated she had placed a red binder at all nurse stations to assist the floor staff with providing the appropriate forms to the resident or resident representative. She indicated when a resident was discharged , the resident or resident representative should receive the notice of transfer form and a bed hold policy. The resident or resident representative would be asked to sign the notice of transfer. The staff should document who received the papers and any attempts to contact the responsible party in the resident's clinical record.On 12/5/25 at 11:11 a.m., the ADON indicated the floor staff would ensure the resident or the resident representative received the notice of transfer, request for hearing form, and the bed hold policy. The staff would need to contact the resident's family to pick up the forms, if the resident was not provided with the forms. The clinical record should indicate who received the necessary forms, all attempts made to contact the representatives, and if the forms had been sent out in the mail.A current facility policy, effective 11/14, titled, Resident Discharge and Transfer Policy, provided by the Administrator on 12/4/25 at 3:30 p.m., indicated the following: . The policy outlines the process for determining when discharge or transfers is appropriate and the expectations for how the process should occur. By encompassing federal and state requirements, this policy provided specific procedures on how to discharge/transfer a resident the paperwork that must accompany the process. Notify the resident of the transfer or discharge and the reasons for the move in writing and in a language and manner that the resident understands. The health facility must place a copy of the notice in the resident's clinical record and transmit a copy to the following, a. The resident, b. A family member of the resident, if known.Notice may be made as soon as practicable before transfer or discharge when:. (d) An immediate transfer or discharge is required by the resident's urgent medical needs.(1) Prior to a hospital transfer or a therapeutic leave (twenty-four (24) hours duration or longer), the facility must provide written information to the resident and a family member or legal representative that specifies the following: (i) The duration of the bed-hold policy under the Medicaid state plan during which the resident is permitted to return and resume residence in the facility.3.1-12 (a)(4)3.1-12(a)(6)(A)(i)3.1-12 (a)(26)

Based on observation, record review, and interview, the facility failed to follow professional nursing standards for PICC (Peripherally Inserted Central Catheter) line dressing changes to mitigate the risk for infection for 1 of 1 resident reviewed for IV (Intravenous) medications. (Resident 71)During an observation and interview on 12/3/25 at 10:21 a.m., Resident 71 was fully dressed seated upright in a specialty bed. There was an IV pole to the right side of the bed. Resident 71 indicated they had a PICC line and were getting IV antibiotics for a MRSA (methicillin-resistant staphylococcus aureus bacteria) infection. The staff provided the antibiotic medication on second shift around 7:00 p.m. every day. The PICC line was located on the right upper arm. The clear dressing covering the PICC line insertion site was dated 11/24/25.Resident 71's clinical record was reviewed on 12/4/25 at 11:54 a.m. Diagnoses included unspecified local infection of the skin and subcutaneous tissue, fusion of spine cervical region and thoracic regions, and weakness.Current orders included the following: PICC line dressing change- change needle free valve during each dressing change, once a day on Mondays on day shift (10/30/25), and PICC line flush- normal saline 5 mL's every shift for each lumen. If a medication is due during your shift flush with 5mL's of normal saline before the medication, followed by 5mL's of normal saline after the medication administrations for each lumen, every shift (10/30/25).A 9/22/25, quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact and was dependent on staff assistance for all ADL's (activities of daily living).A 11/4/25, IV antibiotic care plan, indicated Resident 71 requires antibiotics related to an infection and had the potential for complications. Interventions included the following: administer IV medications as ordered (11/4/25), change IV dressing as ordered (11/4/25), and flush IV per orders (11/4/25).A review of the December 2025, Medication Administration History report indicated the PICC line dressing change due for Monday, December 1, 2025, was not completed due to the resident preferring another staff member to change the dressing.During an observation of the PICC line dressing change on 12/4/25 at 4:42 p.m., RN 8 confirmed the PICC line dressing was dated 11/24/25.During an interview, at the time of the observation, RN 8 indicated she was asked to change the dressing on Monday, 12/1/25, by another nurse but was extremely busy on her own assignment and had forgotten to do it. RN 8 indicated the PICC line was flushed every shift and the other nursing staff should have recognized the date was past due and made attempts to change the dressing.During an interview, on 12/5/25 at 11:11 a.m., the ADON indicated the expectation was for staff follow professional nursing standards for PICC line care. The standard practice indicated a PICC line dressing change was to be completed every seven (7) days. These standards helped to prevent infection. The nursing staff should have been assessing and evaluating the PICC line site and noticed the date was past due. The nursing staff should have made attempts to change the dressing, and any refusals should have been documented in the resident's clinical record.A current facility policy, dated 4/09, titled, Central Venous Catheter Dressing Changes, provided by the Administrator on 12/4/25 at 3:18 p.m., indicated the following: The purpose of this procedure is to prevent catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings. 1. Change transparent semi-permeable membrane (TSM) dressings at least every 7 days and PRN (when wet, soiled, or not intact) .7. Change needleless access device, extension tubing, and stabilization device at time of routine dressing change . 3.1-47(a)(2)

Based on observation, record review, and interview, the facility failed to ensure a resident who required oxygen received services to ensure clean supplies and humidification to reduce side effects for 1 of 1 resident reviewed for oxygen. (Resident 110)Findings include:During an observation and interview on 12/1/25 at 3:30 p.m., Resident 110 was fully dressed and seated in the recliner beside the bed. He was wearing a nasal cannula. The oxygen tubing was undated. He indicated his oxygen was ordered at 3 liters per minute. On 12/2/25 at 10:36 a.m., Resident 110 was fully dressed and seated in the recliner beside the bed. He was wearing a nasal cannula. He indicated he could not recall the last time staff checked on his oxygen level or changed his tubing. He wears oxygen constantly. The oxygen concentrator was set to 5 liters per minute, and the water humidification bottle was empty. The sides and bottom of the water bottle were covered with a white discoloration resembling coarse salt. The oxygen tubing was undated.On 12/3/25 at 10:30 a.m., Resident 110 was fully dressed and seated in the recliner beside the bed. He was wearing a nasal cannula. The oxygen concentrator was set to 5 liters per minute, and the water humidification bottle was empty. The sides and bottom of the water bottle were covered with a white discoloration resembling coarse salt. The oxygen tubing was undated. A portable concentrator sat on the floor in the far corner. The oxygen tubing was undated and laying on the floor. He indicated his nose was dry and itchy, he felt congested, and it was difficult to breathe through his nose.Resident 110's clinical record was reviewed on 12/3/25 at 3:03 p.m. Diagnoses included Tetralogy of Fallot (a congenital heart abnormality), acute respiratory failure with hypoxia, and COPD (Chronic Obstructive Pulmonary Disease).Current order included continuous oxygen at 3-5 liters per minute by nasal cannula, every shift (11/6/25) and change and date oxygen tubing and humidifier bottle, change weekly and PRN (as needed) once a day on Sundays (11/6/25).A 11/6/25, impaired gas exchange care plan indicated the resident required oxygen related to COPD and acute on chronic respiratory failure. Interventions included administer oxygen as ordered (11/6/25), monitor lung sounds as needed (11/6/25), and report signs of hypoxia (11/6/25). A 11/18/25, admission Minimum Data Set (MDS) assessment indicated the resident was cognitively intact and required oxygen therapy.A review of the November 2025, Medication Administration History report indicated the change and date oxygen tubing and humidification bottle order was checked off as completed on 11/30/25.During an observation and interview, on 12/3/25 at 10:33 a.m., LPN 9 indicated when a resident wore oxygen, she checked the oxygen level, checked the residents' respiratory vitals, checked the tubing for cleanliness, and checked the water level in the humidification bottle. LPN 9 indicated she had changed Resident 110's oxygen tubing recently but did not remember the date and forgot to mark the tubing. She confirmed the resident's oxygen concentrator was set to 5 liters per minute and the water humidification bottle was completely empty. A resident might experience dry sinuses and discomfort from wearing oxygen without water humidification.During an interview, on 12/3/25 at 10:48 a.m., the Unit Manager indicated the oxygen tubing change orders were set for Sunday nights. She checked on Monday and Resident 110's oxygen tubing had been changed appropriately. She indicated it could have been changed again after she looked and someone forgot to date the tubing. The nurses should be checking the water humidification on oxygen concentrators on each shift. Resident 110 utilized oxygen at 5 liters per minute, and the water would be used more quickly than those using a lower oxygen level. The staff should be aware of this and check his water bottle more frequently.A current facility policy, revised 3/04, titled, Oxygen Administration, provided by the Administrator on 12/4/25 at 3:19 p.m., indicated the following: The purpose of this procedure is to provide guidelines for safe oxygen administration.Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: . 12. Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through. 14. Periodically re-check water level in humidifying jar. 3.1-47 (a)(6)

Based on interview and record review, the facility failed to protect the resident's right to be free from staff-to-resident abuse perpetrated by RN 2 when the nurse held the hands of a cognitively impaired resident and administered medications while the resident was screaming for 1 of 3 residents reviewed for abuse. (Resident B) Using the reasonable person concept, this abuse could result in Resident B feeling dehumanized and anxious related to their hands being physically restrained and being forced to take oral medications. Findings include: Resident B's clinical record was reviewed on 1/2/25 at 9:13 a.m. Diagnoses included encephalopathy, anemia, hypertension, cerebrovascular disease, dysphagia, stage 4 chronic kidney disease, pain, and memory deficit. The most recent admission Minimum Data Set (MDS) assessment, dated 11/29/24, indicated the resident was severely cognitively impaired. An 11/30/24 at 8:20 p.m. progress note authored by RN 2 indicated, while attempting to administer medications to Resident B, the resident became combative. The note indicated RN 2 sat on the resident's bed, held the resident's hands, and put the medication in the resident's mouth while she was screaming. The resident spat the medications and applesauce out of their mouth. RN 2 wiped the applesauce off the bed and out of her hair. CNA 1 was present in the room. During an interview on 1/2/25 at 2:19 p.m., the Director of Nursing (DON) indicated she received a phone call from the facility on 11/30/24 (at an unspecified time). During the call, CNA 1 indicated RN 2 was involved in an incident of poor customer service and had abused Resident B. The DON immediately went to the facility to ensure Resident B was safe and to initiate an investigation into the incident. RN 2 was not in the facility when she arrived. The DON called RN 2 for an interview and RN 2 indicated she was tired and did not feel the facility was the place for her. RN 2 submitted her resignation during that conversation. The DON indicated Resident B required a calm approach due to her behaviors. The resident had a history of combative behaviors since admission to the facility. One-to-one observation was initiated due to the resident's unsafe and combative behaviors. The facility felt Resident B was not safe to be left alone. During an interview on 1/2/25 at 3:35 p.m., CNA 1 indicated, on 11/30/24, she was providing one-to-one observation for Resident B. While in the resident's room, she witnessed RN 2 providing poor customer service to Resident B. The poor customer service was described as RN 2 performed multiple attempts to administer medications to Resident B while the resident was fighting the nurse. CNA 1 felt that RN 2 should have just stopped trying to administer the medication. Resident B was yelling and saying no. The resident was already agitated and combative. RN 2 was escalating her behavior. The incident happened quickly and CNA 1 did not intervene or try to protect the resident, but she did call the Administrator to report the incident afterwards. During an interview on 1/2/25 at 3:55 p.m., the Administrator indicated, during his notification on 11/30/24 following the event, the incident was reported as abuse involving Resident B and RN 2. The DON entered the facility to initiate the investigation upon notification of the incident on the evening of 11/30/24. RN 2 was not available for interview during the survey on January 2, 2025. A current policy, dated 10/4/2014, titled Abuse, Neglect, and Misappropriation Prohibition and Prevention Policy was provided by the DON on 1/2/25 at 10:55 a.m. The policy indicated the following: III. Preventing Resident Abuse 1. Preventing resident abuse is a primary concern for this Community. It is our goal to achieve and maintain an abuse free environment. 2. Our abuse prevention program includes, but is not limited to, the following: c. Rotating staff working with difficult or abusive residents; ensuring staff on each shift is sufficient numbers to meet the needs of the residents and assuring that the staff assigned has knowledge of individual resident care needs. This citation relates to Complaint IN00448256. 3.1-27(a)

Based on record review and interview, the facility failed to implement their abuse policy when a staff member (CNA 1) failed to intervene when witnessing the abuse of a cognitively impaired resident (Resident B) by a staff member (RN 2) for 1 of 3 residents reviewed for abuse. Findings include: A facility reportable indicated on 11/30/24, CNA 1 reported that RN 2 displayed poor customer service with Resident B. RN 2 was suspended pending investigation and immediately left the facility. Resident B's clinical record was reviewed on 1/2/25 at 9:13 a.m. Diagnoses included encephalopathy, anemia, hypertension, cerebrovascular disease, dysphagia, stage 4 chronic kidney disease, pain, and memory deficit. The most recent admission Minimum Data Set (MDS) assessment, dated 11/29/24, indicated the resident was severely cognitively impaired. An 11/30/24 at 8:20 p.m. progress note authored by RN 2 indicated, while attempting to administer medications to Resident B, the resident became combative. RN 2 sat on the resident's bed, held the resident's hands, and put the medication in the resident's mouth while she was screaming. The resident spat the medications and applesauce out of their mouth. RN 2 wiped the applesauce off the bed and out of her hair. CNA 1 was present in the room. During an interview on 1/2/25 at 2:19 p.m., the DON indicated she received a phone call from the facility on 11/30/24 (at an unspecified time). During the call, CNA 1 indicated RN 2 had been involved in an incident of poor customer service and had abused Resident B. The DON immediately went to the facility to ensure Resident B was safe and to initiate an investigation into the incident. RN 2 was not in the facility when she arrived. The called RN 2 for an interview and RN 2 indicated she was tired and did not feel the facility was the place for her. RN 2 submitted her resignation during that conversation. During an interview on 1/2/25 at 3:35 p.m., CNA 1 indicated, on 11/30/24, she was providing one to one observation for Resident B. While in the resident's room, she witnessed RN 2 providing poor customer service to Resident B. The poor customer service was described as RN 2 performed multiple attempts to administer medications to Resident B while the resident was fighting the nurse. CNA 2 felt that RN 2 should have just stopped trying to administer the medication. The incident happened too quickly and she did not intervene or try to protect Resident B. During an interview on 1/2/25 at 3:55 p.m., the Administrator indicated, during a facility phone call on the evening of 11/30/24, the caller indicated there had been an incident of abuse involving Resident B and RN 2. Upon investigation it was determined that CNA 1 witnessed the alleged abuse and did not, but should have, intervened on behalf of the dependent resident. RN 2 was not available for interview during the survey on January 2, 2025. A current facility policy, dated 10/4/2014, titled Abuse, Neglect, and Misappropriation Prohibition and Prevention Policy was provided by the DON on 1/2/25 at 10:55 a.m. The policy indicated the following: VI. Reporting: 6. Any individual observing an incident of resident abuse or suspecting resident abuse must promptly report such incident to the Administrator, or designee, only after he/she ensures the resident involved is safe from the alleged incident Cross reference F600. This citation relates to Complaint IN00448256. 3.1-28(a)

Based on interview and record review, the facility failed to follow a care plan intervention of providing care with staff pairs to protect the resident from anxiety related to allegations of inappropriate care for 1 of 3 residents reviewed for abuse. (Resident C) Findings include: During an interview on 1/2/25 at 9:35 a.m., Resident C indicated, on 12/26/24 during the night shift, CNA 3 touched him inappropriately during incontinence care. The resident reported the incident to other facility staff. Resident C's clinical record was reviewed on 1/2/25 at 9:39 a.m. Diagnoses included multiple sclerosis, pain, abdominal aortic aneurysm-without rupture, type 2 diabetes mellitus with diabetic polyneuropathy and hyperosmolarity, depressive disorder, and dysphagia following cerebral infarction. Review of the most current quarterly Minimum Data Set (MDS) assessment, dated 11/5/24, indicated the resident was cognitively intact. A current CNA Assignment Sheet, care plan dated 4/28/23, indicated an intervention for care in pairs, initiated 11/7/23 due to resident behaviors as evidenced by making false accusations against staff members. During an interview on 1/2/25 at 10:52 a.m., CNA 4 indicated staff provided care to Resident C in pairs due to his behaviors. During an interview on 1/2/25 at 11:02 a.m., CNA 5 indicated Resident C required two staff members when care was provided. This intervention was listed on the CNA Assignment Sheet. During an interview on 1/2/25 at 2:26 p.m., the DON indicated Resident C came to her to report being physically assaulted by CNA 3. The facility initiated an investigation and sent the resident to the hospital for evaluation. The DON indicated CNA 3 had provided care alone while another CNA was in the hallway. The DON indicated CNA 3 did not follow the intervention to provide care in pairs. Review of a written statement, dated 12/27/24, CNA 3 indicated they did provide care to Resident C on 12/26/24. CNA 3 did not indicate if there had been another staff member present while care had been provided. CNA 3 was not available for interview during the survey on January 2, 2025. This citation relates to Complaint IN00449955 and IN00450213. 3.1-35(b)(1)

Based on observation, interview, and record review, the facility failed to ensure shift to shift narcotic count reconciliation was completed for 1 of 3 medication carts reviewed for medication reconciliation. (Rehab 1 cart) Findings include: During a medication storage observation of the Rehab 1 medication cart, on 10/21/24 at 10:29 a.m., accompanied by LPN 2, the Nurse Narcotic Sign in/out Sheet was reviewed and the following dates lacked shift to shift count reconciliation numbers of controlled medications: October 17, 18, 19, and 20, 2024. During an interview, on 10/21/24 at 10:40 a.m., LPN 2 indicated staff was required to sign in and sign out with each change of the medication cart attendant. They needed to record the narcotic count when they signed the log. She indicated the log lacked the count number for October 17, 18, 19, and 20, 2024. The lack of a count number or signatures on the log was a potential opportunity for drug diversion. During an interview, on 10/21/25 at 11:13 a.m., LPN 3 indicated the narcotic sign in sheets should include signatures and count numbers of the in-coming and off-going staff members with every exchange of the medication cart. The Rehab Cart 1 Nurse Narcotic Sign in /out Sheets were not completed as required. Management had been educating staff frequently for incomplete narcotic reconciliation. During an interview, on 10/21/24 at 1:56 p.m., the Rehab Unit Manager indicated the staff completed shift to shift reconciliation every time the cart changes hands. The staff documented the number of narcotic cards present and then signed to confirm the count was correct. She indicated the narcotic card count was missing for October 17, 18, 19, and 20, 2024. During an interview, on 10/21/24 at 2:16 p.m., the DON indicated the Nurse Narcotic Sign in /out Sheets for the Rehab 1 medication cart lacked narcotic count numbers for October 17, 18, 19, and 20, 2024. She indicated there was no way to know if any drug diversion had occurred if the count was not verified for multiple days. An undated, current facility policy, titled, Controlled Substance Reconciliation, provided by the DON, on 10/21/24 at 1:09 p.m., indicated the following: . Each facility should verify the quantity of controlled substances on hand as well as the number of accompanying count sheets at the end of each nursing shift . 3.1-25(b)(3)

Based on interview and record review, the facility failed to complete an investigation of an allegation of verbal abuse for 1 of 3 residents reviewed for abuse. (Resident D) Findings include: During an interview on 4/23/24 at 10:56 a.m., Resident D indicated she had an incident while in an activities group, before a Bingo game. She was seated at a table waiting for another resident to join her and another resident entered the room. She felt the Activities Director (AD) got the idea that Resident D had rejected the resident to sit at her table. The AD began to yell loudly at her that she was not in control and how dare she turn away an old woman. Resident D indicated she was humiliated and embarrassed, and felt very hurt. She cried a lot over the next few days. She indicated the AD had not followed up with her or apologized. She felt that the AD had a bad day, and Resident D had since forgiven the AD and began to attend activities again. Nothing further had been said about the incident. The clinical record for Resident D was reviewed on 4/23/24 at 11:15 a.m. Diagnoses included major depressive disorder and morbid obesity. A quarterly Minimum Data Set (MDS) assessment, dated 4/16/24, indicated the resident was cognitively intact, had no hallucinations, delusions, and no verbal or physical behaviors. She could make herself understood and could understand others. During an interview on 4/23/24 at 1:20 p.m., Physical Therapy staff (PT) 2 indicated Resident D reported the incident in activities to her, and was extremely upset during the conversation. PT 2 reported the incident to her supervisor and felt it had been reported to the Administrator and/or DON. During a telephone interview on 4/23/24 at 2:36 p.m., PT 3 indicated she had informed the DON regarding the resident's allegation as soon as PT 2 had communicated it to her. During an interview on 4/24/24 at 1:45 p.m., the DON indicated she was unaware of an allegation of verbal abuse regarding Resident D and the Activities Director. A current facility policy, edited 8/2016, titled, SNF Reportable Policy and Procedure, provided by the Corporate Nurse Consultant on 4/24/24 at 1:24 p.m., included the following: Purpose .Administrative staff will immediately report the following incidents to the Indiana Department of Health .1. Any/all alleged violation involving mistreatment, neglect or abuse. This citation relates to Complaint IN00431938. 3.1-28(d)

Based on record review and interview the facility failed to report allegations of sexual abuse to one or more law enforcement and adult protection agencies for 1 of 1 resident reviewed for abuse. (Resident B) Findings include: Review of a State reportable, dated 2/12/24, indicated Resident B reported an allegation of staff to resident sexual abuse. Review of the facility investigation of the allegation, the investigation lacked documentation of law enforcement notification and/or adult protection agency. During an interview on 2/16/24 at 12:29 p.m., Resident B indicated during incontinent care, CNA 1 touched them inappropriately. The resident indicated they felt the interaction was sexual abuse. During an interview on 2/16/24 at 2:55 p.m., the Administrator and Director of Nursing indicated the law enforcement agency was not called due to the family's request to not call the police. During an interview on 2/16/24 at 3:00 p.m., a family member of Resident B indicated they did not request the police not to be called. During an interview on 2/16/24 at 3:06 p.m., the Corporate Consultant indicated the facility did not call the police. A current policy, dated 10/14/2014, titled Abuse, Neglect, and Misappropriation Prohibition and Prevention Policy was provided by the Administrator on 2/16/24 at 2:08 p.m. The policy indicated the following: A. Reporting to Law Enforcement 1. Under the Elder Justice Act. Any individual who has the reasonable suspicion that a resident in one of our Communities has been the victim of a crime, they must report that suspicion to local law enforcement or, if reporting the chain of command, ensure that others have contacted local law enforcement. 2. Any individual who fails to ensure a report to law enforcement of knowledge or suspicion of a crime against a resident may be subject to consequences including loss of employment, loss of professional licensure, registration or certification, a monetary penalty, or criminal prosecution. C. Reporting To State Agencies And Law Enforcement 2. Allegations of mistreatment, neglect, or injury of unknown source that do not result in serious injury will be reported within a reasonable amount off time not to exceed 24 hours to the State licensing/certification agency through the approved method of reporting, Adult Protective Services by fax, and local law enforcement by telephone. This citation relates to Complaint IN00428301. 3.1-28(c)

Based on observation, interview, and record review, the facility failed to ensure a resident was scheduled with urology (a specialist), as ordered by the primary care provider, for 1 of 3 residents reviewed for urinary tract infections/catheter care. (Resident 98) Findings include: During an observation and interview on 10/25/23 at 10:43 a.m., Resident 98's catheter tubing and bag were observed to contain large amounts of sediment and amber colored urine. The resident indicated the appearance of the urine in the tubing was typical of what he would see at any given time. During an observation and interview on 10/26/23 at 11:14 a.m., the urinary catheter tubing continued to have sediment present. The resident indicated there was always junk in the tubing. Resident 98's clinical record was reviewed on 10/26/23 at 9:32 a.m. His diagnoses included neurogenic bladder. Current physician orders, dated 10/4/23, indicated urinary catheter care to be provided twice a day, once upon rising and again at night, and the urinary catheter and drainage bag should be changed as needed for occlusion or dislodgement. The order included any change of the bag, catheter, or tubing, should be documented in the resident's progress notes. A progress note, dated 6/8/23, indicated he had difficulty urinating. A bladder scan revealed a large amount of urine, an in-and-out catheterization was performed, and 800 mL (milliliters) of urine was drained. At that time, a urinary catheter was anchored and he was to be closely monitored over the next several days for urine output. A Nurse Practitioner progress note, dated 6/9/23, indicated the urinary catheter should be continued and, if necessary, he should be referred to urology. A Nurse Practitioner progress note, dated 6/12/23, indicated a referral to urology. A Nurse Practitioner progress note, dated 6/15/23, indicated he was started on ciprofloxacin (an antibiotic) for a urinary tract infection. The clinical record lacked indication the referral to urology was completed. A progress note, dated 7/26/23, indicated blood was found in his urine. A progress note, dated 8/9/23, indicated results from the urinalysis was brown, cloudy urine with sediment. It was positive for leukocytes (white blood cells indicative of infection) and protein. A progress note, dated 8/10/23, indicated the resident was experiencing increased confusion. A progress note, dated 8/14/23, indicated the urinary catheter remained and trimethoprim-sulfamethoxazole (an antibiotic) was ordered for seven days. A physician progress note, dated 8/14/23, indicated an appointment should be set-up with urology to assess whether or not the catheter could be removed. The clinical record lacked indication the referral to urology was completed. A physician's progress note, dated 10/23/23, indicated the urinary catheter was still in place. A physician's progress note, dated 10/25/23, indicated an appointment with urology should set-up for evaluation and assessment to determine if the catheter could be removed. The clinical record lacked indication the referral to urology was completed. During an interview with the Unit Manager on 10/27/23 at 2:15 p.m., she indicated any notes given by the nurse practitioner or physician would be found in the resident's electronic chart. Whenever the physician or nurse practitioner indicated an appointment should be scheduled, she would be the one to put in the order. During an interview with the ADON, on 10/30/23 at 11:56 a.m., she indicated there was no formal procedure or policy for referrals, but the facility's Unit Manager would initiate the process after it was indicated by the physician or nurse practitioner. 3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to ensure narcotics were reconciled per facility policy for 2 of 4 medication carts reviewed for medication storage. (East 1 cart and East 2 cart) Findings include: 1. During a medication storage observation of the East 1 cart, accompanied by LPN 3 on 10/30/23 at 9:30 a.m., the Nurse Narcotic Sign In/Out Sheet record was reviewed and the following dates lacked shift to shift reconciliation of controlled medications: In October 2023- 10/3, 10/4, and 10/5 on night shift, 10/6 on all three shifts, 10/7 and 10/8 on day and evening shifts, 10/9 on all three shifts, 10/10 on day and evening shifts, 10/11 on evening shift, 10/12, 10/13, 10/14, and 10/15 on both day and evening shifts, 10/16 on all three shifts, 10/17 and 10/18 on both day and evening shifts, 10/19 on all three shifts, 10/20 and 10/21 on both day and evening shifts, 10/22 on all three shifts, 10/23 and 10/24 on both day and evening shifts, 10/27 on both day and evening shifts, and 10/29 on both day and evening shifts. In November 2023- 11/19 and 11/20 on both day and evening shifts, 11/21 on all three shifts, 11/22 on both day and evening shifts, 11/23 and 11/24 on both night and day shifts, 11/25 on all three shifts, 11/26, 11/27, 11/28, and 11/29 on both day and evening shifts, and 11/30 on both night and day shifts. 2. During a medication cart observation with QMA 4, on 10/30/23 at 9:45 a.m., of the East 2 cart, the Nurse Narcotic Sign In/Out Sheet record, was reviewed and the following dates lacked shift to shift reconciliation of controlled medications: In September 2023- 9/18 on both night and evening shifts, 9/20, 9/21, and 9/22 on night shift, 9/23 on all three shifts, 9/24 on night shift, 9/25 on day shift, 9/28 on both day and evening shifts, 9/29 on night shift, and 9/30 on all three shifts. In October 2023- 10/1 on both night and day shifts, 10/2 on both day and evening shifts, 10/3, 10/4, 10/5, 10/6, and 10/7 on all three shifts, 10/8 on both day and evening shifts, 10/9 on night shift, 10/10 on evening shift, 10/11, 10/12, and 10/13 on day and evening shifts, 10/14 through 10/23 on all shifts, 10/24 and 10/25 on night shift, 10/26 on both day and evening shifts, and 10/27 through 10/30 on all three shifts. During an interview on 10/30/23 at 10:00 a.m., the Infection Preventionist indicated East cart 1 contained medications for 24 residents and East cart 2 contained medications for 23 residents. During an interview on 10/30/23 at 10:06 a.m., the ADON indicated the expectation for staff was every shift completed a count of narcotics at the beginning and end of their shift. Both employees signed the narcotics book to verify the count was correct and the responsibility of the medication cart had been transferred. An undated, current facility policy titled Controlled Substance Reconciliation, provided by the DON on 10/30/23 at 11:12 a.m., indicated the following: .1. Each facility should verify the quantity of controlled substance(s) on hand as well as the number of accompanying count sheets at the end of each nursing shift 4. Quality assurance checks of the centralized log sheet are the responsibility of the nursing department, but may also be done periodically by the consulting pharmacist(s) 3.1-25(b)(3)

Based on interview and record review, the facility failed to ensure timely communication was maintained between the facility and the hospice provider for 1 of 2 residents reviewed for hospice services. (Resident 31) Findings include: Resident 31's clinical record was reviewed on 10/26/23 at 2:05 p.m. Diagnoses included chronic obstructive pulmonary disease (COPD), pulmonary fibrosis, and vascular dementia. The resident was admitted to hospice services on 7/20/23 with a diagnoses of COPD. A current care plan, initiated 7/20/23, indicated the resident received hospice services. Interventions included coordinate plan of care with hospice to promote comfort with care. During a review of the hospice communication binder on 10/26/23 at 2:38 p.m. with LPN 5, the record lacked a completed plan of care document, CNA visit notes, social worker visit notes, and chaplain visit notes. The binder lacked a visiting schedule for staff to expect services to be provided and the hospice interdisciplinary (IDT) notes section was blank. The nursing notes section contained minimal handwritten information for the following dates: 7/19/23, 8/8/23, 8/11/23, 8/18/23, 8/22/23, 8/24/23, 8/29/23, 9/6/23, 9/20/23. LPN 5 indicated the hospice nurse spoke to staff following her visits. LPN 5 was unsure the last time a nurse or CNA had visited the resident. During an interview on 10/30/23 at 11:29 a.m., the ADON indicated the hospice binder was not updated or current. The plan of care schedule for the provider was not included in the binder. There was no plan of care information, CNA, social services, or chaplain visit notes, and complete nursing notes. The IDT notes section was blank. She had reached out to the provider on 9/18/23, 9/28/23, and 10/11/23, regarding the lack of visit documentation, but had not received a response. A review of a current facility policy, updated July 2020 and titled, Nursing Facility and Hospice Services Agreement, and provided by the DON on 10/30/23 at 11:15 a.m., indicated the following: .3.1 Coordination of Responsibilities Hospice and Facility shall develop a process by which to exchange information between Hospice IDG and Facility staff regarding development and updating of the Coordinated POC and evaluation of care outcomes to insure each Hospice Patient receives necessary and appropriate care and services

Based on record review and interview the facility failed to ensure a criminal background check was completed for 1 of 5 employee records sampled. (Registered Nurse (RN) 2) Finding includes: Employee records were reviewed on 10/25/22 at 10:16 a.m. Records for RN 2 lacked a criminal background check. During an interview, on 10/25/22 at 1:39 p.m., the administrator indicated they had a My Case background check for RN 2 but did not have a criminal background check from the contracted agency. He indicated the agency had hired the nurse in 2009, and this was considered sufficient at that time. He indicated the agency was responsible for the background checks since it was a contracted employee. He provided a background check performed on 10/25/22 for RN 2. A current facility policy, titled Associate Screening Policy with a revision date of 3/1/22, provided by the Assistant Director of Nursing on 10/26/22 at 12:50 p.m., indicated .background checks are completed on all associates, where required by law .A criminal background check, including any Sex Offender or Violent Offender Registries, will be completed prior to any employment or engagement under an interim or professional services contract and upon reasonable suspicion during employment to confirm that no individual has been convicted of an offense that would preclude them from providing care or services to residents .Temporary employment agencies will be required by contract to ensure that temporary staff have undergone all of the employee screening described in this policy and the staff is not precluded from employment . This Federal tag relates to complaint IN 875. 3.1-28(b)(1)

Based on observation, interview and record review, the facility failed to utilize proper infection prevention and control practices for residents in transmission-based precautions during a facility COVID-19 outbreak for 4 of 8 resident's reviewed for transmission-based precautions. (Residents 7, 9, 58, and 109) Findings include: During an interview at entrance conference on 8/8/22 at 10:15 a.m., the Assistant Director of Nursing (ADON) indicated the facility had 5 COVID positive residents in the facility sheltered in place without a designated COVID-19 unit. During an interview on 8/8/22 at 11:40 a.m., the ADON indicated the facilty had two additional residents positive for COVID-19. This was a total of 7 COVID-19 positive residents in the facility. During an interview on 8/8/22 at 3:41 p.m., the ADON indicated the facility had a handful of staff that were COVID-19 positive. 1. During an observation on 8/9/22 at 11:44 a.m., Resident 58's room was labeled yellow zone isolation. The yellow zone isolation sign indicated required personal protection included the following: N95 mask, gown, gloves, eye protection and hand hygiene. During a continuous observation at the time of interview on 8/10/22 at 1:55 p.m., Registered Nurse (RN) 4 wore a surgical mask, face shield, gown and gloves when she entered Resident 58's yellow zone isolation room and delivered his medication within 3 feet of the resident. As she exited the room, she indicated staff were required to wear a surgical face mask, face shield, gown, and gloves in yellow zone isolation rooms. During an interview on 8/10/22 at 1:57 p.m., RN 4 indicated the yellow zone isolation sign on Resident 58's room listed an N95 mask as required personal protective equipment. She had just provided Resident 58's medication to him and had not changed into an N95 mask prior to delivering his medication. RN 4 was unsure why she was unaware of the proper mask to wear in a yellow isolation zone. She indicated should not have worn a surgical mask. Instead, she should have worn an N95 mask in the resident's yellow isolation room when she delivered his medication. Review of the Resident Vaccination List, provided by RN 7 on 8/11/22 at 3:32 p.m., indicated Resident 58 was unvaccinated for COVID-19 due to refusal of COVID-19 vaccinations. Review of the Yellow Zone Isolation list, provided by the ADON on 8/11/22 at 3:50 p.m., indicated Resident 58 was in transmission-based precautions due to an exposure to COVID-19 identified during contact tracing. Review of the COVID-19 Trace Testing Tool, provided by the ADON on 8/15/22 at 9:45 a.m., indicated Resident 58 was exposed to COVID-19 on 8/1/22 from other residents. 2. During an observation on 8/9/22 at 3:05 p.m., Certified Nurse's Aide (CNA) 6 and CNA 8 wore surgical masks with N95 masks donned over the surgical masks, eye protection, gowns and gloves as they entered Resident 109's yellow zone isolation and provided her care. The room was labeled with a yellow zone contact droplet sign. The sign listed required personal protective equipment as follows: N95 mask, eye protection, gown and gloves. During an interview at the time of observation on 8/9/22 at 3:05 p.m., CNA 6 indicated the resident was in isolation due to an identified exposure to a positive staff member during contact tracing and the isolation would be discontinued on 8/13/22. During an observation on 8/9/22 at 3:11 p.m., CNA 8 doffed her gown and gloves as she exited Resident 109's yellow isolation room with her N95 mask over top of her surgical mask. She continued down the 100 unit hallway towards the Nurse's Station with her N95 mask worn over her surgical mask. During an interview on 8/11/22 at 12:14 p.m., Licensed Practical Nurse (LPN) 3 indicated all staff were required to wear an N95 mask, gown, eye protection, and gloves to provide care in the yellow zone or red zone isolation rooms. It was not appropriate infection prevention practice for staff to wear a surgical mask with an N95 donned over it in yellow or red zone isolation rooms. During an interview on 8/11/22 at 12:22 p.m., LPN 3 indicated staff were all aware which residents in the isolation rooms were on transmission-based precautions by the bed indicator written on the isolation sign attached to the door. Review of the Resident Vaccination List, provided by RN 7 on 8/11/22 at 3:32 p.m., indicated Resident 109 was unvaccinated for COVID-19 due to refusal of COVID-19 vaccinations. Review of the Yellow Zone Isolation List, provided by the ADON on 8/11/22 at 3:50 p.m., indicated Resident 109 was in transmission-based precautions due to an identified exposure to COVID-19 during contact tracing. Review of the COVID-19 Trace Testing Tool, provided by the ADON on 8/15/22 at 9:45 a.m., indicated Resident 109 was exposed to COVID-19 on 8/2/22 from a COVID positive staff member. 3. Review of the Resident Vaccination List, provided by RN 7 on 8/11/22 at 3:32 p.m., indicated Resident 7 was not up to date on the COVID-19 vaccinations. Review of the yellow zone isolation list, provided by the ADON on 8/11/22 at 3:50 p.m., indicated Resident 7 was in transmission-based precautions due to an identified exposure to COVID-19 during contact tracing. During an observation on 8/12/22 at 10:23 a.m., Qualified Medication Aide (QMA) 5 had on a surgical mask and donned an N95 mask over her surgical mask. She donned a gown, gloves and eye protection, then entered Resident 7's yellow zone isolation room with his cup of medication. The yellow zone isolation sign on the resident's door listed required personal protective equipment as follows: N95 mask, eye protection, gown and gloves. During an observation on 8/12/22 at 10:25 a.m., QMA 5 exited Resident 7's room after she doffed her gown gloves and eye protection. Her surgical mask was still covered with an N95 mask. During an interview on 8/12/22 at 10:29 a.m., QMA 5 indicated she had passed medication to Resident 7 with an N95 mask donned over top of her surgical mask. Resident 7 was in yellow zone isolation and it was not appropriate infection control practice to wear an N95 mask over top of a surgical mask in yellow zone isolation during resident care. Review of the COVID-19 Trace Testing Tool, provided by the ADON on 8/15/22 at 9:45 a.m., indicated Resident 7 was exposed to COVID-19 on 8/2/22 from a COVID positive staff member. 4. During an observation on 08/11/22 at 12:39 p.m. Activity Assistant 9 placed an N95 mask over the top of a surgical mask then donned the rest of her PPE. She then entered Resident 9's room and delivered her meal tray. During an observation on 8/11/22 at 12:39 p.m., Resident 9's room was labeled yellow zone isolation. The yellow zone isolation sign indicated required personal protection included the following: N95 mask, gown, gloves, eye protection and hand hygiene. Review of the Yellow Zone Isolation list, provided by the ADON on 8/11/22 at 3:50 p.m., indicated Resident 9 was in transmission-based precautions due to an identified exposure to COVID-19 during contact tracing. Review of the Resident Vaccination List, provided by RN 7 on 8/11/22 at 3:32 p.m., indicated Resident 9 was not up to date on her vaccinations for COVID-19. A document, dated 2/25/22, titled [NAME] PPE COVID-19 Quick Reference Guide, provided by the ADON on 8/11/22 at 4:10 p.m., indicated the following: .PPE Category .Known Exposure with Contract Tracing .Door Signage: .Contact Precautions Droplet Precautions Yellow Isolation .Wear standard N95 . A Center for Disease Control (CDC) document, titled HOW TO USE YOUR N95 RESPIRATOR COVID-19, obtained from the Internet on 8/17/22 at 1:40 p.m., indicated the following: Wear your N95 properly so it is effective .N95's must form a seal to the face to work properly 3.1-18(b)(1)

Based on interview and record review the facility failed to identify, assess and prevent residents from developing pressure ulcers. Resident B had a unstageable pressure ulcer which required surgical intervention identified on emergency room visit after an acute condition change. (Resident B) for 4 of 6 residents reviewed for pressure ulcer (Residents B, E, G, H). The immediate jeopardy began on [DATE] when Resident B developed an unstageable necrotic sacral pressure ulcer and a large fungal infection of the hips, groin and lower abdomen. The Administrator was notified of the immediate jeopardy on [DATE] at 3:22 p.m. The immediate jeopardy was removed on [DATE], but non-compliance remained at the lower scope and severity level due to ongoing monitoring. Findings include: 1. The clinical record for Resident B was reviewed on [DATE] at 11:49 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment, dated [DATE], indicated no pressure related skin conditions. The resident required extensive assistance of 1 person for dressing, personal hygiene, bed mobility, transfers, and toilet use. The discharge MDS assessment, dated [DATE], indicated no pressure related skin conditions. The resident required extensive for all activities of daily living except eating and locomotion on the unit. Review of the admission assessment dated [DATE] indicated the resident had a rash to the right forehead due to shingles. No other skin conditions were documented. Review of the Treatment Administration Record (TAR) for [DATE] indicated the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The head- to- toe inspection was documented as being one on [DATE] on the day shift. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident B's clinical record lacked any documentation of any skin conditions such as pressure ulcers or skin infections. Review of a progress note dated [DATE] at 10:41 a.m., indicated the resident had an elevated pulse rate of 131 beats per minute and was sent to the emergency room for evaluation and treatment. Review of the emergency room triage report dated [DATE] at 10:54 a.m., indicated the resident presented to the emergency room with a large pressure ulcer on his sacrum and a large tinea (fungal infection) of the groin. Review of the emergency room physician notes summary indicated the following: Patient has notable sacral pressure sore that has not been dressed repeated [sic]. Patient also appears to have an inguinal tinea infection as well. It was noted the patient had dried urine on the bed sheets and urine-soaked clothes. Review of the Death Certificate indicated Resident B expired on [DATE] at 3:25 p.m. due to [CONDITION(S)]. Review of the hospital triage noted dated [DATE] at 10:54 a.m., indicated the following: . Pt. (patient) has pressure ulcer to mid coccyx with no dressing over site. Pt. also arrives saturated in urine from back to lower legs. Pt's sheets also appeared dirty with dried urine. Review of the hospital Wound Service Team dated [DATE] at 2:19 p.m., indicated the resident presented with necrotic sacral ulcer measuring approximately 8 cm long x 8 cm wide x 0.1 cm deep. The note indicated it was an unstageable necrotic pressure ulcer believed to be at least a stage 3. The skin at hips, groin and low abdomen was pink with uneven margins consistent with crustaceous candidiasis (yeast infection). Review of a hospital nursing progress note dated [DATE] at 6:55 p.m., indicated the resident's family member stated the resident had a rash in the right groin and had been treating it with rubbing alcohol at home. The family member stated the resident did not have any bed sores to the coccyx or buttocks while at home. Review of the hospital surgical note dated [DATE], indicated the resident received surgical debridement of the necrotic sacral decubitus ulcer. During an interview on [DATE] at 11:35 a.m., the Director of the hospital Wound Services indicated it took 48 to 72 hours for necrotic tissue to develop. During an interview on [DATE] at 12:18 p.m., the Assistant Director of Nursing (ADON) indicated skin assessments were done upon admission, once a week and once a month during a facility wide skin sweep. Any newly observed skin condition would be documented in the clinical record. During an interview on [DATE] at 2:30 p.m., RN1 indicated she did not remember Resident B's discharge because it had been so long ago. 2. The clinical record for Resident E was reviewed on [DATE] at 12:43 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated no pressure related skin conditions. The resident required extensive assistance of 3 persons for bed mobility, transfers, dressing and toilet use; extensive assistance of 1 person for personal hygiene and eating. Review of the results of a facility wide skin sweep done on [DATE] indicate Resident E had new stage 3 pressure area on the coccyx measuring 1 cm x 1 cm x 0.2 cm. A care plan for the pressure area was created on [DATE]. 3. The clinical record for Resident G was reviewed on [DATE] at 1:38 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) assessment, dated [DATE], indicated no pressure related skin conditions. The resident required extensive assistance of 2 persons for bed mobility, dressing,and toilet use; total assistance of 2 persons for transfers and extensive assistance of 1 person for personal hygiene. Review of the results from a facility wide skin sweep, done on [DATE] indicated Resident G was found to have a newly identified fluid filled blister to the left heel measuring 7 cm X 3 cm. A care plan for the pressure area was created on [DATE]. 4. The clinical record for Resident H was reviewed on [DATE] at 10:07 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident required extensive assistance of 2 persons for bed mobility, dressing, and toilet use; total assistance of 2 persons for transfers and extensive assistance of 1 person for personal hygiene. Review of the results from a facility wide skin sweep on [DATE] indicated Resident H had a newly identified a red stage 2 pressure area on her coccyx, with no drainage, measuring 0.3 x 0.3 x 0.1 area to coccyx. A care plan for the pressure area was created on [DATE]. During an interview on [DATE] at 1:07 p.m., the ADON indicated she did not know how the newly identified pressure areas were missed for Residents E, G, and H. A current policy, dated [DATE], titled Skin Assessment Policy indicated the following: . Residents within a [NAME] community will have a head to toe skin assessment completed by a licensed nurse upon admission and weekly thereafter. The head-to-toe skin assessment will be charted as completed by the licensed nurse. The nurse doing the assessment will document any abnormal findings affecting the skin. If a new skin condition is identified by a licensed nurse while completing a skin assessment, the nurse will open the appropriate Skin Integrity Event in Matrix and complete all required sections. The licensed nurse that discovers a new open area will perform the following: 1. Notify the MD, obtain and enter a treatment order 2. Apply the initial treatment 3. Notify the family 4. Inform other caregivers to ensure preventative actions are put into place to promote healing and inhibit development of additional areas. 5. Document these items in the medical record. This policy was provided by the ADON on [DATE] at 3:08 p.m. The immediate jeopardy that began on [DATE] was removed on [DATE] when the facility performed a facility wide skin sweep reviewed, and developed care plans for identified skin conditions, educated staff and put into place a system to monitor skin assessments, but non-compliance remained at the lower scope and severity level due to ongoing monitoring. This Federal tag relates to complaint IN 198. 3.,d+[DATE](a)(1)

Based on observation, interview and record review, the facility failed provide adequate supervision to residents who were at risk for falling to prevent falls for 2 of 3 residents reviewed for accidents (Resident C and Resident D). This deficient practice resulted in Resident C sustaining intracranial injuries, rib fractures and a left [MEDICAL CONDITION] and Resident D sustaining a clavicle fracture. Findings include: 1. The clinical record for Resident C was reviewed, on [DATE] at 9:56. His [DIAGNOSES REDACTED]. He was admitted , on [DATE] and expired on [DATE]. An admission MDS (minimum data set) assessment, dated [DATE], indicated he had severe cognitive impairment and he required supervision with the physical support of one person for ambulation. A care plan, dated [DATE], indicated he was at risk for falls. Interventions included, but were not limited to: keep personal items in reach ([DATE]), remind resident to use call light ([DATE]), remove scale from unit ([DATE]) and encourage the use of a walker ([DATE]). A care plan, dated [DATE], indicated he was at risk for elopement related to his wandering. Intervention included, but were not limited to: provide basic needs when wandering ([DATE]), place wander guard ([DATE]), redirect him if wandering unsupervised ([DATE]) and increase staff monitoring ([DATE]). A care plan, dated [DATE], indicated he required the use of a restorative program for walking. Interventions included, but were not limited to: explain the walking task to him ([DATE]), encourage appropriate footwear ([DATE]), walk with him for stand by assistance with his four wheeled walker ([DATE]) and apply gait belt prior to walking. A nurses note, dated [DATE], indicated he was wandering and exit seeking. A nurses note, dated [DATE], indicated he was attempting to leave the unit. A physical therapy discharge note, dated [DATE], indicated he was discharged from therapy. He continued to require stand by assistance with functional mobility due to deceased safety awareness. A nurses note, dated [DATE], indicated he was wandering and exit seeking most of the shift. A nurses note, dated [DATE], indicated he was pacing from room to room on and off for three hours. A nurses note, dated [DATE], indicated he was pacing and wandering for three hours. A nurses note, dated [DATE], indicated he left the unit behind a staff member and redirected back to the secured unit. A nurses note, dated [DATE], indicated he was exit seeking for hours. A nurses note, dated [DATE] at 1:30 a.m., indicated the resident was ambulating in the hallway and attempted to walk onto a weight scale. He lost his balance and fell backwards. he complained of pain to the left knee and hip. He was assisted to a wheelchair and sent to the emergency room for evaluation. emergency room notes, dated [DATE] at 1:51 a.m., indicated he had intracranial (head) injuries and rib fractures. Extremity fractures ruled out by imaging. He was discharged back to the facility with no evidence of emergent traumatic injuries. A nurses note, dated [DATE] at 6:15 a.m., indicated he returned from the emergency room . He continued to complain of severe pain to the left leg. A nurses note, dated [DATE] at 1:37 p.m., indicated he complained of pain to both legs with the inability to walk or stand. Pain medication was administered and ineffective. The resident was sent back the the emergency room for repeat evaluation. A radiology report, dated [DATE] at 2:51 p.m., indicated a left femoral neck (hip) fracture. A nurses note, dated [DATE] at 3:56 p.m., indicated a family member called the facility to inform that the resident was being admitted with a [MEDICAL CONDITION]. A physician discharge summary, dated [DATE] at 1:28 p.m., indicated discharging [DIAGNOSES REDACTED]. He was seen by a surgeon for hip repair and the surgeon indicated he was a high risk surgical candidate, but it would be morally unethical to leave him in pain, so the surgery was scheduled. In the interim the resident had a marked decline, refused to eat and became less responsive. At that time the family was contacted and the resident was discharged to hospice care. During an interview with the Physician, on [DATE] at 11:30 a.m., he indicated the resident had severe dementia and prior to the fall he had a typical slow decline. After the fall he was scheduled for surgery to repair the hip. The surgery was canceled because of a rapid decline the resident experienced. He indicated the decline came from failure to thrive as the resident was in too much pain and refused to eat. After the fall the resident had a rapid decline and the family opted to place him on hospice care. He expired a short time later. He indicated the cause of death was failure to thrive caused by the [MEDICAL CONDITION] which he sustained at the facility. His dementia played a part as he was confused and forgetful and wandered leading to his fall. The surveillance video from the facility was reviewed, on [DATE] at 12:27 p.m., with the Administrator. The video time indicated, [DATE] at 12:29 a.m., a weight scale was in the hallway across from the resident's room. At 12:32 a.m., the resident was seen walking out of his room, he appeared to lift one foot up and at this time fell backwards. The video did not show the transfer of the resident as it skipped. During an interview with the Administrator, on [DATE] at 12:37 p.m., she indicated the resident fell because he lost his balance. She indicated the new intervention was to remove scales from the hallways. For further clarification, she indicated not all items were removed from hallways, just the scales. She was not familiar with the video surveillance so she had no further information as to why the video surveillance skipped. 2. During an observation and interview with Resident D, on [DATE] at 1:23 p.m., he was in bed with no sling to the left arm. He indicated he remembered falling on [DATE]. He wanted to go to the residential building for a quiet place to rest. He went down a dip in the parking lot and he couldn't control his wheelchair. He then fell on to the pavement. He indicated he went out by himself. His shoulder was hurting right away after he fell . He reported it was hurting to the staff when they came to help him. He indicated he did not wear a brace or a sling to the left arm. When he moved his shoulder, it still hurt him most of the time. The clinical record was reviewed, on [DATE] at 11:10 a.m. His [DIAGNOSES REDACTED]. A quarterly MDS, dated [DATE], indicated he was cognitively intact, required extensive assistance with locomotion off of the unit and had no falls. A care plan, dated [DATE], indicated he was at risk for falls. Interventions included, but were not limited to: keep call light in reach at all times ([DATE]), wear non-skid socks ([DATE]), give routine pain medication ([DATE]), keep personal items in reach at all times ([DATE]), assess wheelchair for anti-tippers ([DATE]), apply wander bracelet to ankle ([DATE]) and resident will be observed when going outside ([DATE]). The resident's care plan lacked any care plan for the closed fracture of left clavicle diagnosed on [DATE]. An elopement risk assessment, dated [DATE], indicated he was not an elopement risk. An elopement risk, dated [DATE], indicated he was not an elopement risk. A post fall assessment, dated [DATE], indicated he fell at 3:10 p.m. He was outside in the parking lot in his wheelchair unattended. A staff member of the therapy department, who was inside the building, witnessed the resident loose control of his wheelchair. A nurses note, dated [DATE] at 10:18 p.m., indicated he complained of left shoulder pain with motion. A fall review, dated [DATE] at 9:37 a.m., indicated the resident was walking behind his wheelchair in the parking lot and lost his balance and fell . He indicated he was looking for a quiet place. A nurses note, dated [DATE] at 11:35 a.m., indicated the resident had low oxygen saturation upon rising and an accelerated heart rate upwards into the high 100's. Oxygen was administered and heart rate was still elevated. New orders were obtained to send resident to the emergency room . A hospital discharge summary, dated [DATE] at 1:49 p.m., indicated he was discharged with a [DIAGNOSES REDACTED]. The resident was to wear sling for left arm until healed. A nurses note, dated [DATE] at 9:39 p.m., indicated he returned from the emergency room with a [DIAGNOSES REDACTED]. During an interview with LPN 3, on [DATE] at 1:14 p.m., she indicated the resident was walking outside because he was looking for a quiet place. She did not have any information to provide as to how the resident exited the building or why he was unsupervised at the time. During an interview with LPN 2, on [DATE] at 1:45 p.m., she indicated the resident received pain medication routinely. He did not wear a sling to the left arm. A current policy titled Fall Prevention was provided by the Administrator, on [DATE] at 12:43 p.m. This policy indicated, .PURPOSE: the purpose of this policy is to provide CarDon communities with best practices and evidence based approaches to prevent falls and protect residents who are at risk for falls .POLICY: .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 . 3XXX,[DATE](a)

Based on observation, interview and record review, the facility failed to ensure weight loss prevention interventions were provided to prevent a resident from experiencing a 11.2% significant weight loss. This impacted 1 of 4 residents reviewed for nutrition and weight loss. (Resident #85) Findings include: On [DATE] at 3:37 p.m., Resident #85's record was reviewed. [DIAGNOSES REDACTED]. On [DATE] at 8:48 a.m., the resident ate 50% of her breakfast and drank 120 ml (milliliters) of her orange juice. She was served biscuits and gravy on a plate and cream of wheat cereal was served in a bowl. She was eating her breakfast in her room and no staff member was observed in the room to assist her eat her breakfast. On [DATE] at 6:01 p.m., the resident received a cheeseburger on a plate, three bean salad in a small bowl and vanilla ice cream in a bowl. She received a glass of chocolate milk and cranberry juice to drink for dinner. An unidentified CNA came into her room to assist her with her meal and she accepted the assistance. On [DATE] at 1:25 p.m., the resident had candied sweet potatoes in a bowl, steamed cabbage in a bowl, herbed pork loin sandwich on a plate and a piece of homemade iced chocolate cake on a plate. She was being assisted to eat by LPN #5. She had a chocolate magic cup to eat, 2 chocolate mighty shakes, she drank a 12 oz glass of chocolate milk and she had an 8 oz glass of lemonade. She was eating in the main dining room at a regular table, not an assist table. The resident's current nutrition Physician orders [REDACTED]. [DATE]--Regular diet with supercereal at breakfast, chocolate milk, fortified pudding-double portion for lunch and dinner. Sandwiches at all meals. Special Instructions: Food in bowls. No consumption's could be found documented for fortified pudding-double portion for lunch and dinner, which the physician had ordered on [DATE]. The fortified pudding-double portion was not observed being served to the resident on [DATE] at 6:01 p.m., with her dinner meal or [DATE] at 1:25 p.m., with her lunch meal. The fortified pudding-double portion was not found documented on the resident's lunch meal ticket for one of the items to be served to her on [DATE] at lunch. The resident's weight for the last 180 days were as follows: [DATE]-130 [DATE]-127 [DATE]-127 [DATE]-125 [DATE]-122 [DATE]-123 [DATE]-119 [DATE]-117 [DATE]-118 [DATE]-122 [DATE]-119 [DATE]-112 [DATE]-115 [DATE]-117 [DATE]-117 [DATE]-113 [DATE]-116 The resident's quarterly MDS (Minimum Data assessment) dated [DATE], indicated the resident's ability to see in adequate light was moderately impaired and she did not have corrective lenses. She required limited assist with one person physical assist for eating. The IDT (Interdisciplinary team) Clinically at Risk Review dated [DATE], indicated Resident #85 had a 12% weight loss in 158 days. She had a previous weight of 117 and her current weight was 113. The current intervention was to move the resident to an assist table to encourage more consumption in an attempt to stabilize her weight loss. The resident's annual Nutrition-Nutritional Assessment Comprehensive dated [DATE], indicated the resident's diet was a regular diet with supercereal at breakfast. She ate in the main dining room. She weighed 116 pounds and her usual body weight range was ,[DATE] pounds. Her Body Mass Index (BMI) was 18.8. The resident's average PO (by mouth) intake at meals was 50%. Her weight status indicated she had a <7.5% weight change in 90 days and her BMI was <18.5 or >24.9. Her Oral/Nutritional food intake meets ,[DATE]% of her estimated needs. A Registered Dietician progress note dated [DATE], indicated Resident with noted 11.2% weight loss x 184 days. Weights past month have ranged from ,[DATE] lb. Current BMI is lower for age but WNL (within normal limits) at 18.7. Diet remains regular with intakes averaged at ,[DATE]%. Nutrition interventions in place for weight maintenance include fortified cereal, chocolate milk with meals, double portion of fortified pudding with lunch and dinner, sandwich with all meals. Suggest continuing current nutrition interventions. The resident had a Care Plan dated [DATE], that addressed the problem she would refuse to consume meals at times. The approaches included, but were not limited to, [DATE]--Asist (sic) resident with feeding if she will allow. Food to be served in bowls to make self feeding easier (sic). Offer alternate foods when resident resists eating. Provide snacks/supplements when <50% is consumed. The resident had a Care Plan dated [DATE], that addressed the problem she was at risk for weight loss due to a history of weight loss, poor po (oral) intake, refused meals at times and [DIAGNOSES REDACTED]. Supercereal at breakfast, chocolate milk, Fortified pudding-double portion for lunch and dinner. Sandwiches at all meals. [DATE]--provide sandwich or finger foods for lunch and dinner. [DATE]--Magic cup for lunch and dinner. [DATE]--add chocolate milk at meals. monitor weights weekly. provide supplements as ordered (sic). rd to eval. snacks between meals. The resident had a Care Plan dated [DATE], that addressed the problem she required a regular nas (no added salt) diet and she had the potential for weight loss due to difficulty adjusting. The approaches included, but were not limited to, .XXX[DATE]--Resident will be move to another table in dining room closer to feed table for encouragement. [DATE]--Explain to resident risks versus benefits of following dietary regimen/restrictions. Provide the resident with as much control as possible in routines, food preferences, etc. The resident's meal intakes were reviewed from [DATE] to [DATE] and she averaged these intakes for the following meals: Breakfast-,[DATE]% Lunch-,[DATE]% Dinner-,[DATE]% During an interview on [DATE] at 8:48 a.m., the resident indicated the food she received that morning (biscuits and gravy and cream of wheat) was not fit to feed a dog and that is why I am losing weight. During an interview on [DATE] at 9:10 a.m., LPN #4 indicated the resident was to have a sandwich with every meal. During an interview on [DATE] at 6:01 p.m., the resident indicated she did not like the cereal the facility feeds her every morning. During an interview on [DATE] at 9:30 a.m., the Administrator indicated the resident refused to eat in the assist dining room. The DON indicated there was no documentation on the Care Plan or progress notes to indicate the resident had refused to eat in the assist dining room. During an interview on [DATE] at 9:40 a.m., the Director of Nursing (DON), Registered Dietician (RD), Administrator and Director of Dining Services (DDS) were in attendance. The DON indicated there were no alternatives offered when residents did not eat a certain percentage of food and there was no place to document when an alternative was offered to residents in place of the regular meal. She indicated she had expected the staff to offer an alternative meal to residents when they noticed residents were not eating their meals. She indicated the alternative and regular meal was both totaled into the meal intake together. The RD indicated at that time she was notified about weights by a referral sheet that was given to her, the Assistant Director of Nursing emailed every week with the following information weight losses, current interventions, significant weight losses to review and a weight variance report to review. She indicated this resident's weight loss interventions that were currently in place were feeding assistance, Med pass 120 ml (milliliters) three times daily, fortified pudding-double portions at lunch and dinner, sandwiches with every meal and her food was to be placed in bowls. The DDS indicated at that time any fortified foods, which would be listed on the resident's meal ticket would have a diamond next to the fortified food on the meal ticket. She indicated the meal ticket should print out every meal with the fortified foods listed on the resident's meal ticket. A current policy titled Nutrition & Hydration At Risk Program undated, was provided by the DON on [DATE] at 3:49 p.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, Residents with a pressure ulcer or other significant skin conditions, Residents with a [DIAGNOSES REDACTED]. A current policy titled Nutritional and Weight Monitoring undated, was provided by the DON on [DATE] at 3:49 p.m., indicated It is the policy of (name of company) to monitor the resident's nutritional intake at each meal. This is recorded on a food intake record in percent consumed. 0%=nothing eaten, 25%=,[DATE] of total meal eaten, 50%=,[DATE] of total meal eaten, 75%=,[DATE] of total meal eaten, 100%=all eaten.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 (Certified Dietary Manager) in writing. 3XXX,[DATE](a)(1)