Every finding on record at Healthwin Health & Rehabilitation

Based on record review and interview, the facility failed to supervise a resident during a shower that resulted in a fall with the resident sustaining a major injury for 1 of 3 residents reviewed for accidents. (Resident B) Finding includes:A record review for Resident B was completed, on 8/14/2026 at 9:40 A.M. Diagnoses included, but were not limited to: lack of coordination, difficulty walking, collapsed vertebra thoracic region, unsteadiness on feet and a history of transient ischemic attacks (TIAs, mini strokes) and cerebral infarction (stroke).A Quarterly Minimum Data Set (MDS) assessment, dated 3/12/2026, indicated Resident B had moderate cognitive impairment, required partial/moderate assistance for showering and required substantial/maximal assistance for shower transfers.A Fall Risk Evaluation for Resident B, completed on 3/2/2026, indicated the resident was at risk for falls.A Care Plan, initiated on 4/8/2025 and revised on 4/22/2026, indicated Resident was at risk for falls related to functional impairments, incontinence and the use of psychoactive medications with the goal for Resident B to not sustain any major injuries from a fall. Interventions included, but were not limited to: anticipating needs as able, educate to call for help when needing assistance, ensure shoes are within reach, footwear to prevent slipping and provide reeducation and reorientation to the call light and requesting assistance with ADLs (activities of daily living).A facility Nursing Progress Note, on 4/22/2026 at 8:14 P.M., indicated CNA 2 had summoned LPN 3 to the shower room because Resident B had fallen and was on the shower room floor. Resident B was observed on her right side in the shower room between the sink and commode with a pool of blood underneath her head on both sides spreading across the floor. Resident B had her eyes closed, was moaning in pain/discomfort and had refused to have her vital signs assessed. Resident B indicated, Don't touch my vitals, and don't touch my bones. CNA 2 informed LPN 2 that Resident B had requested emergency services (911) to be called and not to move her. Prior to the fall, Resident B had requested a shower, but only if she could take the shower on her own. LPN 2 had explained to Resident B that taking a shower independently was not safe and staff would check on her frequently for safety while giving Resident B some independence and privacy as requested. Resident B agreed and had been assisted by CNA 2 with set-up of the shower. In addition, CNA 2 had assisted with washing and drying Resident B's posterior side and her feet. Resident B indicated to the Emergency Medical Technicians (EMTs) she had been attempting to dress herself when she had fallen.A Patient Care Record from the area fire department, on 4/22/2026, indicated upon arrival to the facility, Resident B had been found in the shower room, lying in a right lateral recumbent (side lying down) position, screaming in pain, but alert and oriented. Facility staff had indicated there had been no observed changes in Resident B's baseline mental status. Resident B had been observed to have active bleeding from a laceration above the left eyebrow and had an obvious deformity consistent with a closed fracture of the left wrist. Resident B had also complained of left hip pain, but had been able to manipulate her left lower extremity. The report indicated the facility staff had indicated Resident B had not been alone for more than 15 minutes prior to being found on the floor.An emergency room Physician note, dated 4/22/2026, indicated Resident B had presented to the emergency department after she had slipped in the shower room with an obvious left wrist deformity, right head laceration and left forehead laceration with pulsatile (severe arterial bleeding where bright red blood spurts or pulses from the wound in sync with the heartbeat) bleeding. An acute care History and Physical Note, dated 4/23/2026 at 1:12 A.M., indicated Resident B had significant bleeding to her left forehead and most likely had nicked her temporal artery. Resident B underwent left wrist reduction in the emergency room. A Computerized Tomography scan (CT scan) was ordered for the left wrist and left hip.A facility Nursing Progress Note, on 4/23/2026 at 10:08 A.M., indicated the hospital had called and indicated Resident B had been admitted with a left hip and wrist fracture. Resident B's daughter indicated the resident was having surgical repair of the injuries.A Discharge Summary, on 5/2/2026 at 3:17 P.M., indicated although initial left hip radiographs were limited/negative, a subsequent CT scan confirmed an acute left subcapital (just below the head of the bone) femoral neck fracture and the CT scan of the left upper extremity confirmed a distal radius/ulna fracture.During an interview, on 8/14/2026 at 3:15 P.M., Resident B's daughter indicated she had received a telephone call around 8:00 P.M. on 4/22/2026, from LPN 3 indicating Resident B had fallen and had been transported to the emergency department. Resident B's daughter indicated Resident B had broken her ulna and radius, and the fracture had been a compound fracture, as the bones had come out of her skin, had broken her hip and had a laceration on her head. Resident B's daughter indicated she had asked Resident B what had happened and Resident B indicated she had been in the shower room and had reached out for the privacy curtain because she thought CNA 2 had been in the shower room on the other side of the privacy curtain, but there was nobody there in the shower room. Resident B's daughter indicated Resident B's best friend (Resident E) at the facility had been looking for Resident B and had asked LPN 2 at the nurse's station where Resident B had been. LPN 2 had told Resident E that Resident B was in the shower room. Resident E informed Resident B's daughter that Resident B had not come out of the shower and she had gone to find Resident B and had heard Resident B moaning from outside the shower room door. Resident B's daughter indicated Resident E had gone to the nursing station and informed the nursing staff that, something terrible has happened to Resident B. Resident B's daughter indicated that Resident E then observed Resident B on the shower room floor naked and begging to be covered and the staff had placed a bath towel over Resident B's buttocks. Resident B's daughter indicated Resident E had informed her that the Certified Nursing Assistants (CNAs), and the nurse had been at the nurse's station laughing while Resident B had been in the shower room. During an interview, on 8/17/2026 at 1:55 P.M., Resident E indicated she had been looking for Resident B in her room, on the evening of 4/22/2026, as Resident B had been upset at dinnertime. Resident E indicated she had in Resident B's room for about 10 minutes, and then had gone to the nurse's station to inquire of Resident B's whereabouts. Resident E indicated the staff told her that Resident B was in the shower room. Resident E indicated she had gone to just outside the locked shower room door and had hollered for Resident B and heard her moaning. Resident E indicated she then yelled for the staff and told them that Resident B was in the shower room moaning. Resident E indicated that after they responded, the staff had left the shower room door open when they first entered and she had observed Resident B on the floor with blood coming from her head. A policy for falls and ADLs was requested , on 8/17/2026 at 7:43 P.M. but no policies were provided prior to the survey exit.This citation is related to Intake 2995488.410 IAC (Indiana Administrative Code) 16.2-3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure bugs were controlled in 1 of 1 kitchen. During an observation of the kitchen on 4/17/2026 at 9:53 A.M., multiple dead bugs were noted in a light fixture above the 3-compartment sink used to wash food preparation utensils. During an interview on 4/17/2026 at 9:53 A.M. the DD indicated bugs were a problem and had been reported to the maintenance department but it had not yet been addressed. On 4/20/2026 at 10:25 A.M. a list of maintenance requests for the past 6 months was provided and the only issue listed was the peeling paint on kitchen ceiling tiles. On 4/22/2026 at 2:00 P.M. a policy regarding pest control was requested but one was not provided before survey exit. 410 IAC 16.2-3.1-19(f)(4)

Based on observation interview, and record review, the facility failed to serve food at a palatable temperature for 1 of 4 nursing units. (West unit) This potentially affected 20 of 86 residents who ate food prepared in the kitchen. During an observation and temperature check of supper trays from a covered food cart, on the [NAME] 2 unit, on 4/21/2026 at 6:02 P.M., food was not served at a palatable temperature and the following temperatures were obtained:-the pureed grilled cheese was served at 125 degrees Fahrenheit.-the mashed potatoes and gravy was served at 128 degrees Fahrenheit.During an interview on 4/21/2026 at 6:02 P.M., the Dietary Director indicated the food should have been 135 degrees (Fahrenheit) at the point of service.On 4/22/2026 at 3:00 P.M. an undated policy titled, Food Preparation and Service was provided by the DON. The policy indicated, .potentially hazardous food must be maintained below 41 degrees or above 135 degrees 410 IAC 16.2-3.1-21(a)(2)

Based on observation, interview, record review, the facility failed to prepare and serve food in a sanitary manner for 1 of 1 kitchens. This deficient practice potentially affected 82 out 86 residents who ate food prepared in the kitchen. During an initial tour and observation of the kitchen on 4/15/2026 at 9:42 A.M. with the Dietary Director (DD) the following was noted:-a bag of frozen chicken strips and french fries were in the reach-in freezer opened and unsealed.-a baking tray put away as clean had bottom part of the tray covered in a brown substance-a fan in the dry storage area had visible dusty and grime-a silverware caddy had a brown sticky substance on it-white metal shelves above the food prep area had chipped paint and rust on them During an interview on 4/15/2026 at 9:42 A.M., the DD indicated the bags of chicken and french fries in the freezer should have been sealed, the baking tray should have been clean, the fan in the dry storage should have been clean, the silverware caddy should have been clean, and the metal shelves should have been painted. During another observation of the kitchen and the Alcove (where food was served from the steam table) on 4/17/2026 at 11:45 A.M. the following was noted:-the ceiling over the prep area in the kitchen was dirty and the paint was peeling.--the Alcove ceiling vent and the ceiling and wall surrounding the vent was dusty and dirty; and 2 screens in the ceiling were black with a heavy accumulation of dirt and dust. On 4/17/2026 at 11:45 A.M., the DD indicated the peeling and dirty ceilings, vents, and screens, should have been clean. She also indicated maintenance had been notified of all of these issues but had not taken care of them yet. On 4/20/2026 at 10:25 A.M. a list of maintenance requests for the past 6 months was provided and the only issue listed was the peeling paint on the kitchen ceiling tiles. During observations of nutrition pantries on the units on 4/21/2026, the following issues were noted:-at 9:21 A.M. the [NAME] 2 unit refrigerator temperature was 46 degrees and the shelf in the freezer was rusty.-at 9:26 A.M. the Bridgeview unit refrigerator and freezer did not have thermometers and an employee's food was found in the refrigerator.-at 9:29 A.M. the East 2 refrigerator's thermometer was broken.-at 9:35 A.M. the East 1 coffee machine tray had a brown and white crust on it.-at 9:40 A.M. the [NAME] 1 cabinet drawer, under the coffee machine, was missing the outer layer of finish and the cabinet door was buckled. During an interview on 4/21/2026 at 9:40 A.M., the DD indicated the coffee machine tray should have been clean, the cabinet drawer and door should have been repaired, all refrigerators should have had working thermometers and the temperature of the refrigerator should be no higher than 41 degrees, and employee food should not have been stored in the nutrition pantry refrigerator. On 4/22/2026 at 3:00 P.M. the DON indicated a policy for cleaning and maintaining the kitchen environment was not available and indicated the facility followed state regulations.410 Indiana Administrative Code (IAC) 16.2-3.1-20(i)(3)

Based on observation and interview, the facility failed to ensure infection control practices were followed regarding emptying a urinal for 1 of 1 residents observed for urinal care. (Resident 40)Finding include:During an observation, on 4/21/2026 at 2:30 P.M., Certified Nurses Aid (CNA) 15 was exiting Resident 40's room carrying a half full urinal down the hallway. She continued down the hallway to the unit bathroom to empty the urinal. She had wet wipes in her hand grasping the urinal handle. She emptied the urinal but was not noted to wash her hands after emptying the urinal.During an interview with CNA 15, on 4/21/2026 at 2:32 pm, she indicated the way she carried the urinal was proper technique. She indicated that gloves were not to be worn in the hallway. CNA 15 indicated she had not washed her hands after emptying the urinal. She indicated she had had training on personal protective equipment but could not recall when that training had occurred.During an interview on 4/22/2026 at 12:11 PM with RN 14, she indicated staff were not supposed to go outside of resident rooms with gloves on their hands. RN 14 indicated staff were allowed to go outside of resident rooms with gloves on when they were emptying resident urinals due to the fact there were no bathrooms in many of the resident rooms. She confirmed staff must wear gloves when emptying a urinal.A policy titled Personal Protective Equipment-Donning and Doffing dated 1/5/2025, was provided by the Director on Nursing on 4/22/2026 at 10:08 A.M. the policy indicated. Specific Procedure/Guidance: 1. The staff, residents and visitors will be provided education on proper use and donning and doffing PPE. Donning 1. Identify the appropriate PPE to don based on the type of isolation/quarantine per physician's order. 2. Validate appropriate signage on resident's door. 3. Perform hand hygiene. 8. Put on gloves a. Ensure a size for appropriate fit.410 IAC (Indiana Administrative Code) 16.2-3.1-18(b)(1)

Based on interview and record review, the facility failed to ensure laboratory services were obtained timely for 1 of 5 residents whose labs had been reviewed. (Resident 84)Findings include: The clinical record of Resident 84 was reviewed on 4/17/2026 at 11:35 A.M. The resident's diagnoses included, but were not limited to: diabetes mellitus, peripheral vascular disease, hypertension, acidosis, acquired absence of right leg below knee, acquired absence of left leg below knee, and immunodeficiency due to conditions classified elsewhere.A Quarterly Minimum Data Set (MDS) assessment, dated 1/16/2026, indicated the resident was cognitively intact but did not indicate the resident had a peripherally inserted central catheter (PICC) line (a thin, flexible tube inserted into an upper arm vein and threaded to a large vein near the heart for long-term intravenous access).During an interview, on 4/16/2026 at 10:45 A.M., Resident 84 indicated he has had a PICC line and had completed intravenous (IV) antibiotics for a previous urinary tract infection, weeks ago. The resident indicated a urine sample had been sent to the lab, and the results were to have determined the removal of his PICC line. Resident 84 indicated he desired to have the PICC line removed and no one has followed up with his urine sample results yet.Physician Orders included, but were not limited to:Repeat urine with culture (a diagnostic test that detects and identifies bacteria or yeast in the urine to diagnose urinary tract infections), dated 4/3/2026Repeat urine with culture, dated 4/7/2026,Please obtain stat urine and culture to send to labs, dated 4/17/2026. A Nurse's Note, dated 4/4/2026 at 00:51A.M., indicated Resident 84 had completed his course of antibiotics.A Nurse's Note, dated 4/11/2026 at 10:42 A.M., indicated a urine sample had already been obtained from the resident but had not been received by the laboratory company.A Nurse's Note, dated 4/17/2026 at 3:18 P.M., indicated another urine sample from the resident had been collected from Resident 84.A Nurse's Note, dated 4/21/2026 at 1:32 P.M., indicated the urine sample was collected on 4/17/2026 and needed to be re-collected again as instructed by the laboratory.A Nurse's Note, dated 4/21/2026 at 6:17 P.M., indicated yet another urine sample was collected from Resident 84.During an interview, on 4/20/2026 at 3:00 P.M., LPN indicated there were no results for the resident's urinalysis (UA) (a diagnostic test that examines the appearance, concentration, and content of urine to detect disorders like urinary tract infections, kidney disease, and diabetes) and indicated it sometimes takes a while.During an interview, on 4/20/2026 at 3:16 P.M., the Director of Nursing (DON) indicated the facility had called the laboratory for Resident 84's urinalysis results on 4/16/2026 and indicated the laboratory had never received the resident's urine. The Interim DON indicated the facility had sent another urine sample on 4/17/2026.During an interview, on 4/21/2026 at 11:58 A.M., the DON indicated the laboratory had indicated there were no results for the UA for Resident 84 due to the urine sample not being labeled correctly with the date. On 4/22/2026 at 11:00 A.M., the DON provided a policy titled, Laboratory Services, dated 1/5/2025 and indicated the policy was the one currently used by the facility. The policy indicated .If the facility staff obtains a specimen for laboratory testing, the specimen will be:.laboratory testing to be completed and the date the specimen was obtained.9.Shoul d the laboratory test not be obtained, the physician/practitioner will be contacted for further guidance.410 IAC 16.2-3.1-49 (a)

Based on observation, interview and record review, the facility failed to provide gastrostomy tube (G-tube) care as ordered by the Physician for 1 of 1 resident who was observed for G-tube care. (Resident 17)Finding includes: During an observation on 4/16/2026 at 10:12 A.M., LPN 5 removed Resident 17's dressing from around his G-tube and cleaned the skin with sterile water only and no soap. LPN 5 then applied a clean dressing around the G-tube insertion site. The skin around the G-tube insertion site was noted to be reddened. During an interview with LPN 5 on 4/16/2026 at 10:17 A.M., LPN 5 indicated she had not used soap and she was not sure if soap was supposed to be used during Resident 17's G-tube dressing change. Resident 17's record review was completed on 4/18/2026 at 11:00 A.M. Diagnoses included, but were not limit to: dysphagia, aphasia, hemiplegia, and hemiparesis of the left side. A Quarterly Minimum Data Set (MDS) assessment dated , 3/12/2026, indicated the resident was nonverbal, was rarely or never understood by others and rarely or never understood others, had significant cognitive impairment, was dependent on staff for all transfers, personal hygiene, showering/bathing and received 51% or more of his daily caloric requirements from a G-tube feeding. A current Physician's order, dated 4/12/2026, indicated Resident 17's G-tube site was to be cleaned with soap and water and a new drain sponge applied daily and as needed. A current Care Plan, initiated on 7/3/2025, indicated Resident 17 was at risk for complications related to the need for an enteral tube feeding (G-tube). An intervention initiated on 7/3/2025 indicated tube insertion site care should be performed per the Physician's order. On 4/16/2026 at 10:30 A.M., a policy regarding following Physician's orders and a policy regarding following the Plan of Care was requested, but neither were received before the survey exit on 4/22/2026 at 3:00 P.M. 410 Indiana Administrative Code (IAC) 16.2-3.1-44(b)

Based on observation, interview, and record review, the facility failed to ensure preventative measures were implemented for a resident with a pressure ulcer for 1 of 3 residents reviewed for pressure ulcers.(Resident 10)Finding includes: A record review was completed on 4/17/2026 at 8:56 A.M. for Resident 10. Diagnoses included chronic obstructive pulmonary disease and a protein calorie deficit. A Quarterly Minimum Data Set (MDS) assessment, dated 2/19/2026, indicated Resident 10 had a moderate cognitive deficit, a range of motion deficit on both sides of their lower extremities; required maximal assistance with bed mobility and transfers; was frequently incontinent of bladder, and was always incontinent of bowels and had no pressure ulcers. A care plan regarding the resident's risk for pressure ulcer development was initiated on 9/4/2025 with interventions encourage adequate hydration and nutrition, keep skin clean and dry, pressure reducing mattress, skin assessments as indicated, assess per risk of skin breakdown. There were no specific preventative interventions for the resident's heels addressed in the care plan. Physician Orders for Resident 10 included, but were not limited to:-4/13/2026 Regular diet with fortified foods 3 times a day.-8/15/2025 House supplement 1 time a day.-4/2/2025 Resident to wear heel protectors daily. May remove for wound and ADL care, then re-apply.-4/2/2026 Clean right lateral heel with normal saline and pat dry. Apply betadine to wound and leave open to air. A Care Plan problem, for Resident 10, initiated on 4/2/2026 indicated a skin impairment of a deep tissue injury to her right heel. Interventions included, but were not limited to, heel protectors while in bed and keep heels up while in bed. During an observation of wound care on 4/21/2026 at 11:04 A.M., Resident 10 was found in bed with no heel protectors and her heels were resting directly on the mattress. During an interview on 4/22/2026 at 10:53 A.M. the Wound Nurse indicated the resident had heel protectors ordered but staff were not applying them consistently and sometimes the resident would kick them off. She indicated the resident should have had her heels up off the mattress and heel protectors in place. On 4/22/2026 at 3:00 P.M. the DON provided a current policy, dated 1/5/2025 and titled, Pressure Injury Prevention and Management. The policy indicated, .Preventive interventions will be implemented based on the pressure ulcer/injury risk assessment, other related factors, and resident preferences. Such interventions may include: Use of pressure reducing/relieving support surfaces or devices that assist with pressure redistribution and tissue load 410 Indiana Administrative Code (IAC) 16.2-3.1-40(a)(1)

Based on interview, observation and record review, the facility failed to assess a resident after a fall for 1 of 3 residents reviewed for falls. (Resident 16)1. During an interview on 4/15/2026 at 10:42 A.M. Resident 16 indicated he had fallen several times and had gone to the emergency room twice as a result of the falls.During an observation on 4/15/2026 at 10:42 A.M. a fall mat was noted on the floor next to Resident 16's bed.A record review was completed on 4/27/2026 at 1:54 P.M. for Resident 16. Diagnoses included, but were not limited to, dementia and Parkinson's.An admission Minimum Data Set (MDS) assessment, dated 4/6/2026, indicated Resident 16 had a moderate cognitive deficit; required maximum assist for bathing and toileting and required moderate assist for bed mobility and transfers. The assessment indicated the resident had had no falls since admission to the facility and received physical and occupational therapies.An admission Fall Risk assessment dated [DATE] indicated Resident 16 was at risk for falls.On 4/4/2026 an assessment for a change in condition and transfer to the emergency room indicated Resident 16 was being transferred for complaints of chest pain and follow up from a fall. No other documentation could be found regarding how the fall occurred or an assessment of the resident after the fall.A Care Plan problem initiated on 4/13/2026 indicated Resident 16 was at risk for falls. Interventions included, but were not limited to, bed in lowest position, footwear to prevent slipping, and keep call light and personal items in reach.During an interview on 4/22/2026 at 12:22 P.M. the DON indicated there was not an assessment related to the fall present in the record and an assessment should have been documented.On 4/22/20206 at 3:00 P.M. the DON provided a policy, dated 1/5/2025 and titled, Charting and Documentation. The policy indicated, .The following information should be documented in the resident medical record: Events, incidents, or accidents involving the resident 410 IAC 16.2-3.1-37(a)

Based on interview and record review the facility failed to update a resident's care plan for 1 of 3 residents reviewed for falls. (Resident 16) Finding includes: During an interview on 4/15/2026 at 10:42 A.M. Resident 16 indicated he had fallen several times. During an observation on 4/15/2026 at 10:42 A.M. a fall mat was noted on the floor next to Resident 16's bed. A record review was completed on 4/17/2026 at 1:24 P.M. for Resident 16. Diagnoses included, but were not limited to, Parkinson's and dementia. An admission Minimum Data Set (MDS) assessment, dated 4/6/2026, indicated Resident 16 was moderate.y cognitively impaired, required substantial assistance for toileting and bathing; and partial to moderate assistance for transfers. The assessment indicated the resident had had no falls since admission to the facility. In addition, the resident was receiving physical and occupational therapy during the time of the assessment. An admission Fall Risk Assessment, completed on 3/30/2026, indicated Resident 16 was a fall risk and had incurred a fall on 4/4/2026. The care plan regarding falls and interventions to prevent falls was not initiated until 4/13/2026, after the resident's fall. During an interview on 4/22/2026 at 1:27 P.M. the DON indicated the care plan should have been updated for the fall. On 4/22/2026 at 3:00 P.M. a current policy, dated 1/5/2025 and titled Care Planning-Current Comprehensive, was provided by the DON. The policy indicated, .The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: When there is a significant change in the resident's condition 410 Indiana Administrative Code (IAC) 16.2-3.1-35(b)(1)

Based on record review and interview, the facility failed to obtain informed consent for psychotropic medication administration for 1 of 5 residents reviewed for unnecessary medications. (Resident 3)Findings include:The clinical record of Resident 3 was reviewed on 4/17/2026 at 8:45 A.M. The resident's diagnoses included, but were not limited to: gastrostomy status, difficulty in walking, dysphagia, chronic kidney disease, hypertension, personal history of malignant neoplasm of prostate, obstructive sleep apnea, irritable bowel syndrome, tremor, paroxysmal atrial fibrillation and polyneuropathy.A Quarterly Minimum Data Set (MDS) assessment, dated 2/24/2026, indicated the resident was moderately cognitively impaired and was taking an anticoagulant and an antidepressant.Physician Orders included, but were not limited to:Escitalopram Oxalate (antidepressant) Oral Tablet 10 mg (milligrams), give two tablets one time a day, 10/14initiated /2025 and Bupropion Hydrochloride (antidepressant) Oral Tablet 100 mg, give one tablet three times a day, initiated 10/22/2025.A Care Plan, initiated on 9/12/2025, indicated Resident 3 received an antidepressant medication. A Psychotropic Medication Consent form, dated and signed on 12/22/2025, for Resident 3 for the following medications: Escitalopram Oxalate 20 mg every morning and Bupropion Hydrochloride 100 mg three times a day.The clinical record for Resident 3 failed to evidence a signed psychotropic consent form dated prior to the resident beginning psychotropic medications.During an interview, on 4/17/2026 at 10:29 A.M., the Interim Director of Nursing (Interim DON) indicated he was unable to locate a signed psychotropic consent for either medication, the Escitalopram Oxalate or the Bupropion prior to the initiation of the medications for Resident 3. On 4/17/2026 at 11:21 A.M., the Executive Director provided a policy titled, Antipsychotic Medication Use, dated 1/5/2025 and indicated the policy was the one currently used by the facility. The policy indicated .The Physician/practitioner will respond appropriately.clearly documenting (based on assessing the situation) why the benefits of the medication outweigh the risks.410 Indiana Administrative Code (IAC) 16.2-3.1-3(n)(2)

Based on interview and record review the facility failed to ensure physician orders were in place for the treatment of low blood glucose, and failed to ensure the documentation was completed for wound care treatment according to physician orders, for 1 of 3 residents reviewed for diabetic management and wound treatment, (Resident B). Finding includes: On 3/27/25 at 11:30 A.M., a clinical record review was completed for Resident B's. Diagnoses included paraplegia, type 2 diabetes, osteomylitis of the left femur, seizure disorder, history of stroke, colostomy status, neurogenic bladder requiring a catheter, resistance to multiple antibiotics, tachycardia, and pressure ulcers. The Annual Minimum Data Set (MDS) assessment dated [DATE], indicated Resident B was fully cognitively intact, required extensive assistance for bed mobility, transferring, bathing, dressing, and personal hygiene. The resident was assessed to have had two stage 2 pressure ulcers, one unstageable pressure ulcer, and a surgical wound. In addition, Resident B was receiving insulin for diabetes and had received 5 injections in the previous 7 days. Physician's orders included the following: -Lantus Subcutaneous Solution to inject 10 units at bedtime for type 2 diabetes, ordered 11/6/25 and discontinued on 3/6/23. There were no orders in place for the treatment of low blood sugar. -Santyl External Ointment 250 Unit/GM, to apply to the coccyx topically one time daily for eschar, necrotic, red serosanguinoes draining, ordered 2/18/25. -Ostomy care every shift, ordered 2/10/25. Review of Resident B's February and March 2025 Medication Administration Records and Treatment Administration Records indicated a lack of documentation for the administration of Santyl External Ointment 250 Unit/GM, to apply to the coccyx topically one time daily on 2/22/25, 2/23/25, and 3/6/25. There was also a lack of documentation for ostomy care on 2/18/25 on the night shift and on 3/3/25 on the day shift. During an interview on 3/26/25 at 4:30 P.M., the Director of Nursing (DON), indicated there was not a physician's order for hypoglycemic care and some documentation related to Resident B's wound and ostomy care was missing. On 3/27/25 at 9:05 A.M., the Administrator provided a policy dated 10/1/21, titled, Diabetes Mellitus - Nursing Care Of The Older Adult, indicating it was the current facility policy. The policy indicated, .Unless a physician has ordered specific parameters for monitoring, treating, and notifying the physician of blood sugar levels, the facility's routine standing orders will be used . On 3/27/25 at 9:05 A.M., the Administrator provided an undated policy titled, Documentation Of Wound Treatments, indicating it was the current facility policy. The policy indicated, .Wound assessments are documented at the time of each treatment . This citation relates to Complaint IN00456011. 3.1-37(a)

Based on interview and record review, the facility failed to ensure a comprehensive plan of care including a plan for type 2 diabetes, wound care and colostomy care was created for 1 of 3 residents reviewed for care plans. (Resident B) Finding includes: On 3/27/25 at 11:30 A.M., a clinical record review was completed for Resident B's. Diagnoses included, but were not limited to, paraplegea, type 2 diabetes, osteomylitis of the left femur that required surgical intervention and the application of wound vac placement, colostomy status, and pressure ulcers. The Annual Minimum Data Set (MDS) assessment,dated 2/21/25, indicated Resident B was fully cognitively intact, required extensive assistance for bed mobility, transferring, bathing, dressing, and personal hygiene. The resident was assessed to have had two stage 2 pressure ulcers, one unstageable pressure ulcer, and a surgical wound. In addition, Resident B was receiving insulin for diabetes and had received 5 injections in the previous 7 days. Physician's orders included the following: -Lantus Subcutaneous Solution to inject 10 units at bedtime for type 2 diabetes, ordered 11/6/25 and discontinued on 3/6/23. There was no order for the treatment of low blood sugar. -Wound vac to left ischium tuberosity (lower area of the pelvis on the side of the buttock), connect negative pressure wound treatment (NPWT) system at 150mmHg. Change wound vac on Mondays and Fridays for wound care, ordered 2/26/25. -Ostomy care every shift, ordered 2/10/25 A review of Resident B's care plans indicated a lack of goals and interventions for low blood sugar (hypoglycemia), wound vac care to address the pressure ulcers and ostomy care. On 3/27/25 at 9:05 A.M., the Administrator provided an undated policy titled, Care Planning-Comprehensive Person-Centered, indicating it was the current facility policy. The policy indicated, .A baseline care plan to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission .'Baseline Care Plan': is a care plan developed within 48 hours of admission .1. To assure that the resident's immediate care needs are met and maintained, .b .ii. The instructions needed to provide effective and person-centered care that meets professional standards of quality . This citation relates to Complaint IN00456011. 3.1-35(a)

Based on observation, interview, and record review, the facility failed to ensure there was a sufficient number of nursing staff to provide care to residents on all nursing units. This deficient practice had the potential to affect of residents. See F677 for additional information regarding Residents B, M, D, E, and 55 Findings include: During a Resident/surveyor group meeting, conducted on 2/13/2025 at 1:41 P.M., 22 of 22 residents attending complained about untimely response to call lights, not receiving at least two showers a week and not receiving medications timely and/or not receiving all of their medications. During a Family meeting with the new corporate representatives and the Director of Nursing, conducted on 2/12/2024 at 2 PM, several resident representatives complained about the lack of staffing to provide care, especially at night and residents not receiving timely showers or medications. The family representatives queried the new corporate staff and DON about reducing the number of staff and firing the QMAs (Qualified Medication Aides) and shower aides. The Director of Nursing informed the family members that the staff were not fired but were just not given as many work hours. The corporate representative informed the family members that the facility was staffed at a 3.5 PPD (hours of direct nursing care per resident per day) which was above the national average. The meeting ended abruptly when family members became emotional and loud after being told individual concerns would not be directly addressed during the meeting. During an interview on 2/17/2025 at 11:18 A.M., the DON indicated the facility determined the staffing levels needed to meet each residents' needs each day based on acuity. The DON indicated in addition, during emergencies they used nursing staffing agencies and staff were allowed to pick up hours through their messaging service. She indicated the facility was staffed with a nursing supervisors every shift, 7 days a week. She indicated she had not received any staffing concerns from the families or residents until the newscasters had came to the facility. She did concede the nursing staff had voiced their concerns and the facility was trying to adjust to the new corporations staffing patterns. Review of the Facility Assessment, provided on 2/17/2025 at 10:30 A.M. by the DON, regarding nursing staffing needs, dated 1/16/2025, indicated the following staffing needs: RN 14.8 (hours scheduled per day) LPN 18.6 (hours scheduled per day), CNA 63.5 per day (hours scheduled per day). Using this ratio for a census of 107 residents, the required, facility assessed PPD would be 6.79. However, after a discussion with the DON, on 2/17/2025 at 1:38 P.M., a corrected facility assessment was provided which indicated the following nursing staff requirements: RN 5.38 (hours per day), LPN 12.55 (hours scheduled per day) and CNA 26.88 (hours scheduled per patient per day). This ratio, utilizing the current facility census of 98 residents equaled 3.42 PPD of nursing staff. It was unclear if any adjustments had been made to the PPD requirements due to resident acuity. On 2/17/2025 at 1:30 P.M., the DON provided documentation of current resident needs. The form indicated the following: 40 residents required the use of a mechanical lift to transfer, 21 residents required extensive assistance with personal hygiene and toileting needs and 17 residents required feeding assistance with their meals. Review of the nursing schedules as worked from 1/20/2025 through 2/20/2025 indicated the facility failed to provide the assessed required staffing levels of 3.42 PPD on the following dates: 1/20, 1/21, 1/26, 2/1, 2/15 and 2/16/2025. Although the staffing PPD scheduled was much higher than the 3.42 required staffing levels, the actual PPD for staff that had worked was much lower. During an interview on 2/11/2025 at 2:21 P.M., CNA 5 indicated the facility used to have 3 CNA's on each unit, a nurse, a QMA that worked from 10:00 A.M. until 6:00 P.M., a shower aide and a restorative aide for the day and evening shift, minus a shower aide on the evening shifts. He indicated now the facility only had two aides on the floor per unit and shower aide that worked a couple times a week, a restorative aide and a nurse for the day and evening shift He indicated the night shift had one CNA on all units. He indicated the residents had been complaining they had to wait longer for their call lights to be answered. He indicated they were understaffed and had to hurry and rush to provided the needed care. He indicated it was difficult to complete the scheduled showers. During an interview on 2/17/2025 at 9:28 A. M., CNA 6 indicated she was assigned ten residents to get up and ready for breakfast by 8:30 A.M She indicated she did not have enough time to do extra things like nails, hair, showers and charting. She indicated the residents did not get showered unless there was a shower aide scheduled. She indicated she had only been able to pass ice water to four residents this morning. She indicated the weekends were worse because there were many staff that called off and did not show up for work. She indicated due to the lack of staffing, she had noticed there were now odors in the hallways. She was indicated she was often asked to pick up hours on her day off and asked stay over late. She indicated she was suffering from burn out. During an interview on 2/17/2025 at 12:05 P.M., CNA 17 indicated she was a shower aide 1-2 times a week. She indicated when she worked on the floor and there were only two CNAs, she was assigned 10-11 residents. She indicated she had to work at a faster pace, and could not complete tasks such as nail care, showers and charting. During an interview on 2/17/2025 at 1:56 P.M., CNA 15 indicated staffing the previous weekend did not go well. Sunday, he had worked on the a nursing unit by himself and had been assigned 14 residents. He indicated three of the 14 required feeding assistance in their rooms and by the tine he got done with breakfast trays, the lunch trays had arrived to the unit. The residents were so upset with him because their call lights were also not answered timely. He indicated he had only had time to check and change some residents and make sure they were comfortable. He indicated he had not had time to complete the four scheduled showers and had only completed half of his charting. He indicated residents that were usually continent had ended up wetting themselves because he could not assist them timely and they were very upset. CNA 15 indicated there was no time to wash everyone, do nail care, shave residents or provide oral care. During an interview on 2/17/2025 at 2:40 P.M., CNA 14 indicated this past weekend, staffing was horrible. She indicated she had only had time to provide one out of four scheduled showers on Saturday and none of the scheduled showers on Sunday. She had been assigned fourteen residents. She indicated she was unable to complete the entire required assignment every day such as showers, charting and the little things that residents had requested. During an interview on 2/18/2025 at 10:48 A.M., CNA 2 indicated that he was assigned to care for 11 residents. He indicated he was unable to complete the following tasks:: showers, nail care, charting. He indicated he attempted to get everyone changed or toileted before he went home, but could not always accomplish it. During an interview on 2/18/2025 at 11:00 A.M., CNA 7 indicated she was assigned to care for 11-12 residents and had problems getting the following tasks done: showers and charting. During an interview on 2/17/2025 at 2:10 P.M., Resident K indicated she had to wait this past Sunday to use the toilet. She indicated her back hurts when she had to hold it for too long. She indicated she had hardly seen the CNA working. She indicated she had ended up wetting the bed, which made her feel terrible. She had to ask her husband to help her with the bed pan because no staff had answered her call light. She indicated her husband had tried to help her but when he took her off the bedpan, it had spilled onto the bed and soiled the linens. During an interview on 2/17/2025 at 2:21 P.M., Resident L indicated his care this past weekend was non-existent. He indicated it was like that every weekend. He indicated he had gone without fresh ice water all weekend, even though he had asked for it but no one had answered his call. When the aide had arrived, the resident was informed the aide was the only one working and so the resident was unable to get out of bed, be washed up or dressed. He laid in his bed, in a gown, all weekend. Resident L indicated he had really wanted to get up on Sunday because he needed to have a BM. He indicated he had tried to hold it, for over an hour but when help had finally arrived, he had an explosion in his brief and on the floor. He indicated he was so embarrassed about the accident. During a interview on 2/17/2025 at 7:21 P.M., Resident C indicated that she had been at the facility for 5 weeks and had only received one shower. She indicated she was never offered a shower by the staff. On 2/13/2025 at 9:00 A.M., a policy was requested for staffing and the DON provided a policy titled, Nursing Staffing Information Policy, undated and indicated the policy was the one currently used in the facility. The policy indicated .The facility will post nursing staffing information daily in a prominent place readily assessable to residents and visitors . There was no specific information in the policy regarding actual staffing requirements or adjustments to be made based on resident acuity levels. 3.1-17(a)(b)

Based on record review, interview and observation, the facility failed to ensure physician ordered medications were available for 6 of 13 residents whose medications were reviewed (Resident 86, L, M, N, O and Q) and failed to ensure medications were administered as ordered for 4 of 9 residents reviewed for quality of care. (Resident M, N, 47, 71) Findings include: 1. During an observation, on 2/14/2025 at 10:30 A.M., Resident 86's resident representative was at the nursing station and asked RN 23 about the resident's Vancomycin (antibiotic). RN 23 informed the resident's representative that the pharmacy had not delivered the antibiotic yet. During an observation, on 2/14/2025 at 11:10 A.M., RN 23 notified the nursing supervisor that the oral Vancomycin was not available for Resident 86. During an interview, on 2/14/2025 at 1:54 P.M., RN 23 indicated the antibiotic (Vancomycin) for Resident 86 was ordered on the morning of 2/12/2025 and the pharmacy had not delivered it. RN 23 indicated she had called the pharmacy and the pharmacy indicated the antibiotic would be delivered on 2/14/2025. During an interview, on 2/14/2025 at 2:10 P.M., RN 19 indicated the facility had an emergency drug kit (EDK) to pull medications, if needed, but oral Vancomycin was not included in the kit. The clinical record of Resident 86 was reviewed on 2/18/2025 at 11:51 A.M. The resident's diagnoses included, but were no limited to: cerebral infarction, metabolic encephalopathy, diabetes mellitus, gastrointestinal hemorrhage, osteomyelitis, peripheral vascular disease, paroxysmal atrial fibrillation, morbid obesity, hypertension, heart failure, chronic kidney disease, neuromuscular dysfunction of bladder and osteomyelitis. A 5-Day Minimum Data Set (MDS) assessment, dated 2/7/2025, indicated the resident was moderately cognitively impaired and was always incontinent of his bowels. Current Physician Orders included but were not limited to: -Clostridium difficile (C-diff) collection (stool sample) on 2/7/2025 -Vancomycin Hydrochloride oral capsule 125 milligrams (mg) (antibiotic) give one capsule by mouth every six hours for C-diff colitis for ten days, ordered on 2/12/2025. A Lab Report, dated 2/12/2025, indicated a positive C-difficile Toxin [NAME] for Resident 86. Review of the lab report completed from the stool sample ordered on 2/7/2025 indicated the resident tested positive for a bowel infection, Clostridium difficile (C-Diff) The test results were dated 2/12/2025. Nursing Progress notes completed on the following dates and times indicated the resident's Vancomycin (antibiotic) had not yet been delivered from the pharmacy and could not be administered: -2/13/2025 at 5:37 A.M., -2/13/2025 at 12:11 P.M, -2/13/2025 at 5:04 P.M., -2/14/2025 at 1:59 P.M., and -2/14/2025 at 6:03 P.M. There was no notation the physician had been notified of the delay in treatment, nor was there any documentation the pharmacy had been contacted regarding the need for the medication The February 2025 Medication Administration Record (MAR) indicated Resident 86 did not receive his first dose of the Vancomycin (antibiotic) until 2/14/2025 at 11:00 P.M. An Advanced Practice Provider Note, dated 2/13/2025, indicated the Nurse Practitioner had noted the resident was positive for C-Diff (bowel infection) and she had indicated the treatment had begun on 2/12/2025. During an interview, on 2/19/2025 at 11:39 A.M., RN 3 indicated if an antibiotic was unavailable, then she would notify the pharmacy. If the pharmacy was unable to deliver the ordered medication, she would have tried to get the medication out of the EDK. If the EDK did not have the medication the resident needed, RN 3 indicated she would have notified the nursing supervisor of the missing dose of antibiotic. During an interview, on 2/19/2025 at 1:59 P.M., LPN 24 indicated if there was a missing medication for a resident, she would have called the nursing supervisor to see if it was in the EDK. LPN 24 indicated if the medication was not in the Emergency Drug Kit, then she would have contacted the pharmacy. Lastly, LPN 24 indicated she would have notified the supervisor and updated the provider regarding the missing medication. 48145 2. Resident M's record review was completed on 2/18/2025 at 11:13 A.M. Diagnoses included, but were not limited to: paraplegia, sacral osteomyelitis, neuromuscular dysfunction of bladder and epilepsy. A current Physician's order dated, 2/11/2025, indicated Resident M was to receive one gram ertapeneum (antibiotic) intravenously one time a day for sacral osteomyelitis from 2/11/2025 to 2/17/2025. A February 2025 Medication Administration Record (MAR) indicated Resident M had not received her dose of ertapeneum on 2/13 and 2/16/2025. Resident M's record lacked the documentation she had refused her medication or a Physician had been notified that she had missed two doses of her medication. During an interview on 2/18/2025 at 2:15 P.M., the Director of Nursing indicated she was not sure why Resident M had missed two doses of ertapeneum, but Resident M should have received a dose of ertapeneum on 2/13 and 2/16/2025. 3. Resident L's record review was completed on 2/18/2025 at 1:05 P.M. Diagnoses included but were not limited to: spinal stenosis, chronic obstructive pulmonary disease, heart failure and influenza type A. A current Physician's order dated, 2/11/2025, indicated Resident L was to receive 75 milligrams of Tamiflu (antiviral) twice a day for 5 days due to the Influenza type A (flu) infection. A February 2025 MAR indicated Resident L had not received either dose of the Tamiflu medication on 2/12/2025. Resident L's record lacked the documentation he had refused his medication or a Physician had been notified that he had missed two doses of his medication. 4. Resident N's record review was completed on 2/19/2025 at 9:05 A.M. Diagnoses included, but were not limited to: neurogenic bowel, osteomyelitis of vertebra, urinary tract infection. A current Physician's order dated, 2/10/2025, indicated Resident N was to receive 500 mg capsule of cephalexin (antibiotic) by mouth every eight hours for seven days for a urinary tract infection. A February 2025 MAR indicated Resident N had not received his 1:00 P.M. dose of cephalexin on 2/10, 2/11 and 2/13/2025. Nursing Progress notes, on 2/10 and 2/11 at 1:00 P.M. indicated the medication was not available to administer. Resident N's record lacked the documentation a Physician had been notified that he had missed two doses of his cephalexin. 5. Resident O's record review was completed on 2/19/2025 at 10:15 A.M. Diagnoses included, but were not limited to: osteomyelitis, type two diabetes mellitus, hyperlipidemia and hypertension. The current Physician's orders included the following medication orders: -Admelog SoloStar Solution (Insulin pen) 1 unit at bedtime ordered on 2/4/2025 - daptomycin (antibiotic) one time a day IV ordered on 2/5/2024 - ergocalciferol (Vitamin D 2) one time a day orally ordered on 2/5/2024 - metformin (oral antidiabetic) one time a day orally ordered on 2/5/2024 The February 2025 Medication Administration Record (MAR) indicated Resident O had not received a scheduled dose of Admelog SoloStar Solution on 2/4, 2/5 or 2/6/2025. Resident O had not received 500 mg of daptomycin intravenously on 2/5 or 2/13/2025. He also had not received 50000 units of ergocalciferol on 2/5, 2/7, 2/8 or 2/9/2025 or his scheduled metformin on 2/4 or 2/18/2025. Resident O's record lacked the documentation he had refused his medications, or a Physician had been notified that he had missed a dose of his medications or the reason for the missed meditation. During an interview on 2/19/2024 at 9:50 A.M., the Nursing Supervisor indicated the facility had been having difficulties obtaining prescriptions since the facility had switched pharmacies. She indicated if a medication was not available, the nurse was supposed to let the Nursing Supervisor know and the medication would have been obtained from the Emergency Drug Kit, if it was available. If the medication was not available, an order was sent to the pharmacy. The order would be sent as stat if the medication was anything other than a vitamin. The facility had a back-up pharmacy, but the Nursing Supervisor was unaware what the back up pharmacy's name was or how to contact the back-up pharmacy. She indicated if the main pharmacy was not able to fill the prescription timely, the main pharmacy contacted the back-up pharmacy. She indicated the back-up pharmacy was located in Indianapolis and it took several hours for prescriptions to be delivered even if they were ordered stat. In addition, she indicated if the resident misseds a dose of any medication, the provider should have been notified. During an interview on 2/19/2024 at 2:00 P.M., the Director of Nursing indicated the facility had had problems with their pharmacy supplying medications timely. She indicated residents should have received their medications as ordered and the provider should have been notified of any missed medications. 51598 6. A record review for Resident Q was completed on 2/18/2025 at 9:00 A.M. Diagnosis included but were not limited to osteomyelitis right foot/ankle, diabetes mellitus type 2, anxiety, depression, hypertension, and chronic kidney disease stage 3. Physician orders included but were not limited to: ceftazidime 1.25 grams (gm) intravenously (IV) every 8 hours for osteomyelitis and tamiflu 75mg two times daily for 7 days for influenza. A current care plan indicated Resident Q had Influenza A and interventions included but were not limited to administer oxygen as ordered, droplet isolation precautions, and check oxygen saturation as needed. Resident Q's Medication Administration Record (MAR) for February 2025 indicated Tamiflu doses on 2/14/2025 were not administered and the order was not adjusted to account for the missed doses. In addition, it also indicated the ceftazidime 2.5mg, ordered on 2/7/2025 at 9:00 P.M., was not administerd 2/7/2025 through 2/10/2025. A nursing medication note regarding the Tamiflu medication dated 2/14/2025 at 12:52 P.M. indicated the facility was still waiting for medication to arrive from pharmacy. A nursing medication note for ceftazidime dated 2/08/2025 at 9:12 A.M., indicated the nurse had called pharmacy regarding the antibiotic and the pharmacist the medication would be delivered later the same night. However, nursing medication notes on 2/9/2025 at 5:22 A.M., 2/10/2025 at 6:11 A.M., and 2/11/2025 at 8;23 A.M., all indicated the medication had not yet been delivered from pharmacy. During an interview, on 2/19/2025 at 11:00 A.M., RN 4 indicated the facility could request the medication stat and the pharmacy would decide if they would send the medication from backup pharmacy. She indicated the back up pharmacy was located in Indianapolis and it took several hours to obtain the medication from the back up pharmacy. She indicated the facility had not had pharmacy problems before the facility had switched over to the new pharmacy, the change has not been ideal and the new pharmacy was not on top of delivering ordered medications timely. On 2/19/2025 at 1:50 P.M., the Director of Nursing indicated the pharmacy and backup pharmacy were both located in Indianapolis and orders took several hours to receive. She was not aware how to use the backup pharmacy but had been in contact with the main pharmacy and had been trying to switch the backup pharmacy to a local pharmacy. 7. A record review for Resident 47 was conducted on 2/17/2025 at 8:24 A.M. Diagnoses included but were not limited to: cerebral infarction, Alzheimer's, diabetes mellitis type 2, depression, and anxiety. Physician orders included but were not limited to Insulin lispro (a fast acting diabetic medication) 100units/milliliter(ml)before meals, if 0 - 60 milligrams per deciliter (mg/dL) Administer nasal Baqsimi (a medication to increase blood sugar levels) and recheck BS in 15 mins; 61 - 149 = 0; 150- 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 400 = 10; 401+ = 10 notify MD/NP, Baqsimi nasal powder 3 milligrams/dose for hypoglycemia (low blood sugar). A current care plan indicated Resident 47 had Diabetes. The interventions included but were not limited to diabetes medications as ordered, check blood sugar at 4:00 A.M. and offer snack if below 150, and consult doctor regarding any changes in diabetic medications. The Medication Administration Record for December 2024 indicated Resident 47 had the following blood sugar readings: 12/6/2024 of 60 mg/dL, there was no documentation baqsimi was administered. The Medication Administration Record for January 2025 indicated Resident 47 had the following blood sugar readings: 1/22/2025 of 60 mg/dL and 1/12/2025 of 57 mg/dL, there was no documentation baqsimi was administered for either of these readings. The Medication Administration Record for February 2025 indicated Resident 47 had the following blood sugar readings: 2/15/2025 of 60 mg/dL, there was no documentation baqsimi was administered. During an interview with LPN 19 on 2/18/2025 at 11:44 A.M., he indicated with a blood sugar reading equal to 60 mg/dL or less the facility was to administer baqsimi. During an interview with the DON on 2/18/2025 at 12:00 P.M., she indicated with a blood sugar reading equal to or less than 60 mg/dL, staff should have administered baqsimi. 8. A record review for Resident 71 was conducted on 2/13/2025 at 3:36 P.M. Diagnoses included but were not limited to: cancer head/face/neck, diabetes mellitus, depression, dysphagia, and heart disease. Physician Orders included, but were not limited to: sotalol (medication for hypertension) 20 milligrams (mg) twice a day (BID) hold for systolic blood pressure (SBP) <110 and midodrine (medication for hypotension) 10 mg as needed (PRN) for SBP<110. Resident 71's current care plan indicated he had hypertension. Interventions, included but were not limited to: Check blood pressure per order, give medications as ordered, and observe for side effects such as orthostatic hypotension and increased heart rate (Tachycardia) and effectiveness. The medication administration record (MAR) for January 2025 indicated Resident 71's systolic blood pressure was below 110 on 48 occasions. The same MAR indicated the residents Sotolol was held as ordered, but did not indicate the resident received Midodrine as ordered. The MAR for February 2025 indicated Resident 71's systolic blood pressure was below 110 on 16 occasions. The same MAR indicated the residents Sotolol was held as ordered, but did not indicate the resident received Midodrine as ordered. During an interview with LPN19 on 2/18/2025 at 11:44 A.M., he indicated if Resident 71 had a blood pressure reading under 110, the facility nurses should have administered midodrine. During an interview with the DON on 2/18/2015, at 12:00 P.M., she indicated staff should have administered midodrine when the resident's systolic blood pressure reading was below 110. A policy for pharmacy services was requested but one was not received before the exit of the survey. This Federal tag relates to Complaint IN00451914, IN00451952, IN00452177, IN00451978, and IN00451284. 3.1-25(a) 3.1-25(b)

Based on observation, interview, and record review the facility failed to follow Physician orders related to tubi grips, and to failed to assess and treat an area of impaired skin for 2 of 12 residents reviewed for quality of care. (Residents J & 67) 1. During an interview on 2/11/2025 at 10:41 A.M., Resident J indicated she wore Tubi-grips to help with the swelling in her lower legs and feet. She indicated she could not put the Tubi-grips on by herself and staff had not regularly placed the Tubi-grips on her legs. During observations of Resident J, the resident was not wearing Tubi-grips (compression socks) on either leg and her right lower leg and foot were swollen: -2/11/2025 10:41 A.M. -2/12/2025 at 9:05 A.M. -2/13/2025 at 3:37 P.M. -2/14/2025 at 12:05 P.M. -2/17/2025 09:06 A.M. -2/17/25 2:01 P.M. Resident J's record review was completed on 2/17/2025 at 9:34 A.M. Diagnoses included, but were not limited to: post polio syndrome, hemiplegia and hemiparesis, Parkinson's disease and anxiety. A Quarterly Minimum Data Set (MDS) assessment, dated 1/24/2025, indicated Resident J had intact cognition, had not rejected care, had impairment of one side, was dependent on staff for dressing her lower body and putting on and taking off her socks and shoes. A current Physician's order dated, 10/16/2024, indicated Resident J was to wear Tubi-grips on both of her legs and feet at all times. Resident J's record lacked the documentation she had refused wearing the Tubi-grips. During an interview on 2/18/2025 at 2:10 P.M., the Director of Nursing indicated Resident J should have been wearing Tubi-grips at all times. On 2/18/2025 at 2:10 P.M., a policy for following Physician's orders was requested, but one was not received before the exit of the survey. 44111 2. During an observation on 2/11/2025 at 10:52 A.M. and on 2/23/2025 at 11:30 A.M., Resident 67 had two dressings noted on his right arm that were undated. During an observation on 2/17/2025 at 3:13 P.M., Resident 67 had just received a shower from the Hospice CNA's and two undated bandages remained on the resident's right arm. During an interview with the Hospice CNA's, on 2/17/2025, they indicated they were not allowed to remove dressings prior to showering. During an observation and interview on 2/17/2025 at 3:15 P.M., RN 9 indicated she did not know what was under the dressings. RN 9 proceeded to pulled the dressings back and there was bloody drainage and scabs attached to the dressing, a crescent shaped skin tear and discolored skin under the bandage. RN 9 indicated the dressing should have been dated and initialed. RN 9 indicated there was no documentation of Resident 67's impaired skin integrity to the right arm. She indicated when a new area was found, nursing staff were to fill out a skin packet, notify the doctor and document the wound care and obtain a treatment. A record review was completed on 2/11/2025 at 2:00 P.M. for Resident 67. Diagnoses included but not limited to: osteoarthritis of right hand, localized swelling, mass and lump right upper limb, dementia unspecified with other behavioral disturbance, unspecified psychotic disorder with hallucinations due to known physiological condition and metabolic encephalopathy. A Physician's Order, dated 8/19/2024, indicated a skin assessment was to be completed every Thursday on night shift. Review of weekly skin assessments for Resident 67, completed on 1/30/2023, 2/6/2025 and on 2/13/2025 indicated the resident did not have any new skin issues. A care plan related to skin, dated 7/14/2022, indicated the facility was to complete weekly skin assessments. On 2/18/2025 at 2:02 P.M., the DON provided a policy titled, Non-Pressure Injury/Ulcer Management, undated, and indicted that the policy was the one currently used by the facility. The policy indicated .The nursing facility will ensure systems and processes to assist in the identification, investigation, treatment and care of residents with non-pressure injury related to wounds. Skin wounds affect quality of life for resident's because they may limit activity, may be painful, and may require time-consuming treatments and dressing changes. Specific Procedures/ Guidance: 2. Weekly skin observations will be conducted by a licensed nurse and findings will be documented in the resident's medical record. 3. Observations of new areas of impaired skin integrity will be reported to the physician/practitioner for further evaluation and treatment. Treatment Protocols: 1. Treatment will be ordered by the physician/practitioner. Care Plans: 1. A resident centered care plan will be developed and implemented to address the resident's wound including interventions to promote healing and to minimize worsening or wound or development of additional wounds . 3.1-37(a)

Based on interview, observation and record review, the facility failed to ensure dependent residents received showers or complete bed baths as scheduled for 5 of 8 residents who were reviewed for showers or complete bed baths. (Residents B, M, D, E, and 55) Findings include: 1. During an interview on 2/11/2025 at 9:48 A.M., Resident B indicated she was scheduled to receive three showers a week, but had not received a shower for over two weeks. She indicated there was not enough staff to give her a shower, but she had had a couple of bed baths over the last two weeks. During an interview on 2/12/2025 at 9:55 A.M., Resident B's family member indicated the resident had not had a shower in over two weeks and she had called and left multiple messages for the Administrator, but had not received a call back. During an interview on 2/12/2025 at 10:05 A.M., Resident B's family member indicated the resident was alert and oriented and the resident had been upset about not receiving any showers for over two weeks. Resident B's record review was completed on 2/12/2025 at 11:13 A.M. Diagnoses included, but were not limited to: hemiplegia and hemiparesis affecting left non-dominant side, atrial fibrillation, depression and hypertension. An Annual Minimum Data Set (MDS) assessment dated , 12/13/2024, indicated Resident B had intact cognition, required maximal assistance for showering and her preference indicated it was very important for her to choose between a shower or bed bath. A current Care Plan dated, 1/26/2023, indicated Resident B had a self care deficit and required assistance with bathing. The goal of the Care Plan was for the resident to make her own decisions regarding daily care. An intervention of the Care Plan included, but was not limited to: resident to receive a shower on Monday, Wednesday and Friday. A January 2025 Treatment Administration Record (TAR) indicated Resident B had not received a shower on 1/8, 1/10, 1/13, 1/15, 1/20, 1/24, 1/27, 1/29 or 1/31/2025. A February 2025 TAR indicated Resident B had not received a shower on 2/3, 2/5, 2/7 or 2/10/2025. Resident B's there was no documentation Resident B had refused any showers. During an interview on 2/12/25 at 11:33 A.M., CNA 2 indicated Resident B preferred to take showers, but the lack of staff had resulted in the resident not receiving three showers a week. He indicated the resident had received a few complete bed baths but she should have been showered every Monday, Wednesday and Friday. 2. During an interview on 2/11/2025 at 2:57 P.M., Resident M indicated she did not get two bed baths or showers a week and was lucky if she received one bath or shower a week. Resident M's record review was completed on 2/14/2025 at 11:23 A.M. Diagnoses included but were not limited to: paraplegia, epilepsy, major depressive disorder and neuromuscular dysfunction of bladder. A Quarterly MDS assessment dated , 2/6/2025, indicated Resident M had intact cognition, had not refused care and was dependent on staff for showering or bathing. A current Care Plan initiated, 7/2/2023, indicated Resident M required assistance with bathing. The goal of the Care Plan was for the resident to make her own decision regarding daily care. Interventions included, but were not limited to: resident to be well groomed, odor free, clean and comfortable on all shifts, and showers would be Monday and Thursday on the 6:00 A.M. to 2:00 P.M. shift. A January 2025 TAR indicated Resident M had not received a shower or complete bed bath on the following dates: 1/9, 1/16 and 1/23/2025. Resident M's record there was no documentation she had refused any showers in January. During an interview on 2/18/2025 at 2:05 P.M., the Director of Nursing indicated Resident M should have received either a shower or a complete bed bath twice a week. 49229 3. During an observation, on 2/11/2025 at 10:36 A.M., Resident 55 was seated in her padded Broda (reclining) chair and her hair was visibly greasy, pulled into a ponytail on top of her head. During an interview, on 2/11/2025 at 12:15 P.M., the Director of Nursing (DON) indicated the facility did not document showers on paper; but only documented showers and bathing in the electronic medical record. During an observation, on 2/12/2025 at 9:48 A.M., Resident 55 had sat in her Broda chair with greasy looking hair pulled into a ponytail at the top of her head. The clinical record of Resident 55 was reviewed on 2/17/2025 at 8:46 A.M. The resident's diagnoses included, but were no limited to: Alzheimer's disease, dementia, peripheral vascular disease, depression, anxiety, unspecified convulsions and insomnia. A Quarterly Minimum Data Set (MDS) assessment, dated 1/22/2025, indicated the resident was severely cognitively impaired, was dependent in all areas of self-care including but not limited to: eating, oral and personal hygiene, upper and lower body dressing, toileting, bathing and/or showering, and footwear. A current Care Plan, revised 11/7/2024, indicated Resident 55 required assistance with bathing. Interventions included but were not limited to: showers scheduled for Mondays and Wednesdays. Resident 55's medical record lacked documentation of a bath or a shower from 1/15/2025 through 1/28/2025. During an interview, on 2/17/2025 at 1:30 P.M., CNA 20 indicated all the residents were supposed to be bathed or showered three times per week. During an interview, on 2/17/2025 at 8:33 P.M., CNA 21 indicated residents' hair was to be shampooed when they were given a shower or bed bath. During an interview, on 2/18/2025 at 9:44 A.M., CNA 22 indicated residents were showered or given bed baths according to the resident's preferences. CNA 22 indicated some residents preferred bed baths, some preferred showers. Residents hair was to be shampooed during their bed bath or shower. During an interview, on 2/19/2025 at 10:24 A.M., CNA 22 indicated Resident 55 had never demonstrated any behaviors towards facility staff or others that prevented staff from providing her any Activities of Daily Living (ADL) cares. 44111 4. During a family interview on 2/12/2025 at 9:55 A.M., the family member for Resident D indicated she had not been receiving her showers and after two and half weeks, she had finally received a shower. The family member indicated showers had not been completed routinely at the facility. A record review was completed on 2/13/2025 at 10:00 A.M. for Resident D. Diagnoses included but were not limited to: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and unspecified osteoarthritis. A Quarterly Minimum Data Set (MDS) assessment, dated 1/15/2025 indicated Resident D could not use one upper extremity and was total dependent for all activities of daily living with the exception of set up assistance for eating. A self-care deficit care plan, dated 7/6/2018, indicated Resident D requires assistance with bathing, dressing and hygiene. An intervention, dated 10/6/2022, indicated will shower every Monday, Wednesday and Friday as the resident desires. A review of the Documentation Survey Report for bathing. dated January of 2025, indicated Resident D received a bed bath on 1/20/2025 and 1/27/2025. There was no documentation of any bathing from 1/7/2025 through 1/16/2025. A review of the Documentation of Survey Report for bathing, dated February of 2025 indicated Resident D received one shower on 2/12/2025 and one bed bath 2/15/2025. There was no other documentation of any bathing opportunities in February, from 2/1 through 2/15/2025. During an interview on 2/14/2025 at 10:33 A.M., CNA 6 indicated she had not given Resident D a shower, even though it was her shower day because she was waiting to see if a shower aide was going to come in later in the day. She indicated if the facility did not have a shower aide working, she could not give the scheduled showers/baths because she did not have time to complete them. During an interview on 2/14/2025 at 10:40 A.M., CNA 10 indicated if the facility did not have a shower aide scheduled and working, she did not have the time to complete the scheduled showers. She indicated the facility only had a shower aide scheduled a couple days of the week. During an interview on 2/17/2025 at 9:35 A.M., CNA 6, indicated the previous Friday, the shower aide did not show up to work so Resident D did not receive her scheduled shower. CNA 6 confirmed Resident D not had not always received her scheduled showers. 5. During a family interview on 2/11/2025 at 11:23 A.M., the family member indicated they took care of Resident E's fingernails and facial hair, but the resident had not gotten her scheduled showers. The family member indicated staff had told them they would try to get to it, but they did not get around to giving the shower or bath. The family member indicated Resident E had developed a yeast infection under her abdominal folds/groin area that the family member felt was due to not receiving proper cleaning and showering. The family member indicated the resident had not had this infection when she had received her scheduled showers. During an observation on 2/18/2025 at 10:00 A.M., and 2/19/2025 at 9:01 A.M., Resident E's hair looked greasy. During a family interview on 2/19/2025 at 1:43 P.M., the family member for Resident E indicated her hair smelled and looked dirty. The facility had informed the family member that Resident E's shower schedule had been changed to every Sunday and Wednesday, but the family member indicated it did not look like the resident had received a shower on 2/16/2025. A record review was completed for Resident E on 2/14/2025 at 10:00 A.M. Diagnoses included but not limited to: Alzheimer's Disease, dementia unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbances and anxiety. A Quarterly Minimum Data Set (MDS) assessment, dated 11/7/2024, indicated Resident E was severely cognitively impaired and required extensive assistance for transfer, bed mobility, and toileting. A self- care deficit care plan, initiated 9/11/2024, indicated Resident E required assistance with bathing, dressing and hygiene. An intervention dated 9/11/2024 indicated she would be bathed at times and days of her choosing on Sunday and Wednesday. A Progress note, dated 1/28/2025 from the Nurse Practioner (NP) indicated the following: the chief complaint was redness to the groin. She was seen for the redness to the groin skin folds. The NP ordered Nystatin powder twice a day for 14 days, washed daily with soap and water, dry and apply the powder. A review of the electronic charting system for documenting bathing for Resident E indicated there was no bathing or showers documented from 1/1/2025 through 1/14/2025. A review of the electronic charting system for documenting bathing for Resident E dated February of 2025, indicated there was no documentation for bathing from 2/1/2025 through 2/11/2025. During an interview on 2/19/2025 at 9:05 A.M., CNA 8 indicated Resident E's groin was still red this and she had washed the resident's groin area and applied a cream. On 2/18/2025 at 2:02 P.M., the DON provided a policy titled, Activities of Daily Living, undated, and indicated the policy was the one currently used by the facility. The policy indicated, . Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Each resident shall be given proper daily personal attention and care including skin, nail, hair, and oral hygiene, in addition to any specific care ordered by the attending physician. 4. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); i. Each resident shall receive tub or shower baths as often as needed, but not less than twice weekly or as required by state law. Residents preference and/or whose medical conditions prohibit tub or shower baths shall have a sponge bath daily . This Federal tag relates to Complaint IN00451914, IN00451952, IN00452177, and IN00451978. 3.1-38(a)(3)

Based on observation, interview, and record review, the facility failed to ensure a resident's allegation of verbal abuse was reported timely after an allegation was made to the Indiana Department of Health for 1 of 1 resident reviewed for abuse. (Resident 51) Finding included: During an observation and interview, on 2/12/2025 at 11:17 A.M., Resident 51 indicated there was an agency nurse on the evening shift that had yelled at her during her shifts at the facility. The resident was unable to recall the staff member's name. Resident 51 indicated the last incident where this staff yelled at her had occurred approximately two to three weeks ago. Resident 51 indicated this last incident occurred when she was lying in bed, felt unwell and did not want to attend meal service in the dining room. The resident indicated the nurse raised her voice and demanded the resident get out of her bed and go to the dining room for her meal. Resident 51 was tearful during the re-telling of this occurrence. Resident 51 said, I feel like I'm going to die here. Resident 51 indicated she reported the incident to the Director of Nursing (DON) the day after the incident occurred. The resident indicated she was told by the DON that the nurse was talking loudly to her because she (the nurse) was from a different culture. During an interview, on 2/12/2025 at 11:55 A.M., the DON indicated she recalled an incident several weeks ago reported to her by Resident 51 but was unable to recall the specific date. She indicated it involved a staff nurse not an agency nurse. The DON indicated the nurse involved was from another culture and was the incident had been presented by the resident as a cultural difference. The DON indicated she did not report it to the Indiana Department of Health (IDOH) because she did not believe it was an allegation of abuse. During an interview, on 2/13/2025 at 10:10 A.M., after the discussion with the surveyor on 2/12/2025, the DON indicated she had begun investigating the Resident 51s claims of abuse and had reported the allegation to the IDOH. The clinical record of Resident 51 was reviewed on 2/14/2025 at 10:11 A.M. The resident's diagnoses included, but were no limited to: Parkinson's without dyskinesia, unilateral primary osteoarthritis of the left hip, depression, anxiety, post-traumatic stress disorder, personal history of transient ischemic attack and cerebral vascular accident and hypertension. A Quarterly Minimum Data Set (MDS) assessment, dated 1/10/2025, indicated the resident was cognitively intact. A current Care Plan, revised on 2/4/2025, indicated Resident 51 had diagnoses of post-traumatic stress disorder and depression. Interventions included, but were not limited to: increase the resident's control by giving her all the choices she can make and let the resident know staff is empathetic. The investigation completed by the Director of Nursing indicated the nurse indicated she had not raised her voice towards Resident 51 at the time of the incident. The investigation indicated Resident 51 felt the nurse yelled at her but after speaking to the DON, Resident 51 indicated she no longer felt the nurse had yelled at her An Incident Report was sent to the IDOH by the Director of Nursing on 2/12/2025. However, the allegation had been reported to the DON a few weeks prior to 2/12/2025. On 2/14/2025 at 2:05 P.M., the DON provided a policy titled,Abuse, dated 10/20/2022 and indicated the policy was the one currently used by the facility. The policy indicated .designated staff will immediately review and investigate all allegations .of abuse .each covered individual/mandated reporter shall report .not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury .the organization will report all alleged violations involving .abuse . 3.1-28(c)

Based on observation, interview and record review, the facility failed to ensure a resident from free from a physical restraint for 1 of 1 residents reviewed for restraints. (Resident 67) Finding includes: During an observation on 2/11/2025 at 10:52 A.M., Resident 67 was seated in the dining room in a wheelchair being fed his breakfast by the CNA 11. There was a fastened seat belt noted to be across the resident's lap. During an observation and interview on 2/11/2025 at 11:00 A.M., Resident 67 was had finished his breakfast and w the resident was asked to release his button seat belt. Resident 67 was unable to release the button clasp. During an observation on 2/12/2025 at 11:29 A.M., Resident 67 was seated in his wheelchair in the hallway with the seat belt fastened. During an observation on 2/17/2025 at 3:12 P.M., Resident 67 was seated in his wheelchair with the seat belt fastened. A record review was completed on 2/11/2025 at 2:00 P.M. for Resident 67. Diagnoses included but not limited to: osteoarthritis of right hand, localized swelling, mass and lump right upper limb, dementia unspecified with other behavioral disturbance, unspecified psychotic disorder with hallucinations due to known physiological condition and metabolic encephalopathy. A Significant Change Minimum Data Set (MDS) assessment, dated 2/3/2025, indicated Resident 67 was severely cognitively impaired, required extensive assistance for eating, bed mobility and toilet use and required was totally dependent for transfers. A Physician's Order, dated 1/16/2023, indicated every shift the staff were to command the resident to remove the seat belt and check for placement for positioning and safety. The therapy department was to be notified of failed attempts (of resident removing the seatbelt). A fall care plan, initiated on 1/17/2023 and reviewed as current, included an intervention for staff to ensure the resident was able to independently remove the seat belt upon command. Review of a Treatment Administration Record (TAR), from 1/1/2025-1/31/2025, indicated Resident 67 was unable to release the seat belt on 1/28/2025 on evening shift and 1/31/2025 on day shift. Review of a TAR, from 2/1/2025-2/28/2025, indicated Resident 67 was unable to release the seat belt on 2/5/2025 on the day shift. During an interview on 2/17/2025 at 3:10 P.M., CNA 5 indicated Resident 67 had worn a seat belt and was not able to take it off. He indicated that the resident could not take it off because his fingers were unable to do it. CNA 5 did not know why the resident had the belt because he had not fallen. During an interview on 2/18/2025 at 8:53 A.M., CNA 4 indicated Resident 67 had the belt to prevent him from sliding out of the wheelchair. The CNA indicated Resident 67 was not always able to undo the belt or able to use his hands to feed himself and needed assistance for both activities. During an interview on 2/28/2025 at 9:28 A.M., CNA 6 indicated Resident 67 did not stand up on his own but scooted his wheelchair forward, and could not unbuckle due to his dementia. During an interview on 2/28/2025 at 9:41 A.M., RN 3 indicated the seat belt was used so Resident 67 did not get up and fall down. She indicated Resident 67 could not remove the belt when asked to unfasten the restraint. During an observation on 2/28/2025 at 9:43 A.M., Resident 67 was awake, alert and seated in his wheelchair in his room. RN 3 asked Resident 67 several times to remove his seat belt but Resident 67 made no attempt. Both of his hands remained on his lap in a fisted position. He was asked to open his left hand and he picked up his hand and opened it. Then he was asked to open his right hand, but although he raised it, he was unable to open it. The resident's right hand was red and swollen. During an interview on 2/28/2025 at 9:57 A.M., the DON indicated the medical condition that the seat belt was used for was positioning and safety. The DON indicated it was for fall prevention and the interventions attempted prior to the seat belt were: reacher, offer toilet, incontinence check and changes every 2 hours, assisting him to get up at midnight as he preferred, making sure his clothing fit and did not drag on the floor, maintaining room and pathways to ensure they were free of clutter, ensuring the resident wore proper foot wear, ensuring the call light was within reach and installing antiroll back brakes for his wheelchair. The DON indicated the seat belt was not a restraint because Resident 67 could remove it. The DON indicated the facility did not do an on-going evaluation quarterly of the seat belt because it was not a restraint. In addition, the DON indicated the nurses had an order for the resident to be checked every shift to see if he could release the seat belt by himself. She indicated the resident never attempted to release the seatbelt, except when asked to release it by the nursing staff. During an interview on 2/18/2025 at 10:12 A.M., the Director of Therapy indicated the positional device of the seat belt was necessary to prevent the resident from rising unassisted due to Resident 67's impaired recall. The Director of Thereapy indicated the seat belt was not to be used if the resident was not able to remove the belt upon command. She indicated nursing staff assessed the resident's ability to remove the seat belt every shift the resident was awake. Finally she indicated the therapy department re-evaluated the use of restraints and positioning devices when there was a change in the resident's condition, decline in mental status and function and if the resident was unable to release the seat belt for the nursing staff. On 3/18/2025 at 8:54 A.M., the DON provided a policy titled, Physical Restraint, undated, and indicated the policy was the one currently used by the facility. The policy indicated .Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptoms(s) and never for discipline or staff convenience, or for the prevention of falls. When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented. Specific Procedures/Guidance 1. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition and this restricts his/her typical ability to change position or place, that device is considered a restraint. 3. Practices that inappropriately utilize equipment to prevent resident mobility are considered a restraints and are not permitted, including: c. Placing a resident in a chair that prevents the resident from rising 13. Restrained individuals shall be reviewed regularly (at least quarterly) to determine whether they are candidates for restraint reeducation, less restrictive methods of restraints, or total restraint elimination . 3.1-3(w)

Based on observation, interview and record review, the facility failed to ensure a resident was free from verbal abuse for 1 of 1 residents reviewed. (Resident 51) Finding includes: During an observation and interview, on 2/12/2025 at 11:17 A.M., Resident 51 indicated there was an agency nurse on the evening shift that had yelled at her during her shifts at the facility. The resident was unable to recall the staff member's name. Resident 51 indicated the last incident where this staff yelled at her happened approximately two to three weeks ago. Resident 51 indicated the last incident had occurred when she was lying in bed, felt unwell and did not want to attend meal service in the dining room. The resident indicated the nurse raised her voice and demanded the resident get out of her bed and go to the dining room for her meal. Resident 51 was tearful during the re-telling of this occurrence. Resident 51 said, I feel like I'm going to die here. Resident 51 indicated she had reported the incident to the Director of Nursing (DON) the day after the incident had occurred. The resident indicated she was told by the DON the nurse was talking loudly to the resident because she was from a different culture. During an interview, on 2/12/2025 at 11:55 A.M., the DON indicated she recalled an incident several weeks ago reported to her by Resident 51 but was unable to recall the specific date. She indicated it involved a staff nurse not an agency nurse. The DON indicated the resident had presented the interaction as a cultural difference between herself and the nurse. The DON indicated the resident had reported to her the nurse had talked loudly to her. The Director of Nursing indicated she did not report it to the Indiana Department of Health (IDOH) because she did not believe it was abuse. During an interview, on 2/13/2025 at 10:10 A.M., the DON indicated after discussing the allegation further with the surveyor, on 2/12/2025, she had begun investigating the resident's claims of abuse and had reported it to the IDOH. The clinical record of Resident 51 was reviewed on 2/14/2025 at 10:11 A.M. The resident's diagnoses included, but were no limited to: Parkinson's without dyskinesia, unilateral primary osteoarthritis of the left hip, depression, anxiety, post-traumatic stress disorder, personal history of transient ischemic attack and cerebral vascular accident and hypertension. A Quarterly Minimum Data Set (MDS) assessment, dated 1/10/2025, indicated the resident was cognitively intact, was independent with eating and personal hygiene, required partial assistance with oral hygiene, toileting, bathing and/or showering, upper and lower body dressing and footwear. A current Care Plan, revised on 2/4/2025, indicated Resident 51 had diagnoses of post-traumatic stress disorder and depression. Interventions included,, but were not limited to: increase the resident's control by giving her all the choices she can make and let the resident know staff is empathetic. The investigation completed by the Director of Nursing indicated the nurse indicated she had not raised her voice towards Resident 51 at the time of the incident. The investigation indicated Resident 51 initially felt the nurse yelled at her but after speaking to the DON, Resident 51 indicated she no longer felt the nurse had yelled at her. On 2/14/2025 at 2:05 P.M., the DON provided a policy titled,Abuse, dated 10/20/2022 and indicated the policy was the one currently used by the facility. The policy indicated .abuse is the willful infliction of .intimidation .includes verbal abuse .mental abuse .willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .

Based on observations, record review and interviews, the facility failed to ensure, two of three residents, reviewed for falls were provided safe transfer assistance. This deficient practice resulted in significant injuries for both residents which required transfers to acute care centers for treatment. (Residents E and G) Findings include: 1. The clinical record for Resident E was reviewed, on 9/21/2023 at 11:49 A.M. Resident E was admitted to the facility, on 10/16/2022, with diagnosis including, but not limited to: paroxysmal atrial fibrillation, type 2 diabetes mellitus, asthma, sleep apnea, hypertensive heart and chronic kidney disease, depression, dizziness and giddiness, insomnia, hemiparesis dominant side following cerebral vascular accident and anxiety disorder. The most recent Quarterly Minimum Data Set (MDS) assessment, completed on 9/11/2023 indicated the resident was alert and oriented and required the extensive assist of two staff for bed mobility, transfers and toilet use. The resident was non ambulatory and required one person extensive assistance for wheelchair mobility. The quarterly MDS assessment, completed on 3/27/2023, indicated the resident was alert and oriented and required the extensive assist of two staff for transfers and toilet use. The resident was non ambulatory and required one person extensive assistance for bed mobility, dressing and wheelchair locomotion. A Fall risk assessment, completed on 6/16/2023, indicated she was at risk for falls. The current care plan related to activities of daily living needs included an intervention to utilize two staff for transfer assistance. The denotation of two staff was initiated, on 12/10/2021 and continued with each review. A Nursing Progress Note, dated 4/30/2023 at 7:51 P.M., indicated the resident fell during a transfer from her wheelchair into the recliner. The note indicated the resident lost her balance and the CNA was unable to correct. The resident fell on her left side and suffered a laceration to her forehead above the left eye. The resident was sent to the acute care emergency room for an evaluation. The emergency room Report, dated 4/30/2023, indicated the resident was diagnosed with a concussion, a facial laceration, facial swelling and sprain of the left elbow and left shoulder. The facility investigation #352, dated 5/1/23, indicated the resident's injuries consisted of a 2.0 cm (centimeter) by .4 cm laceration above the left eye and a missing tooth. Subsequent nursing progress notes indicated the resident continued to have swelling and a hematoma formation above the left eye. The Director of Nurses provided a copy of the CNA assignment work sheets, which indicated the resident required the extensive physical assistance of two persons for transfer status. The CNA involved in the accident was re-educated regarding following the CNA assignment sheets for transfer needs. During an interview with CNA 3, on 9/22/2023 at 11:00 A.M., she indicated she checks the CNA assignment sheets to know how to transfer residents on the unit. She indicated the facility does a good job of keeping the form updated 2. The clinical record for Resident G was reviewed on 9/21/2023 at 2:19 P.M. Resident G was admitted to the facility on [DATE], with diagnoses including, but not limited to: hemiparesis and hemiplegia s/p CVA, chronic obstructive pulmonary disease, heart failure and atrial fibrillation. The most recent Quarterly MDS assessment, completed on 6/14/2023, indicated the resident was alert and oriented, and required the extensive assistance of one staff for bed mobility, transfers and toileting needs. A Fall Risk Assessment, completed on 6/20/2023, indicated the resident was a high risk for falls. The current care plan indicated she required the extensive assistance of one staff member for transfers, however, a nursing progress note, dated 8/30/2023, indicated the resident had a new transfer status of two person assistance. A Nursing Progress Note, dated 9/5/2023 at 3:13 A.M., indicated at the beginning of the shift, the resident had reported to the nurse she had fallen during a transfer in the bathroom and landed on her knees. The nurse noted a new bruise to her left knee. The resident complained of pain to the knee and the nurse administered pain medication and notified the physician of the issue. A Nursing Progress Note, dated 9/5/2023 at 6:08 A.M., indicated there was swelling noted to the left knee and the resident was in so much pain when the leg is touched or moved. An order was received for an x-ray of the left knee. The X-ray result indicated the resident had incurred a distal femur fracture. The resident was discharged to an acute care facility for treatment . A Hospital Progress Note, dated 9/8/23, indicated the resident was brought into a local hospital, on 9/5/23, with complaints of left leg pain, following a fall while transferring yesterday (9/4/23). An x-ray confirmed a left femur fracture. The patient was admitted for management of the fracture, with an orthopedic consult and evaluation. It was determined the resident had additional comorbidities and had not ambulated for the last 8 years therefore the family wished to proceed with conservative management with immobilization Facility investigation #356, dated 9/8/23, regarding the fracture for Resident G, indicated nursing administration had identified the CNA who had transferred the resident on the evening of 9/4/2023. During an interview with the CNA, he reported he had transferred the resident by himself. The staff member indicated the resident had not fallen but the transfer was very difficult. The staff member admitted to not checking the assignment sheet and was not aware of the updated need for two staff for transfers. The employee was counseled and re-educated regarding the facility policies and procedures On 9/22/23 at 10:02 A.M., the Director of Nursing (DON) provided a policy titled, Fall Management Program, dated 5/10/23, and indicated the policy was the one currently used by the facility. The policy indicated .Each resident will be assessed for the risks of falling using the Fall Risk Assessment and will receive care and services in accordance with the level of risk to minimize the likelihood of falls. The program will include measures, which determine the individual needs of each resident by assessing the risk for falls and implementation of appropriate interventions to provide necessary supervision and assistive devices to be utilized as necessary This Federal tag relates to complaints IN00409445 and IN00414031. 3.1-45(a)

Based on record review & interview, the facility failed to protect a resident's right to be free from neglect related to lack of timely, appropriate nursing interventions and services in response to a significant change in condition which resulted in the death of a resident for 1 of 3 residents reviewed for abuse/ neglect. (Resident B) The Immediate Jeopardy began on [DATE] at 1:30 A.M., when the facility failed to ensure staff assessed and notified the physician of a resident who was found by a CNA to be exhibiting symptoms of acute distress and failed to initiate cardiopulmonary resuscitation (CPR) timely when found unresponsive.(Resident B) The Administrator and Director of Nursing were notified of the Immediate Jeopardy on [DATE] at 2:45 P.M. The Immediate Jeopardy was removed on [DATE], but the noncompliance remained at the lower scope and severity level of isolated, no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. Finding includes: The investigation of a facility reported death was reviewed on [DATE] at 9:20 A.M. The investigation indicated on [DATE] at 4:30 P.M., CNA 6 reported to the Director of Nursing that she had concerns with LPN 5's lack of care for Resident B on the night of [DATE]. The report indicated the Nursing Administration were able to verify CNA 6 had entered Resident B's room at 1:30 A.M. on [DATE] and had exited quickly. LPN 5 did not enter Resident B's room to assess her until 5:07 A.M. At 6:00 A.M., a CODE BLUE was called, and CPR (Cardiopulmonary resuscitation) was initiated and 911 (emergency services) was called. The investigation indicated the ambulance took the resident and then returned with her deceased body and verified a time of death as 6:56 A.M. on [DATE]. During an interview and review of the facility reported death form,with the Director of Nursing on [DATE] at 10:04 A.M., she corrected the date of CNA notification of the event to [DATE] at 4:30 P.M. The DON indicated as she was speaking with CNA 6 regarding another issue, on [DATE] at 4:30 P.M., she was informed of the aide's concerns with LPN 5. CNA 6 told her when she entered Resident B's room on the night of [DATE], she heard gurgling noises coming from the resident and she immediately notified LPN 5. She indicated LPN 5 did not go assess the resident as she had requested. The DON indicated CNA 6 did not do anything more regarding her concerns. The DON indicated she had watched the facility's video footage and verified CNA 6 had entered Resident B's room at 1:30 A.M. on [DATE] and then quickly exited. LPN 5 did not enter Resident B's room unit 5:07 A.M. The video footage showed LPN 5 going in and out of Resident B's room several times and then at 6:00 A.M. a CODE BLUE was called and other nursing staff and a cart with emergency supplies was brought to Resident B's room. The DON indicated the paramedics arrived soon after the CODE BLUE was called. She was notified of the CODE BLUE on [DATE] at 6:19 A.M. The DON was interviewed regarding follow up interventions to the investigation and indicated after she was notified of the CNA's concern on [DATE] at 4:30 P.M., she and her ADON, watched the video footage. After watching the video footage, the DON notified the Administrator of her concerns. The DON indicated she had attempted to call LPN 5, but she did not answer her phone. She indicated she had an education form ready for CNA 6 but had not given it to the aide because she had not been scheduled to work, since she had spoken with her on [DATE]. The DON indicated on [DATE] at 10:00 P.M., she had the nursing night supervisor intercept LPN 5 at the time clock and escort her to their office. Once in the office, the DON had been called and the DON attempted to interview LPN 5 regarding the event the previous night involving Resident B. LPN 5 became very upset, started verbally rambling and the only concrete statement the DON could understand was She's lying. The DON indicated she ended the interview and directed the night supervisory staff to terminate the employee and escort her from the building. The DON indicated there had not been any further action by the facility in response to the issue. The record for Resident B was reviewed on [DATE] at 9:43 A.M., Resident B had been admitted to the facility on [DATE] with diagnosis included, but not limited to: acute respiratory failure with hypoxia, s/p (status post) heart valve replacement, combined systolic and diastolic congestive heart failure and chronic obstructive pulmonary disease. The physician's orders for Resident B, completed on [DATE], included an order for Full Code status with full interventions. A copy of a POST (Physician Orders for Scope of Treatment) form for Resident B indicated the resident desired to have CPR and full interventions initiated. The form was signed by the physician on [DATE]. A Nursing Progress Note, dated [DATE] at 5:18 P.M., indicated the resident was complaining of having difficulty breathing and a new order for oxygen at 2 liters was obtained. The note further indicated the resident's blood oxygen level was low (85 - 87 percent) so the oxygen was increased to 3 liters which raised the blood oxygen level to 92 to 97%. A Nursing Progress Note, dated [DATE] at 6:00 P.M., indicated the physician was notified of the need for an oxygen order and a chest X-ray due to congestion. A Nursing Progress Note, dated [DATE] at 10:21 P.M, indicated an order for oxygen was received by the physician. A Health Status Note, dated [DATE], at 7:30 A.M., indicated, . Resident noted to be congested. Biox-99%, no cough noted. HOB [head of bed] elevated, LS [lung sounds] with noted rhonchi [abnormal coarse], updraft [medicated respiratory treatment] given as ordered, tolerated. Resident after updraft still noted to be congested. This nurse went to get suction machine in case it is needed. When this nurse arrived back to the unit noted resident was unresponsive. VS [Vital signs-pulse, blood pressure, respiratory rate, temperature and blood oxygen level] taken- absent of VS. Resident is a full code, Code blue called. 911 was also called while code was started along with AED [automated external defibrillator] applied. EMS arrived and worked on resident for about ,d+[DATE] minutes and left with resident via stretcher to take her to Memorial Hospital. Family notified The nursing assessments, completed on [DATE] indicated only a pulse had been obtained on [DATE]. The other vital signs, documented on the assessments, had been obtained on [DATE] and had automatically pulled forward on the assessment form. There were no specific times of nursing actions related to the event in the nursing progress notes or in the assessments completed on [DATE]. The timing of the nursing progress note and assessments documented were after the resident's body had been returned to the facility. The Fire Department/Paramedic Incident Reports, from the two responding fire departments indicated they had been notified on [DATE] at 6:09 A.M., by the nursing home of a female in cardiac arrest. When paramedics arrived, they found the resident lying in bed, unresponsive with facility staff performing CPR and utilizing an ambu bag (device to push air into mouth manually) to breathe for the resident, while the resident was in her bed. The paramedics from one department, placed the resident on the floor and continued life safety measures until the other fire department placed resident on stretcher and placed in an ambulance. The resident's body was warm to touch but her pupils were fixed and dilated. CPR continued for 30 minutes but the resident remained asystole (no heart beat) when CPR was stopped. CPR was stopped at 6:55 A.M. and the resident was returned to her room in the facility. During an interview with CNA 6, on [DATE] at 3:11 P.M., she indicated on [DATE] she had entered Resident B's room and noticed her breathing was making a gurgling sound. She indicated the resident was sitting upright in her bed with oxygen in place. CNA 6 indicated she asked Resident B if she was okay and Resident B nodded her head Yes. CNA 6 indicated she left the room, without giving care and immediately told LPN 5. CNA 6 indicated LPN 5 just looked at her and did not go to assess Resident B. CNA 6 indicated she did not seek assistance from the nurse on a nearby unit, nor did she notify the Night Supervisor. CNA 6 indicated at some point during the night, she walked by Resident B's room and again noticed her breathing continued to emit a gurgling sound, so she again notified LPN 5. At approximately 5:00 A.M., CNA 6 entered Resident B's room and LPN 5 was already in the resident's room and LPN 5 was holding medications for her in her hand. CNA 6 indicated she left the room and completed her work, gave report to the nursing assistant replacing her and left the building around 6:00 A.M. CNA 6 indicated she was aware of how to contact the Director of Nursing and the Night Nursing Supervisor, but she had not attempted to contact them, even though she was concerned. Review of the current policy and procedure, titled, Physician Notification, provided by the Director of Nursing, on [DATE] at 2:16 P.M., indicated: .1. Immediate Notifications: The nurse should contact the practitioner by phone for Immediate Notification items and must document the notification in the residents' chart. The nurse should notify the Supervisor, DON or ADON of the situation and then complete a Physician Notification. 2. Assessment (PN2) in PCC. The PN2 should include updated vital signs, pertinent labs, thorough assessment, and clear request. The Supervisor, DON, or ADON will send the assessment via Tiger Text in the Urgent group to the house practitioner as follow up notification for phone call placed. If the primary physician is an outside physician, the PN2 may be faxed to the physician's office Signs and symptoms warranting Immediate Notification i.1.Sudden onset or worsening a. Shortness of breath The Immediate Jeopardy that began on [DATE] and was removed on [DATE] when the facility completed education regarding addressing change in resident conditions timely and notifying the nursing administration and physician timely of any significant resident condition changes, but the noncompliance remained at the lower scope and severity level of isolated, no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy, because the shift rounding audit and the daily monitoring of physician orders and 24 hour reports to ensure timely physician and administrative notification of acute changes in condition had not been implemented at the time of survey exit. This Federal tag relates to complaint IN00409312. 3XXX,d+[DATE](a)(3)

Based on observation, interview and record review, the facility failed to ensure safety their elopement policy was followed for a resident who was deemed at high risk for elopement and displayed exit seeking behaviors, which resulted in a resident exiting the premesis unattended. (Resident B) The immediate jeopardy began, on 10/24/22 at 7:54 A.M., when Resident B was last observed on the facility's video surveillance system exiting the facility, with the Administrator. The Administrator was observed to return inside the facility, leaving the resident unattended in a facility park area, which allowed the resident to proceed to an unlocked gate and exited the facility park, circling around to the front of the facility and ended up in the facility parking lot, before the resident was assisted back into the facility. The Administrator was notified of the immediate jeopardy on 11/15/22 at 1:04 P.M. Finding includes: A self-report incident, dated 10/24/22, indicated .Wander guard was placed on [name of Resident B] on 10/20/22. [Name of resident] wanted to go out the front door around 7:57 am. She was redirected from the front door and offered the park area to go outside. She was shown the park area. She asked if she could hang out in the park by herself. Went out to check on her about 5 minutes later. [Name of resident] left the walker in the park and exited the east gate door. There were no security chains in place. [Name of resident] was found walking down the front parking lot by the ADON [Assistant Director of Nursing]. She was brought back into the facility asked where she was going. She stated, I'm going home. This writer asked how she was getting there; she stated, by taxi. This writer asked how was she going to pay for the tax, she stated, I was going to go to the bank and get some money . During an interview, on 11/14/22 at 10:37 A.M., the Administrator indicated Resident B was wandering near the front entrance and displaying exit seeking behaviors. The Administrator indicated she had re-directed the resident to a park area, outside of the facility. She left the resident unattended and explained to the resident she would be back, to check on her, in 5 minutes. When the Administrator returned to the park, the resident was no longer in the area, where she had left her. The Administrator indicated she spotted the resident's walker in some tall grass and the security chain, which locked the exit gate, was located on the ground. The Administrator indicated she followed the sidewalk, around building, towards the front of the facility. The resident was observed, by the Administrator, walking across the parking lot. The Administrator observed the ADON, who was walking toward the facility entrance and motioned her to retrieve the resident. The ADON brought the resident back into the building. A hand-written note, dated 10/24/22, indicated the Administrator had spoken to Maintenance Staff Member 2 and the Maintenance Director/Chief Financial Officer and they indicated a new groundskeeper had left the gate unlocked. (This had been verified by a video surveillance system by the CFO) The note indicated .wasn't locked after yard work around fences, completed on 10/21/221, chain link fence was located on the ground On 11/14/22 at 10:50 A.M., a review of the clinical record for Resident B was conducted. The record indicated the resident was admitted on [DATE]. The resident's diagnoses included, but were not limited to: diabetic ketoacidosis, acute encephalopathy, depression and anxiety. A Hospital Transfer Form, dated 10/11/22, indicated the resident was alert and confused. A Nurse Practitioner Progress Note, dated 10/13/22, indicated the resident was confused, disoriented and trying to get out of her room. An Elopement Risk Assessment, dated 10/13/22, indicated the resident had scored a 3. The Assessment indicated .Score of 4 or More indicates Risk and Requires Interventions/Care Plan A Minimum Data Set (MDS) Assessment, dated 10/18/22 indicated the resident had wandering behavior 1-3 days a week and had no wander/elopement alarm. A Nursing Progress Note, dated 10/18/22, indicated the resident was extremely non-compliant with isolation precautions, had required re-direction, reassurance and education multiple times. A Nursing Progress Note, dated 10/20/22 at 2:03 P.M., indicated Resident B remained on Covid isolation precautions and remained non-compliant with following those precaution by .continuing to exit intermittently out of room, and opening door, resident continues to require frequent redirection and reminders that precautions need to be followed .Resting in room at this time with call light within reach, resident does not utilize call light and requires reminders to utilize call light to summon staff to room A Nursing Progress Note, dated 10/20/22 at 5:30 P.M., indicated a wanderguard was placed on the resident's right wrist. A Care Plan, dated 10/21/22, indicated resident was at risk for an elopement related to confusion and wandering the facility. The interventions included but were not limited to: bracelet alarm in place, with placement checks every shift, alarm function checks weekly, and a photo of resident placed at front desk. Distract resident from eloping or wandering by offering pleasant diversions, structured activities, food, conversation, TV, or book. And provide identification band on resident, walker or wheelchair. An Elopement Risk Assessment, dated 10/22/22, indicated the resident was at high risk for an elopement. The assessment indicated Resident B was frequently stating she wanted to go home and was having purposeful exit seeking behaviors. On 11/14/22 at 12:01 P.M., an observation of the facility's video surveillance system was conducted with the Maintenance Director/CFO. The video indicated the resident was observed on 10/24/22 at 7:52 A.M., as she entered the front lobby area. She was using a walker and had a jacket on with a hood. The resident attempted to go out the front entrance/exit door, after leaving her walker behind. A staff member was observed to re-direct the resident while another staff member was observe to punch in a code to disarm the wanderguard alarm. The CFO indicated when the resident walked near the door the wanderguard would alarm. Then staff blocked the door way with a retractable ribbon. Resident was observed on the camera to go up to the ribbon several times, then at 7:54 A.M. resident goes toward a hallway and out of camera observation. At 7:54 A.M. the resident and the Administrator were observed to exit out another door to a park area, on the facility grounds. The Administrator was observed showing the resident a button to press when she was ready to return inside the building. Administrator then goes into the facility and leaves the resident unattended, in the park area The resident was observed to walk away from the door and down a ramp with her walker at 7:55 AM. At 7:56 AM the resident goes out camera as she turns toward the side of the facility. At 8:01 AM the resident is picked up by the video camera, out in the parking lot, walking towards the handicap parking areas and out of camera visualization. At 8:05 AM the camera located at the front lobby area shows the resident walking into the facility with a staff member. The CFO indicated the camera which could possibly visualize where and what the resident did in the parking lot had a blank screen, a possible malfunction. On 11/14/22 at 12:34 P.M., the CFO and surveyor traced the resident's steps. The resident walked down a ramp that had a fence located on both sides of the ramp. The first turn in walkway, the resident was observed to take, went directly to aluminum/steel gate with a chain-link and padlock. The CFO indicated this was the gate that was left unlocked. The gate was swung opened and quickly shut itself closed. The gate had a push button and lever that had to be opened, at the same time, to allow the gate to re-open. The walkway took us to parking lot where the resident had exited the walkway out into the parking lot. This was approximately 1000 feet from the gate to the parking lot. Once the resident was in the parking lot, she was between 100-200 feet from the front door, with a busy street, to the south of the parking lot.\ During an interview, on 11/14/22 at 3:07 A.M., Maintenance Staff Member 2 indicated he was instructed to check the fences to make sure they were secure, the day of the resident's elopement. He indicated he found the east gate closed, however the chain-link and lock were located on the ground, next to the gate. On 11/14/22 at 4:23 P.M., the Administrator indicated the resident was not placed on 1:1 observation and had not made any other attempts to exit the facility. On 11/14/22 at 10:20 A.M., the Administrator provided a policy titled, Elopement and Wandering Residents, undated and indicated it was the policy currently used by the facility. The policy indicated .Policy: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Policy Explanation and Compliance Guidelines: 1. Wandering is random or repetitive locomotion that may be goal-directed (e.g., the person appears to be searching for something such as an exit) or non-goal directed or aimless. 2. Elopement is defined as when a patient or resident who is cognitively, physically, mentally, emotionally, and/or chemically impaired wanders away, runs away, escapes, or otherwise leaves a care-giving facility or environment unsupervised, unnoticed, and/or prior to their scheduled discharge.6. Monitoring and Managing Residents at Risk for Elopement .e. Adequate supervision will be provided to help prevent accidents or elopements The immediate jeopardy was removed and corrected, on 10/25/22, when the facility maintenance/grounds keepers were in-serviced, regarding the locking of an exit gate, and the implementation of audits confirming gates were being observed/checked daily for compliance and all staff were informed of the resident's elopement to ensure her safety until she discharged from the facility on 11/1/22. This Federal tag relates to complaint IN00393010. 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure adequate supervision and assistive devices were provided to prevent [CONDITION(S)], from hot coffee, for 2 of 2 residents, reviewed for accidents. Resident B, who was moderately cognitively impaired and required assistance with eating, experienced a 2nd degree burn from hot coffee on 8/28/21, and interventions were not implemented to attempt to prevent further [CONDITION(S)]. Resident D, who was severely cognitively impaired and required supervision, experienced a 2nd degree burn from hot coffee on 9/18/21. Interventions and supervision were not implemented, and the resident experienced 2nd degree [CONDITION(S)] again, on 11/03/21, to her thighs from the hot coffee. (Residents D and B) The immediate jeopardy began on 8/28/21 when Resident B experienced 2nd degree [CONDITION(S)] from hot coffee. Interventions were not implemented to attempt to prevent additional [CONDITION(S)] from coffee. Resident D then experienced a 2nd degree burn from hot coffee on 9/18/21 and again on 11/03/21, resulting in multiple 2nd degree [CONDITION(S)] to her thighs. The burn on Resident D's left thigh worsened, was painful and required wound treatment in the hospital. The Administrator was notified of the immediate jeopardy on 12/10/21 at 12:08 P.M. The immediate jeopardy was removed on 12/12/21, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. A self-reported incident to IDOH (Indiana Department of Health), dated 9/19/21, indicated Resident D was noted to have a fluid filled blister during her morning care. The blister was located on her right lower thigh. The resident's slacks were inspected, and a coffee stain was found in the location of the blister. The resident was screened for an adaptive cup, and dietary was to follow up with the service company regarding temperatures of the coffee machines on the units. A Quality Assurance & Performance Improvement (QAPI) Toolkit, dated on 9/20/21, indicated .COFFEE TEMPERATURES TOO HOT FOR MANY RESIDENTS. This is posing a safety concern. Coffee [CONDITION(S)] reported on 2 residents Resident D and Resident B. Coffee temperatures were taken and it was discovered the temperatures ranges were 175-185 degrees in 5 of 5 coffee dispensers. The toolkit added, on 9/27/21, .Coffee machines on the units will be turned down to 155 degrees .MDR [main dining room] machine will remain at 185 since coffee goes in pitchers where it cools. Investigation of the temp changes in the pitcher over time for further reference The next communication, dated 10/12/21, via an email indicated the representative of the coffee dispensers was contacted, on 9/23/21 and he suggested to turn down the temperatures on one unit and see how the taste is and he was going on vacation, would order parts and come to the facility on [DATE]. The next communication, via email, on 10/12/21, indicated .Did the coffee temps get turned down .No, he was calling today and was stopping by to do equipment checks and would let me know then There was no indication the facility had developed an improvement plan to monitor the coffee's temperature. On 12/3/21 at 1:31 P.M., a review of the clinical record for Resident D was conducted. The resident's diagnoses included, but were not limited to: dementia, diabetes, [CONDITION(S)], arthritis and non-traumatic [CONDITION(S)]. A Quarterly MDS (Minimum Data Set) Assessment, dated 8/29/21, indicated the resident's cognition was severely impaired, and the resident required the supervision/oversight of one person with eating and/or drinking. A Nutrition care plan, dated 2/14/20, indicated the resident had no nutritional concerns. One of interventions, which was dated 9/03/21, indicated, .Adaptive equipment orders being clarified. Email out to therapy A Progress Note, dated 9/19/21, indicated the resident had a new area on her right lower thigh, which was fluid filled. A Skin & Wound Evaluation, dated 9/20/21, indicated the resident received a second degree burn, with an intact serum filled blister, to the left front thigh on 9/19/21, which measured 4.5 x 2.7 cm. Upon investigation, it was discovered the resident had spilled coffee onto the leg the day prior (9/18/21) and formed a blister on 9/19/21. Area was cleansed with normal saline, patted dry and [MEDICATION(S)] non-adherent dressing was applied and covered with a gauze and secured with elastic retention netting. The evaluation indicated OT (Occupational Therapy) was to assess the resident for safety with hot liquids. An Occupational Therapy (OT) Evaluation & Plan of Treatment, dated 9/21/21, indicated resident was not using any adaptive equipment for self-feeding and resident spilled coffee on herself with the need for OT intervention. Assessment indicated .Patient demonstrates limitations related to her disability, feeding difficulties and impaired coordination. These factors limit her safety with self-feeding tasks An OT Note, dated 10/14/21, indicated .Attempted use of 2 handed sippy cup to decrease risk for spilling liquids with difficulty noted lifting cup .Patient is currently requiring 75% to 80% assistance with self-feeding tasks with initiation and ability to remain on task An OT Discharge Note, dated 10/26/21, indicated .Patient currently requires Max [maximum] assist with feeding tasks. A Skin & Wound Evaluation, dated 9/28/21, indicated the burn wound measured 2.6 x 1.6 cm, and all blisters had reabsorbed with 80% scabbing intact. Redness noted around burned area and wound not improving. A new order was received to apply Medi-honey to wound bed, continue to cover with [MEDICATION(S)] non-adherent dressing and cover with 4x4 gauze and secure with elastic retention netting. Skin & Wound Evaluation, dated 10/19/21, indicated the burn wound measured 3.6 x 2.4 cm and dark/thick scab had resolved, with small amount of necrotic tissue left. The area was improving. Skin & Wound Evaluation, dated 11/2/21, indicated the burn wound measured 1.3 x 0.9 cm and dark/thick scab had fallen off, and few small scabs scattered throughout the epithelial tissue. A self-reported incident, dated 11/3/21, indicated .Resident has dropped her coffee into her bilateral thighs, where previous wound is. Resident was placed in her bed and clothing removed. Coffee cup did not have handles. C.N.A gave the resident her coffee in the wrong cup. NP [Nurse Practitioner] was on site and evaluated the area. Wound team notified and treatment orders were received to assist with the healing of the affected areas. Family was notified. The preventative measure was to educate staff member on verifying the plan of care to prevent injury to a resident Evaluation of 4 [CONDITION(S)]: 1. Left Front Thigh Skin & Wound Evaluation, dated 11/3/21, indicated the resident had previously received a second degree burn to left front thigh from spilling coffee on her lap, measuring 12.0 x 4.8 cm, and area was nearly resolved. The wound nurse was called to the unit due to resident spilling coffee on her lap again, re-burning the area to the left thigh. Blisters had not formed, and blisters were anticipated due to 2nd degree burn. Area was cleansed with NS (Normal Saline), patted dry, applied [MEDICATION(S)] (ointment for [CONDITION(S)]), placed Xeroform (non-adherent primary dressing used to maintain a moist wound environment, and is made of fine mesh gauze [MEDICATION(S)] with [MEDICATION(S)]) over wound, covered with abdominal dressing (ABD) pad and secured with spandage (stretch bandage). Dressings to be changed 3 times a week and as needed. Staff was re-educated on making sure resident is only provided with two handled cup and close supervision with hot fluids. Skin & Wound Evaluation, dated 11/16/21, indicated burn left front thigh wound measured 8.5 x 6.4 centimeters (cm), and had moderate amount of serosanguineous drainage (consisting of both blood and serous fluid) with no odor. The serum filled blister had ruptured. Epidermis had started to pull away, and coagulated blood and slough (dead skin tissue that may have yellow or white appearance) noted to wound bed. There were no signs or symptoms of infection. Old dressing had dried serosanguineous drainage. Resident was experiencing increased pain. The area was cleansed gently with normal saline, patted dry, applied [MEDICATION(S)], placed Xeroform over wound, covered with ABD pad and secured with spandage. Skin & Wound Evaluation, dated 11/30/21, indicated burn wound measured 9.1 x 8.7 cm with moderate amount of serosanguineous drainage, with no odor. Coagulated blood & slough were noted to wound bed. Wound Physician at bedside to assess. Slough easily came off with cleansing. Granular tissue remains with epithelial tissue to peri-wound (tissue surrounding a wound). 2. Right medial thigh Skin & Wound Evaluation, dated 11/3/21, indicated a new 2nd degree burn to the right medial thigh measured 5.0 x 2.8 cm. Skin & Wound Evaluation, dated 11/23/21, indicated the right medial thigh burn measured 2.1 x 1.3 cm with intact serum filled blister, with no drainage or odor. 3. Left rear thigh Skin & Wound Evaluation, dated 11/3/21, indicated left rear thigh 2nd degree burn measured 13.1 x 6.2 cm. Skin & Wound Evaluation, dated 11/9/21, indicated left rear thigh 2nd degree burn measured 9.1 x 5.2 cm., with light amount of serosanguineous drainage. The serum-filled blister had ruptured, epidermis had started to pull away, and coagulated blood and slough were noted to wound bed. Skin & Wound Evaluation, dated 11/16/21, indicated left rear thigh 2nd degree burn measured 8.9 x 5.3 cm. with moderate amount of serosanguineous drainage, with no odor. Serum-filled blister had ruptured, epidermis had started to pull away, coagulated blood and slough were noted to wound bed. There were no signs or symptoms of infection. Resident had increased complaints of pain. Skin & Wound Evaluation, dated 11/30/21, indicated left rear thigh 2nd degree burn had no measurements, with moderate amount of serosanguineous drainage, with no odor. 4. Left medial thigh Skin & Wound Evaluation, dated 11/3/21, indicated left medial thigh, 2nd degree burn measured 18.3 x 11.2 cm. Skin & Wound Evaluation, dated 11/9/21, indicated left medial thigh 2nd degree burn measured 8.7 x 8.0 cm, with light amount of serosanguinous drainage, with no odor. Skin & Wound Evaluation, dated 11/23/21, indicated left medial thigh 2nd degree burn measured 10.3 x 6.6 x 0.1 cm. with light serosanguineous drainage with no odor. The serum filled blister has ruptured, epidermis had pulled away, and coagulated blood and slough were noted to wound bed. Epithelial tissue was forming around the wound bed, as edges heal. Resident has had increased pain. Resident to be pre-medicated with PRN (as needed) [MEDICATION(S)] ([MEDICATION(S)] - narcotic pain medication) prior to dressing changes. A Care Plan, dated 7/16/20 and revised on 11/9/21, indicated the resident had fragile skin with potential of skin tears/bruising. The facility added the [CONDITION(S)] to left anterior thigh, burn to left medial thigh and burn to right medial thigh to the care plan, on 11/9/21. The interventions, dated 11/9/20, included, but were not limited to: have wound team assess areas of concern, observe for signs/symptoms of infection-such as area reddened, warm to touch, increased complaints of pain or drainage and provide treatment as ordered. There was no indication the care plan had been updated after the first burn. An Occupational Therapy (OT) Note, dated 11/5/21, indicated .Patient with recent burn to her thighs related to spilling of coffee on her lap without use of 2 handed sippy cup. OT services requested to complete education on how to assist patient with feeding and drinking tasks to decrease injury The note explained the resident was not able to safely complete drinking and/or feeding tasks unsupervised and unassisted. Dietary and nursing communication forms were completed regarding the need to have assistance with all food and liquids as well as adaptive equipment needed for assisted dining. An OT Note, dated 11/22/21, indicated .Patient continues to demonstrate the need for assistance from Mod [moderate] to total dependence from day to day A Facility Wound Physician Progress Note, dated 11/30/21, indicated resident .was seen today after suffering [CONDITION(S)] to inside of her thighs bilaterally with the left being worse than the right. The patient has been unable to be an accurate historian, but the nurses relate that the patient has been experiencing quite a bit of pain with bandage changes and they are now giving [MEDICATION(S)] to help with this. The patient is getting Xeroform, [MEDICATION(S)], ABD [Abdominal Dressing] and Ace bandage to hold it in place bilaterally. The patient suffered a burn on 11/3/21 from coffee. OBJECTIVE FINDINGS: Bandages were removed today. It shows that the wound that was present to the right leg is now fully healed. There is some dislocation to the skin but it has completely epithelialized. The patient also has a wound noted to the medical and anterior aspect of the left thigh. The wound is mostly granular. It measures 10.0 x 21.3 x 0.1. There is area of slough that I was able to debride .I would say the wound is approximately 80-90% fully granular at this time. There is no redness, no odor, just small amount of serous fluid present .We will switch the patient over to [MEDICATION(S)] as opposed to Xeroform in addition to [MEDICATION(S)], ABD, and Ace bandage to the left leg and change it three times a week A Progress Note, dated 12/1/21 at 5:35 P.M., indicated the nurse received a call from resident's POA (power of attorney) saying she had called 911, and that 911 was on their way to take her mom to ER (emergency room ) for an evaluation of [CONDITION(S)]/wound. The Emergency Report, dated 12/1/21, indicated resident was seen for wound infection. The wound had purulent and foul smelling material, concerning for infection, and needed IV antibiotics and aggressive wound care. The resident was admitted and was hospitalized for five days. An Inpatient Wound Care Note, dated 12/3/21, indicated the resident was referred to a Physical Therapist, at the hospital, for wound care and treatment of burn, caused by a coffee spill about a month ago. The note indicated the wound measured 14.4 x 19.2 x 0.2 cm. and was irregularly shaped. The margins of the wound were jagged, necrotic, red, tender and had less than 10%, of the wound, covered with loose adherent black and yellow necrosis (cell injury/death). The area was debrided clean and treated with silver gel to decrease bioburden (defined as bacteria living on a surface) to promote healing. Coffee machine temperatures were checked with the Assistant Dietary Director and observed on 12/8/21 from 1:30 P.M. - 2:51 P.M. on the units with coffee machines, and indicated the following: West 2 coffee was 130 degrees, Bridgeview coffee was 174 degrees - the machine had a sign which stated Do not use, kitchen will provide coffee carafe. The Assistant Dietary Director indicated the sign was placed today as part of the PIP (Performance Improvement Plan). East 2 coffee was 132 degrees, East 1 coffee was 130 degrees and Main Dining Room was 170 degrees. The Assistant Dietary Director indicated the coffee was put in insulated carafes and poured from them to the residents in the Main Dining Room. During an interview, on 12/8/21 at 3:34 P.M. the Director of Nursing (DON) indicated on 9/27/21 all coffee dispensers on the units had their temperatures decreased to 145 degrees and was told by the provider the coffee dispenser could not go down any lower. The facility was going to remove the dispensers and the provider came back and indicated dispensers could be lowered again and they were lowered yesterday, 12/7/21. She did not indicate the facility had been monitoring the coffee dispensers themselves. During an interview, on 12/9/21 a 9:49 A.M., the DON indicated the adaptive sippy cup order was not completed by the OT therapist, therefore MDS staff did not add the order to the care plan and the medical records staff did not update the CNA assignment sheets with the resident need for the use of an adaptive sippy cup with a lid. Therefore, the need for an adaptive drinking cup was never communicated to the Nursing staff. In addition, Resident D had had no prior assessment regarding the safe usage for hot liquids, until after her first burn. During an interview, on 12/9/21 at 9:58 A.M., CNA 2 indicated she had been called to help on the floor the day the second [CONDITION(S)] occurred to Resident D. She was usually working at the facility as a restorative aide. She indicated she had given the resident a cup of coffee and left the resident in the assist dining area to go into the other assisted dining area (they are attached with a half wall to separate) to get a cup of coffee for another resident. When she returned, the nurse was taking the resident from the area and she wasn't sure what had happened, until later she discovered the resident had spilled coffee on herself. The CNA indicated she had not used an adaptive cup due to she had no knowledge the resident was to have one, and the information was not on her CNA assignment sheet. During an interview, on 12/9/21 at 10:35 A.M., the Wound Nurse indicated she entered the room approximately 5 minutes after the hot coffee spill and the nurse had removed the resident's clothing and dressing. The wound nurse indicated the resident didn't have any blisters until the next day. The wound/burn blisters eventually popped and the skin started pulling away and some slough appeared. She described slough as dead necrotic tissue. She indicated she had contacted the NP in regard to the pain and slough. She indicated she had talked to the resident's health care representative regarding getting something more than Tylenol for pain and the family did not get back right away. Family asked to observe the wound, and after their observation, family asked the facility to get another pain medication. She never noted an odor. The Medical Director got consent for the Wound Doctor for the facility to see the resident just prior to going to the hospital. He did a debridement (removal of dead tissue) of the slough, and the dressing was modified at that point. [MEDICATION(S)] (burn dressing) was added, which is placed directly on the wound and has holes in it and could stay on for a week but she still did other dressing changes with [MEDICATION(S)] three times a week and as needed. Pain with treatments was a concern, but most of the resident's pain was experienced when cleansing/dressing the wound. She did not associate pain with possible infection or wound concerns. She had been told the resident wasn't communicating pain at any other times of the day and could verbally express pain or discomfort. During an interview, on 12/9/21 at 11:35 P.M., the MDS Coordinator indicated she had no knowledge of the OT use of a sippy cup after the resident's first accident/burn, and therefore the care plan had not been updated to inform nursing staff to use a sippy cup for liquids. During an interview on 12/9/21 at 1:14 P.M., OT 3 indicated she was asked to evaluate Resident B after the first coffee spill to determine if adaptive equipment was needed to improve her safety with hot liquids. She used a green paper, which was given to the unit supervisor, to notify them of a change - use of adaptive equipment and an order was documented in the resident's PCC (electronic medical record). She believed the resident had a previous order for a sippy cup but could not find the order. On 12/9/21 at 1:37 P.M. the Administrator provided an order dated 9/27/21, for, .pt [patient] to utilize 2 handed sippy cup with straw for consumption of liquids On 12/10/21 at 2:25 P.M., the resident's burn/wound was examined with the DON and the Wound Nurse. The left thigh had a large dressing on it dated, 12/6/21. The wound was on the mid thigh area and extended around the thigh to the right, to back of the thigh. Wound Nurse indicated all 4 [CONDITION(S)] now one area. Area had yellow, loose stringy slough, covering the wound, which some was wiped off with Normal Saline. The wound measured 11.1 x 19.5 cm. A special wound/burn dressing, called Versatel, with Silver Gel (burn ointment) was laid over the entire area, then the area was wrapped in Kerlix and secured with elastic. 2. A self-reported incident to the Indiana Department of Health (IDOH), dated 8/28/21, indicated, at 9:15 A.M., Resident B had spilled coffee on herself in her room. The resident called it a silly accident. The resident received a reddened area with a blister on 8/29/21 to her sternum area, which measured 3.5 x 3.0 centimeters (cm). Staff received a treatment order and family was notified. The Ombudsman and APS (Adult Protective Services) were notified via fax. A statement from the resident indicated it was her own fault; she did something stupid. She indicated she was sitting up and just spilled the coffee on herself. The preventative measure was to provide a lid for the coffee cup to prevent accidental spillage. On 12/8/21 at 12:12 P.M., a review of the clinical record for Resident B was conducted. The resident was admitted on [DATE]. Diagnoses included, but were not limited to: fracture of knee joint, neoplasm of breast and diabetes with [CONDITION(S)]. An Admission MDS (Minimum Data Set) assessment, dated 8/29/21, indicated the resident was moderately cognitively impaired and required the supervision/oversight of one person with eating and/or drinking. A Progress Note, dated 8/28/21 at 7:41 P.M., indicated .Burn noted to mid sternum during evening med pass. Measured approx.[approximately] 3.5 x 3.0. There had been a blister that had broken open and there was some skin present. Stated that she had spilled her morning coffee and it was HOT AS H---! The Self Care Deficit Care Plan, dated 8/24/21, indicated .Eating: supervision but may increase to one staff PRN [as needed] This care plan was not revised to identify the resident's need to have a lid on the resident's coffee cup to prevent spillage. A Skin & Wound Evaluation, dated 8/30/21, indicated the resident had a 2nd degree burn to right chest area. The burn measured 3.1 x 3.9 x 0.1 cm. The serum filled blister had ruptured, had slight serous drainage with no odor. Area was cleansed and dressing applied as ordered with daily dressing changes. Resident was educated on properly sitting in bed when drinking fluids especially hot coffee. The 9/8/21 Skin & Wound Evaluation indicated the burn had resolved and left a scar with light redness. During an interview, on 12/8/21 at 1:46 P.M., the Director of Nursing (DON) indicated there was no plan of care regarding the use of a lid for the resident's coffee cup and the resident had had no assessment at admission nor after her burn regarding the safe usage for hot liquids. During an interview, on 12/9/21 at 11:30 A.M., the MDS Coordinator indicated the incident report, for preventative measures, had not been communicated to her, and therefore the care plan was not updated to include the cup with a lid to prevent spillage and possible recurrent burn from hot liquids. An email correspondence, dated 12/9/21, provided by the Administrator, indicated the following: .Here are the dates for our coffee temperature project as it transpired in a timeline. 1. 9/27/21-Contacted [name of coffee dispenser provider] to set machine at 155 spec [a particular specification] temp [temperature] 2. 10/12/21 Perform test on East 1 floor and set to 155 temp. on coffee machines 3. 10/14/21 - After success on East 1 155 temp, we were able to set all machines to 140 degrees on East 2 and West 2 Units. 4. 12/7/21 East 2 machine adjusted programming after loss of programing. Machine reverted back 195 degrees. East 2 Machine is now set to 140 degrees. 5. Set Alcove [main dining room name] to 140 degrees on 12/9/21. Review of Studies of Thermal Injury - The Relative Importance of Time and Surface Temperature in the Causation of Crustaceous [CONDITION(S)], retrieved from the National Center for Biotechnology Information (NCI) website on 12/13/2021, at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 04/?page=16, indicated the time and temperature relationship to serious [CONDITION(S)] with the following temperatures and the time required for a 3rd degree burn (full thickness burn going through the dermis and affecting deeper tissue) to occur: 155 degrees Fahrenheit (F) - 1 second 148 degrees F - 2 seconds 140 degrees F - 5 seconds 133 degrees F - 15 seconds On 12/4/21 at 12:50 P.M., the DON indicated there was no policy, procedure or protocol for hot liquid accidents. The immediate jeopardy that began on 8/28/21 was removed on 12/12/21 when the facility implemented systematic changes, such as: inservicing all staff on the hot liquid policy, assessing residents for the use of hot liquids safely and determining if adaptive equipment and/or supervision was needed for each resident and then communicated to staff effectively, but the noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that was not immediate jeopardy because of the facility's need to continue inservices and monitoring of residents' safety with hot liquids. This Federal tag relates to complaint IN 810. 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure coffee was served at a safe temperature. Resident B, who was moderately cognitively impaired and required assistance with eating, experienced a 2nd degree burn from hot coffee on 8/28/21. Resident D, who was severely cognitively impaired and required supervision with eating, experienced a 2nd degree burn from hot coffee on 9/18/21 and multiple 2nd degree [CONDITION(S)], on 11/03/21. This deficient practice had the potential to affect 34 residents, who drank coffee, out of 94 total residents. The immediate jeopardy began on 8/28/21 when Resident B experienced 2nd degree [CONDITION(S)] from coffee. The facility did not correct or adequately monitor the problem, and Resident D then experienced a 2nd degree burn from hot coffee on 9/18/21 and again on 11/03/21, resulting in multiple 2nd degree [CONDITION(S)] to her thighs. The burn on Resident D's left thigh worsened, was painful and required wound treatment in the hospital. The Administrator was notified of the immediate jeopardy on 12/10/21 at 12:08 P.M. The immediate jeopardy was removed on 12/12/21, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. On 12/3/21 at 1:31 P.M., a review of the clinical record for Resident D was conducted. The resident's diagnoses included, but were not limited to, dementia, diabetes, [CONDITION(S)], arthritis and non-traumatic [CONDITION(S)]. A Quarterly MDS (Minimum Data Set) Assessment, dated 8/29/21, indicated the resident's cognition was severely impaired and the resident required the supervision/oversight of one person with eating and/or drinking. A Progress Note, dated 9/19/21, indicated the resident had a new area on her right lower thigh which was fluid filled. A self-reported incident to IDOH, dated 9/19/21, indicated Resident D was noted to have a fluid filled blister during her morning care. The blister was located on her right lower thigh. The resident's slacks were inspected, and a coffee stain was found in the location of the blister. The resident was screened for an adaptive cup, and dietary was to follow up with the service company regarding temperatures of the coffee machines on the units. A Skin & Wound Evaluation, dated 9/20/21, indicated the resident received a second degree burn, with an intact serum filled blister, to the left front thigh on 9/19/21, which measured 4.5 x 2.7 cm (centimeters). Upon investigation, it was discovered the resident had spilled coffee onto the leg the day prior (9/18/21) and formed a blister on 9/19/21. Area was cleansed with normal saline, patted dry and [MEDICATION(S)] (non-adherent) dressing was applied and covered with a gauze and secured with elastic retention netting. The evaluation indicated OT (Occupational Therapy) was to assess for a different cup, for the resident, to use with liquids. A facility QAPI (Quality Assurance Performance Improvement) Toolkit, dated 9/20/2, was provided by the Administrator. The Toolkit indicated .COFFEE TEMPERATURES TOO HOT FOR MANY RESIDENTS. This is posing a safety concern. Coffee [CONDITION(S)] reported on two residents The Toolkit indicated temperatures were taken from 5 coffee machines and ranged from 175 to 185 degrees. The QAPI toolkit indicated on 9/27/21 the coffee machines temperatures were turned down to 155 degrees, then on 10/14/21 the temperatures of the coffee machines were turned down to 140 degrees. There was no indication the facility had initiated monitoring, of the coffee, temperatures at point of service. A self-reported incident to IDOH, dated 11/3/21, indicated .Resident has dropped her coffee into her bilateral thighs, where previous wound is. Resident was placed in her bed and clothing removed. Coffee cup did not have handles. C.N.A. [Certified Nurse Assist] gave the resident her coffee in the wrong cup. NP [Nurse Practitioner] was on site and evaluated the area. Wound team notified and treatment orders were received to assist with the healing of the affected areas. Family was notified. The preventative measure was to educate staff member on verifying the plan of care to prevent injury to a resident The Emergency Report, dated 12/1/21, indicated resident was seen for a wound infection. The wound had purulent and foul smelling material, concerning for infection, and the resident needed IV (intravenous) antibiotics and aggressive wound care. The resident was admitted and was hospitalized for five days. 2. On 12/8/21 at 12:12 P.M., a review of the clinical record for Resident B was conducted. The record indicated the resident was admitted on [DATE]. The resident's diagnoses included, but were not limited to, fracture of knee joint, neoplasm of breast and diabetes with [CONDITION(S)]. A Progress Note, dated 8/28/21 at 7:41 P.M., indicated .Burn noted to mid sternum during evening med pass. Measured approx [approximately] 3.5 x 3.0. There had been a blister that had broken open and there was some skin present. Stated that she had spilled her morning coffee and it was HOT AS H---! A self-reported incident to the Indiana Department of Health (IDOH), dated 8/28/21, indicated, at 9:15 A.M., Resident B spilled coffee, on herself, in her room. Resident called it a silly accident. The resident received a reddened area, with a blister on 8/29/21 to her sternum area, which measured 3.5 x 3.0 centimeters (cm). Staff received a treatment order and family was notified. The ombudsman and APS (Adult Protective Services) was notified via fax. A statement from the resident indicated it was her own fault; she did something stupid. She indicated she was sitting up and just spilled the coffee on herself. The preventative measure was to provide a lid for the coffee cup to prevent accidental spillage. An Admission MDS (Minimum Data Set) assessment, dated 8/29/21, indicated the resident was moderately cognitively impaired and required the supervision/oversight of one person with eating and/or drinking. Coffee machine temperatures were checked with the Assistant Dietary Director and observed on 12/8/21 from 1:30 PM - 2:51 P.M., on the units with coffee machines and indicated the following: West 2 coffee was 130 degrees, Bridgeview coffee was 174 degrees - the machine had a sign which stated Do not use kitchen will provide coffee carafe. The Assistant Dietary Director indicated the sign was placed today as part of the PIP (Performance Improvement Plan). East 2 coffee was 132 degrees, East 1 coffee was 130 degrees and Main Dining Room was 170 degrees. The Assistant Dietary Director indicated the coffee was put in insulated carafes and poured from them to the residents in the Main Dining Room. An email correspondence, dated 12/9/21 and provided by the Administrator, indicated the following: .Here are the dates for our coffee temperature project as it transpired in a timeline. 1. 9/27/21-Contacted [name of coffee dispenser provider] to set machine at 155 spec [a particular specification] temp [temperature] 2. 10/12/21 Perform test on East 1 floor and set to 155 temp. on coffee machines 3. 10/14/21 - After success on East 1 155 temp, we were able to set all machines to 140 degrees on East 2 and West 2 Units. 4. 12/7/21 East 2 machine adjusted programming after loss of programing. Machine reverted back 195 degrees. East 2 Machine is now set to 140 degrees. 5. Set Alcove [main dining room name] to 140 degrees on 12/9/21 On 12/11/21 at 1:10 P.M., the Administrator indicated there were a total of 94 resident residing at the facility on 12/10/21 and 34 of those residents drank coffee from the coffee dispensers. Review of Studies of Thermal Injury - The Relative Importance of Time and Surface Temperature in the Causation of Cutaneous [CONDITION(S)], retrieved from the National Center for Biotechnology Information (NCBI) website on 12/13/2021, at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 04/?page=16, indicated the time and temperature relationship to serious [CONDITION(S)] with the following temperatures and the time required for a 3rd degree burn (full thickness burn going through the dermis and affecting deeper tissue) to occur: 155 degrees Fahrenheit (F) - 1 second 148 degrees F - 2 seconds 140 degrees F - 5 seconds 133 degrees F - 15 seconds On 12/10/21 at 3:14 P.M., the Administrator provided a policy titled, Hot Liquid Safety, undated, and indicated the policy was the one currently, used by the facility, and had been recently developed. The policy indicated .Policy: Hot liquids are to be served at proper (safe and appetizing) temperatures using appropriate safety precautions .2. The temperatures of hot liquids will be checked in the dietary department prior to distribution to the nursing units. If temperature is greater than 140 degrees Fahrenheit, hold the liquid in the dietary department until it reaches appropriate temperature. 3. All residents are assessed for their ability to handle containers and consume hot liquids. Residents with difficulties will received appropriate supervision and use of assistive devices in order to consume hot liquids The immediate jeopardy that began on 8/28/21 was removed on 12/12/21 when the facility implemented systematic changes, such as: in-servicing all staff on the hot liquid policy, monitoring the use of adaptive equipment and/or supervision with hot liquid and monitoring the temperatures of the coffee dispensers daily, but the noncompliance remained at the lower scope and severity level of pattern, no actual harm with potential for more than minimal harm that was not immediate jeopardy because of the facility's need to continue inservices, monitoring of residents' safety with hot liquids and continued monitoring of the coffee dispenser temperatures. This Federal tag relates to complaint IN 810. 1.3-21(a)(2)

Based on observation, interview and record review, the facility failed to endure a resident admitted with a Stage 3 pressure ulcer did not worsen resulting in admission to hospital for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #23) and to ensure a resident did not develop a suspected deep tissue pressure area after admission (Resident # 62). Findings include: 1. The clinical record for Resident #23 was reviewed on August 12, 2017 at 12:00 P.M. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission MDS (Minimum Data Set) assessment, completed 7/3/17, indicated Resident#23 was admitted on [DATE], had a BIMS (Brief Interview of Mental Status) score of 15, cognitively intact, and had an unstagable pressure area measuring 10.5 cm (centimeters) x 5.5 cm x 0.0 depth. A care plan, dated 6/26/17, indicated resident was admitted with pressure area to sacrum, interventions included, but were not limited to , assess lab and diagnostic work, report to physician and skin risk assessment on admit and at regular interval and notify appropriate staff (Registered Dietician, MDS nurse, and Wound Team) of any changes in skin and assessment. A consultation report, dated 6/22/17, indicated Resident #23 was admitted with urosepsis with ileal conduit (outside drainage system for urine). A progress note, dated 6/27/17 at 7:09 A.M., indicated Resident #23 was admitted with spinal stenosis, [CONDITION(S)], [CONDITION(S)], and urinary tract infection for which she was receiving antibiotic therapy. A wound assessment, dated 6/27/17 ay 3:30 P.M., indicated Resident #23 had unstageable pressure area to sacrum measuring 10.5 cm x 5.5 cm that presented with small amount of serosanguine drainage, 10% granulation (healthy tissue) and 90% slough (necrotic tissue) noted to wound bed. Santyl was ordered per facility wound care guidelines protocol. No physician clarification for wound care orders. A progress note, dated 6/27/17 at 4:02 P.M., indicated Resident #23 was admitted with chronic sacral wound. A wound assessment, dated 7/4/17 at 3:47 P.M., indicated unstageable pressure ulcer to sacrum measuring 8.4 cm x 3.4 cm x 0.3 cm, scant amount of serosanguine drainage. A wound assessment, dated 7/9/17 at 5:31 P.M., indicated Resident #23 had a Stage 3 pressure area to coccyx measuring 10 cm x 3.0 cm x 0.8 cm with small amount of ensanguine drainage, and wound bed presented with 80% granulation and 20 % slough, no undermining or tunneling noted. A wound assessment, dated 7/17/17 at 5:10 P.M., indicated Resident #23 had unstageable pressure area measuring 9.8 cm x 5.2 cm (no depth) with moderate ensanguine drainage, and wound bed presented with 20% granulation and 70% slough tunneling and undermining (no measurements). A progress note, dated 7/18/17 at 9:03 P.M., indicated Resident #23 presented with nausea and dry heaves x 1 this shift, [MEDICATION(S)] (antiemetic) was administered with effectiveness. Lab results, dated 7/18/17, indicated WBC (white blood cell) count was 13,000. A progress note, dated 7/19/17 at 3:49 P.M., indicated Resident #23 continued with coccyx wound that was followed by the wound team and was showing signs of getting worse. Wound nurse and DON (Director of Nursing) were notified and asked to assess. A wound assessment, dated 7/20/17 at 4:24 P.M., indicated Resident #23 had an unstageable pressure area to sacrum measuring 9.8 cm x 6 cm (no depth) with moderate amount of ensanguine drainage, wound bed presented with 50% granulation and 50% eschar (necrotic tissue), and tunneling at 6 o'clock with greatest depth of 2 cm. Wound culture obtained. A progress note, dated 7/20/17 at 4:31 P.M., was late entry note for 6/2 shift that indicated Resident #23 had been complaining of nauseated, wound had further degraded, foul smelling with dark drainage. Resident was assisted to wheelchair/ in hoyer, where she immediately became nauseated and began vomiting. Resident did agree to attempt therapy but was returned to bed promptly afterwards. Resident #23 indicated to writer she was tired of being ill and just wanted to go home. Nurse spoke with family and the infection control nurse. Family concerns conveyed to nurse and requested that she consult physician and administration to see what steps should be taken next. A progress note, dated 7/20/17 at 8:57 P.M., indicated physician was notified of blood cultures and received new orders to send to emergency room for evaluation and treat. A progress note, dated 7/20/17 at 5:17 P.M., indicated Resident #23 was transported to emergency room . The hospital discharge summary, dated 8/2/17, indicated Resident #23 presented with complaints of fever and generalized weakness. She had increased drainage from the sacral decubitis ulcer and the drainage was foul smelling. The patient had temperature of 102.9 degrees and was hypotensive with blood pressure of 93/48. Her sed rate was greater than 120 and her CT scan of pelvis showed sacrococcyheal osteomylelitis (infection of the bone) with new presacral soft tissue stranding suspicious for additional infection. She was started on empiric antibiotics with [MEDICATION(S)] and [MEDICATION(S)]. She received vigorous IV (intravenous) hydration. She underwent wound debridement and coccygectomy with surgeon. Wound cultures from 7/26/17 showed [CONDITION(S)] resistant Staph aureus and enterococcus. Blood cultures from 6/22/17 were negative. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. The clinical record for Resident #62 was reviewed on 8/9/17 at 10:50 A.M. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS (Minimum Data Set) assessment, dated 6/26/17, indicated Resident #62 had a BIMS (Brief Interview for Mental Status) score of 6, severe impairment, and required extensive assist of two people using a standing lift for transfers and ADLs (activities of daily living). A physicians order summary, dated 8/11/17, indicated all active orders as of 8/11/17 included, but were not limited to, patient to wear immobilizer to left leg at all times, may be removed for bathing and dressing (started 8/1/2017) and undo immobilizer and check skin integrity of left lower extremity every 4 hours and document any concerns, thoroughly document any concerns (started 8/11/17 with order date 8/11/17). A care plan, revised 8/9/17, for skin breakdown potential related to leg immobilizer, decreased mobility, fragile skin had interventions that included, but were not limited to, remove leg immobilizer for bathing and dressing. A care plan, dated 8/10/17, for alteration in musculoskeletal status related to/ fracture of the left femur had interventions that included, but were not limited to, immobilizer to left leg, may remove for bathing and dressing. A progress note, dated 8/11/17 at 9:28 A.M., indicated new skin issue found on resident's left posterior ankle, area was reddened unblancable. Therapy working on getting shorter brace. The altered skin integrity notification, dated 8/11/17 at 9:28 A.M., indicated location of skin issue was left posterior ankle with root cause as immobilizer that was in place to the left lower extremity and ABD (abdominal) pad was placed to relieve pressure from immobilizer. An occurance report, dated 8/11/17, indicated supervisor was notified of red area to left ankle was unblanchable. No physician notification documentation noted. A progress note, dated 8/11/17 at 12:21 P.M., indicated PT (physical therapy) was notified by nursing supervisor that Resident #62 had a reddened area on posterior aspect of left leg for apparent rubbing of knee immobilizer, current immobilizer padded and is being worn on the outside of her pants. There was no wound assessment completed. During an observation, at 8/12/17 at 12:49 P.M., Resident #62 was observed sitting up in wheelchair in room with left leg in immoblizer that extends from mid thigh to her ankle. Her left foot was hanging just below leg stabilizer that on wheelchair leg that was in place to prevent her left leg from falling off foot pedal. There was nothing in place to prevent weight of foot from adding pressure to ankle where immobilizer ends at left posterior ankle (spot where pressure area was documented). During an interview, on 8/12/17 at 1:45 P.M., the DON indicated a wound assessment had not been completed by the wound nurse of area to left posterior ankle and there were set days for wound nurse to see wounds. She indicate the nurse should do an assessment of the wound at the time it was found and the skin assessment should include description of the wound to include measurements. During an interview, on 8/12/17 at 1:48 P.M., the CCO (Chief Clinical Officer) indicated the area to left posterior ankle was from immobilizer and the one she currently had had since return on 8/1/17 was too long for her. A skin assessment, dated 8/12/17 at 9:48 P.M., indicated Resident #62 had a Stage 1 pressure area (area of persistent redness) to left posterior ankle. No measurements documented. On 8/12/17 at 3:00 P.M., Resident #62 was observed laying in her bed with immobilizer of left leg that extended from mid thigh to just above ankle on top of pants, there was pink padding placed in posterior portion of the immobilizer at the ankle. The nurse removed immobilizer and suspected deep tissue injury (appears as dark purple area). On 8/13/17 at 3:14 P.M., Resident #62's reddened area was larger in size compared to 8/12/17. The reddened area extended up lower portion of ankle that was not present the day prior and the dark purple are remained on bony prominence of heel bone. During an interview, on 8/13/17 at 3:15 P.M., LPN (Licensed Practical Nurse) #11 indicated area to ankle bone was pressure related. She indicated the reddened area to posterior portion of ankle area was on a bony prominence and was due to the immobilizer causing friction from rubbing it. She described that area as dark brown in color. She indicated she would have reported it as a pressure area. During an interview, on 8/14/17 at 9:19 A.M., the CCO indicated the DON was the wound certified nurse for the building and she consults with wound nurse who is not certified, the DON had not made an assessment of wound area to left heel that was reported on Friday morning (8/11/17) because she did not have time. During an interview, on 08/14/17 at 9:55 A.M., the CCO indicated area to left posterior ankle was a suspected deep tissue injury and that resident was not assessed by wound nurse until today. She indicated measurements should have been completed at the time the area was first identified. No wound assessments documented. On 8/11/17 at 2:00 P.M., the MR (Medical Records Personnel) provided the Lippincott Procedures for Staging Pressure Injuries, no date, and indicated the policy was the one currently be used by the facility. The policy indicated Stage 1 pressure injuries are characterized by intact skin with nonblanchable redness of a localized area. Color changes don't include purple or maroon discoloration. These changes may indicate deep tissue pressure injury. A deep tissue injury is characterized by intact or nonintact skin with a localized area of persistent nonblanchable deep red, purple, or maroon discoloration. On 8/14/17 at 10:00 A.M., the CCO provided the Pressure Ulcer Report policy, dated 5/14/09, and indicated the policy was the one currently being used by the facility. The policy indicated it's purpose was to assure proper documentation and follow through on pressure ulcers. On 8/14/17 at 10:00 A.M., the CCO provided the Altered Skin Integrity Form policy, dated 5/21/14, and indicated the policy was the one currently being used by the facility. The policy indicated early treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Altered Skin Integrity Form was a means of communication to assure complete and competent treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] documented. 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, record review and interviews, the facility failed to ensure the safety of a resident during repositioning in bed, resulting in the resident falling and fracturing his (R) (right) hip. This deficiency affected 1 of 1 residents in a sample of 3 who were reviewed for falls. (Resident "D") Findings include: The record of Resident "D" was reviewed on 02/101/14 at 10:45 a.m. Resident "D" was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's "Progress Notes" indicated: "01/20/14 0858 (8:58 a.m.) At 0725 (7:25 a.m.), this nurse was called to room (number) found resident lying on floor next to bed. Resident c/o (complained of) pain to (R) hip. External rotation noted to (R) leg. ROM (Range Of Motion) to (L) (Left) leg present. Resident unable to move (R) leg...." The family and physician were notified and the resident was sent to the emergency room . The resident was transferred back to the ECF (Extended Care Facility: nursing home) the same day with no surgical interventions done. Review of the ACF (Acute Care Facility: Hospital) record indicated: "01/20/14 Radiology Report: EXAM: AP pelvis and right hip. INDICATION: Fracture...IMPRESSION: There is abnormal contour of the right hip favoring a right femoral neck fracture with at least mild degree of impaction..." "emergency room REPORT; 01/20/14 1643 (4?43 p.m.) ...CLINICAL COURSE: The patient had right hip fracture which showed a positive femoral neck fracture, nondisplaced or impacted. ...At this time discussion with (Physician's name) and family, family noticed the patient is a very poor surgical candidate and question whether can handle nonsurgically...(Physician's name) looked at the films, stating ...there is the possibility can try to treat it nonsurgically, but if there is any displacement with movement in transfer that there might be a long term issue with pain control..." On 2/12/14 at 1:45 p.m., the resident was observed sleeping in his bed with enabler bars in the up position. (Enabler bars: short bars, measuring approximately 20 inches in length located near the head of the bed. The bars are to enable residents to reposition & turn in bed with ease.) Review of Care Plans for Resident "D" indicated: Focus: "FALL RISK POTENTIAL R/T (Related/To): Date Initiated: 05/08/13..Revision on 09/26/2013 ...Is at risk for injury d/t (due/to) hx (history) of falls, (L) hemiparesis, use of pain/antidepressant meds...Poor safety awareness and (name) tends to scoot self around causing poor position. Goals: (Name) will be free of injury from falls. (Name) will be provided safe environment to decrease risk of injury r/t falls. Interventions...Initiated: 05/08/13 Revision on 01/24/14 ...INTERVENTIONS:...4. MOBILITY-TRANSFER STATUS-BEDREST...." The "Quarterly MDS" (Minimum Data Set: a tool used for resident care planning) for Resident "D", prior to the fall and dated 12/09/13, was reviewed. The MDS indicated Resident "D" required extensive assistance of 2 or more for "Bed mobility-how resident moves to and from the lying position, turns side to side, and position body while in bed or alternative sleep furniture." In addition, the resident required extensive assist of 1 for bathing, dressing and toileting. The resident was totally dependent for transfers from the bed to chair. On 02/11/14, at 1:00 p.m., the Administrator provided a copy of the facility's fall investigation, dated 1/20/14. The report indicated: "...This resident is a Hoyer lift, 250 pound resident with the limited ability to assist with some simple tasks such as holding the side rail during care/repositioning, ...while providing AM (morning) care, she had rolled resident over to his left side. Resident was holding the side rail with his right hand. Resident is able to provide some assistance in positioning himself using the side rail...." The facility's Administrator, CCO (Chief Clinical Officer-RN), DNS (Director Nursing Services), and 2 CNA's who provided care for Resident "D" on 01/20/14 were interviewed. The CCO, during interview on 02/10/14 at 9: 30 a.m., indicated the CNA's have a cardex system to reference resident needs and receive a verbal report from nurses at the start of their shift to address any resident changes. The Administrator indicated staff have permanent assignments to provide continuity of care. During the survey, each staff member interviewed indicated the Resident "D" was a 1A (Assist of 1) for repositioning and turning in bed prior to the fall. The DNS was interviewed on 02/10/14 at 1:40 p.m. The DNS indicated Resident "D" required 2A (assist of 2 staff) for transfers from the bed and 1A (assist of 1) when turning in bed. CNA #3 was interviewed on 02/10/14 at 1:50 p.m. CNA #3 indicated Resident "D" required 1A when turning in bed and would hold onto the "siderail" (enabler). CNA #3 indicated on 01/20/14, she was providing care while the resident was on his (L) side. Resident "D" let go of the siderail and reached towards his bedside stand, which was not unusual, and rolled out of bed onto the floor. CNA #3 indicated CNA #5 had checked to see if she needed assistance, which she did not believe she did, and then stepped out of the room. CNA #5 was interviewed on 02/10/14 at 2 p.m. CNA #5 indicated she had entered the room to see if Resident "D" was ready to get up using the Hoyer lift (A mechanical device to enable safe transfers from bed to chair.) CNA #5 indicated CNA #3 was completing A.M. care, while Resident "D" was on his (L) side & holding onto the siderail. CNA #5 indicated this was usual for the resident and he only required 1A when turning side to side. CNA #5 indicated she stepped out of the room and shortly thereafter heard the resident fall. CNA #5 returned to the room to assist in the resident's care. 3.1-45(a)(2)