Every finding on record at Harrison Springs Health Campus

Based on record review and interview, the facility failed to hold blood sugar and blood pressure medications when vital signs were out of the physician-ordered set parameters. This deficient practice affected 5 of 8 residents reviewed for medications with set parameters that were to be held based on the vital sign results (Residents 20, 22, 53, 6, and 52)1.The physician's order for Resident 20, dated 12/4/24, indicated the physician or Nurse Practitioner (NP) was to be notified of a systolic blood pressure (SBP-the top number in a blood pressure reading, measuring the maximum pressure in your arteries when your heart muscle contracts and pumps blood) greater than 165 milliliters of mercury (mmHg) or diastolic blood pressure (DBP-the bottom number in a reading, measuring the pressure in your arteries when the heart muscle rests between beats and fills with blood) greater than 100 mmHg taken twice daily. A physician's order, dated 2/3/26, was received for metoprolol succinate extended release 24 hours 50 milligrams (mg). The resident was to receive one tablet daily for high blood pressure. Staff were to hold (not give) for SBP less than 105 mmHg and heart rate less than 60 bpm. The medication was to be given between 6:00 a.m. and 10:00 a.m. The record for Resident 20 was reviewed on 4/20/26 at 11:04 a.m. The diagnoses included, but were not limited to, paroxysmal atrial fibrillation (an irregular, rapid heart rhythm that starts and stops on its own) and portal hypertension (elevated blood pressure within the portal venous system). A Quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident had some trouble with recall but was able to make daily cognitive decisions. A care plan, dated 9/25/24 with a review date of 3/23/26, indicated the resident had the potential for cardiovascular distress related to the diagnoses of atrial fibrillation and hypertension. The goal was for the resident to be free from signs and symptoms of cardiovascular distress. The approaches included, but were not limited to, observe for signs and symptoms of cardiovascular distress and report as needed; medications as ordered, observe for and report side effects as needed; and obtain vital signs as ordered and needed. The review of the February and March 2026 Medication Administration Records (MARs) indicated the set parameters to hold the medications were not followed. The resident's Metoprolol Succinate extended release 25 mg tablet was administered to the resident when the resident's pulse or blood pressure readings were out of the set parameters on the following dates: -On 2/13/26, the resident's pulse was 59. -On 3/1/26, the resident's pulse was 55. -On 3/7/26, the resident's pulse was 56. -On 3/12/26, the resident's Blood pressure reading was SBP 119 over DBP 55. -On 3/13/26, the resident's Blood pressure reading was SBP 108 over DBP 57. -On 3/16/26, the resident's pulse was 57. -On 3/20/26, the resident's pulse was 59. The Medical Doctor (MD) or Nurse Practitioner (NP) was to be notified of the resident's SBP greater than 165 bpm or DBP greater than 100 bpm. The resident's blood pressure readings were to be taken twice daily at 6:00 a.m. to 10:00 a.m. The resident's clinical record lacked the MD's or NP's notification related to an elevated SBP of 169 on 2/9/26. 2. The record for Resident 22 was reviewed on 4/17/26 at 2:10 p.m. The diagnoses included, but were not limited to, interstitial pulmonary disease (an umbrella term for over 200 disorders that caused progressive inflammation and irreversible scarring of lung tissue); orthostatic hypotension (a sudden drop in blood pressure within 3 minutes of standing); and atherosclerotic heart disease of native coronary artery without angina pectoris (a condition caused by the buildup of plaque inside artery walls which narrows vessels and restricts oxygen-rich blood flow to the heart). A care plan, dated 4/13/21 with a review date of 3/1/26, indicated the resident had the potential for cardiovascular distress related to diagnoses of congestive heart failure, coronary artery disease, hypertension, high cholesterol and a history of a heart attack. The goal was for the resident to be free from signs and symptoms of cardiovascular distress. The approaches included, but were not limited to, observe for signs and symptoms of cardiovascular distress and report as needed; medications as ordered, observe for and report side effects; and obtain vital signs ordered and needed. A physician's order, dated 1/7/25, indicated the Resident 22 received metoprolol succinate extended release 24 hour tablet, 50 mg, twice daily for hypertension. The staff were to hold the medication if the resident's SBP was less than 100 bpm or DBP was less than 60 bpm. Review of the March 2026 MAR, indicated the set parameters for the staff to hold the resident's medications were not followed. The resident's metoprolol succinate extended release 24 hour tablet was administered on the following dates outside of the parameters: -On 3/30/26 6:00 p.m. to 10:00 p.m. dose, the resident's DBP was 58. -On 3/31/26 6:00 p.m. to 10:00 p.m. dose, the resident's DBP was 57. 3. The clinical record for Resident 53 was reviewed on 4/17/26 at 9:19 a.m. The diagnoses included, but were not limited to, acute respiratory failure with hypoxia (clinical condition where body tissues are deprived of oxygen) and diabetes mellitus (a chronic condition characterized by high blood sugar due to inadequate insulin production). A care plan, dated 3/17/26 with a review date of 3/24/26, indicated the resident had the potential for hypertension and high cholesterol. The goal was for the resident to be free from signs and symptoms of cardiovascular distress. The approaches included, but were not limited to, observe for signs and symptoms of cardiovascular distress and report as needed; medications as ordered, observe for and report side effects; and obtain vital signs ordered and needed. A care plan, dated 3/17/26 with a review 3/24/26, indicated the resident was at risk for hyper and hypoglycemia related to diabetes mellitus. The goal was for the resident to be free of symptoms of hypo or hyperglycemia. The approaches included, but were not limited to, medications per order; monitor blood sugars per MD orders; and observe resident for symptoms of hypo or hyperglycemia. A physician's order, dated 3/16/26, indicated the resident was received for insulin lispro pen 100 unit per milliliter (mL) per sliding scale: If the resident blood sugar reading was 150 to 199, the staff were to administer 3 units of insulin; if the resident's blood sugar reading was 200 to 249, the staff were to administer 5 units of insulin; if the resident's blood sugar reading was 250 to 299, the staff were to administer 8 units of insulin; if the resident's blood sugar reading was 300 to 349, the staff were to administer 10 units of insulin; if the resident's blood sugar reading was 350 to 400, the staff were to administer 12 units of insulin; if the resident's blood sugar reading was greater than 400, the staff were to give 14 units and call the MD. The review of the March and April 2026 MARs, indicated the resident's MD was not notified when the resident's blood sugar readings were over 400 on the following dates and times: -On 4/14/26 at 6:30 a.m. to 9:00 a.m. check, the resident's blood sugar reading was 478. -On 4/14/26 at 10:00 a.m. to 12:00 p.m., the resident's blood sugar reading was 461. A physician's order, dated 3/18/26, indicated the resident received metoprolol succinate tablet extended release 24 our tablet twice daily. The staff were to hold the medication if the resident's SBP was less than 105, if the DBP was less than 60, or for a heart rate of less than 60 bpm. The resident received the medication outside of the prescribed administration parameters on the following dates and times: -On 3/27/26 at 6:00 p.m. to 10:00 p.m., the resident's DBP was 59. -On 3/31/26 at 6:00 a.m. to 10:00 a.m., the resident's DBP was 51. -On 4/7/26 at 6:00 p.m. to 10:00 p.m., the resident's DBP was 58. -On 4/15/26 at 6:00 a.m. to 10:00 a.m., the resident's pulse was 59. On 4/20/26 at 2:10 p.m., the Director of Health Services (DHS) indicated that if the physician had given set parameters for certain medications, then nursing would hold the medication and notified the physician that the vital signs fell outside the ordered parameters. On 4/20/26 at 2:20 p.m., the Executive Director (ED) indicated that they had checked with the Clinical Support nurse and there was no set parameters policy to address what they would do. On 4/21/26 at 9:57 a.m., the DHS presented a copy of an action plan for medications not being held per set parameter orders that they indicated was started last week. Review of this action plan indicated they were going to follow all residents who have parameters within the blood pressure medication orders to ensure parameters were met. The action plan failed to identified all residents receiving medication with hold parameters during the survey investigation. Only the same residents were being monitored for the plan of action and not all residents as indicated. 4. The clinical record for Resident 6 was reviewed, on 04/15/26 at 10:00 a.m., the resident's diagnoses included, but were not limited to, atrial fibrillation (an irregular heart rhythm starting in the atria), non-rheumatic aortic valve stenosis (narrowing of the aortic valve), chronic pulmonary edema (fluid in the lungs), hypertensive heart, congestive heart failure (chronic condition where the heart does not pump blood efficiently, leading to fluid backup). The care plan, dated 2/28/24 and revised 2/24/26, indicated the resident had potential for cardiovascular distress. The interventions, dated 2/28/24 and revised 2/24/26, included, but were not limited to giving medications as ordered by the physician. A physician's order, with a start date of 10/28/25, indicated the resident was to receive midodrine 10 mg three times daily before meals at 6:00 a.m. to 9:00 a.m., 10:00 a.m. to 12:30 p.m., and 3:30 p.m. to 5:30 p.m. The medication was to be held if the resident's SBP was greater than 130. A physician's order, with a start date of 10/28/25, indicated the resident was to receive metoprolol succinate 25mg once daily and the medication was to be held if the resident's SBP was less than 100 mmHg or if the resident's heart rate was less than 60 beats per minute. The March and April 2026 MAR indicated the resident's midodrine was to be held if the resident's SBP was greater than 130. On the following dates in the EMAR the resident's midodrine was held, but no blood pressure reading was documented on the following dates: 3/6/26, 3/8/26, 3/19/26, 4/2/26, 4/4/26, 4/6/26, 4/8/26, and 4/9/26. The EMAR indicated on 3/18/26, the resident's midodrine was held for a SBP of 122 and the resident's midodrine was administered on 3/28/26 for a SBP of 135. The March and April [DATE] indicated the resident's metoprolol succinate was to be held if the resident's SBP was less than 100, or if the residents pulse was less than 60. The resident's metoprolol was administered out of parameters on 4/7/26 with a SBP of 98 and on 4/12/26 with a SBP of 98. 5. The clinical record for Resident 52 was reviewed on 4/15/26 at 11:00 a.m. The resident's diagnoses included, but were not limited to, congestive heart failure and chronic pain syndrome. The care plan, dated 4/10/26, indicated the resident had potential for cardiovascular distress. The interventions, dated 4/10/26, included, but were not limited to observation for signs and symptoms of cardiovascular distress and report as needed; medications as ordered; and obtain vital signs as ordered. A physician's order, with a start date of 4/11/26, indicated the resident was to receive midodrine 10 mg every 8 hours and the medication was to be held if the resident's SBP was greater than 125. The March and April 2026 EMAR indicated the resident's midodrine was to be held if the resident's SBP was greater than 125. The resident was administered the midodrine out of parameters on 4/12/26 with a SBP of 127. During an interview, 4/17/26 at 9:45 a.m., Registered Nurse (RN) 6 indicated that with abnormal blood pressure or heart rate and physician set parameters a medication would be held, and the physician and DHS would be notified. During an interview, 4/20/26 at 10:00 a.m., the Licensed Practical Nurse (LPN) 7 indicated that the medication would be held if outside the physician order parameters. The medication being held would be charted and the physician notified of holding the medication. During an interview, 4/20/25 11:00 a.m., the LPN 8 indicated that if a resident's blood pressure was outside the set parameters, then the medication would be held and notifications made. During an interview on 4/20/26 at 2:10 p.m., the Director of Health Services (DHS) indicated that if the physician had given set parameters for certain medications, then nursing would hold the medication and would notify the physician that the vital signs fell outside the ordered parameters. During an interview on 4/20/26 at 2:20 p.m., the Executive Director (ED) indicated that they had checked with the Clinical Support nurse and there was no set parameters policy to address what they would do. On 4/21/26 at 9:57 a.m., the DHS presented a copy of an action plan for medications not being held per set parameter orders that they indicated was started last week. The review of this action plan indicated they were going to follow all residents who have parameters within the blood pressure medication orders to ensure parameters were met. This plan would continue until 100% compliance was met. It was identified during this review, that the same residents were being monitored the prior week as well as this week. During the final exit meeting, the DHS was asked why the same residents were being monitored every week instead of choosing other residents also with parameter orders to hold the medications. She indicated these were the ones who had issues with the medications not being held per order. 410 IAC (Indiana Administrative Code) 16.2-3.1-37

Based on record review and interview, the facility failed to ensure Resident Council Minutes were recorded monthly for 11 of 13 months and failed to ensure Resident Council Minutes for follow-up responses to grievances were documented for 13 of 13 months reviewed. This had the potential to affect all 52 of 52 residents residing in the facility. Findings include:During an interview, on 4/15/26 at 10:06 a.m., Activity Aide 3 indicated the Resident Council President 18 had the Resident Council Minutes. She found the binder with the Minutes for the last meeting on 4/14/26. During the review of the 4/14/26 Resident Council Minutes, on 4/15/26 at 10:17 a.m., the following concerns were voiced: The menus changed from the printed menu. Residents wanted more assistance with wheelchair transfers. No follow-up for any previous meetings were documented. The Resident Council Minutes in the binder, from April 2025 to April 2026, lacked documentation of minutes since 2023 and 2024, except for the December 2025 and April 2026 Minutes. These were the only Minutes kept by activities in the Resident Council binder since 2023 and 2024. During an interview, on 4/15/26 at 12:35 p.m., the Resident Council President 18 indicated that meetings were held monthly, with staff present, but she didn't document all of the meetings. She indicated she felt it was her responsibility, but she let it slide. During an interview, on 4/16/26 at 8:35 a.m., Activity Aide 4 indicated the residents had monthly meetings. Two Activity Aides helped to direct the meetings. The Resident Council President 18 took notes and Activities staff also took notes. The notes were kept in a binder in their office and she was not aware if anyone had changed or thinned the binder. During a Resident Council Meeting, on 4/17/26 at 9:11 a.m., Resident Council President 18 indicated the residents continued to wait in the bathroom for staff to come back to assist the residents with transfer to their bed or wheelchair. They had not pulled the cord, but once they did, the staff responded quickly. Resident 50 started to cry and indicated it took the staff 30 to 40 minutes to respond, when she was on the bedside toilet or bathroom toilet. She needed consistency with care. The residents at the meeting were unsure if the facility responded to their concerns. There was usually an activity staff member present during the meetings. Resident Council President 18 indicated maybe the notes she took were not good notes, but she did take some notes. The staff copied the notes. Resident 18 kept the notes in her room in a folder. She was unsure what the activity person did with the copy of the meetings. During an observation and interview, on 4/17/26 at 9:50 a.m., Resident Council President 18 presented the minutes she had documented from the last 2 months of meetings in February and March 2026. Sometimes the staff made a copy of the minutes. Sometimes it got lost in the transmission. September 9, 2025 was the only other notes she had documented, before February 2026. The resident indicated she started as Resident Council President in September 2025. The Resident Council notes presented by the President only indicated one to two issues, but no grievance follow-up. The residents in attendance during those meetings were not documented on the February 2026 or March 2026 notes. The notes lacked documentation of follow-up responses by management. During an interview, on 4/17/26 at 10:00 a.m., the Activity Aide 4 indicated she was never at the Resident Council meetings, but Activity Aides 3 or 5 could answer questions. The form that they filled out for the minutes would have been used. During an interview, on 4/17/26 at 10:07 a.m., the Executive Director (ED) indicated the Activities Director just didn't show up for work after training recently. The Activity Aides verbalized resident grievances presented during the meetings to Administration if they felt they were important. Sometimes they would bring copies of the minutes, if there were concerns. She would review those and let the staff know what follow-up would be completed. During an interview, on 4/20/26 at 9:01 a.m., Activity Aide 3 indicated she and Activity Aide 5 sat in on the Resident Council meetings. When the Activities Director worked in the building, she would sit in on the meetings. She or Activity Aide 5 would set the minutes in front of the previous Activity Director or set them on her desk to enter into the computer. She wasn't sure if the Activities Director documented those on the form on the computer. The Activity staff would take notes and if the Resident Council President wanted a copy, they would provide it to her. They would also write down the names of residents in attendance. She personally didn't have access to the Resident Council form on the computer, where the minutes would be documented, but the ED did and she would ask her to print those out. The Activity Aide opened the Resident Council binder. There was now a note on a form for the March 2026 meeting with residents in attendance. During an interview, on 4/20/26 at 9:59 a.m., the ED indicated a previous Activity Director was not documenting the Resident Council meetings as she should have. The ED had spoken to the Activity Director about this issue, among other things and she had gone back to her old habits. Any staff member could document the Resident Council Minutes in the facility's computer system. The ED presented more Resident Council Minutes at this time. The 10/7/25 Minutes had no documentation on it. She also presented minutes for 12/11/15, 2/10/26, 3/10/26, and 4/14/26. The Minutes had no grievance follow-up documentation other than Old Business was read and approved as revised. The Resident Council Policy, dated April 2025, included, but was not limited to, . 6. Minutes of the meeting will be recorded and maintained for at least 2 years. Minutes will not disclose specific individuals who voice concerns about the Campus. 7. The group facilitator will determine the prevalence of the concern/recommendations voiced to determine appropriate follow-up. 9. Actions taken and/or considerations given to issues will be reported back to the Resident Council at the next meeting. 410 IAC (Indiana Administrative Code) 16.2- 3.1-7(a)(2)

Based on record review and interview, the facility failed to ensure staff were available for one to one supervision related to residents with behaviors requiring one to one supervision for 3 of 4 residents reviewed for sufficient staff for behavior Health Needs. (Residents B, C, and D)Findings Include:1.The record for Resident B was reviewed on 11/6/25 at 10:00 a.m. The diagnoses included, but were not limited to, wedge compression fracture of the first lumbar vertebra, urinary tract infection altered mental status, and dementia. The Minimum Data Set (MDS) assessment, dated 9/9/25, indicated the resident was moderately cognitively intact. The physician order indicated the following: - Buspirone 30 (mg) milligram tablet, given twice a day related to anxiety. The start date was 9/5/25 - Risperidone 0.5 mg tablet once a day related to psychosis. The start date was 9/5/25. - Venlafaxine 150 mg capsule extended release at bedtime related to depression. The start date was 9/5/25. - Effexor XR (venlafaxine) 75 mg capsule, extended release once a day. The start date was 9/8/25. - Risperdal (risperidone) 0.5 mg tablet at bedtime related to psychosis. The start date was 9/13/25. The care plan, dated 9/14/25 and revised on 9/17/ 25, indicated Resident B demonstrated exit-seeking behaviors. The interventions included, but were not limited to, monitor for wandering triggers, encourage regular family contact and visits with others, evaluate the need for a secure unit and transfer the resident if needed, apply a wander guard monitor as ordered, offer diversional activities as needed, re-direct the resident away from doors and exits as needed, a family member present with the resident and an outside agency sitter present with the resident when the family member was not at the bedside. The nurse's note, dated 9/12/25 at 9:26 a.m., indicated the resident was in her room and assistance was provided with her morning routine. Resident B indicated she needed to go out the exit door beside her room because she had to go to town. The Social Service Director (SSD) note, dated 9/12/25 at 11:00 a.m., indicated the resident was observed walking in the hallway by the therapy gym headed towards hallway exit door. Resident B was walking without her assistive device or her back brace. When asked where she was going, she indicated to office one eleven. The resident was assisted to a chair in the hallway, and a wheelchair was obtained, and the resident was taken to her room with one-on-one supervision. The resident's family member was notified and requested to sit with the resident due to her exit seeking behaviors. The family member indicated he would get to the facility as soon as he could; however, he had an appointment and did not know what time he would be at the facility. Verbal consent was obtained from the family member for a wander guard to be applied related to the resident's exit seeking behaviors. The family member was notified that if the family was unable to provide the resident with supervision related to exit seeking behavior, then the facility may need to find alternate placement for resident related to her safety. The SSD note, dated 9/12/25 at 6:12 p.m., indicated the resident was exit seeking. The family member was asked to stay or to ensure 24-hour care for the resident. The family member signed a contract with an outside private agency to provide 24-hour care. The SSD faxed the contract to the outside agency, and they confirmed the above service agreement. The family member indicated he understood he had to stay with the resident until the outside agency arrived. The IDT note, dated 9/14/25 at 8:40 a.m., indicated the resident was observed with exit seeking behaviors, increased confusion and anxiety, and ambulating without assistance in the hallways without her back brace on. Her mood remained pleasant but only oriented to herself. The resident indicated she had to leave to go to town and she had to get to her husband's office. A wander guard was placed for the resident's safety. She was being treated for a urinary tract infection (UTI). The resident's family member was called, and he came to the facility to see the resident. The family member indicated he was unable to stay with the resident. The SSD spoke with the family member and arrangements were made for a sitter to stay with the resident. The nurse's note, dated 9/15/25 at 5:52 a.m., indicated the resident had periods of increased confusion. The sitter was at the resident's bedside. The Director of Nursing (DON) note, dated 9/16/25 at 12:31 p.m., indicated the resident was observed to be up wandering on the hallway with no assistance and had removed her wander guard. The wander guard was replaced. The resident's family member was notified of the resident requiring one on one supervision for her safety. The family was at the facility sitting with the resident. The SSD followed and assisted with deciding to transfer the resident to an appropriate facility and assisted the family member with arranging a sitter. 2. The record for Resident C was reviewed on 11/6/25 at 10:45 a.m. The diagnoses included, but were not limited to, diverticulitis of large intestine with perforation and abscess without bleeding, immunodeficiency, panlobular emphysema, atherosclerotic heart disease of the native coronary artery with angina pectoris, spondylosis of the lumbar region, tobacco use, depression, psoriasis, severe protein-calorie malnutrition, anxiety disorder, and hypertension. The nurse's note, dated 10/3/25 at 12:52 p.m., indicated the nurse spoke to the resident's family regarding psychotropic medications and narcotics. The family member indicated they did not want the resident to utilize narcotics while at the facility because they caused the resident to have hallucinations and delusions and did not help the resident. The nurse practitioner was notified The nurse's note, dated 10/3/25 at 4:49 p.m., indicated the resident was observed in his bathroom toileting himself. The resident was walking with his pants around his ankles. The nurse assisted the resident with his toileting needs. Upon entering the restroom, the resident was anxious and agitated. The resident began raising his voice toward staff and cursing them. The resident voiced a desire to exit seek. The resident indicated, I am getting out of here. I am going home. I am going to go right out that front door. The resident was offered activities but refused at this time. The resident was provided with one-on-one supervision. A call was placed to the resident's family to inform them of the resident needing a sitter for resident safety. The resident's family was notified of the need for a wanderguard and the wanderguard would need to be placed on the resident for his safety. Verbal consent was obtained from the resident's family, for the wanderguard to be applied. The resident's family member indicated they were on their way to the facility; however, could not provide one-on-one care due to leaving for a trip tomorrow. The resident's family member was informed that a sitter could be hired by the family to sit with the resident, the resident could be sent to the hospital of their choice for evaluation, or an alternate facility placement could be attempted for his safety. The family member wanted to speak with the resident upon arrival at the facility. Upon the attempt to place a wanderguard, the resident refused for the wanderguard to be placed. The Executive Director (ED) and the nurse discussed with the resident the need for the wanderguard to be placed for safety. The resident continued to refuse the wanderguard. The resident continued to exhibit verbal and physical aggression toward staff. The resident had behaviors of throwing objects in his room and cursing toward staff. The resident explained to the staff that he had required hospitalization in the past related to behavioral issues. The resident continued to voice exiting seeking behaviors. The resident indicated a need to have a cigarette at this time. Staff explained to the resident that the facility was a non-smoking facility. The resident's family member arrived at this time and his behavior was explained. One-on-one care was provided by the family member at this time and the Nurse Practitioner (NP) was notified. The nurse's note, dated 10/3/25 at 5:16 p.m., the family member indicated to the staff the resident would not exhibit behaviors going forward and would not continue to exit seek. The nurse indicated to the family member the resident was in need of a secure facility related to his exit seeking behaviors as the facility was not equipped for one-on-one care of a skilled secure unit. The nurse indicated to the family member that it was unknown when the exit seeking behaviors and verbal and physical aggression behaviors would occur and the resident needed a sitter to provide one-on-one care when his behaviors occurred as the facility did not provide one-on-one care. The nurse informed the family member that a sitter could be hired to sit with the resident. The family member indicated that there was family that could come to the facility to sit with the resident if needed or that a sitter could be hired. The family would provide 24-hour supervision to the resident for his safety. The family member was informed that staff would attempt to find alternate facility placement. The nurse's note, dated 10/3/25 at 5:31 p.m., indicated staff placed calls to several facilities. Some facilities requested resident documents to be faxed to their facilities. Resident insurance required precertification for rehabilitation facilities and would not be able to accept the resident on this day. Voice messages were left at other facilities. The family member was notified. The family member voiced concerns with cancelling a scheduled vacation. The family member was informed that the resident would need 24-hour supervision related to his exit seeking behaviors. The nurse's note, dated 10/3/25 at 6:50 p.m., indicated the resident's family member asked staff if alternate facility placement had been arranged for the resident. The family member was informed that documents had been faxed, but the resident had not been accepted to another facility at this time and that with the resident's insurance, he would require a precertification to be admitted to a different rehabilitation facility. The family member indicated she pushed her vacation back and would provide one-on-one care for the resident through the weekend. The nurse's note, dated 10/3/25 at 7:40 p.m., indicated the resident's family member inquired with the nursing staff what companies provided sitting services that could be hired to sit with resident. The family member was informed that staff would call and obtain sitter prices and services. The family member requested to self-call the services and was provided with names of the companies. The family member indicated they were going to call to obtain pricing in case they would need to hire a sitter for the resident. The family member indicated to staff, they were staying with the resident to provide him with 24-hour supervision. The nurse's note, dated 10/3/24 at 7:54 p.m., indicated staff attempted to apply the wanderguard to the resident. Consent was obtained from the resident's family member to apply the wanderguard. The wanderguard was applied to the resident's left wrist. The family member was contacted if staff could call facilities that provided sitting services for the family. The family member indicated they did not want staff to call the services, that she had already called the services and did not want to use them. The staff reiterated to the family member that the resident needed 24-hour supervision at this time related to his exit seeking behavior. The family member indicated they understood and would be at the facility to stay with the resident. The resident was currently resting in bed with no behaviors. The DON, ED, NP, and nursing staff were notified. The nurse's note, dated 10/4/25 at 4:09 a.m., indicated the resident was resting abed with his eyes closed at this time. The resident had slept well this shift with minimal behaviors. The resident had personal items packed to go home, but the resident was easily redirected, with no outbursts. His family member was at his bedside and the wanderguard was in place. The nurse's note, dated 10/4/25 at 4:12 a.m., the resident's family member indicated they were going to be staying with the resident 24/7 at this time, but verbalized they had a flight on Monday. The family member indicated on the phone earlier that they might not stay all weekend and had things to do. The family member had stayed with the resident this shift without incident. The nurse's note, dated 10/4/25 at 9:55 a.m., indicated the family member remained one-on-one with the resident. The resident's eyes were closed with no exit seeking, agitation, anxiety, or behaviors during this shift. The nurse's note, dated 10/4/25 at 12:05 p.m., indicated the resident's family member requested to speak with the ED regarding plans for the resident. The family member was told that the ED was out of town. The family member then requested to speak to the DON. Information was provided to the DON, and the family member was called by the DON. The DON indicated that 24/7 supervision would need to remain in the meantime, but for short periods at a time, the family member could leave as long as someone came back. The family member indicated to the nurse she needed to go home and shower in a couple of hours and pack for her vacation and then attend mass on Sunday morning. The nurse indicated she could provide the one on one care for those times, but the family member would have to return. The nurse's note, dated 10/4/25 at 2:59 p.m., indicated the family member left to go home and shower and obtain more clothes. The nursing staff provided one-on-one care at this time. The resident was toileted and was in bed at this time resting. The family member indicated they would be back before 6:00 p.m. The family member also indicated they had been talking to a local nursing facility regarding moving the resident. The nurse's note, dated 10/4/25 at 5:10 p.m., indicated the resident remained one on one with staff at this time. The resident had no behaviors during this shift. The resident was in the dining room eating dinner and socializing with peers at this time. He was pleasant and cooperative with all care today. The nurse's note, dated 10/5/25 at 3:50 p.m., indicated the resident had no behaviors this shift. No exit seeking, no agitation, and no anxiety. He was pleasant and cooperative with all care. The resident ate his meals in the dining room and socialized with his peers. The family member and/or staff had remained one on one all day. The resident was encouraged to attend activities. The admission MDS assessment, dated 10/6/25, indicated the resident was moderately cognitively impaired. The Interdisciplinary Team (IDT) note, dated 10/6/25 at 5:37 a.m., indicated in attendance were the DON and Assistant Director of Nursing (ADON). The resident had agitation when he was told he could not leave the facility alone and go home. The resident began to exhibit verbal and physical aggression and throwing objects in his room and cursing toward staff. The resident indicated to the ADON he had required hospitalization in the past related to behavioral issues. The resident continued to voice exit seeking behaviors. Staff attempted to place a wanderguard and the resident initially refused to let staff place it. The family member was called and then came to the facility. The family member indicated the resident was acting out because of frustrations he had towards the family member. The family member indicated to staff of the initial plans to fly out of town on Saturday. The ED and ADON spoke with the family member and made them aware that for resident safety, family would need to provide one-on-one care with the resident whether that be by a hired service, family, or themself. The resident eventually allowed staff to provide the wanderguard. Alternate placement could not be found for a secure unit facility before the weekend, so the resident continued with one-on-one supervision. The admissions team and family member were to resume finding alternate placement. The resident did not have any further behaviors once the family member arrived. The resident did admit to the facility with an order for as needed (prn) Ativan, but the family member indicated this medication caused the resident to have hallucinations and family asked to have it discontinued. The care plan, dated 10/6/25 and last revised 10/14/25, indicated the resident demonstrated exit-seeking behaviors. The interventions, dated 10/6/25, included, but were not limited to, apply a wanderguard to the left wrist and monitor as ordered, evaluate the resident's need for a secured unit and transfer if needed, monitor for wandering triggers such as a need for toileting, inactivity, time of the day, et cetera (etc)., offer diversional activities as needed, encourage regular family contact and/or visits with others, provide a structured routine to the resident's day, and redirect the resident away from the doors and exits as needed. The nurse's note, dated 10/6/25 at 3:07 p.m., indicated a call was received for the family member indicating they would be unable to provide 24-hour supervision for the resident. The family member indicated their spouse would be in the facility to sit with the resident tonight, but the family member would be unable to provide supervision 24-hours. The family member indicated, I'm getting on a plane and I can't work it out. The nurse's note, dated 10/6/25 at 5:41 p.m., indicated the family member inquired as to whether the resident actually needed 24-hour supervision. The family member was informed that the resident needed one-on-one supervision at this time related to the resident previously voicing a desire to exit seek and due to the facility not being equipped to provide one-on-one care. The resident's family member indicated they did not see the point in sitting with the resident all day but would continue to provide one-on-one care for resident. The nurse's note, dated 10/17/25 at 11:38 a.m., indicated the resident discharged home with his family member. The discharge paperwork was reviewed with the resident and family. Colostomy education was provided, and the resident was able to show the nurse how to change the bag. All supplies were sent with the resident. Leftover routine medications were sent home with the resident. Prescriptions were called into the resident's pharmacy of choice. During an interview, on 11/6/25 at 11:45 a.m., the Social Services Director indicated a hospital liaison would see the resident prior to admission to the facility to evaluate the resident for needs. Things could slip through this evaluation at times. The policy for wandering or a one-on-one sitter was that the resident's family would be contacted to sit with the resident. For exit seeking, a wanderguard would be placed. The facility would have family or an agency sit with a resident. Either the Social Service Director or family could contact an agency. One specific agency would be contacted first or another provider. The facility's policy indicated the resident would have to be provided safety. If family couldn't afford it, the family would be asked to sit with the resident. Someone would sit with a resident, like a staff member could sit with them. If this had to be done long term, this would take away care from other residents. Another facility would have to be contacted for placement. It could take a few days to locate a placement facility. If a resident was close to the end of a hall with an exit door, they could be moved closer to the center of the hall. This would be tried to get the resident away from the exit doors. If the residents' needs could not be fulfilled with interventions, then it was an issue of safety and during morning meetings this would be discussed. Whatever would be best for their safety. The facility has had family who could not stay with residents, and the resident would discharge for their safety. If needed the resident could stay in her office at times. The sitting agency would have to be financially covered by family. Safety protocols were for a wanderguard to be place. It would alarm when the resident neared an exit door. Residents could sit in her office. The facility could provide 24/7 one on one care, but if this was for an extended amount of time, the resident would be sent to another facility for safety. It was unlikely for a resident to be taken to the Assisted Living (AL) dementia unit, due to accommodation. During an interview, on 11/6/25 at 12:00 p.m., the DON indicated she was not sure what the policy was for exit seeking residents. Staff would sit with the resident until family could arrive to sit with the resident. If family couldn't, the Social Service Director would look for placement elsewhere. The facility asked family to find an outside agency for one-on-one services. The Social Service Director would contact the agency. Management would come into the facility if family could not afford or provide one on one care. She was unsure of the policy. She was unsure if the facility would pay for the agency. It wouldn't be long term. She would want them in a secure unit. 3. The record for Resident D was reviewed on 11/6/25 at 11:52 a.m. The resident's diagnoses included, but were not limited to, hypotension, bradycardia, paroxysmal atrial fibrillation, dementia, history of falls, and cardiac implant. The nurse's note, dated 10/13/25 at 5:58 p.m., indicated the resident arrived to the facility via ambulance for admission. The nurse's note, dated 10/13/25 at 8:30 p.m., indicated the resident had been found outside the facility attempting to go home. The care plan, dated 10/14/25, indicated the resident was demonstrating exit-seeking behaviors. The interventions, dated 10/14/25, included, but were not limited to one-on-one supervision until alternate placement was found; wanderguard applied to right wrist and monitored as ordered; monitor for wandering triggers; and encourage regular family contact and/or visits with others. The IDT note, dated 10/14/25 at 9:17 a.m., indicated in attendance were the DON, ADON, Therapy director, ED, SSD, and Infection Preventionist. The note indicated the resident had left the facility building and had a fall on the grounds while outside the facility. The staff at the facility called the resident's family to make them aware of the elopement and that they needed to come into the facility and provide one-on-one supervision for the resident's safety. The nurse's note, dated 10/15/25 at 9:33 a.m., indicated Resident D discharged to a higher level of care at a different facility. The facility bus transported the resident and a family member packed and took all of the resident's belongings. The admission Packet, dated 10/28/24, indicated .Many services provided to you, as part of your care at our Facility, are offered by participants in one of our organized healthcare arrangements. These participants include a variety of providers such as physicians, (e.g. MD DO, Podiatrist, Dentist, Optometrist), therapies, (e.g., Physical therapist, Occupational; therapist, Speech therapist), portable radiology units, clinical labs, hospice, caregivers, pharmacies, psychologists, LCSW's, and suppliers (e.g., prosthetic, orthotics). This citation related to Intake 2644284. 3.1-3 (v)(1)

Based on record review and interview, the facility failed to ensure the physician was notified and/or follow up with the physician when a resident's surgical wound opened up for 1 of 2 residents reviewed for quality of care. (Resident 20) Findings include: The record for Resident 20 was reviewed on 3/21/25 at 8:30 a.m. The resident's diagnoses included, but were not limited to, acquired absence of the left toe, an open wound of the left foot, gangrene, orthopedic aftercare, and diabetes. The care plan, dated 2/7/25, indicated that the resident had a surgical incision. The interventions included, but were not limited to, administer analgesics per the physician's order, observe the surgical incision for signs of infection, observe the surgical site to ensure well approximated and for non-healing, and treatment to the surgical site as ordered by the physician. The physician's order, dated 2/8/25, indicated staff were to paint the resident's left foot surgical wound with betadine, cover with gauze, wrap with kerlix dressing, and apply ace wrap. The Admission Minimum Data Set (MDS) assessment, dated 2/10/25, indicated the resident was cognitively intact. The resident had a surgical wound and required surgical wound care. The physician's note, dated 2/18/25, indicated the resident's pain in his left foot had worsened. He also reported increased drainage from the surgical site. Due to the increased pain, increased drainage, dorsal flap redness, extending necrosis, and increasingly cool temperature to the dorsal and planter flap of the left foot. The physician believed the resident was going to need a more proximal amputation. The physician indicated the foot had not progressed and only worsened. A call was placed for vascular surgery for the resident to be seen. The nurse's note, dated 2/22/25 at 4:50 p.m., indicated the nurse went to complete the resident's dressing change per the physician's order. The resident's incision sight was observed to have a small 3 milligram (mm) by 1 mm open area along with one staple still left in place. The weekend supervisor was notified, and the treatment was completed. The nurse's note, dated 2/22/25 at 5:01 p.m., indicated a staple was observed on the resident's right foot incision. The physician had removed other staples earlier in the week. The physician's office was notified about the staple, but could only leave a voicemail. There were no signs of infection noted. The nurse's note, dated 2/25/25 at 11:30 a.m., indicated the Nurse Practioner (NP) requested to see the resident's left foot. The foot dressing was unwrapped, and the NP examined the site of the resident's amputation. The site had dehisced and had an area on the bottom of foot. New orders were received to send the resident to the hospital emergency room for evaluation and treatment. The record lacked documentation indicating the physician was informed that the residents surgical wound had opened. During an interview, on 3/25/25 at 1:10 p.m., RN 3 indicated the residents wound gradually opened. She did not feel it all happened at once. She did not know what day the wound started to open. On the day the resident was sent to the hospital she was assisting the NP with the residents' dressing change. After removing the dressing, the wound had dehisced, and the resident was sent to the hospital. During an interview, on 3/25/25 at 1:40 p.m., LPN (Licensed Practical Nurse) 4 indicated he walked in the room while the nurse was changing the resident's dressing change. The doctor had removed his staples, and the nurse indicated one staple was left. LPN 4 indicated he called and left a voicemail about the staple. The nurse would have had to call the doctor and inform him about the open incision. He did not know if there was a follow up with the physician or NP. He indicated normally the NP would document in the progress notes, but the LPN did not see any documentation indicating there was a follow up with the physician or NP. During an interview on 3/26/25 at 11:30 a.m., LPN 5 indicated she informed the Supervisor/Charge Nurse that the resident's wound had opened, and a staple was observed. The Supervisor indicated he would notify the physician, and the LPN assumed the physician was informed. She did not recall if there was a follow up with the physician or not. The LPN indicated she notified her supervisor and thought the Supervisor notified the physician about the wound opening. The Physician Notification policy, dated 9/12/17 and revised 12/17/24, included, but was not limited to, .11. Attempts to notify the physician/provider and their response should be documented in the resident electronic health record.12. The 24-Hour report shall be utilized for nurse to nurse communication regarding the status of the notification and response back. 13. If the attending physician, or their practitioner does not respond to notification attempts the Medical Director and Director of Health Services should be notified for further instructions. 3.1-37(a)

Based on record review and interview, the facility failed to appropriately respond to and act upon resident concerns from the Resident Council meetings. This deficient practice had the potential to affect the 51 health care residents currently residing in the facility. Findings Include: The resident council meeting minutes, dated 9/6/23, indicated residents voiced concerns related to dining services. The dining times were inconsistent, and they were supposed to serve lunch at 11:30 a.m., and dinner ran late. There was sloppy food presentation, too many peas and carrots, and more variety was desired. Residents had concerns about staff transportating them back to their rooms and they wanted rolls. The response, as documented by the Dietary Manager on 9/8/23, indicated the concern could have been a one time occurrence. Dinner started on time every day. Lunch was at 11:30 a.m. and dinner was at 4:30 p.m. Some residents requested their meals early and that was their right. If the meal was ready, they would serve them. The response did not address the concerns with the presentation, transport back to the resident's rooms, or food concerns. The resident council meeting minutes, dated 10/6/23, indicated the residents voiced concerns related to dining services, which indicated lunch did not start until noon. Mealtimes were inconsistent, and it was still hard to find someone to transport residents back to their rooms after meals. The response, as documented by the Dietary Manager on 10/8/23, indicated lunch had been very consistent on a specific day. A lot of residents made special requests and service fell behind about 10 minutes. The Dietary Manager did not agree that this situation happened. The response did not address the concerns relating to staff transport back to the resident's rooms. The resident council meeting minutes, dated 11/6/23, indicated residents voiced concerns related to dining services. The room trays were very late and the food was not an accurate temperature. The response, as documented by the Dietary Manager on 11/7/23, indicated room trays were served every day at 8:00 a.m., 12:00 p.m., and 5:00 p.m. at their posted time. It did not vary often. Sometimes it was off 5 or 10 minutes because of special orders by residents that were not on the menu. It was very common for residents to order breakfast items at dinner time, which slowed service down. The response did not address the concerns relating to staff transport back to the resident rooms or food temperatures. The resident council meeting minutes, dated 12/7/23, indicated residents voiced concerns related to dining services. They were requesting that silverware be rolled and placed at the steam table for every meal, not set out on the tables. Dishes were coming out dirty and gritty. There was no help getting back after meals. One resident reported feeling as if she didn't get big enough food portions. Residents were tired of getting the same food, including chicken and burgers, over and over. Residents wanted staff to read their diets and many orders. Food was still cold and not being prepared properly. The response, as documented by the Dietary Manager on 12/19/23, indicated he followed the company's policies on how they should set the tables. They would not set the tables in the evening because the silverware sat on the tables all night and the residents were afraid the silverware would be contaminated, so he honored that request. Only one resident wanted the silverware to be rolled all day long, but he explained to her it was not the policy. The resident who requested larger portions could have whatever she wanted and did. She ate very large portions every meal which was why she had a considerable weight gain and there was some confusion there. He would mention the food temperatures in the next chef circle. He recently had a chef circle, and no residents voiced any concerns about the food to him. The response did not address the concerns regarding dirty dishes, repetitive menus, or reading menus and orders. The resident council meeting minutes, dated 1/5/24, indicated residents voiced concerns with dining services. The dining plates were cold they needed to be heated up before serving. The dishes were gritty. Potatoes were coming out partially rotten. Chili beans were too hard, and too much salt was being used in meals. The response, as documented by the Social Services director on 1/5/24, indicated dietary was notified of the concerns and dishes were to be gathered and washed nightly. The response did not address the concerns any further, and did not address cold plates, the partially rotten potatoes, chili beans or too much salt. Resident council meeting minutes, dated 2/2/24, indicated residents voiced concerns with dietary services. They were not getting what they circled on their menu. One resident had to wait a long time to get back to their room. The response, as documented by the Social Services Director on 2/5/24, indicated staff were to check all trays before serving to make sure the menu was correct, and staff were to make sure residents were taken back to their rooms after meal service. The facility could not provide any documentation where they had thoroughly investigated the resident concerns and actions taken to correct them. During an interview on 2/13/24 at 9:35 a.m., the Executive Director indicated he was the grievance official and did the final resolutions. When the grievances were brought up the Activities Director typed them up and they distributed them to whatever department had a grievance and the department leader addressed the issue. He would expect them to speak to the residents and investigate to verify concerns. They tried to address all concerns. He would follow up on them. There had been some repetitive concerns on food. There was one certain individual who voiced the concerns about being taken back to their rooms, but it was not across the board. Some things were getting addressed, but he didn't know why it was getting brought up again. They had not interviewed residents. He had stayed on evening dinners to monitor, but he didn't have an audit sheet to show he was there. As far as the repetitive concerns, he read them, and he did the resolution and signed off on them, but did not do anything on his part to address the concerns. Ultimately it would come down to him. His expectation would be not to deflect the concern, but to investigate the concern. During an interview on 2/13/24 at 9:59 a.m., the Activities Director indicated he conducted the meetings. Residents voiced concerns to him, and he filled the concerns out. He reported the concerns to the IDT (interdisciplinary team). One of the main concerns voiced was residents not being taken back to their rooms after meals. They tried to approach those concerns by making themselves available, but it was not good enough. As far as things being able to change immediately, that didn't happen, and it added fuel to the problem. Some things could not be fixed. It was one specific resident who voiced the concerns about being taken back to her room, but other residents did agree it was a concern as well. The meals were often late, the kitchen had been struggling. Their times were never consistent, and he had observed that. Residents would wait for food forever. They were often just waiting for their food, and he did not know what to say to them. It was an operation in the kitchen that stopped that from happening. They didn't come back and tell the residents about the resolution like they should. It usually waited until the next meeting. He did not get responses. When the new meeting would come up, he would ask if old business had gotten better, because he didn't know if anything got better unless the residents told him. During an interview on 2/13/24 at 12:07 p.m., the Resident Council President indicated they did have some continued concerns at the resident council minutes. The big issue was getting a resident back to their room after the meals. It was just one resident, but there were others who did experience that as well. She did mention the concern multiple times. They had been late serving in the dining room. Concerns were typed into the computer, and then the head of whatever division it fell under saw it and tried to adjust to the problem. She had experienced cold food one time. Other residents had complained about it at the meetings. They had tried different serving techniques and whether to use the steam table or not. The most current Resident Council policy included, but was not limited to, . The resident Council was created to promote the resident's right to organize and participate in resident groups in the Campus for the purpose of self-determination . 7. The group facilitator will determine the prevalence of the concern/recommendations voiced to determine the appropriate follow-up. 8. The group's grievances and recommendations will be brought to the attention of the Executive Director who will forward the concerns to the appropriate department leader for attention and response . 8.2 Individual issues should be handled by following the Campus concern/grievance policy and procedure. 9. Actions taken and/or considerations given to issues will be reported back to the Resident Council at the next meeting . The most current Resident Concern policy included, but was not limited to, . Procedures 1. The facility will provide an open and customer friendly atmosphere for residents and their families and representatives to voice concerns and problems with the assurance that their concerns will be heard and acted upon. 2. The facility will be committed to the on-going education of their employees on immediately responding to and resolving customer concerns . 4. The facility will follow these basic steps in responding to a complaint . Listen to the concern without interruption . Thank the person who brought the concern to the staff . Apologize to the person bringing the concern and acknowledge that what happened is not to our standards . Not make excuses for why or how this has happened . Take steps to correct the problem . Make the problem their own by following up to make sure it is resolved, and stays resolved . 9. The department leader will investigate and discuss the concerns with the team and will implement, or educate to prevent further concerns . The department leader will document the resolution on the concern form using an addendum when needed and will follow up with the person reporting the concern to explain the resolution . 3.1-3(1) This citation relates to Complaint IN00428084.

Based on observation, record review, and interview, the facility failed to ensure the kitchen, dry storage room and equipment were clean and in good repair for 3 of 3 kitchen observations. This deficient practice had the potential to affect 52 of 52 residents that received food from the kitchen. Findings included: 1. During the initial tour of the kitchen on 1/19/23 between 9:20 a.m. and 9:45 a.m., while accompanied by Cook 10, the following concerns were observed: - Ice machine - around the top where the door connected to the machine, there was a moderate build-up of lime scale which dripped down both sides and in the front. - The shelf under the steam table had black and brown food particles and dirt on it and heavy rust on the metal wires. - The drain and cover below the preparation sink had a heavy build-up of food particles in it. - The flour and sugar bins had brown streaks down the outside with crumbs on the tops. - The grill had a heavy coating of brown and black grease in the drip pan and black build-up on the grill racks. - The floor under and behind the wheels of the steamer, convection oven, dish storage racks and condiments cart had black particles in the ground-in dirt with food particles on the floor all the way to the wall. - The condiment cart had streaks down all sides. - The dry storage floor under and in front of the shelving had pepper packets, pieces of paper, and brown food crumbs with a black dirt build-up. The snack bin in the dry storage had large yellow food crumbs in it. - Walk in freezer - the floor under the shelves and in the pathway had pieces of paper, peas, carrots, and multiple brown/black spots ranging in size from a dime to a half-dollar size. - Walk-in refrigerator - the floor under and in front of the shelving had pieces of lettuce, an apple, pieces of paper, and brown crumbs. - The floor under the steam table and the food preparation table by the stove and the food preparation counter which held the slice toaster, mixer and food processor had heavy ground-in black dirt. - The big toaster had a moderate amount of black and brown bread crumbs in it. - The floor behind and under the fryer had a heavy brown grease build-up. - Around the entire kitchen, the baseboards and three (3) inches of floor, which extended from the baseboards had a build-up of black and brown dirt and food particles. - There was a heavy amount of food particles in the drain and cover under the 2 compartment sink. There also was a scattering of white large particles on the floor to the right of the drain. - The plate warmer machine had multiple white and yellow spots down all the sides and food particles at the base and around the edge of where the plates were put into the machine. 2. During the temperature and meal service check on 1/19/23 between 11:00 a.m. and 12:30 p.m., the following concerns were observed: - The same issues already identified at 9:20 a.m. remained. - The 2 slice toaster had multiple brown spots and smears on all sides and the top had large brown dried spots on it. - The flat top had egg and potatoes residue on it. The cook was observed to place hamburgers, hot dogs, and a ham sandwich on it for lunch. - The stove and burners had a moderate amount of brown, yellow and black dried-on debris on them. - The butter pan had a thick coating of white and yellow coating around the inside. Cook 10 at this time indicated the pan was used for frying eggs and other foods, which required butter and staff just kept filling up the pan with new liquid butter as it got low. He could not remember when it was last washed. - The floor under the ice machine and the dish machine had a heavy build-up of black dirt with black particles on the shelves. - One of three food strainers which were hanging up with the spoons had a moderate coating of food particles dried on the inner rim. - Maintenance Staff 11 and 12 were observed to enter the kitchen to fix a faucet at the handwashing sink. No hairnets were observed on their heads. When questioned, both staff members indicated they did not have a hairnet on and knew they were supposed to. A large note was observed placed on the wall as one entered the kitchen which indicated Notice - hair restraints required beyond this point: which was underlined in yellow. - The floor under the ice machine and the dish machine had a heavy build-up of black dirt with black particles on the shelves. - The shelf just below the cutting boards had a moderate amount of brown and tan food particles on it. - An inner pan and lid to a crockpot was observed on a shelf with brown and white crumbs and residue on the lid, edges and inside. - Cook 10 at this time, was observed to pick up 2 frozen hamburger patties, 2 slices of rye bread, slices of ham and 2 slices of cheese from a bag and placed them on the flat top to cook. He then placed a handful of sauerkraut onto the bread and spread it out, picked up the ham slices and placed them onto the sandwich and pressed the sandwich down. He also took some frozen chicken fingers and tossed them in a bowl of bread crumbs and placed them into the fryer. All of these things were done with the cook's bare hands. He then placed the bowl of used bread crumbs on a shelf. He also took the food processor he had just used for hot dogs, rinsed it in the 2 compartment sink and then used it to make pureed fries all the while he had the same pair of gloves on. - The mobile steam table which went to the units had multiple orange and white splatters and streaks on the front and back with food crumbs on the base. 3. During a kitchen observation on 1/23/23 between 10:30 a.m. and 11:10 a.m., the following concerns were observed: - The same issues identified on 1/19/23 at 9:40 a.m. remained. - The 2 slice toaster had multiple brown spots and smears on all sides and the top had large brown dried spots on it. - The stove and burners had a moderate amount of brown, yellow and black dried-on debris on them. - The floor under the ice machine and the dish machine had a heavy build-up of black dirt with black particles on the shelves. - The shelf just below the cutting boards had a moderate amount of brown and tan food particles on it. - An inner pan and lid to a crockpot was observed on a shelf with brown and white crumbs and residue on the lid, edges and inside. - The mobile steam table which went to the units had multiple orange and white splatters and streaks on the front and back with food crumbs on the base. In an interview with the Director of Food Services at this time, he indicated he had just put up stock in the walk-in refrigerators and freezer, so everything was good in there. On 1/24/23 at 12:55 p.m., the Director of Food Service presented a copy of the as-completed cleaning schedules for November and December 2022 and January 2023 for the kitchen. He indicated that he had been short of staff in the kitchen for 2 years and he had been pulling a lot of over hours. The cleaning schedules were being maintained as directed and the floor that had been laid was the wrong type of floor as the floor machine tended to rip up the flooring. The drains with the food particles should not have been like that. Review of the as-completed cleaning schedules between November and December 2022 and January 2023 indicated the following tasks had been signed off as having been cleaned: - Monday AM Cook - Convection oven and 2 stove burners, flat top, and drip pan every day. - Monday PM Cook - 2 stove burners and drip pan. - Monday Dietary Aide - pull out shelves food service cart clean and sanitize both sides. - Tuesday AM Cook - Flat top and drip pan every day. - Tuesday PM Cook - Backsplash on stove and flat top - Wednesday PM Cook - Deck scrub Floor - Wednesday Dietary Aide - Condiment cart was to be cleaned and organized - Thursday AM Dietary Aide - Stainless steel, clean ice machine - Thursday PM Cook - Char-grill and drip pan - Friday AM Cook - Backsplash behind equipment and sides - Friday AM Dietary Aide - Help with backsplash behind all equipment 3.1-21(i)(3)

Based on record review and interview, the facility failed to ensure fall interventions were implemented to prevent future falls for 1 of 4 residents reviewed for accidents. (Resident 21) Findings include: The clinical record for Resident 21 was reviewed on 1/20/23 at 1:06 p.m. The diagnoses included, but were not limited to, disc degeneration, lumbar region, dementia with other behavioral disturbance, unspecified fall, subsequent encounter, repeated falls, muscle weakness, difficulty in walking, need for assistance with personal care, wedge compression fracture of T5-T6 vertebra, multiple fractures of ribs, left side. The Quarterly MDS (Minimum Data Set) assessment, dated 11/25/22, indicated the resident was severely cognitively impaired, required extensive assistance of one staff member with transfers, and had one fall without injury since her last assessment. The care plan, initiated on 9/27/21 and last revised 12/27/22, indicated the resident was at risk for falling related to impaired mobility and medications. The nurse's note, dated 4/27/22 at 3:36 p.m., indicated the resident reported she had fallen in her room when transferring from the toilet and her foot slipped. The IDT (Interdisciplinary Team) note, dated 4/28/22 at 9:14 a.m., indicated the root cause of the resident's fall was her foot slipping during transfer. The immediate intervention was to provide the resident with education to use call light for assistance. The new intervention placed after discussion with the IDT was to have therapy evaluate and treat the resident as indicated for proper, safe transfer techniques. The therapy discharge note, dated 5/20/22, indicated the resident had an automatic brake system (ABS) placed to her wheelchair to lock brakes due to her inaccuracy with remembering to lock her brakes. The nurse's note, dated 5/21/22 at 6:06 p.m., indicated the resident was found sitting on the bathroom floor with her head against the wall by her shower bench. The resident appeared to have been toileting herself without her wheelchair or calling for assistance. The resident was sent to the hospital for evaluation. The nurse's note, dated 5/21/22 at 9:01 p.m., indicated the resident returned from the hospital with no evidence of acute breaks or fractures and orders for an antibiotic for a UTI (urinary tract infection). The IDT note, dated 5/23/22 at 9:14 a.m., indicated the resident was recently discharged from therapy and an ABS was placed to her wheelchair for safety due to the resident not locking the brakes when transferring. The root cause of the fall was forgetfulness, poor safety awareness, poor cognitive function, and the resident attempting to transfer without assisstive devices. The new intervention was for the resident to be assessed by the psychiatric consult team for increased behaviors, treatment for a UTI, and increased frequency of toileting to every 2 hours. The clinical record lacked documentation of the intervention of an ABS being added to the resident's care plan. The fall event report, dated 12/14/22 at 3:51 p.m., indicated the resident fell in her room while transferring herself. The personal inspection indicated the resident's wheelchair did not have anti-rollbacks in place. The IDT note, dated 12/15/22 at 9:20 a.m., indicated the resident had a non-injury fall with the root cause being the resident attempted to get into her wheelchair and due to cognitive deficits the resident did not lock her brakes. The new intervention placed was to provide the resident with anti-roll backs to her wheelchair. During an interview on 1/25/23 at 11:02 a.m., PTA (Physical Therapy Assistant) 13 indicated the ABS went on the back of the wheelchair and prevented it from tilting back. It was the same thing as anti-rollbacks. During an interview on 1/25/23 at 11:30 a.m., OT (Occupational Therapist) 14 indicated the ABS went on the back of the wheel chair and prevented it from tipping or rolling. It was the same as the anti-roll back system. If a resident was determined to need an ABS they would go to the Therapy Director and let her know and she would make the orders for it. During an interview on 1/25/23 at 11:37 a.m., the Therapy Director indicated the ABS was the same as the anti-roll back system. They used it a lot for a resident who forgot to put their brakes on their wheelchairs. When they stood it had a hydraulic system that when it feels the weight come off the seat it had two silver arms that put pressure on the rear wheels and kept it from moving. When they got up, their wheelchair auto locked. It was a great way to prevent falls for residents that had cognitive impairments who forgot to lock their wheelchairs. Typically they went to the meeting after any falls and if an ABS was needed she would let the IDT team know so they could put in an order and update the care plan for the intervention. Maintenance would install the system. When the resident fell on [DATE], it was a different wheelchair. She did not know what happened to the wheelchair she was in previously, and they had not assessed and determined her to not need the ABS any more. If the resident's wheelchair had changed for some reason the ABS should have been continued onto the new wheelchair. She did not know why it was not continued and based on the last time she saw her, the resident would benefit from the ABS. She had not changed the recommendation at any time. During an interview on 1/25/23 at 11:43 a.m., the DON (Director of Nursing) indicated if a therapy referral was the intervention and therapy suggested a new fall intervention, the intervention should have been put into place on the care plan. Why it did not happen with the ABS intervention she did not know. The Fall Management policy, provided on 1/23/23 at 1:30 p.m. by the Campus Support Clinical, included, but was not limited to, . Purpose . mitigate fall risk factors and implement preventative measures . Procedure . 1 . b. Care plan interventions should be implemented that address the resident's risk factors . 5. The resident care plan should be updated to reflect any new or change in interventions . 3.1-45(a)(1)

Based on observation, record review, and interview, the facility failed to ensure appropriate social services follow-up and monitoring for residents experiencing grief and poor adjustment to the facility for 2 of 3 residents reviewed for social services. (Residents 45 and 20) Findings include: 1. The clinical record for Resident 45 was reviewed on [DATE] at 11:10 a.m. The diagnoses included, but were not limited to, depression and generalized anxiety disorder. The nurse's note, dated [DATE] at 4:10 p.m., indicated the resident arrived to the facility by ambulance and was alert and oriented and able to make her needs known. The care plan, dated [DATE], indicated the resident demonstrated an altered mood due to recent life losses and admission to facility. The interventions included, but were not limited to, adjustment counseling contacts as needed, monitor for increased signs of depression with the PHQ-9 assessment as needed, observe the resident's adjustment to facility, rehab program, daily activity, and refer to psychiatric services as needed. The Admission MDS (Minimum Data Set) assessment, dated [DATE], indicated the resident was cognitively intact and exhibited no rejection of care. The Social Service Comprehensive Note, dated [DATE], indicated the resident was seen for her initial first assessment. Her PhQ-9 (depression screening assessment) indicated the resident had moderate depression. She had a diagnosis of depression. She had no rejection of care behaviors in the past week. She signed the consent for psychiatric care services. She planned to discharge to assisted living if able. The Social History Observation dated [DATE], indicated the resident was a widow, had a history of mental illness and abuse. The nurse's note, dated [DATE] at 2:04 p.m., indicated the resident was refusing care that morning. The nurse's note, dated [DATE] at 12:55 p.m., indicated the resident was refusing to attend her doctor's appointment. The nurse's note, dated [DATE] at 8:53 a.m., indicated the resident had a trending weight loss. She had lost 10 pounds over 30 days and a request would be made for an appetite stimulant. The nurse's note, dated [DATE] at 10:35 a.m., indicated the resident was refusing her breakfast. The nurse and the CNA (Certified Nurse Aide) tried to talk the resident into eating, but she was refusing. The nurse's notes, on [DATE] at 10:40 a.m. and 11:34 a.m., indicated the resident was refusing her medications and refused her lunch. Nursing staff would follow up with the NP (Nurse Practitioner) and the DON (Director of Nursing). The care plan, dated [DATE], indicated the resident had a history of a traumatic experience or event. The interventions included, but were not limited to, assist the resident to identify and avoid triggers from the traumatic experience, encourage the resident to voice feelings of nervousness, fears, and general uneasiness related to trauma history and refer to physician as needed, observe for signs of re-traumatization such as anxiety, avoidance, depression, disassociation, intrusive thoughts, new/worsening behaviors, or sleep disturbances, provide supportive contacts to resident as needed, and offer psychiatric and supportive services to the resident and/or resident representative. The care plan indicated to add resident specific trauma triggers, however there were none added. The nurse's note, dated [DATE] at 10:21 a.m., indicated the resident was refusing her medications. She was educated on the importance of taking her medications as scheduled, and the adverse effects that included up to and leading to death. The resident stated she understood. The care plan, initiated on [DATE], indicated the resident was non-compliant with physician orders and plan of care as evidenced by rejecting medications at times. The interventions included, but were not limited to, encourage the resident to actively participate in care plan and decision making, and encourage the resident to participate in decision making by offering choices and discussion of advance directives. The nurse's note, dated [DATE] at 11:15 a.m., indicated the resident had refused all medications, wanted to stay in bed with the door closed and lights off. The nurse's note, dated [DATE] at 9:20 a.m., indicated the resident continued to be poorly motivated to participate in rehab. The nurse's note, dated [DATE] at 9:56 a.m., indicated staff encouraged the resident to get out of her bed and come to meals but she continued to refuse. The nurse's note, dated [DATE] at 9:07 a.m., indicated staff encouraged the resident to get out of her bed and come to meals but she continued to refuse. The clinical record lacked documentation of any social services follow-up related to the resident's refusal of care, medication, and meals or any referrals to counseling or psychiatric services. During an observation, on [DATE] at 11:39 a.m., Resident 45 was lying abed staring towards her closed window. She had a flat affect and refused to complete an interview at the time. She was very quiet and reserved. During an observation, on [DATE] at 1:10 p.m., Resident 45 was lying abed staring towards her closed window. She indicated she did not eat lunch today, she just didn't want to. The resident's answers were short and clipped and she did not make eye contact. During an interview on [DATE] at 2:12 p.m., the SSD (Social Services Director) indicated all of her notes were in the clinical record either under observations or the progress notes. She did not keep any separate notes. She met with residents, some of them every week, or as needed, and she tried to do daily rounding. She would do daily rounding as needed or weekly. She said hi to the residents weekly but did not document every single time. If the resident experienced a death she would go and chat with them, talk with them, open up an event so they could document, and see how they're doing. She would put a progress note in, and would try to do it at least once a week. If they showed signs of depression, such as exhibiting a lot of tearfulness, she would offer them therapy services and to see the psychiatric NP. Signs of depression could include irritability, the stages of grief, difficulty sleeping, eating or not eating well, isolating themselves, not coming out of their rooms, or any change in their behavior. If they exhibited these symptoms she would go in and talk with them, do an assessment, notify the NP, try to talk to them about evaluation with the therapist and psychiatric services. She did not know Resident 45 very well. She was pretty quiet. During an interview on [DATE] at 2:29 p.m., the SSD indicated Resident 45's spouse had died recently and she didn't want any psychiatric services when she first came in. Initially the resident was going to transition to Assisted Living, but she wasn't doing great medically and they decided to have her stay in long term care. She was very private and did not talk much at all. She was aware the resident didn't want to come out of her room. She was not aware of the resident refusing meals. She had asked the resident about psychiatric services but had not documented it. She was very resistant. She would talk to her at her quarterly review and try to get her to open up and get the services, she thought they would be good for her. During an observation on [DATE] at 12:57 p.m., Resident 45 was laying abed, still in her pajamas. Her meal tray was untouched. She indicated she didn't feel like eating and was feeling down. Her answers were short and quiet. She remained abed, staring towards the closed window during the conversation. During an interview on [DATE] at 11:54 a.m., the Director of Nursing indicated they believed the resident's behavior was just her normal and that it was just who she was. 35732 2. The clinical record for Resident 20 was reviewed on [DATE] at 1:55 p.m. The diagnoses included, but were not limited to, traumatic subdural hemorrhage without loss of consciousness, metabolic encephalopathy, sepsis, unspecified organism, urinary tract infection, pneumonia, unspecified organism, acute respiratory failure with hypoxia, acute kidney failure, surgical aftercare following surgery on the digestive system, paroxysmal atrial fibrillation, depression, anxiety disorder, and insomnia. The Admission MDS assessment, dated [DATE], indicated Resident 20 was moderately cognitively intact. The care plan, dated [DATE], indicated the resident recently experienced the death and dying of a someone close to them. The resident was progressing through the stages of grief. The interventions included, but were not limited to, encourage the resident to continue to eat meals in the dining room with other residents, encourage the resident to participate in structured activities and individual leisure activities, life enrichment, nursing, and social services, provide supportive counseling contacts as needed, refer to psychiatric services as needed, monitor for increased signs and symptoms of depression, observe the resident's mood, affect, and behaviors with all hands-on care and contacts. The clinical record lacked documentation indicating the resident was seen by the Social Services during the grieving process. The nurse's note, dated [DATE] at 9:16 a.m., indicated the resident recently lost his spouse. Staff would monitor the resident for any depression or adverse effects. The nurse's note, dated [DATE] at 2:20 a.m., indicated the resident had seemed sadder during the shift, but no tearfulness or signs and symptoms of increased depression. The nurse's note, dated [DATE] at 1:51 p.m., indicated the resident's family member transported the resident to his family member's funeral. He had been very quiet during the shift. During an interview on [DATE] at 1:10 p.m., LPN (Licensed Practical Nurse) 9 indicated when a resident lost a loved one staff would monitor for increased depression symptoms like tearfulness, sadness, lack of interest and decreased appetite. She would sit 1 on 1 with the resident and encourage the resident to express his feelings and do more frequent checks. If she identified these symptoms of increased depression she would notify the DON, psychiatric services, and make the SSD aware. The Director of Social Services Job Description, provided on [DATE] at 1:10 p.m. by the Campus Support Clinical, indicated the Duties and Responsibilities of the Director of Social Services included, but were not limited to, . 4. Reviews and revises care plans and assessments as necessary . 9. Ensure that social service progress notes are informative and descriptive of the services provide and of the resident's response to the service . 3XXX,d+[DATE](a)

Based on record review and interview, the facility failed to ensure residents were free from unnecessary psychotropic medications for 1 of 5 residents reviewed for Unnecessary Psychotropic Medication Use. (Resident 15) Findings include: The clinical record for Resident 15 was reviewed on 7/13/21 at 10:38 a.m. The diagnoses included, but were not limited to, generalized anxiety disorder, major depressive disorder, repeated falls, cognitive communication deficit, unsteadiness on feet, insomnia, and dementia with behavioral disturbance. The Quarterly MDS (Minimum Data Set) assessment, dated 10/18/22, indicated the resident was severely cognitively impaired. The physician's orders dated 4/3/22 included, but were not limited to, sertraline 50 mg (milligram) tablet once a day, memantine 5 mg tablet twice a day, buspirone 15 mg tablet twice a day, alprazolam 0.25 mg tablet at bedtime with a start date of 4/4/22, and Abilify (aripiprazole) 1 mg at bedtime with a start date of 9/5/22. The care plan, dated 12/7/22 and last revised on 1/17/23, indicated the resident was at risk for adverse consequences related to receiving antipsychotic medication for: dementia with behavior disturbance. The interventions included but were not limited to, GDR (Gradual Dose Reduction) at least twice a year unless contraindicated, observe and report signs of sedation, anticholinergic and/or extrapyramidal symptoms, administer medication per physician order, review for continued need at least quarterly, attempt to give the lowest dose possible, and pharmacy consultant review as needed. The clinical record lacked documentation indicating the resident had more than 1 behavior before adding an antipsychotic medication. The nurse's note, dated 7/8/22 at 1:11 p.m., indicated the NP (Nurse Practitioner assessed the resident on 7/7/22. The GDR, dated 6/2/22, indicated the decrease in the Abilify dose was effective. A new order was received to discontinue the Abilify. The nurse's note, dated 7/18/22 at 2:38 p.m., indicated the resident had no adverse reactions observed related to the GDR of Abilify. The resident was pleasant and cooperative with staff. She was out of her room and going to the dining room for meals. The nurse's note, dated 9/1/22 at 9:52 p.m., indicated the resident was yelling at the staff. She was upset with staff regarding her current isolation status and related covid exposure. She was tearful and yelling at staff with numerous complaints. She complained about meals, linens being changed on bed, and staff responsiveness. Staff attempted to offer reassurance to the resident. A family member visited and offered reassurance to the resident. The resident's behavior improved after the visit with her family member. The resident had no further yelling out, and no further tearful episodes were observed. A message was left for NP to inform her of the behavior. The nurse's note, dated 9/1/22 5:15 p.m., indicated the Director of Social Services was called to the resident's room. The resident was observed yelling and tearful. The resident stated, the man in the kitchen told me to get out, and you all are feeding me leftovers. She was in isolation and had not left her room. The CAR (Clinically at Risk) notes, dated 10/28/22, indicated the resident had orders for Abilify, buspirone, and Xanax. No behaviors were documented on the care assistance record. The CAR notes, dated 12/22/22 at 4:04 p.m., indicated the resident had orders for Abilify, buspirone, and Xanax. She remained at the facility for long term care. The targeted behaviors were being monitored, and no behaviors are noted on the care assistance record. During an interview on 1/24/22 at 1:10 p.m., LPN (Licensed Practical Nurse) 9 indicated interventions for behaviors included, but were not limited to, distraction, 1 on 1 care, offer food or fluids, toileting, and activities. She indicated nonpharmacological interventions would be used before adding or increasing the resident's medication. The resident had not had any behaviors during her care of the resident. The resident was sweet and very kind. During an interview on 1/24/23 at 1:42 p.m., the DON indicated interventions would depend on the behavior the resident was having or the cause. IDT would meet and talk about the behaviors. They would then open an event and discuss the appropriate treatment for the resident. There was not a specific number of behaviors or how often the resident had behaviors that they went by. The interventions would include talk therapy, validating feelings, investigate the root cause of the behavior, anticipate needs, and assess for pain. The facility doctor or the Nurse Practitioner would be called. The Psychotropic Medication Usage and Gradual Dose Reduction policy, last revised 11/7/22, provided on 1/25/23 at 10:53 a.m., included, but was not limited to, .1 Residents shall receive psychotropic medications only if designated medically necessary by the prescriber, with appropriate diagnosis or documentation to support its usage. The medical necessary will be documented in the resident's medical record and in the care planning process . 3.1-48(a)(4)

Based on interview and record review, the facility failed to ensure staff verified a resident's (Resident D) code status prior to the initiation of CPR for 1 of 3 residents reviewed for resident rights. Findings include: The clinical record for Resident D was reviewed on [DATE] at 11:38 a.m. The diagnoses included, but were not limited to, respiratory failure with hypoxia, hypertension, diabetes and right sided hemiparesis. The annual MDS (Minimum Data Set) assessment, dated [DATE], indicated the resident's cognition was intact. Review of the resident's Face Sheet indicated a Do Not Resuscitate status. The care plan, dated [DATE], indicated the resident/resident representative had chosen an advance directive and that the decision will be honored. The Stat of Indiana Out of Hospital Do Not Resuscitate Declaration and Order, dated [DATE], indicated that if Resident D experienced cardiac failure in a place, other than an acute care hospital, cardiopulmonary resuscitation (CPR) procedures should be withheld. The form was signed by Resident D on [DATE] and by the resident's physician on [DATE]. The progress note, dated [DATE] at 9:36 a.m., indicated LPN (Licensed Practical Nurse) 2 was called to the resident's room by staff emergency light at 8:00 a.m. Upon entering the resident's room, the resident was found lifeless. It was asked if the resident was a full code and a verbal yes was given. CPR was initiated and 911 called per other staff. EMS (emergency medical services) arrived at 8:15 a.m. and took over CPR. The progress note, dated [DATE] at 10:00 a.m., indicated LPN 9 entered the resident's room at 8:00 a.m. to give the resident her morning medication. Resident D was sitting in her chair like she normally does. LPN 9 went over to the resident and could not wake her. Her skin was clammy and cold. LPN 9 immediately activated the emergency call light. With the help of staff, the resident was moved to the floor and CPR was initiated. EMS arrived at 8:15 a.m. and immediately took over CPR. The resident was announced as expired at 8:40 a.m. The progress note, dated [DATE] at 12:43 p.m., indicated the nurse entered the resident's room at 8:00 a.m. to administer medications and observed the resident in her recliner, unresponsive and without respirations or heartbeat. CPR was initiated and EMS called. EMS arrived at 8:15 a.m., relieved campus staff and continued CPR. The DSS (Director of Social Services) was present and discovered that Resident D had a DNR (Do Not Resuscitate) on file. EMS was notified of the DNR, called their physician and received orders to stop CPR. During an interview on [DATE] at 1:04 p.m., LPN 2 indicated prior to initiating CPR, she asked LPN 9 if the resident was a full code and she responded yes. During an interview on [DATE] at 1:07 p.m., LPN 9 indicated she did tell LPN 2 that the resident was a full code. LPN 2 had looked at the advance directives a while back and the resident was a full code. She went from memory rather than checking. The resident was a full code and then changed to a DNR. On [DATE] at 1:20 p.m., the Director of Nursing provided a current copy of the document titled Cardiopulmonary Resuscitation (CPR) dated [DATE]. It included, but was not limited to, Procedure .If a resident has Do Not Resuscitate orders signed by the physician, no CPR is expected

Based on observation, record review, and interview, the facility failed to ensure services were provided to ensure thorough assessments were performed to accurately identify pressure injuries, effective interventions to prevent the development of pressure injuries were implemented for 2 of 4 residents reviewed for pressure injuries. (Resident 32 and Resident 10) This deficient practice resulted in Resident 32 experiencing a full thickness wound, initially identified as a stage three pressure injury, on the right thumb Findings include: 1. During an observation of wound treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's hand was contracted and lying on his chest. There was a pillowcase under the resident's hand on the resident's chest. The wound was in 2 areas of the right thumb. One area measured 2.5 cm (centimeters) by 2 cm. The wound bed was pink with dry edges around the wound. There was no odor or exudate. The other wound area measured 1 cm by 0.3 cm and had 2 scabs dark red in color. The clinical record for Resident 32 was reviewed on 2/1/22 at 10:54 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Quarterly review assessment, dated 1/11/22, indicated the resident was severely cognitively impaired, required extensive assistance of 1 to 2 staff assistance with all ADL's (activities of daily living), had impairment to functional mobility of the upper and lower extremities on one side, was at risk for the development of pressure ulcers, and had one stage 3 pressure ulcer which was not present on admission. The care plan, dated 8/30/21 and last revised on 1/12/22 at 10:52 a.m., indicated the resident was at risk for skin breakdown related to weakness, decreased mobility, contracture to right hand and fingers. Interventions included, but were not limited to, conduct weekly skin assessment. Pay particular attention to bony prominences. The care plan, dated 10/18/2021 and last revised on 1/12/22 at 10:52 a.m., indicated the resident had a pressure ulcer to his right thumb. The interventions included, but were not limited to, assess and record the condition of the skin surrounding the pressure ulcer. Observe and report signs of infection (e.g., localized pain, redness, swelling, tenderness, drainage, odor, and fever). Observe for and report signs of pain related to pressure ulcer. Weekly skin assessment, measurement, and observation of the pressure ulcer and record. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's note, dated 10/9/21 at 10:13 a.m., indicated the resident had a reddened area to the right upper chest measuring 1.5 cm (centimeters) by 1.5 cm under the contracted right arm. The nurse cleansed the area and applied a foam dressing to the area. Slight drainage was noted to the pressure area. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's note, dated 10/14/21 at 5:31 p.m., indicated there was an open area observed on the resident's right hand near the thumb. The area measured 1.2 cm long by 1.2 cm wide. A small amount of drainage was noted. The area was cleansed, and a foam dressing was applied. A note was left for the nurse practitioner to assess. A nurse's note, dated 10/15/21 at 2:15 p.m., indicated the resident was observed to have an open area to the right thumb. The resident's right arm/hand/fingers were contracted and tight to his chest. Initially the open area to the chest was thought to be from the resident's call light being attached to the residents clothing. Upon investigation into the cause of the open area to the right thumb, the location of the breakdown on the thumb was the location of the open area on resident's chest. She was only able to pull the right hand/thumb away from the resident's body approximately 3 inches. The area was observed with white slough, no granulation tissue, and moderate serous exudate. A stage 2 to the 3rd digit from where the 3rd digit and 2nd digit rest against each other was observed. The family member wanted the wound doctor to evaluate and treat the wounds. The following interventions were put in place for pressure relief device, pillow at this time, between right thumb and chest. Requested for therapy recommendation on pressure relieving device, splint to right thumb, awaiting recommendation. Wrapped hand weaving between fingers to allow for pressure relief until therapy recommendation. The Wound Management note, dated 10/15/21, indicated the stage 3 pressure ulcer to the right thumb was first identified. It measured 2 cm long by 2 cm wide and had white slough noted to the wound bed. A strong foul odor was noted to the wound. There was 100% slough and moderate serous exudate. A wound doctor was to evaluate the wound and order treatment. Requested a therapy recommendation on sling/pressure relieving device related to the contracture. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A pressure relieving device (may be a pillow) placed between the resident's right thumb and chest. Staff were to check placement every hour. The nurse's note, dated 10/17/21 at 9:18 a.m., indicated the resident's wound had scant bloody drainage from 2 pressure sores to the right hand. The area of the posterior thumb was macerated around the wound borders. The wound was cleansed with normal saline and gently patted dry with a clean gauze. The wound was covered with a small foam dressing and secured with a soft elastic bandage. The area to the ring finger had an odor. She gently cleansed between the fingers with normal saline and gently patted dry. An elastic gauze was placed loosely between each finger. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff were to cleanse the wounds with normal saline and pat dry. A wet to dry gauze with Dakins (antiseptic) solution was to be applied and wrapped with rolled woven gauze twice a day. The Wound Management note, dated 10/22/21, indicated the resident's wound measured 1.7 cm long by 1.4 cm wide and the wound doctor was in and assessed the wound. There was light bloody exudate and 100% granulation. New recommendation for treatment and preventative measures given. Order placed to administer prn (as needed) pain medication 30 minutes before treatment to right hand wounds due to contracture pain with manipulation of hand/digits. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . As needed pain medication was to be administered 30 minutes before treatment. The Wound Management note, dated 11/12/21, indicated the resident's wound measured 3 cm long by 3 cm wide. The wound was observed with serous exudate. Slough was present to the wound bed. The current treatment was continued. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician was to be notified of any abnormal findings. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Reassess the wound in one week and report to the DON (Director of Nursing), twice daily. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . As needed pain medication to the administered 30 minutes before treatment. The Wound Management note, dated 12/3/21, indicated the wound measured 3 cm long by 3.5 cm wide. There was moderate serosanguineous exudate. A new treatment was in place due to hypergranulation tissue. A nurse's note, dated 12/9/21 at 1:02 p.m., indicated when changing the resident's hand wound dressing today she noticed that there was green discharge on the silver foam, and it was bleeding. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The Wound Management note, dated 12/10/21, indicated the wound measured 3.5 cm long by 3.5 cm wide. There was light serosanguineous exudate. The resident was started on antibiotic treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . As needed pain medication to be administered 30 minutes before treatment. A nurse's note, dated 12/15/21 at 4:46 p.m., indicated hospice came in, changed and measured the resident's wound. Hospice nurse asked us to put an ABD (abdominal dressing) pad below the silver foam to prevent the silver foam sticking to residents wound. The Wound Management note, dated 12/17/21, indicated the wound measured 3 cm long by 4.5 cm wide. There was light bloody exudate and 100% hypergranulation. The Wound Management note, dated 1/21/22, indicated the wound measured 2.5 cm long x 2.5 cm wide. There was light bloody exudate and 50% granulation tissue. During an interview on 2/7/22 at 1:45 p.m., the Campus Support Clinical Nurse, indicated the resident had been receiving weekly skin assessments. The resident had been so contracted that a splint carrot could not be placed between the fingers and the palm. Normally contracted residents would be screened by therapy to see if the resident could receive a prosthetic device on the hand. During an interview on 2/7/22 at 2:04 p.m., DON (Director of Nursing) indicated the hospice doctor gave a onetime order for the wound doctor to see the resident for a wound assessment. The call light was thought to be the cause of the chest redness but was then determined not to be the cause. Once they realized the pressure was on the chest from the hand, the interventions were put into place. The foam dressing would have been a cushion for the hand and would have prevented the thumb wound. She could not explain why the thumb wound appeared or became infected. Dakin's was the treatment ordered for the infection of the right thumb wound. She indicated when a resident was admitted with a contracture, orders for monitoring for signs of pressure areas and pain, and a therapy assessment would be ordered. They thought the wound was a stage 3 initially. During an interview on 2/8/22 at 2:27 p.m., the DON indicated the nurse was responsible for doing skin assessments weekly. The DON did the pressure ulcer skin assessments with the wound doctor. If the nurse didn't observe a pressure ulcer, then the DON would not know to do the pressure ulcer skin assessments. On 2/8/22 at 3:16 p.m., the DON provided a copy of the Guidelines for Weekly Skin Observation, dated 1/7/19, which included, but was not limited to, . To monitor the effectiveness of intervention for pressure reduction, identify areas of skin impairment in the early development stage and implement other preventative and/or treatment measures as indicated . In addition to the Weekly Observation by the licensed nurse, the nursing assistant shall observe the skin for areas of impairment with bathing and daily dressing and pericare and notify the nurse if an area is identified. 2. During an observation, on 2/1/22 at 10:13 a.m., Resident 10 was sitting in her wheelchair in her room. There was a folded towel in the seat under the chair, but no pressure relieving cushion was in place. During an observation, on 2/1/22 at 2:20 p.m., CNA (Certified Nurse Aide) 6 assisted Resident 10 to remove her pants and brief. There was a patch to the resident's left buttock, dated 2/1/22. The CNA assisted the resident to remove the dressing. There was a small open area to left buttock measuring approximately 0.5 cm in length by 0.5 cm in width. During an observation, on 2/7/22 at 2:28 p.m., Resident 10 was sitting in her wheelchair in her room. Her ROHO (a specialized cushion that reduces pressure) cushion was behind her back and was deflated. The resident indicated the cushion was supposed to be under her bottom, but it kept deflating. She had told staff prior, and they had aired it back up, but the cushion would not stay aired up. The clinical record for Resident 10 was reviewed on 2/1/22 at 10:30 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Quarterly MDS (Minimum Data Set) assessment, dated 11/16/21, indicated the resident was cognitively intact, required setup assistance with bed mobility, supervision of one staff physical assistance with transfers and personal hygiene, and supervision and setup with toileting, and was at risk for pressure ulcers. The resident did not have any current pressure ulcers. The care plan, start date of 2/8/21 and last revised on 11/21/21, indicated the resident was at risk for skin breakdown related to weakness and decreased mobility. Interventions included, but were not limited to, avoid shearing skin during positioning, turning, and transferring. Staff were to conduct weekly skin assessments. Staff were to pay particular attention to bony prominences. Staff were to encourage the resident to turn and provide assistance to help the resident turn. The resident was to be repositioned for comfort. The resident's heels were to be floated as needed. Staff were to keep the resident's linens clean and dry. The resident was to be kept clean and dry as possible to minimize skin exposure to moisture. The resident was to utilize a pressure reducing cushion to her chair and a pressure reducing mattress to the bed. Staff were to use a lifting device as needed for bed mobility, and moisture barrier product to perineal area as needed. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had no skin impairment, no new skin impairment, or any old impairments. The skin event, dated 7/1/21, indicated the resident had excoriation to her bottom. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Pharmacy Recommendation, dated 12/27/21, indicated a recommendation to discontinue the order for the prescriptive barrier cream due to non-use. The nurse practitioner reviewed and accepted the recommendation to discontinue the barrier cream. The resident's administration record, indicated weekly skin assessments were conducted on January 8, 15, 22, and 29, and the resident had no areas of skin impairment. The clinical record lacked documentation of any current wounds, wound assessments, or orders for treatments. The Wound Management Detail Report, dated 2/2/22 at 3:01 p.m., indicated the resident had a new stage 2 pressure ulcer to the left gluteal fold, measuring 0.6 cm in length, by 0.7 cm in width, with a depth of 0.1 cm. The wound had 50% red nonblanchable tissue, surrounding wound bed covered with nonviable skin. The nursing note, dated 2/2/22 at 5:43 p.m., indicated the resident had a wound to her left buttocks. The resident indicated the wound stung sometimes when lying in supine in her bed with poor turning and repositioning. She had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Pressure could not be ruled out as a cause. During an interview, on 2/1/22 at 10:15 a.m., Resident 10 indicated she had a spot on her bottom that had recently come up. Staff had put patches on it. She thought she had it because she couldn't handle sleeping on her side due to her hip hurting, and often laid on her back and the mattress wore against her skin. During an interview, on 2/2/22 at 2:15 p.m., Resident 10 indicated she had shown the wound to the nurse the night prior and she had put a bandaid on it. The resident indicated the area had started several weeks ago, maybe a month and a half ago. During an interview, on 2/2/22 at 2:19 p.m., CNA 6 indicated she had not been informed of the resident having any areas of skin impairment. During an interview, on 2/2/22 at 2:29 p.m., LPN 8 indicated LPN 9 had informed her on report the resident possibly had a blister that had opened on her bottom but had not said if there were any treatment orders and she did not know if anyone had contacted the doctor. The resident had been at [CONDITION(S)], and she had not gotten a chance to look at it. Staff responsibility was to contact the NP (Nurse Practitioner), get treatment orders, document a skin assessment, and put an event in for the new area. She believed this was to be done within 2 hours, but she would complete it at least by the end of her shift. The resident had not brought it to her attention before, but she knew for a fact it had been brought to LPN 9's attention, and she figured she had checked it out. During an interview, on 2/7/22 at 2:24 p.m., the NP indicated she was not aware of the resident having a new pressure ulcer until she was informed by the facility on 2/1/22. The resident was a [CONDITION(S)] patient and was high risk for skin breakdown. She expected to be notified when skin breakdown was observed, ideally a CNA or nurse would document it first with skin checks and changes. Staff could call her any day or time. Her office was on call 24 hours a day and they were never not reachable. During an interview, on 2/7/22 at 2:30 p.m., OT (Occupational Therapist) 10 indicated the resident's ROHO cushion was supposed to be inflated more than it was and should ideally be underneath of her, but the resident had taken it out because it was not staying inflated. Several cells on the cushion were deflated. The most recent Guidelines for General Wound and Skin Care, last revised 5/23/18, provided on 2/8/22 at 3:16 p.m., by the Director of Nursing, included, but was not limited to, . Provide measures that will promote and maintain good skin integrity . The following general wound and skin care guidelines should be followed for all residents with potential and/or actual impairment in skin integrity . 15. Reevaluate dressing and skin integrity every shift . Inform MD of changes in wound status . Document type of wound, location, stage (if applicable), length, width, depth in centimeters, base, drainage, periwound tissue, and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Notify wound care nurse/nurse supervisor for all new stage II-IV [2 thru 4] pressure ulcers or if you have any questions . The Notification of Change in Condition policy, dated 5/23/18, provided on 2/8/22 at 3:16 p.m. by the DON, included, but was not limited to, . The facility must inform the resident, consult with the resident's physician and if known notify the resident's legal representative when . a significant change in the resident's physical, mental, or psychosocial status . a need to alter treatment significantly . Sample reasons to notify the physician immediately but not limited to . A deterioration in health . or clinical complications . need to alter treatment significantly . clinical complications such as development of a pressure area . documentation of notification or notification attempts should be recorded in the resident electronic record . 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, record review, and interview, the facility failed to ensure nursing services met professional standards of care for pressure ulcers, respiratory care, urinary tract infections, nursing assessments, and physician notification. This deficient practice had the potential to affect all 44 residents residing in the facility. Findings include: 1. Resident 32 developed a pressure ulcer to the right hand thumb on 10/14/21. The pressure ulcer was not identified during weekly skin assessments until it had progressed to a stage 3. No documentation from the nursing staff indicated an area developing to this thumb on skin assessments. Cross Reference F686 2. Resident 141, who was admitted on [DATE] with orders for oxygen at night. The resident did not receive oxygen during the night until she requested the oxygen during the evening of 2/1/22 from the nursing staff. Cross Reference F695 3. Resident 10 developed a stage 2 pressure ulcer in-house. Nursing staff did not adhere to professional standards of assessing a new area of skin impairment, ensuring interventions were in place appropriately, implementation of treatment orders, or notification to the physician of new areas of skin impairment. Cross Reference F686 4. Resident 42 admitted to the facility after a surgical procedure on his urinary tract and insertion of a urinary catheter. Nursing staff failed to adhere to professional standards of accurate and complete nursing assessments, timely and complete notification to the physician of urinary tract changes. The Nurse Practitioner prescribed an antibiotic to the resident, however no urinalysis was completed until the resident subsequently went to the hospital and was diagnosed with a urinary tract infection. Cross reference F690 3.1-35(g)(1) 3.1-35(g)(2)

Based on record review and interview, the facility failed to ensure appropriate monitoring, assessment, physician notification, and prompt treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident 42) Findings include: The clinical record for Resident 42 was reviewed on 2/8/22 at 10:41 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The pre-admission screening form, dated 11/15/21, indicated the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The urologist report, dated 11/11/21, indicated the resident was seen for a cystoscopy, however it could not be completed due to a urethral stricture, and the resident would need to come back for a fluoroscopy with urethral dilation surgical procedure under general anesthesia. The operative report, dated 11/12/21, indicated the resident had a cystoscopy with urethral dilation and Foley catheter placement for recurrent prostatic urethral stricture. He had aggressive dilation with fluoroscopy under general anesthesia in the operating room. A catheter was placed because the resident was about ready to be diuresed due to significant lower extremity [CONDITION(S)]. It was recommended he keep his catheter for four weeks before removing and he would follow up in the office in six weeks for urethral calibration. The nurse's note, dated 11/16/21 at 6:20 p.m., indicated the resident had arrived to the facility at 10:30 a.m. He had a catheter in place, and had severe [CONDITION(S)] to the bilateral lower extremities. There was no description of urine color or clarity. The care plan, initiated on 11/23/21, indicated the resident had a potential for [CONDITION(S)] (Urinary Tract Infection), related to a history of urinary tract infections. Interventions included, but were not limited to assess for [CONDITION(S)] (burning, pain w/urination, urgency, frequency, bladder cramps/spasms, low back pain, flank pain, malaise, nausea, vomiting, pain/tenderness over the bladder, chills, fever, foul odor of urine, concentrated urine, blood in urine, confusion). The were to report to MD and encourage the resident to intake fluids. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If the urine was positive for leukocytes staff may send the urine for C&S (culture and sensitivity). Staff were to provide Foley catheter care every shift and monitor for signs of dehydration twice daily related to diuretic use. The admission assessment, dated 11/16/21 at 11:51 a.m., indicated the resident had a catheter with clear urine observed. The clinical record lacked documentation of any specific post-operative instructions, or any specific monitoring for post-operative complications upon admission. The daily skilled observation, dated 11/18/21 at 11:08 p.m., indicated the resident had a catheter and the resident's urine was dark in color. The daily skilled observations, dated 11/19/21 at 10:42 p.m. and 11/20/21 at 1:06 a.m., indicated the resident did not have a Foley catheter. There was no assessment of urine color or clarity, or any other [CONDITION(S)] concerns. The nursing note, dated 11/20/21 at 10:43 a.m., indicated the resident's urine was dark and he stated he'd had a recent urethral surgery. Scant bloody drainage was observed around his catheter insertion site and he indicated he'd had some bleeding since his surgery. The daily skilled observation, dated 11/21/21 at 11:00 p.m., indicated the resident did not have a Foley catheter. There was no assessment of urine color or clarity, or any other [CONDITION(S)] concerns. The clinical record lacked documentation of any further monitoring of the catheter, any continued bleeding, or notification to the physician until 11/22/21. The NP's progress note, dated 11/22/21, indicated the resident was evaluated for possible dysuria per nurse request. The physical exam lacked documentation of any assessment of the [CONDITION(S)] system of incontinence, drainage or discharge. The note did not address any bleeding of the penis or in the resident's urine. Orders were given to start the resident on [MEDICATION(S)] twice daily for seven days, however no orders were given to conduct a urinalysis. The daily skilled observations, dated 11/24/21 at 7:50 p.m. and 11/25/21 at 10:48 a.m., indicated the resident did not have a Foley catheter. There was no assessment of urine color or clarity, or any other [CONDITION(S)] concerns. The nursing note, dated 11/26/21 at 2:39 p.m., indicated, the nurse took over care of resident at 2:00 p.m. The resident was observed to have large amount blood in his Foley catheter and the CNA (Certified Nurse Aide) reported the catheter had been emptied of blood 6 times. The resident had increased [CONDITION(S)] and redness to his bilateral lower extremities. Therapy reported the resident had a notable change in performance with therapy and increased weakness. The resident was requesting to be sent out. The NP was notified and the resident was sent to the emergency room for evaluation and treatment. The nursing note, dated 11/26/21 at 11:51 p.m., indicated the resident had returned from the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The urine in his leg bag was dark yellow in color with no blood. During an interview, 2/7/22 at 2:18 p.m., the NP indicated they should get surgeon's orders on their discharge summary and they were monitored typically each shift. The resident had lots of things going on and was being followed by urology. Staff were to notify the NP if there were any changes, at the onset of the changes. Staff should notify her office for any change of condition or any concern and she would typically follow-up the next day. She would have expected to be notified of any bleeding or dark urine, as that would have been different for him, and if he came in with dark urine and blood in his urine they should still notify her as that would be an unresolving condition. She would have expected the facility to be monitoring for any bleeding or change in urinary status. During an interview, on 2/8/22 at 10:53 a.m., the DON (Director of Nursing) indicated the resident was admitted for weakness. His admission had nothing to do with the surgical procedure. The scant blood was normal, and it resolved from what she understood. During an interview, on 2/8/22 at 11:34 a.m., the Executive Director indicated preadmission paperwork was done prior to admission and was used for guiding continuance of care. During an interview, on 2/8/22 at 2:15 p.m., the DON indicated the resident had been started on [MEDICATION(S)] for a [CONDITION(S)] on 11/22/21, however there had not been a urinalysis completed prior to the resident going to the hospital. The only reason there would not have been a urinalysis test completed would be because it was not ordered. The Notification of Change in Condition policy, dated 5/23/18, provided on 2/8/22 at 3:16 p.m. by the DON, included, but was not limited to, . The facility must inform the resident, consult with the resident's physician and if known notify the resident's legal representative when . a significant change in the resident's physical, mental, or psychosocial status . a need to alter treatment significantly . Sample reasons to notify the physician immediately but not limited to . A deterioration in health . or clinical complications . need to alter treatment significantly . clinical complications such as . recurrent urinary tract infections . 3.1-41(a)(2)

Based on record review, and interview, the facility failed to ensure a resident was free from unnecessary medications for 1 of 5 residents reviewed for unnecessary medications. (Resident 31) Findings include: The clinical record for Resident 31 was reviewed on 2/1/22 at 8:48 a.m. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual MDS (Minimum Data Set) assessment, dated 1/6/22, indicated the resident was cognitively intact. The physician orders, dated 12/1/21 to 1/31/22, indicated the resident was prescribed the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] syrup 6.25 mg (milligram)/5 mL (milliliters)15 ml, oral. Special Instructions: 30 minutes before meals with a restart date of 12/25/21. - [MEDICATION(S)] HCl tablet; 10 mg oral every 6 hours with a start date of 3/10/20. - [MEDICATION(S)] syrup 6.25 mg/5 mL, 15 ml oral at bedtime and as needed 1 time for nausea/vomiting. - Omeprazole capsule, delayed release 40 mg oral once a day for GERD with a start date of 7/29/21. - [MEDICATION(S)] ([MEDICATION(S)]) 4 mg tablet, give 8 mg (2 tablets) oral once a day. The clinical record lacked documentation indicating the resident had complaints of nausea and vomiting. The nurse's note, dated 12/24/21, indicated NP (Nurse Practitioner) assessed the resident. New orders were to restart [MEDICATION(S)] syrup 15 mg oral 30 minutes before meals, no change to PRN (as needed) and bedtime order. During an interview, on 2/7/22 at 1:50 p.m., the DON (Director of Nursing) indicated Resident 31 does have stomach issues. She didn't regularly have nausea and vomiting. They tried to discontinue the [MEDICATION(S)], but she didn't do well without it. Nursing was concerned she would start having delusional episodes. She goes to different doctors, and they would give her what she wanted. She indicated the residents [MEDICATION(S)] probably could be discontinued. Documentation for nausea and vomiting should be documented in the nurse's notes. During an interview, on 2/8/22 at 10:31 a.m. LPN (Licensed Practical Nurse) 5 indicated the resident does have stomach issues. She took the [MEDICATION(S)], so she did not vomit when eating. She had not observed the resident complaining of nausea or vomiting. She indicated she thought the [MEDICATION(S)] was as needed and the resident had not taken it in quite a while. The LPN indicated she thought the [MEDICATION(S)] could be discontinued. The Organizational Aspect policy, last revised 11/18, provided on 2/8/22 at 10:53 a.m., included, but was not limited to, .2. Communicating to the responsible prescriber and the facility leadership potential or actual problems detected and other findings relating to medication therapy orders including recommendations for changes in medication therapy and monitoring of medications therapy as well as regulatory compliance issues. 3.1-48(a)(4)

Based on observation, record review, and interview, the facility failed to ensure a resident's physician's orders were followed for oxygen use for 1 of 5 residents reviewed for respiratory care . (Resident 141) Findings include: During an observation, on 1/31/22 at 1:48 p.m., Resident 141 had no oxygen concentrator machine in her room. The resident indicated she used oxygen at home and requested it, but the facility had not provided it yet. The clinical record for Resident 141 was reviewed on 2/1/22 at 11:15 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Baseline Care Plan conducted on 1/26/22, indicated the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The desired approaches included, but was not limited to, oxygen per MD (Medical Doctor) order. The care plan, dated 1/26/22 and revised on 1/26/22 at 9:08 a.m., indicated the resident had shortness of breath while lying flat related to [CONDITION(S)]. The interventions, dated 1/26/22, indicated staff were to administer oxygen per MD order and as needed. The physician's order, dated 1/25/22, indicated the resident was to receive Oxygen at 2 liters per nasal cannula continuously at HS (night) twice a day. The physician's order, dated 1/26/22, indicated the resident was to be Assessed/Observed for signs and symptoms of shortness of breath while laying flat twice daily, related to [CONDITION(S)]. During an interview on 2/1/22 at 1:05 p.m., the resident indicated she did not receive her oxygen until 1/31/22, then she pointed at the oxygen machine by her bed. During an interview on 2/1/22 at 1:10 p.m., LPN (Licensed Practical Nurse) 4, indicated the resident had not been supplied with oxygen because the message wasn't passed along. The resident mentioned it last night to staff that she needed it and they obtained it for her. During an interview, on 2/1/22 at 2:15 p.m., the DON (Director of Nursing) indicated the staff should follow the physician's orders. On 2/1/22 at 3:05 p.m., the DON provided a copy of the Guidelines for the Administration of Oxygen policy, last reviewed on 9/17/18, which included, but was not limited to, . Guidelines to properly Administering Oxygen and any Respiratory procedure . 1. Verify physician's order for the procedure . 3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure the consultant pharmacist recommendations were addressed with the attending physician for 1 of 5 residents reviewed for Drug Regimen Review. (Residents 31) Findings include: The clinical record for Resident 31 was reviewed on 2/1/22 at 8:48 a.m., Diagnosis included, but were not limited to, [CONDITION(S)], irritable bowel syndrome without diarrhea, constipation, type 2 diabetes mellitus with diabetic [CONDITION(S)] and gastrointestinal reflux disease (GERD). The annual MDS (Minimum Data Set) assessment, dated 1/6/22, indicated the resident was cognitively intact. The physician orders, dated 12/1/21 to 1/31/22, indicated the resident was prescribed the following medications: - [MEDICATION(S)] syrup 6.25 mg (milligram)/5 mL (milliliters) give 15 ml, oral. Special Instructions: 30 minutes before meals. The start date was 6/2/20 and discontinue date 12/22/21. - [MEDICATION(S)] syrup 6.25 mg/5 ml give 15 mg oral with a start date of 12/25/21. [MEDICATION(S)] HCl tablet; 10 mg oral every 6 hours with a start date of 3/10/20. - [MEDICATION(S)] syrup 6.25 mg/5 mL, 15 ml oral at bedtime and as needed 1 time for nausea/vomiting. - Omeprazole capsule, delayed release 40 mg oral once a day for GERD with a start date of 7/29/21. - [MEDICATION(S)] ([MEDICATION(S)] hcl) 4 mg tablet, give 8 mg (2 tablets) oral once a day. On 12/20/21, the Consultant Pharmacist made the following recommendation: [Name of Resident 31]is taking both routine [MEDICATION(S)] and routine [MEDICATION(S)] for nausea. Please evaluate need for both of these medications and consider discontinuing one or the other. May consider discontinuing [MEDICATION(S)] and increasing dose of [MEDICATION(S)] if needed. If both are kept, please document rational for 2 routine anti-emetic medications to be used long term. The clinical record lacked documentation of the pharmacist recommendation being addressed by the resident's nurse practitioner (NP). During an interview, on 1/6/22 at 1:56 p.m., the DON (Director of Nursing) indicated when the pharmacy made a recommendation an event would be initiated. During the morning meeting every resident with an event open would be reviewed. The nurse on the units would print out the events and put them in the NP binder. The NP would review the recommendations and make changes. They would usually follow the majority of the recommendations. There should be documentation in the nurse's notes or the event form addressing the recommendations or rational for a medication. During an interview, on 2/8/22 at 10:31 a.m., LPN (Licensed Practical Nurse) 5 indicated when the pharmacy recommendations came in, they would go to the nurse who was taking care of the resident and inform her. She would text the doctor and get new orders if they agreed with the recommendation. They would then put the form in the doctor's file for them to review and sign when they came in. The Organizational Aspect policy, last revised 11/18, provided on 2/8/22 at 10:53 a.m., included, but was not limited to, .2. Communicating to the responsible prescriber and the facility leadership potential or actual problems detected and other findings relating to medication therapy orders including recommendations for changes in medication therapy and monitoring of medications therapy as well as regulatory compliance issues. 3.1-25(i)

Based on record review and interview, the facility failed to update resident care plans when a resident began dangling her legs from a geri-chair for 1 of 3 resident care plan revisions reviewed. (Resident B). Findings include: The clinical record was reviewed on 9-22-20 at 9:27 a.m The [DIAGNOSES REDACTED]. The resident's care plan lacked documentation for monitoring or interventions of the resident dangling her legs from the geri-chair (geriatric chair that was a large padded chair that was designed to help seniors with limited mobility). During an interview on 9-22-20 at 12:36 p.m., the Clinical Support RN indicated he had reviewed the care plans and he felt it vaguely mentioned her behaviors of dangling her legs. He could not locate interventions to monitor or prevent the foot/leg dropping. During an interview on 9-22-20 at 12:16 p.m., the Executive Director indicated the resident had become unsafe in her high back chair and slid out. She was then placed in a geri-chair. She dangled her legs from the geri-chair leg rest. There was an incident where the resident was grimacing and had bruising. The resident was discovered to have a fracture at the leg rest level and her legs would dangle there. The facility could not pinpoint when it occurred. They had gone back a couple of days in their investigation and no staff remembered anything happening. During an interview on 9-22-20 at 12:28 p.m., CRCA (Certified Resident Care Aide) 4 indicated the resident would drop her legs when she was in the geri-chair. When the CRCA saw them drop, she would put them back up and put a pillow between the resident's legs. During an interview on 9-22-20 at 12:54 p.m., LPN (Licensed Practical Nurse) 3 indicated when the resident was in her geri-chair, she was known to drop her leg off. On 7-24-20 a CRCA came to her and said the resident's toes were hurting. There was just a little bit of bruising on the shin area above the ankle and the resident was wincing. During an interview on 9-22-20 at 1:02 p.m., the hospice nurse 5 indicated she was told by the facility staff the resident would drop her foot over the side of the chair. The comprehensive care plan guideline, dated 5/22/18, indicated .The comprehensive care plan, once completed .Should new identified areas of concern arise during the resident's stay, they should be addressed on the care plan .Interventions should be reflective of the individual's needs and risk influence as well as resident's strengths . This Federal tag relates to Complaint IN 711. 3.1-35(d)(2)(B)

Based on record review and interview, the facility failed to ensure care plans were developed for residents with chronic urinary tract infections for 2 of 4 residents reviewed for care plans. (Residents 27 and 2) Findings include: 1. The clinical record for Resident 27 was reviewed on 11/07/19 at 10:33 a.m. The resident's [DIAGNOSES REDACTED]. The care plan lacked documentation related to the resident's chronic urinary tract infections (UTIs). The physician's orders [REDACTED]. A progress note, dated 10/30/19 at 12:21 p.m., by the Interdisciplinary Team (IDT) reviewed for the resident indicated the resident had an elevated temperature and Continues on ABT (antibiotic) . related to an UTI. A progress note, dated 10/21/19 at 1:45 p.m., by the IDT reviewed for the resident indicated the resident started an antibiotic related to a positive for UTI .Will continue to monitor. A progress note, dated 10/19/19 at 3:58 p.m., indicated the Resident resting in room at this time, has been restless . has been incontinent of bladder entire shift. UA (urinalysis) results back, new order received [MEDICATION NAME](antibiotic) . A progress note, dated 10/05/19 at 2:18 p.m., indicated the resident . Cont (continue) ABT for UTI, remains afebrile. Resident continues to be more lethargic than baseline, jerking/twitching movements still noted at times. Will cont to observe. A progress note, dated 10/2/19 at 6:30 p.m., indicated Order received to straight cath (catheterize) resident to obtain UA C/S (culture and sensitivity) . A progress note, dated 9/27/19 at 9:48 p.m., indicated (Recorded as Late Entry on 09/27/2019 09:50 PM) Resident began antibiotic therapy at HS (bedtime) R/T (related to) UTI . A progress note, dated 9/27/19 at 3:30 p.m., indicated .Final UA back at this time, positive for UTI. Call out to (name) NP (Nurse Practitioner), new order received to start [MEDICATION NAME] 100 mg PO BID x 10 days . A progress note, dated 7/24/19 at 2:27 p.m., indicated the resident's ABT completed . A progress note, dated 7/16/19 at 1:50 p.m., indicated resident's UA results reviewed per APRN (Advanced Practice Registered Nurse). New order obtained for [MEDICATION NAME] 500 mg po bid x 7 days . A progress note, dated 7/12/19 at 10:00 p.m., indicated the resident's urine was collected by a Clean catch U/A . A progress note, dated 7/2/19 at 3:13 p.m., indicated the resident's ABT completed Will continue to monitor. A progress note, dated 6/22/19 at 1:24 a.m., indicated Resident began antibiotics this shift for UTI . A progress note, dated 6/21/19 at 3:10 p.m., indicated New order received (sic) for [MEDICATION NAME] 100 mg po bid x 10 days for uti . The resident's Events tab for UTIs, dated 9/27/19, indicated on 9/25/19 a culture was obtained. Signs and symptoms included, increased lethargy and confusion; hx (history) UTIs. The resident's Events tab for UTIs, dated 10/19/19, indicated a culture was obtained and the sign's and symptoms were frequent urination; incontinence. During an interview on 11/6/19 at 11:38 a.m., a family member indicated the resident has had three to four UTIs over the last four months. During an interview on 11/13/19 at 2:04 p.m., LPN (Licensed Practical Nurse) 13 indicated the resident has had a few UTIs. I think she was colonized with a few things. It was hard to tell when she had UTIs, due to the dementia. She checked her temperature and that was better than cognitive changes. She also looked for a foul smell, and a mucousy [MEDICATION NAME]. Urinary changes could be found by monitoring the resident's brief. They (residents) are all care planned for UTIs. She should be. 2. During the clinical record review on 11/7/19 at 10:28 a.m., Resident 2's [DIAGNOSES REDACTED]. The resident's care plan lacked documentation for chronic urinary tract infections. The physician's orders [REDACTED]. A progress note, dated 11/12/19, indicated the .Resident has recently had a change of condition, recent [DIAGNOSES REDACTED]. A progress note, dated 10/28/19, indicated N.O. (new order) received Hospice md (physician) for [MEDICATION NAME] (antibiotic) 500 mg po bid x 7 days for possible uti. Res.(resident) on [MEDICATION NAME] for [MEDICATION NAME] uti . A progress note, dated 5/22/19, resident Conts (continues) with IM, (Intramuscular) PO, ABT/UTI .Resident alert and oriented with periods of confusion .(catheter) in place and anchored to bedside. Urine in bag dark yellow in color, sediment and blood present in tubing. Foul odor detected in room. A progress note, dated 4/25/19, indicated NP .called at this time with new orders received to start [MEDICATION NAME] 300 mg, PO, BID x 10 days for UTI. A progress note, dated 3/15/19, indicated .EMS (emergency medical services) came and she was sent to (Hospital name) for eval (evaluation). She returned at 4pm (4:00 p.m.) .[MEDICATION NAME] mg .10 days for UTI . During an interview on 11/13/19 at 9:25 a.m., LPN 6 indicated the resident should have had a care plan for chronic UTIs. She was on a [MEDICATION NAME] medication for the UTIs. Nursing needed to be aware of what they should do. During an interview on 11/13/19 at 10:49 a.m., the MDS (minimum data set) Coordinator indicated, We hold morning meetings every morning Monday through Friday and review the events from the previous day. We monitor the identified issue for at least 72 hours and longer if we need to. These are acute events. For the chronic issues like UTI's I would have to consult with cooperate because we don't have a template for chronic UTIs. Even if they are on [MEDICATION NAME] medication, we resolve them out when the antibiotics are completed. During an interview on 11/13/19 at 11:10 a.m., the Clinical Support Nurse indicated We have (Resident 2 and Resident 27) that have chronic UTI's. We don't have a template for chronic UTIs. We need to do better with that . The comprehensive care plan guideline, dated 5/22/18, indicated .Acute problems that arise with the resident and are expected to be resolved within a short time frame will be addressed on the Event form specific for that problem. Address problems that become on going or chronic with a new comprehensive care plan . 3.1-35(a) 3.1-35(b)(1)

Based on observation, record review, and interview, the facility failed to follow appropriate infection control guidelines related to urinary catheter care for 2 of 2 residents observed for catheter care. (Residents 188 and 135) Findings include: 1. During an observation of urinary catheter care for Resident 188 on 11/8/19 at 10:30 a.m., CRCA (Certified Resident Care Aide) 5 took a wet wipe and periwash and proceeded to cleanse the around the meatus area. She made four passes with the same part of the disposable wipe. She picked up a clean wet wipe and cleansed the head of the penis. She changed the position of the wipe after three wipes. During the clinical record review on 11/13/19 at 8:21 a.m., Resident 188's [DIAGNOSES REDACTED]. The physician's orders [REDACTED].catheter care every shift Three Times A Day . The Admission MDS (Minimum Data Set) assessment, dated 11/3/19, indicated the resident was cognitively intact. The care plan, dated 11/4/19, indicated .the resident uses a .catheter for [DIAGNOSES REDACTED].catheter per physician's orders [REDACTED]. During an interview on 11/13/19 at 9:15 a.m., LPN (Licensed Practical Nurse) 6 indicated, When we do .catheter care we should get a new wet wipe after every wipe or fold the wet wipe after each wipe. During an interview on 11/13/19 at 1:33 p.m., LPN 7 indicated, With .catheter care we use only 1 wet wipe at a time and throw it away after each wipe. I don't think we should even fold the wipe and use it again. 2. During an observation of urinary catheter care for Resident 135 on 11/12/19 at 2:00 p.m., CRCA 4 took a wet wipe and cleanser. She proceeded to cleanse the resident's left groin area and changed the position of the wipe after three passes. She took a wet wipe and cleanser and cleansed the right groin area. She changed the position of the wet wipe after three passes. CRCA 8 completed the urinary catheter care. During the clinical record review on 11/13/19 at 8:53 a.m., Resident 135's [DIAGNOSES REDACTED]. The physician's orders [REDACTED].catheter care every shift Three Times a Day . Review of the admission MDS assessment, dated 10/31/19, indicated the resident was moderately, cognitively intact. The care plan, dated 10/29/19, indicated . Resident uses a .catheter for dx (Diagnosis) of [MEDICAL CONDITION]. Resident will be free from adverse effects from catheter use . Maintain a closed system with urinary bag below the resident's bladder and cover. Observe for any signs of complication such as UTI, urethral trauma, strictures, bladder [MEDICATION NAME] or silent hydro[DIAGNOSES REDACTED] notify my doctor, Observe tubing and avoid any obstructions. Please record resident urinary output. Provide assist with catheter care and change .catheter per physician orders. During an interview on 11/13/19 at 2:21 p.m., CRCA 9 indicated When I do .catheter care, I use 1 wet wipe with cleanser, clean the area, and then throw away the wipe. If I use the wipe more than once, I will fold the wipe and always use the clean area to wipe. During an interview on 11/13/19 at 3:47 p.m., CRCA 10 indicated, When I do .catheter care, I will use a wet wipe, and wipe once, turn the cloth, and wipe again, then throw it away, unless the wipe is soiled the first time, then I will wipe and throw it away. The Urinary Catheter Care policy, dated 11/5/16, included, but was not limited to, .Change the position of the wipe or washcloth with each cleansing stroke . 3.1-41(2)

Based on interview and record review, the facility failed to ensure a residents (Resident B, C, and D) rights were not violated when a staff member posted a photo and videos or residents, without consent, for 3 of 4 residents reviewed for resident rights. The past noncompliance of a staff member posting a photo and videos without a residents' consent on social media began on 8/13/19. The deficient practice was corrected on 8/14/19, prior to the surveyor's entrance, after the facility implemented a systemic plan that included staff education regarding policy and procedure referencing Resident Rights, Cell phones, cameras, and other electronic devices. Auditing and monitoring were put in place. Findings include: 1. The clinical record for Resident B was reviewed on 9/26/19 at 11:30 a.m. [DIAGNOSES REDACTED]. The annual MDS (Minimum Data Set) assessment, dated 9/24/19, indicated te resident's cognition was intact. The incident report, dated 8/13/19 at 9:25 a.m., indicated Environmental Assistant 5 posted pictures and videos of residents on social media. The Statement of Witness, dated 8/13/19, indicated Environmental Assistant 5 agreed that she did take a photo and video of Resident B and posted them on social media. Environmentalist 5 was aware it was against facility policy. Review of the mandatory training log on 9/26/19 at 12:25 p.m., indicated Environmental Assistant 5 completed training on 12/9/16 related to the use of cell phones, cameras, and other electronic devices. The clinical record lacked documentation of permission from the resident or family to post the picture or video on social media. During an interview on 9/26/19 at 10:40 a.m., Resident B indicated permission was not granted to post her picture or video on social media. During an interview on 9/26/19 at 10:55 a.m., the Administrator indicated Environmental Assistant 5 posted a photo and a video of Resident B singing on social media. Environmental Assistant 5 was aware it was against company policy. 2. The clinical record for Resident C was reviewed on 9/26/19 at 11:39 a.m. [DIAGNOSES REDACTED]. The annual MDS assessment, dated 8/7/19, indicated the resident's cognition was moderately impaired. The incident report, dated 8/13/19 at 9:25 a.m., indicated Environmental Assistant 5 posted pictures and videos of residents on social media. The clinical record lacked documentation of permission from the resident or family to post the picture on social media. During an interview on 9/26/19 at 10:55 a.m., the Administrator indicated Environmental Assistant 5 posted a photo of Resident C on social media. Environmental Assistant 5 was aware it was against company policy. 3. The clinical record for Resident D was reviewed on 9/26/19 at 11:45 a.m. [DIAGNOSES REDACTED]. The quarterly MDS assessment, dated 9/21/19, indicated the resident's cognition was severely impaired. The incident report, dated 8/13/19 at 9:25 a.m., indicated Environmental Assistant 5 posted pictures and videos of residents on social media. The clinical record lacked documentation of permission from the resident or family to post the picture on social media. During an interview on 9/26/19 at 10:55 a.m., the Administrator indicated Environmental Assistant 5 posted a photo and a video of Resident D singing on social media. Environmental Assistant 5 was aware it was against company policy. On 9/26/19 at 10:54 a.m., the Administrator provided a current copy of the document titled Cell Phones, Cameras & Electronic Devices dated 12/1/18. It included, but was not limited to, Policy .The Company prohibits unauthorized use of personal cell phones, cameras .Unauthorized taking, storage or distribution of photographs and/or recordings, including multimedia messages or social media, is prohibited .This policy is designed to .protect resident's rights and privacy to confidentiality .Any unauthorized photographs or recordings of a resident and/or his/her personal space .without the resident's or designated representative's written consent, is a violation of the resident's right to privacy and confidentiality This Federal tag relates to Complaint IN 831 3.1-3(t)