Every finding on record at Holy Cross Rehabilitation and Wellness

Based on interview and record review, the facility failed to assess a resident who had fallen for 1 of 3 residents who were reviewed. (Resident G)Finding includes:During an interview on 5/15/2026 at 10:00 A.M., Resident G indicated she had fallen about a month prior when a staff member had moved her with the Hoyer lift by themselves. Resident G indicated she had not been injured during the fall. Resident G denied have been assessed by a staff member before she was lifted off the floor and back into her bed. She also denied having been assessed by staff after she was put back into her bed. Resident G's record review was complete on 5/15/2026 at 11:00 A.M. Diagnoses included, but were not limited to: type two diabetes mellitus, chronic kidney disease, obesity and major depressive disorder. An Annual Minimum Data Set assessment, dated 3/9/2026, indicated Resident G had moderate cognitive impairment and had been dependent on staff for transfers.A Rehabilitation Evaluation assessment, completed on 3/8/2026, indicated it was appropriate for Resident G to be transferred with a Hoyer lift. Resident G's record lacked the documentation to indicate the resident had been assessed by a staff member after she had fallen. During an interview on 5/15/2026 at 9:30 A.M., the Director of Nursing (DON) indicated there had been an incident when Resident G had been in the process of being transferred with a lift by CNA 2 on 4/13/2026. The resident had been assisted to the floor during the transfer because the resident had been falling out of the mechanical lift transfer sling. CNA 2 had been sent home on 4/13/2026. An investigation into the incident had been started. During the facility's investigation it was determined that CNA 2 had moved Resident G with a mechanical lift, but had not had the assistance of another staff member. The DON indicated the resident's medical record lacked documentation that an assessment had been completed after the fall. The DON indicated after a fall, an assessment of the resident's condition should have been completed and documented by the nurse who was assigned to the resident. On 5/15/2026 at 10:30 A.M., the DON provided a policy, dated 11/2022, and titled, Safe Lifting/ Handling/ Repositioning of Residents. The DON identified the policy as the one currently used by the facility. The policy indicated, .3. A falling resident is to be assisted to the floor, made comfortable and instructed to remain on the floor until licensed nurse/designee evaluates the resident .This deficiency relates to Intake 2967200.410 Indiana Administrative Code 16.2-3.1-37

Based on interview and record review, the facility failed to transfer a resident appropriately resulting in the resident falling for 1 of 3 residents reviewed for falls. (Resident G)Finding includes:During an interview on 5/15/2026 at 9:30 A.M., the Director of Nursing (DON) indicated there had been an incident when Resident G had been in the process of being transferred with a lift by CNA 2 on 4/13/2026. The resident had been assisted to the floor during the transfer because the resident had been falling out of the mechanical lift transfer sling. CNA 2 had been sent home on 4/13/2026. An investigation into the incident had been started. During the facility's investigation it was determined that CNA 2 had moved Resident G with a mechanical lift, but had not had the assistance of another staff member. The DON indicated all mechanical lifts required the assistance of two staff members. CNA 2 was terminated on 4/15/2026 for not following the facility's policy related to transferring residents with a mechanical lift. During an interview on 5/15/2026 at 10:00 A.M., Resident G indicated she had fallen about a month prior when a staff member moved her with the Hoyer lift by themselves. Resident G indicated she had not been injured in the fall. Resident G denied being moved any other time with the Hoyer lift when only one staff member had been present. Resident G's record review was complete on 5/15/2026 at 11:00 A.M. Diagnoses included, but were not limited to: type two diabetes mellitus, chronic kidney disease, obesity and major depressive disorder. An Annual Minimum Data Set assessment, dated 3/9/2026, indicated Resident G had moderate cognitive impairment and had been dependent on staff for transfers. A Rehabilitation Evaluation assessment, completed on 3/8/2026, indicated it had been appropriate for Resident G to be transferred with a Hoyer lift. On 5/15/2026 at 10:30 A.M., the DON provided a policy, dated 11/2022, and titled, Safe Lifting/ Handling/ Repositioning of Residents. The DON identified the policy as the one currently used by the facility. The policy indicated, .2. Associates will not lift or reposition residents in which the individual staff would bear more than 35 pounds of the resident's weight, the National Institute of Occupational Safety and Health safe lifting limit, without the use of appropriate mechanical devices or with the appropriate number of qualified associates/caregivers .This deficiency relates to Intake 2967200.410 Indiana Administrative Code 16.2-3.1-45 (a)

Based on observation, record review, and interview, the facility failed to ensure wound treatment orders were obtained timely and wound treatments were completed and signed out as ordered for 2 of 2 residents reviewed for non-pressure related skin conditions. (Residents B and C)Findings Include:1.Resident B's record was reviewed on 3/12/26 at 10:00 a.m. The diagnoses included, but were not limited to, diabetes, atrial fibrillation, high blood pressure, and GERD.The admission Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact for daily decision making. The resident had a surgical wound prior to admission.A Care Plan, dated 2/5/26, indicated the resident had alteration in skin integrity related to an incision of the scrotal and perineal area. Approaches were to provide treatments as ordered, monitor for pain, and observe for signs/symptoms of infection and notify physician of any abnormal findings.A Physician's Order, dated 2/5/26, indicated to apply vacuum assisted closure dressing with white foam, with a Negative Pressure Wound Therapy (NPWT) dressing to the scrotal/perineal area. Wound vac to be changed every 48-72 hours.A Nurse's Note, dated 2/6/26 at 2:19 p.m., indicated the resident was offsite for a wound vac placement.The Treatment Administration Record (TAR) did not have a wound order signed out for 2/5/26.During an interview on 3/12/26 at 9:33 a.m., the Director of Nursing (DON) indicated she was Resident B's guardian angel. Resident B had come from the hospital with a surgical wound to his testes. The hospital had removed the wound vac prior to him being admitted to their facility. She indicated she personally tried to apply the wound vac and had no success after multiple attempts and interventions. She had called the hospital and the wound nurse reported to her that it took three people and three hours to get the resident's wound vac on. She indicated she made an appointment for wound clinic right away and accompanied the resident the next day to wound clinic. They wound vac was eventually discontinued a couple days later due to the inability to get a seal. At 12:22 p.m., the DON indicated she took off the wet to dry dressing the resident came to their facility with and she had tried to apply the wound vac. When the wound vac was unsuccessful, she did not call to get a new order. She packed the wound with wet to dry gauze and placed an adaptic dressing over it. 2. On 3/13/26 at 10:38 a.m., a wound treatment was observed on Resident C. Wound treatment began at 10:41 a.m. with RN 1 removing the previous foam dressing that was dated 3/12/26. RN 1 stated Don't look, that is the wrong dressing on the wound. Resident C's record was reviewed on 3/13/26 at 10:30 a.m. The diagnoses included, but were not limited to, non-pressure ulcer of the left foot, heart failure, anemia (low iron), and restless leg syndrome.The Initial Minimum Data Set (MDS) assessment, dated 3/10/26 had been initiated but there was no additional information.A Physician's Note, on 3/10/26 indicated the resident was alert and oriented x 3 and had a normal cognitive status. The plan was to continue current medications and orders.A Care Plan, dated 3/10/26, indicated the resident had alteration in skin integrity to the left foot. Approaches were to complete treatments as ordered, observe for signs/symptoms of infection, and assess impaired area weekly and document per protocol.A Physician's Order, dated 3/11/26, and scheduled to begin on 3/12/26, indicated treatment for left plantar foot was lodoform packing strip to the wound bed, apply a betadine-soaked gauze, dry 4x4 gauze pad, and then wrap with kerlix gauze, and then wrap with an ace bandage.The Treatment Administration Record (TAR) indicated the order for the left plantar foot had been signed out as completed on 3/12/26.During an interview on 3/13/26 at 12:15 a.m., the Director of Nursing indicated she understood the concerns with the wound treatment and the signed out treatment that was not followed.This citation relates to Intake 2784366410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure infection control guidelines were implemented regarding glove change and hand hygiene during a dressing change. In addition, the facility failed to ensure nursing staff understood the required protective equipment needed to care for a resident requiring Enhanced Barrier Precautions for 1 of 2 resident's reviewed for non-pressure skin conditions. (Resident C)Findings include:On 3/13/26 at 10:38 a.m., a wound treatment was observed on Resident C. Wound treatment began at 10:41 a.m. with RN 1 removing the previous foam dressing that was dated 3/12/26. RN1 removed his gloves and left the room to clarify treatment orders. At 10:45 a.m., RN 1 returned with the Nurse Practitioner (NP) and she assessed the wound and agreed that the wound did not require packing and that it was healing great. She gave new verbal orders to RN 1 to clean with a gauze pad soaked with betadine, apply a 4x4 to the wound bed and wrap with kerlix.RN 1, donned gloves and proceeded to cleanse the wound with a soaked betadine pad. After he had completed the wound cleansing and had covered the wound with a clean gauze pad, RN 1 began to unroll the Kerlix gauze (a large gauze roll that is typically used to wrap/secure dressings on body parts) and realized he did not have any tape to secure the dressing. He set the Kerlix gauze roll down and began rummaging through Resident C's side dresser drawers, with his gloved hands, to see if any tape had been left behind. He was unsuccessful in locating any tape, so he returned to the kerlix roll and began dressing the wound again. There was no hand hygiene or glove change after RN 1 looked in the resident's dresser drawers. Once the left foot was wrapped in Kerlix RN 1, doffed Personal Protective Equipment (PPE) and went in search of tape.At 9:49 a.m., RN 1 appeared at resident C's doorway and asked, Is applying tape gown worthy? RN 1 eventually decided to put on the PPE (patient protective equipment), and tape was applied to the resident's kerlix dressing.During an interview at the time, RN 1 indicated he was not sure if he needed to put a gown on if he was just going to apply tape to the top of the dressing. Resident C's record was reviewed on 3/13/26 at 10:30 a.m. The diagnoses included, but were not limited to, non-pressure ulcer of the left foot, heart failure, anemia (low iron), and restless leg syndrome.The Initial Minimum Data Set (MDS) assessment dated [DATE] had been initiated but no additional information had been completed.A Physician's Note, on 3/10/26 indicated the resident was alert and oriented x 3 and had a normal cognitive status. The plan of care was to continue current medications and orders.A Care Plan, dated 3/10/26, indicated the resident had alteration in skin integrity related to left foot. Approaches were to complete treatments as ordered, observe for signs/symptoms of infection, and assess impaired area weekly and document per protocol.During an interview on 3/13/26 at 12:15 a.m., with the Director of Nursing indicated she understood the concerns with the wound treatment as the nurse should have changed his gloves after searching for tape.This citation relates to Intake 2784366410 IAC (Indiana Administrative Code) 16.2-3.1-18(b)

Based on interview and record review, the facility failed to adequately address resident grievances regarding call light wait times for 18 of 18 residents reviewed for call-light wait times, (Residents B, C, D, E, F, G, H, K, L, M, N, P, Q, R, S, T, and U).Findings include:During an interview, on 9/17/25 at 9:10 A.M., the Director of Nursing indicated the facility call light system was in working order and had not been out of working order at any time that she was aware of. The Director of Nursing indicated that each resident had a staff member, called a Guardian Angel, who checked on their assigned residents addressing concerns including concerns regarding call ight wait times. The Director of Nursing indicated when residents had concerns, the Guardian Angel was to address the concern and/or file a grievance or complete a Call Light Response Survey form. The Director of Nursing provided a call light audit form that had been created following the previous annual survey on 4/28/25, and indicated call light wait time audits were ongoing but there was no audit documentation completed after 6/30/25. The Director of Nursing indicated there was no further documentation of call light monitoring after 6/30/25. There was no explanation as to why the auditing had been discontinued after 6/30/25.On 9/17/25 at 9:58 A.M., during a telephone interview with Resident B's family member, she indicated Resident B's call light often went unanswered, or staff turned the light off and did not return.During an interview, on 9/17/25 at 10:20 A.M., the Assistant Director of Nursing (ADON) indicated when residents initiated the call button from their rooms, the call went to a beeper system, first to the Aide on the floor, then if not answered in a certain amount of time, the floor nurse was alerted via the beeper system. The ADON indicated there were no lights outside resident doors and no lights at the nurse's station to visualize when call-lights had been activated by the residents. The ADON indicated that the aides and nurses were responsible for checking the beepers frequently. The ADON indicated that the facility no longer utilized their call light monitoring system because the facility felt the call light times were accurate due to nursing staff not consistently turning the call light off when resident's needs had been met. The Assistant Director of Nursing indicated the call light system was in place at the most recent Annual Survey on 4/28/25 when the facility had been cited for excessive call light wait times. The Assistant Director of Nursing could not say when the call light monitoring system had been discontinued. The Assistant Director of Nursing indicated the facility did not have a specific policy regarding the answering of call lights nor was there an expectation of a reasonable period of time when a call light should be answered. She indicated the facility followed Nursing Standards of Practice, but was unable to indicate what the Nursing Standard of Practice was for a reasonable period of time a resident should have to wait for their call light to be answered. The ADON indicated an Education/In-service had been completed on 8/5/25 in response to a grievance that had been filed on 7/25/25 regarding a resident who had waited two hours to have her call light answered. The Assistant Director on Nursing indicated the Education/In-Service record, dated 8/5/25, indicated the education included when to provide Activities of Daily Living (ADLs) care and honoring resident's preferences. The Assistant Director of Nursing indicated the Education/In-service Record had not specifically listed an education and instructions regarding answering call lights in a timely manner.On 9/17/25 from 12:00 P.M. to 1:08 P.M., during a facility tour, resident interviews were conducted throughout the facility. The interviews indicated the following:On the [NAME] Unit, Resident C indicated she had to wait over 30 minutes to get help after she had pressed her call light. She indicated it often took longer than 30 minutes and it had frustrated her because she had not wanted to wet herself but has had no choice. She indicated staff had not asked her if she had concerns about anything, because she would have told them she has concerns about the call lights not being answered timely.Resident D indicated staff were terrible about answering call lights. She indicated she had waited over an hour for someone to answer the light and then staff sometimes turned the light off and had not helped her to the bathroom. She indicated this had been an ongoing problem and she had filed a grievance.On the St. Paul's Unit, Resident E, indicated there was a serious concern with her call light not being answered in a timely manner. Resident E indicated she normally waited 1 1/2 hours to 2 hours for help. The resident indicated that she ended up wetting herself and she had become very uncomfortable and indicated she felt embarrassed. The resident indicated that it was just not right to make a person wait so long for help. Resident E indicated she had filed grievances for having to wait so long for help, but no one had addressed the concern with her.On the St. Joseph's Unit, Resident F indicated she waited over an hour for help.Resident G indicated she had filed grievances about the long wait for her call light to be answered, but nothing had improved and no one had talked to her about her grievances. The resident indicated her wait times were at least 30 minutes during the day and at least 2 hours at night. Resident G indicated she got very uncomfortable and dreaded the nighttime because she would not get help when call light was used. Resident G indicated she felt like crying due to the call light response issue.Resident H indicated she was very upset about the long call light wait times. She indicated she had to wait over an hour for her needs to be met and many times the call light was not answered at all. Resident H indicated she has had to wet herself and that made her feel angry and humiliated.On the St John's Unit, Resident K indicated her call light was normally answered within 30 minutes (after she had activated it) and that was fine because she knew the staff were busy and she had not wanted to complain.On the St. Mark's Unit, Resident L, indicated she has had to lay in her own urine for hours at a time waiting for staff to answer the call light. She indicated she did not feel human sometimes because of the lack of care related to toileting. Resident L indicated staff came into her room and turned off the call light and left without helping her, many times. The resident indicated the staff had told her they would be back but they never came back. The resident indicated it did no good to complain about it because it did not make a difference and if she complained, it would probably get worse for her.Resident M, indicated she has had to lay in her own feces for 2 hours. She indicated she laid and cried and cried because she was so humiliated. Resident M indicated the night shift was the worst, but no shifts answered her light in a timely manner.An interview with Resident M's family member indicated when they pressed the call light button for help, it took a very long time to get answered and then staff came in the room and turned the call-light of saying they would return, but they did not return.Resident N, indicated he always has to wait at least 15 minutes for anyone to answer his call light and it was usually longer. He indicated he used a bed pan for BMs and it got very uncomfortable to have to wait for help to get him off the bed pan and he felt frustrated.The following resident records were reviewed on 9/17/225 at 4:30 P.M.:Resident B had diagnoses that included, but were not limited to, syncope and collapse, history of falling, orthostatic hypotension, difficulty in walking. Resident B had moderate cognitive impairment and required substantial to maximal assistance for toileting hygiene and was always incontinent of bowel and bladder. The resident's Care Plan included a plan for Activities of Daily Living (ADLs), dated 6/18/25, which indicated the resident required assistance with activities of daily living.Resident C had diagnoses that included, but were not limited to atrial fibrillation, congestive heart failure, stoke, cognitive communication deficit, urine retention. Resident C cognitive ability had not been assessed, but the resident was able to answer questions during the interview process. The Care Plans included but were not limited to Self-Care Deficit associated with need for assistance with ADLs including transfers, and monitoring of incontinence of bowel and bladder and to provide incontinence care as needed, dated 1/23/25.Resident D had diagnoses that included, but were not limited to, difficulty in walking, muscle weakness, depression, anxiety, and unsteadiness on feet. Resident D was cognitively intact, required substantial to maximal assistance for toileting and most ADLs and was frequently incontinent of bladder and occasionally incontinent of bowel. Resident D's Care Plans included but were not limited to Self-Care Deficit dated 8/30/19 to observe for incontinence of bowel and bladder and to provide incontinence care as needed.Resident E had diagnoses that included, but were not limited to, hip displacement, stroke, anxiety, history of falling, need for assistance with personal care. Resident E was cognitively intact, required substantial to maximal assistance for toileting and most ADLs and was occasionally incontinent of bladder and frequently incontinent of bowel. Resident E's Care Plans included but were not limited to Self-Care Deficit dated 8/31/23 with goals to be neat, clean, without odor with assistance as needed. to observe for incontinence of bowel and bladder and to provide incontinence care as needed.Resident F had diagnoses that included but were not limited to, chronic kidney disease, muscle weakness, lack of coordination, difficulty in walking, and anxiety. Resident F had severe cognitive impairment. The residents' ADLs had not been assessed during the current assessment period. Resident F's undated Care Plans included but were not limited to Self-Care Deficit with goals to be neat, clean, without odor with assistance as needed. Incontinence for bowel and bladder, to check for incontinence; change if wet or soiled.Resident G had diagnoses that included but were not limited to, Parkinson's Disease, lack of coordination, difficulty in walking, and anxiety. Resident G was cognitively intact. Resident G's Care Plans included but were not limited to Self-Care Deficit dated 3/22/25 with goals to be neat, clean, without odor with assistance as needed.Resident H had diagnoses that included but were not limited to, hemiplegia following a stroke. Resident H's cognition was not assessed. The resident required assistance for toileting and was frequently incontinent of bladder and always incontinent of bowel. Resident H's Care Plans included but were not limited to Self-Care Deficit dated 5/24/18 with goals to be neat, clean, without odor with assistance as needed. to observe for incontinence of bowel and bladder and to provide incontinence care as needed.Resident K had diagnoses that included but were not limited to, epilepsy, chronic respiratory failure, neuropathy, and difficulty in walking. Resident Ks cognition was not assessed. The resident was dependent on others for toileting and personal care and was always incontinent of bladder and bowel and utilized a catheter. Resident K's Care Plans included but were not limited to Self-Care Deficit dated 8/9/25 with goals to be neat, clean, without odor with assistance as needed. to observe for incontinence of bowel and bladder and to provide incontinence care as needed.Resident L had diagnoses that included but were not limited to respiratory failure, congestive heart disease, lack of coordination, and difficulty in walking. Resident L was cognitively intact. Resident L's Care Plans included but were not limited to Self-Care Deficit dated 5/24/18 with goals to be neat, clean, without odor with assistance as needed. Resident M had diagnoses that included but were not limited to, Pyogenic arthritis, difficulty in walking, lack of coordination, heart failure, renal impairment, chronic kidney disease, and corneal degeneration. Resident M's cognition was not assessed. Resident M's Care Plans included but were not limited to Self-Care Deficit dated 9/8/25 with goals to be neat, clean, without odor with assistance as needed. to observe for incontinence of bowel and bladder and to provide incontinence care as needed.Resident N had diagnoses that included but were not limited to, congestive heart failure, atrial fibrillation, muscle wasting, and abnormal gait. Resident N was cognitively intact. Care Plans included but were not limited to Self-Care Deficit dated 9/11/25 with goals to be neat, clean, without odor with assistance as needed. to observe for incontinence of bowel and bladder and to provide incontinence care as needed.Review of facility Grievances from 7/1/25 to 9/15/21 included but were not limited to the following:On 7/1/25, Resident Q indicated to his Guardian Angel that he recently had had to wait 30 to 60 minutes for assistance during the night. Actions taken indicated the facility was monitoring call lights to improve the call light times. The Grievance form did not indicate that the concern had been resolved.On 7/10/25, Resident D indicated she felt it took staff an hour to answer the call light sometimes. Action taken indicated, call light report. The Grievance form did not indicate that the concern had been resolved.On 7/25/25, Resident E indicated her call light had not gotten answered for over 2 hours on the night of 7/24/25. The Action taken indicated that the Certified Nursing Assistance (CNA) and Nursing staff had been educated and in-serviced on call light response times. The Resolution indicated the resident was satisfied with the resolution at that time.On 7/30/25, Therapy indicated Resident T's call light was on upon the therapist's arrival. The patient had been very upset and stated her call light had been on for hours throughout the morning. The resident's CNA was observed in the cubicle on a phone call before and after the therapy session. The Action taken indicated that staff had spoken with the resident and reassured the resident that they would be watching the response times and had discussed the concern with the CNA. On 8/5/25, Resident R reported to the therapy department that she had not had help during the night so she had called the cops because her call light was not working and she needed help. Actions taken indicated staff had not been aware of the long call-light issue and they had discussed the importance of having their pagers with them and checking the screen often.On 8/8/25, Resident S' family member reported to the Chaplin that they had waited 45 minutes for the call light to be answered and the resident had been waiting for a long time to go to the bathroom. They indicated that the CNA had came into the room and turned off the light without completing the tasks. Action taken indicated the facility had apologized for the delay in answering the call light and had spoken with the CNA and nurse. They had checked both the pager and batteries and had assured resident and family they were addressing the concern.On 8/12/25, Resident U indicated it took 25 to 30 minutes to get help. Action taken indicated there had been no action taken regarding the long call-light wait.On 8/12/25, Resident P indicated she had turned on the call-light and it was not answered for 1 hour and 5 minutes. Action taken indicated the CNA who had not answered the light had been terminated.On 8/13/25 Resident R reported to therapy staff that she had called 911 during the night because the call light had not worked. Action Taken indicated the call light was checked and it was functioning properly. Guest did report she is becoming delirious from sleep deprivations. Her complaint is more about sleep and wanting Ambien ordered. The Resolution indicated the resident was not satisfied with the outcome.On 8/18/25, Resident R contacted the front desk and had informed them she had been waiting an hour to get cleaned up. The receptionist indicated she looked at the nurse's pager and had not seen the resident's light on, and the CNA indicated she told Resident R that she would be back to clean her up when she had finished with another resident. The receptionist indicated she observed many occasions when Resident R would use the call light as staff left her room. The receptionist indicated staff had spoken to Resident R asking her to request all needs in one trip. The Resolution indicated Resident R was not satisfied with the resolution and planned to call 911 if response times were greater than 15 minutes. The form did not indicate why the nurse's pager had not been carried by the nurse and was left at the desk for the receptionist to view.On 8/29/25, Resident G's family member had indicated she and the resident were concerned about the call light response times and that the resident sometimes had to wait for over 1 hour for help. The family member indicated she had come to visit and the Resident was soaked with urine and urine was dripping off of the resident's chair. Action taken indicated staff working during that period had been given corrective actions.Review of an Education/In-service Record, dated 8/5/25 related to Resident E's concerns on a 7/25/25 Grievance, indicated the in-service topic were ADL care for residents. It had not specifically indicated education related to answering resident call-lights had been provided.On 9/15/25 at 3:30 P.M., the Assistant Director of Nursing provided an undated policy titled, FEDERAL RESIDENT RIGHTS & FACILITY RESPONSIBILITIES, and indicated that it was the current facility policy regarding resident rights. The policy indicated, .The resident has a right to a dignified existence, self-determination.Dignity, Respect & Quality of Life. A facility must treat each resident with respect and dignity and care for each resident in a manner and in and environment that promotes maintenance or enhancement of his or her quality of life.Resolution of Grievances. The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have.This citation relates to Complaint 1232367.3.1-3(a)

Based on interview and record review, the facility failed to effectively act and resolve Resident Council's concerns related to long call light response times. This failure affected 2 of 7 residents attending the Resident/Surveyor group meeting. Findings Include: During a Resident/surveyor meeting on 4/22/25 at 12:59 P.M., seven of seven residents indicated the Resident Council had complained about long wait times for their call lights to be answered. Two of seven residents reported they were experiencing continued delays, and Resident B stated he had waited as long as an hour within the past couple of weeks. A review of Resident Council meeting minutes revealed repeated concerns over the past year about delayed call light responses on the following months: - 1/27/2025 - 10/16/2024 - 7/8/2024 During an interview on 4/24/2025 at 10:00 A.M., the Executive Director (ED) acknowledged he had been made aware of the Resident Council concerns regarding long call light response times. He indicated he had identified two potential causes for the issue related to long call light response times: the call light system required a 2-3 second hold to properly reset and some staff ignored call light alarms assuming they had already been answered and care had been provided. The ED indicated the call light concerns and system had been addressed in the facility's QAPI (Quality Assurance and Performance Improvement) meetings and a Performance Improvement Project (PIP) had been implemented for both October 2024 and January 2025. However, the long call light response/wait times had persisted. The ED indicated call light response times had been added to QAPI as a PIP in October 2024 and the plan had been closed out after two months because he was not receiving complaints from residents anymore. The ED indicated the staff had been educated on the call light system and the need to hold the reset buttons on the call lights but he was unable to provide the documentation of the education prior to the exit of the survey. In January 2025, call lights were again added to QAPI as a Performance Improvement Plan (PIP) after several complaints. One intervention was the facility had implemented was running daily reports for call light times and discussing the reports at the morning meetings. Another intervention was to have an Administrator hold a call light pager while they were in the building and the on-call manager held the call light pager while in the building on the weekends. The ED indicated after the Administrators left for the day, there was no one to monitor the call lights during the evening and night shifts. In addition, the ED indicated staff had not followed up with the residents that had experienced long call light wait times based on the call light response reports. He indicated the maintenance department was aware of the problem and had worked on the system several times. Although the facility had implemented PIP plans, the ED indicated he had based the call light wait times on resident feedback, but again indicated no one had followed up with the residents who had experienced long call light wait/response times from the call light report A review of the call light report was completed on 4/24/2025 at 11:00 A.M. The following dates and times had a call light response time of 30 minutes or longer. When asked what the facility considered a reasonable maximum call light wait/response time, the ED indicated he was not able to give a timeframe regarding when the call light should have been answered because the answer would have been different based on what the staff were working on at the time the call light went alarmed. -4/10/2025 at 12:12 A.M. call light from room [ROOM NUMBER] took 45 minutes to be turned off. -4/10/2025 at 12:23 A.M. call light from room [ROOM NUMBER] took 1 hour 15 minutes to be turned off. -4/10/2025 at 12:46 A.M. call light from room [ROOM NUMBER] took 51 minutes to be turned off. -4/10/2025 at 2:08 A.M. call light from room [ROOM NUMBER] took 59 minutes to be turned off. -4/10/2025 at 4:05 A.M. call light from room [ROOM NUMBER] took 44 minutes to be turned off. -4/10/2025 at 5:07 A.M. call light from room [ROOM NUMBER] took 34 minutes to be turned off. -4/10/2025 at 8:19 A.M. call light from room [ROOM NUMBER] took 44 minutes to be turned off. -4/10/2025 at 8:37 A.M. call light from room [ROOM NUMBER] took 1 hour and 36 minutes to be turned off. -4/10/2025 at 8:41 A.M. call light from room [ROOM NUMBER] took 1 hour and 45 minutes to be turned off. -4/10/2025 at 12:23 A.M. call light from room [ROOM NUMBER] took 59 minutes to be turned off. -4/10/2025 at 9:48 A.M. call light from room [ROOM NUMBER] took 35 minutes to be turned off. -4/10/2025 at 10:45 A.M. call light from room [ROOM NUMBER] took 56 minutes to be turned off. -4/10/2025 at 10:57 A.M. call light from room [ROOM NUMBER] took 1 hour and 37 minutes to be turned off. -4/10/2025 at 11:07 A.M. call light from room [ROOM NUMBER] took 34 minutes to be turned off. -4/10/2025 at 1:52 P.M. call light from room [ROOM NUMBER] took 37 minutes to be turned off. -4/10/2025 at 1:59 P.M. call light from room [ROOM NUMBER] took 34 minutes to be turned off. -4/10/2025 at 2:10 P.M. call light from room [ROOM NUMBER] took 1 hour and 33 minutes to be turned off. -4/10/2025 at 2:28 P.M. call light from room [ROOM NUMBER] took 53 minutes to be turned off. -4/10/2025 at 2:53 P.M. call light from room [ROOM NUMBER] took 44 minutes to be turned off. -4/10/2025 at 3:14 P.M. call light from room [ROOM NUMBER] took 1 hour and 46 minutes to be turned off. -4/10/2025 at 4:30 P.M. call light from room [ROOM NUMBER] took 32 minutes to be turned off. -4/10/2025 at 5:28 P.M. call light from room [ROOM NUMBER] took 41 minutes to be turned off. -4/10/2025 at 6:05 P.M. call light from room [ROOM NUMBER] took 30 minutes to be turned off. -4/10/2025 at 6:44 P.M. call light from room [ROOM NUMBER] took 1 hour and 57 minutes to be turned off. -4/10/2025 at 7:10 P.M. call light from room [ROOM NUMBER] took 40 minutes to be turned off. -4/10/2025 at 7:58 P.M. call light from room [ROOM NUMBER] took 60 minutes to be turned off. -4/10/2025 at 8:42 P.M. call light from room [ROOM NUMBER] took 38 minutes to be turned off. -4/10/2025 at 9:58 P.M. call light from room [ROOM NUMBER] took 45 minutes to be turned off. -4/10/2025 at 10:01 P.M. call light from room took 2 hours and 26 minutes to be turned off. -4/10/2025 at 10:03 P.M. call light from room [ROOM NUMBER] took 51 minutes to be turned off. -4/10/2025 at 10:13 P.M. call light from room [ROOM NUMBER] took 44 minutes to be turned off. -4/10/2025 at 10:15 P.M. call light from room [ROOM NUMBER] Bed A took 30 minutes to be turned off. -4/10/2025 at 10:43 P.M. call light from room [ROOM NUMBER] Bed B took 2 hours and 1 minute to be turned off. -4/10/2025 at 11:35 P.M. call light from room [ROOM NUMBER] Bed A took 32 minutes to be turned off. -4/11/2025 at 1:08 A.M. call light from room [ROOM NUMBER] Bed B took 1 hour and 40 minutes to be turned off. -4/11/2025 at 1:27 A.M. call light from room [ROOM NUMBER] took 36 minutes to be turned off. -4/11/2025 at 1:29 A.M. call light from room [ROOM NUMBER] took 1 hour and 44 minutes to be turned off. -4/11/2025 at 4:15 A.M. call light from room [ROOM NUMBER] took 1 hour and 9 minutes to be turned off. -4/11/2025 at 5:07 A.M. call light from room [ROOM NUMBER] took 2 hours and 45 minutes to be turned off. -4/11/2025 at 5:20 A.M. call light from room [ROOM NUMBER] took 1 hour and 5 minutes to be turned off. -4/11/2025 at 6:35 A.M. call light from room [ROOM NUMBER] took 2 hours and 7 minutes to be turned off. -4/11/2025 at 8:59 A.M. call light from room [ROOM NUMBER] took 1 hour and 2 minutes to be turned off. -4/11/2025 at 10:20 A.M. call light from room [ROOM NUMBER] took 38 minutes to be turned off. -4/11/2025 at 10:35 A.M. call light from room [ROOM NUMBER] took 1 hour and 40 minutes to be turned off. -4/11/2025 at 11:57 A.M. call light from room [ROOM NUMBER] took 53 minutes to be turned off. -4/11/2025 at 12:15 P.M. call light from room [ROOM NUMBER] took 2 hours to be turned off. -4/11/2025 at 1:10 P.M. call light from room [ROOM NUMBER] took 1 hour and 8 minutes to be turned off. -4/11/2025 at 1:39 P.M. call light from room [ROOM NUMBER] took 2 hours and 48 minutes to be turned off. -4/11/2025 at 3:01 P.M. call light from room [ROOM NUMBER] took 1 hour and 28 minutes to be turned off. -4/11/2025 at 3:20 P.M. call light from room [ROOM NUMBER] took 1 hour and 10 minutes to be turned off. -4/11/2025 at 3:36 P.M. call light from room [ROOM NUMBER] took 1 hour to be turned off. -4/11/2025 at 4:30 P.M. call light from room [ROOM NUMBER] took 30 minutes to be turned off. -4/11/2025 at 6:41 P.M. call light from room [ROOM NUMBER] took 59 minutes to be turned off. -4/11/2025 at 6:46 P.M. call light from room [ROOM NUMBER] Bed A took 43 minutes to be turned off. -4/11/2025 at 8:08 P.M. call light from room [ROOM NUMBER] Bed B took 54 minutes to be turned off. -4/11/2025 at 8:21 P.M. call light from room [ROOM NUMBER] took 48 minutes to be turned off. -4/11/2025 at 8:38 P.M. call light from room [ROOM NUMBER] took 40 minutes to be turned off. -4/11/2025 at 9:15 P.M. call light from room [ROOM NUMBER] took 41 minutes to be turned off. -4/11/2025 at 9:44 P.M. call light from room [ROOM NUMBER] took 35 minutes to be turned off. -4/11/2025 at 10:39 P.M. call light from room [ROOM NUMBER] took 1 hour and 29 minutes to be turned off. -4/11/2025 at 11:14 P.M. call light from room [ROOM NUMBER] took 40 minutes to be turned off. This citation relates to Complaint IN00454362. 3.1-19(u)

Based on record review and interview, the facility failed to ensure the Discharge Minimum Data Set (MDS) assessment was completed and submitted in a timely manner for 1 of 4 residents who were reviewed for discharge assessments. (Resident 29) Findings include: Resident 29's record review was completed on 04/23/2025 at 10:47 AM. Diagnoses included, but were not limited to: hypertension, atrial fibrillation, and arthritis. Resident 29 was discharged on [DATE]. Resident 29's Discharge MDS assessment was completed and submitted on 4/23/2025, 122 days after discharge. During an interview on 04/28/25 at 11:15 AM, the Director of Nursing (DON) indicated the MDS assessment had not been completed or submitted timely. The DON also indicated the facility did not have a policy related to MDS assessment completion and followed the Resident Assessment Instrument (RAI) manual as their guidance. According to the RAI User's Manual, Chapter 2, Page 2-17, a Discharge assessment must be completed (i.e., signed and dated as complete) within 14 days after the resident had been discharged from the facility, and submitted within 14 days of completion.

Based on observation, interview and record review, the facility failed to develop a comprehensive care plan for 2 of 17 residents reviewed for care planning ( Resident 22-bowel issues) and (Resident 27-skin issues). Findings include: 1. A record review was completed on 4/23/2025 at 9:01 A.M. for Resident 22. Diagnoses included, but were not limited to, Parkinson's disease and chronic kidney disease. A Significant Change Minimum Data Set (MDS) assessment, dated 1/29/2025, indicated Resident 22's cognition was moderately impaired and he was occasionally incontinent of bowels. Physician Orders included, but were not limited to: -3/20/2025 Linzess 145 micrograms (mcg) by mouth daily for constipation. -3/13/2025 polyethylene glycol 17 grams by mouth daily mixed with 4-8 ounces of water for constipation. -12/10/2024 docusate sodium 100 milligrams (mg) by mouth twice a day for constipation. The record lacked a care plan that addressed bowel issues, including constipation, and the use of bowel medications. During an interview on 4/25/2025 at 1:40 P.M., the ADON confirmed although Resident 22 received three different medications for his bowels, there was no care plan addressing the bowel issues or medication use. 48145 2. During an observation of a medication administration on 04/23/2025 at 8:51 A.M., Resident 27 had a dime-sized blister located directly below the G-tube site on his abdomen. LPN 4 indicated the blister was new and attributed it to friction caused by the G-tube tubing being too long. LPN 4 pointed to a band-aid located toward the center of Resident 27's abdomen and indicated the resident had developed a similar blister several days earlier due to friction from the tubing rubbing on the resident's skin. LPN 4 indicated the resident did not have an order for the treatment of the second blister and she did not know if the facility had created a Care Plan to address further blister formation from the G-tube. Resident 27's record review was completed on 04/23/2025 at 10:51 AM. Diagnoses included, but were not limited to: cerebral infarction, rhabdomyolysis, dysphagia, and chronic kidney disease. An Admission Minimum Data Set (MDS) assessment, dated 1/28/2025, indicated the had a G-tube. There was no care plan for Resident 27 to address the skin issues caused by his gastostomy tube. A Nurse's Progress Note, dated 04/21/2025, indicated, Blister noted to belly near G-Tube holder, red, unopened, possibly due to friction and rubbing of G-tube and clamp. Repositioned tubing, secured with paper tape and blister covered with band aid for protection. Clinical Care Coordinator (CCC) was aware. During an interview with the Director of Nursing (DON) on 4/25/2025 at 10:59 A.M., the DON indicated Resident 27 should have had a G-tube care plan created after admission. On 4/25/2025 at 1:18 P.M., the Director of Nursing (DON) indicated the facility did not have a policy related to creating care plans and the facility used the Nursing Standards of Practice for creating care plans. American Nurses Association (ANA), Nursing: Scope and Standards of Practice, 4th Edition, 2021, included, The registered nurse develops a collaborative plan encompassing strategies to achieve expected outcomes. The plan reflects current evidence, is derived from the assessment, and is modified as needed in response to the patient's condition or situation 3.1-35 (d)

Based on observation, interview and record review, the facility failed to ensure the skin of a resident with a Gastronomy tube (G-tube) did not develop blisters caused by the friction from the G-tube for of 1 of 6 residents who were reviewed for skin problems. (Resident 27) Finding includes: During an observation of a medication administration on 04/23/2025 at 8:51 A.M., Resident 27 had a dime-sized blister directly located below the G-tube site on his abdomen. LPN 4 indicated the blister was new and attributed it to friction caused by the G-tube tubing being too long. LPN 4 pointed to a band-aid located toward the center of Resident 27's abdomen and indicated the resident had developed a similar blister several days earlier due to friction from the tubing rubbing on the resident's skin. LPN 4 indicated the resident did not have an order for the treatment of the second blister and she did not know if the facility had created a Care Plan to address further blister formation from the G-tube. Resident 27's record review was completed on 04/23/2025 at 10:51 AM. Diagnoses included, but were not limited to: cerebral infarction, rhabdomyolysis, dysphagia, and chronic kidney disease. A Nurse's Progress Note, dated 04/21/2025, indicated, Blister noted to belly near G-Tube holder, red, unopen, possibly due to friction and rubbing of G-tube and clamp. Repositioned tubing, secured with paper tape and blister covered with band aid for protection. Clinical Care Coordinator (CCC) was aware. Resident 27's record lacked the documentation that the provider had been notified of the new blister, orders for treatment of the new blister had been obtained, or a Care Plan had been created after either blister developed. During an interview with the CCC and the Director of Nursing (DON) on 4/25/2025 at 10:59 A.M., the CCC indicated she had been notified verbally about the blister but because the notification was verbal, she had forgotten to follow up. The CCC indicated the provider and family had not been notified but should have been and the resident's plan of care should have been updated. The CCC indicated, in addition, physician orders should have been obtained regarding treatment of the blister and preventative treatments for the G-tube site. The DON indicated Resident 27 should have had a care plan created for a G-tube after the first blister had formed On 4/25/2025 at 1:18 P.M., the Director of Nursing (DON) indicated the facility did not have a policy for contacting the provider for a change in the resident's condition or a policy related to creating care plans. The DON indicated the facility used the Nursing Standards of Practice for contacting the provider and creating a care plan. American Nurses Association (ANA), Nursing: Scope and Standards of Practice, 4th Edition, 2021, included, The registered nurse communicates effectively in all areas of practice. This includes timely and appropriate communication with healthcare providers regarding changes in patient condition The registered nurse develops a collaborative plan encompassing strategies to achieve expected outcomes. The plan reflects current evidence, is derived from the assessment, and is modified as needed in response to the patient's condition or situation. 3.1-37 (a)

Based on record review and interviews, the facility failed to ensure there was adequate monitoring of an antipsychotic medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 25) Findings include: A record review for Resident 25 was completed on 4/23/2025 at 4:01 P.M. The resident's diagnoses included, but were no limited to: hypertension, diabetes mellitus, anxiety, depression, bipolar disorder and hereditary and idiopathic neuropathy. A Quarterly Minimum Data Set (MDS) assessment, dated 4/15/2025, indicated Resident 25 was cognitively intact. The MDS assessment indicated the resident had no potential indicators of psychosis, no behavioral symptoms, had not demonstrated any rejection of care and had no wandering behaviors. In addition, the MDS assessment indicated the resident was receiving an antipsychotic, an antidepressant, an anticoagulant and a diuretic medication. A Physician Order, dated 2/20/2025, indicated the resident was to receive Aripiprazole (anti-psychotic) 2 mg (milligrams) tablet oral six times weekly for bipolar disorder. A Pharmacy Consultation Report, dated 8/8/2024, recommended an AIMS (Abnormal Involuntary Movement Scale) or similar assessment be completed for Resident 25, as one had not been completed in the previous 6 months. A Pharmacy Consultation Report, dated 9/17/2024, indicated a second request for an AIMS assessment, or similar assessment, be completed for Resident 25. The recommendation was signed by the medical provider. However, an AIMS assessment was not completed for Resident 25 until 1/19/2025. A current Care Plan, revised 1/19/2025, indicated Resident 25 had a diagnosis of bipolar disorder and was treated with an antipsychotic medication. Interventions included, but were not limited to: perform an AIMS test quarterly and as needed. During an interview, on 4/24/2025 at 3:22 P.M., the Assistant Director of Nursing (ADON) indicated Resident 25 has been on an antipsychotic and had an AIMS assessment completed in January and April of 2025. The ADON indicated the facility's policy was for nursing to complete AIMS assessments for residents taking antipsychotic medications every quarter or with any new dosage changes. During an interview, on 4/25/2025 at 10:02 A.M., the Social Services Worker (SSW) indicated she created the care plans for the residents in conjunction with the Unit Manager. SSW indicated the interventions in the care plan were monitored for completion by herself and the Unit Manager or other nursing management. SSW indicated she was unsure how the completion of AIMS assessments were being monitored. During an interview, on 4/25/2025 at 2:52 P.M., the ADON indicated there was no written facility policy regarding AIMS but that the facility standard was to perform an AIMS assessment every 6 months on any resident taking an antipsychotic. 3.1-25(i)

Based on observation and interview, the facility failed to ensure the kitchen equipment was in working order for 1 of 1 kitchen reviewed. This deficient practice had the potential to affect 66 of 66 residents who received meals from the kitchen. Finding includes: On 4/21/2025 at 9:26 A.M., an observation included the northernmost sink of the cooking area of the kitchen. This sink was leaking underneath into the drainage area from the drain pipe in addition to the faucet slowly running and unable to be turned off. During an interview, on 4/21/2025 at 10:15 A.M., the Dietary Manager indicated Maintenance was aware of the broken sink and she indicated maintenance was waiting for a part to fix the sink. During an interview, on 4/24/2025 at 1:44 P.M., the Maintenance Director indicated he had never received a work order for the kitchen sink and was unaware of any broken sink in the kitchen. During an interview, on 4/24/2025 at 1:51 P.M., Registered Dietician 1 indicated she was unaware of any leaking sink in the kitchen and stated, I usually just go through there and haven't noticed anything. On 4/24/2025 at 3:15 P.M., the Director of Nursing (DON) provided a policy titled, Director of Dining Services, undated and indicated the policy was the one currently used by the facility. The policy indicated, .the Director of Dining Services .directs and conducts safety, sanitation, and maintenance programs . On 4/24/2025 at 3:15 P.M., the DON provided a policy titled, Registered Dietitian, undated and indicated the policy was the one currently used by the facility. The policy indicated, .The Registered Dietitian .set and communicate objectives, communicate, and reinforce high standard in all areas, monitor performance and addresses issues . 3.1-19(bb)

Based on observation, record review and interview, the facility failed to ensure enhanced barrier precautions were followed for 2 of 5 residents reviewed for isolation needs. (Resident 27 and 35) Findings include: 1. The clinical record of Resident 35 was reviewed on 4/24/2025 at 10:26 A.M. The resident's diagnoses included, but were no limited to: diabetes mellitus, septicemia, obstructive uropathy, hypertension, anxiety and depression. An Annual Minimum Data Set (MDS) assessment, dated 2/24/2025, indicated Resident 35 was moderately cognitively impaired, was taking an antibiotic and had an indwelling catheter. A Physician Order, dated 10/19/2024, indicated Resident 35 was to be in enhanced barrier precautions; with instructions noted to maintain enhanced barrier precautions during high-contact resident care activities. A current Care Plan, created 5/31/2024, indicated Resident 35 required enhanced barrier precaution isolation. During an observation and interview on 4/24/2025 at 11:08 A.M., CNA 3 entered Resident 35's room without any PPE (personal protective equipment or gear worn to minimize exposure to workplace hazards that could cause serious injuries or illnesses, such as chemical, radiological, physical, electrical, or mechanical hazards) in place. The PPE cart was located outside of the resident's room door. CNA 3 then performed hand hygiene with hand sanitizer and donned clean gloves once inside Resident 35's room but she did not don a gown or a mask. CNA 3 then transferred Resident 35 from her bed to her wheelchair. CNA 3 exited Resident 35's room after removing her gloves and performed hand hygiene. CNA 3 indicated she was unaware the resident was on contact precautions as CNA 3 indicated the nurse had not instructed her regarding the need for enhanced barrier precautions. CNA indicated if the resident was on enhanced barrier precautions, she should have been following the policy and worn a gown and mask. 48145 2. During an observation of a medication administration on 04/23/2025 at 8:51 AM, LPN 4 administered a 200 milliliter (mL) water flush to Resident 27 Gastrostomy tube while only wearing gloves. LPN 4 was not wearing a gown when she administered the flush. An Enhanced Barrier Precautions (EBP) sign was hanging on Resident 27's to room door. During an interview on 04/23/2025 at 8:58 AM, LPN 4 indicated Resident 27 was in EBP and she should have worn a gown while administering the flush. Resident 27's record review was completed on 04/23/2025 at 10:51 AM. Diagnoses included, but were not limited to: cerebral infarction, rhabdomyolysis, dysphagia, and chronic kidney disease. A current Physician's order, dated 02/04/2025, indicated Resident 27 was on EBP. A current Care Plan, initiated on 01/28/2025, indicated Resident 27 was on EBP related to a Gastrostomy Tube (G-tube). On 04/23/2025, the Assistant Director of Nursing (ADON) provided a policy, dated 11/12/2024, and titled Infection Prevention. The ADON indicated it was the policy currently used by the facility. The policy indicated: .2. Enhanced Barrier Precautions .The use of gown and gloves for high-contact resident care activities may be indicated, when Contact Precautions do not otherwise apply, for nursing home residents with chronic wounds and/or indwelling medical devices regardless of MDRO colonization 3.1-18(a)

Based on observation and interview the facility failed to ensure water faucets were functional in 4 of 30 rooms in the long term care unit. (Rooms W7, W12, W15 and W24) Findings include: 1. During an observation on 4/25/2025 at 2:00 P.M., the faucet in Room W7 was running and could not be turned off. During an interview on 4/25/2025 at 2:00 P.M., Resident 57 indicated it had been running for quite awhile but did not know how long. She had reported it to the facility but it had not been fixed yet. She indicated she turned her television volume up louder so she forgot about it and was able to sleep. 2. During an observation of Room W24 on 4/22/2025 at 11:12 A.M., the faucet was missing and water was continuously dripping down the back of the sink. 3. During an observation of W15 on 4/22/2025 at 9:44 A.M., the faucet was dripping continuously. 4. During an observation of Room W12 on 4/22/2025 at 9:45 A.M., the faucet was dripping continuously. During a tour and an interview on 4/25/2025 at 2:35 P.M., the Maintenance Director indicated he had tried to fix the faucets but they needed to be replaced and he was not sure how many leaking sinks the facility had but admitted there were several. He indicated he had ordered new parts several months ago, and the parts had come in, but he was now waiting on a new tool that he had ordered. When asked when the tool was ordered he returned with the tool indicating it had just been delivered, and he would begin fixing the leaking faucets. On 4/25/2025 at 2:35 P.M. dates of work orders for leaking faucets and invoices, or purchase orders for parts and tools were requested, but none were provided prior to the exit of the survey. During an interview on 4/28/2025 at 11:00 A.M., the ED. indicated the facility did not have a policy for maintenance of the building. 3.1-19(f)

Based on record review and interviews the facility failed to ensure a resident received the required transfer assistance for 1 of 2 residents reviewed for accident hazards. (Resident E) Finding includes: The record for Resident E was reviewed on 6/24/24 at 1:41 P.M. Resident E's diagnoses, included but were not limited to: cerebrovascular accident and osteoporosis. The Admission Minimum Data Set (MDS) assessment, dated 5/29/24, indicated Resident E's cognition was moderately impaired and she was dependent on staff to complete all activities of daily living (ADLs) including transfers. A care plan for Resident E, dated 5/23/24, indicated the resident had a self care deficit related to right side hemiparesis and staff were to transfer the resident with the extensive assistance of 2 staff members. During an interview on 6/24/24 at 1:53 P.M., Resident E's family member indicated during her visit on 6/6/24, the resident told her she had fallen and her leg was injured. During an interview on 6/24/24 at 1:42 P.M., the DON indicated during the investigation of the incident regarding a potential fall for Resident E and leg injury, all staff who had cared for Resident E on 6/6/2024 were interviewed and no one was aware and/or had witnessed any falls for Resident E. However, a CNA reported she had transferred the resident without any assistance from another staff person. An x-ray was completed on 6/8/24 for Resident E and indicated the resident had a non-displaced fracture of the right tibia and fibula. The Nursing Progress notes, dated 6/8/24, indicated the resident's family member was notified of the fracture, the resident was sent to the emergency room for an evaluation and was later admitted to the hospital. During an interview on 6/25/24 at 11:54 A.M., CNA 3 indicated when she received her assignments for her shift she checked the computer for any care information for her residents. There was a Resident Care Summary posted on the inside of the resident's closet doors. If a resident required a 2 person transfer, she would ask a co-worker for help. If another CNA was not available she would ask the nurse or a staff member from a nearby unit for help. CNA 3, when asked directly why she had transferred Resident E by herself previously, gave no reason for the incorrect transfer. CNA 3 kept repeated the above information regarding where she obtained resident information regarding the care needs of her assigned residents. During an interview on 6/25/24 at 11:32 A.M., the DON indicated the facility did not have a policy regarding following resident's plan of care. She initiated there had not been any other issues or resident injuries reported regarding CNA 3 not following the plans of care. This citation relates to complaint IN00436381. 3.1-45(a)(2)

Based on interview, observation and record review, the facility failed to maintain appropriate food temperatures of the meal trays on St. Paul's Unit. This had the potential to affect the 21 Residents who eat on St. Paul's Unit. Finding includes: During an interview, on 4/15/2024 at 11:15 A.M., Resident 117 indicated he ate his meals in the dinning area on the unit and most of his meals were cold. Resident 117 was able to request to have his meals heated to a warmer temperature, but stopped asking because every meal was cold. An observation of food temperatures for the meal trays on St. Paul's Unit was completed, on 5/20/2024 at 12:13 P.M. The Dietary Project Manager pulled the first tray off the food cart and used her thermometer to take the temperature of the food. The cabbage had a temperature of 135 degrees Fahrenheit and the pot roast had a temperature of 141 degrees Fahrenheit. The Dietary Project Manger requested a dietary aide begin microwave each plate. There were 21 trays on the food cart. During an interview, on 5/20/2024 at 12:15 P.M., the Dietary Project Manager indicated the cabbage and pot roast were not at the correct temperature to serve and all the meals trays on St. Paul's Unit would have to be heated in the microwave until the food was 145 degrees Fahrenheit. On 5/20/2024 at 2:13 P.M., the Administrator provided a current policy, dated 1/2024, and titled, Meal Quality and Temperature. The policy indicated, .Food and drinks are palatable, attractive and served at a safe and appetizing temperature to ensure resident satisfaction and to meet nutrition and hydration needs 3.1-21(a)(2)

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared and served in a sanitary manner in 1 of 1 kitchens observed. The facility also failed to ensure food brought in by outside sources and placed in resident nourishment refrigerators was stored in accordance with professional standards for food safety and used for food and beverages only for 4 of 4 panty rooms observed. This deficient practice had the potential to affect 76 of 77 residents who resided in the facility and consumed from from the kitchen or pantries Findings include: 1. Upon entering the kitchen on [DATE] at 9:05 A.M., on top of the ice machine was 2 scoops lying uncovered, and the storage container was open but empty. During an interview on [DATE] at 9:06 A.M., the Dietary Supervisor indicated that the scoop storage container was broken, and they had just been laying the scoops on top of the machine, another container had been ordered. On [DATE] at 3:33 P.M., the Administrator provided a policy titled, Sanitation and Infection Prevention/Control, dated ,d+[DATE] and indicated the policy was the one currently used by the facility. The policy indicated .Use a scoop to remove ice from the storage bin into the receptacle used for service. Store the scoop in a self-draining container, in an area protected from contamination. The scoop cannot be stored in the ice bin, unless the container for the scoop is placed in a way that does not allow the ice scoop handle to come in contact with the ice . 2. On [DATE] at 9:07 A.M. to 9:44 A.M., an initial tour of the kitchen was completed with the Dietary Supervisor and the following was observed: a. Dry storage there was a bag of stuffing with an open date of [DATE] with a best used by date of [DATE], a bag of wheat pasta opened [DATE] with best used by date of [DATE], a bag of ziti noodles opened [DATE] with best used by date of [DATE], a box of Orzo opened [DATE] with best used by date of [DATE] and a container of coriander spice expired [DATE]. b. In the freezer the following items were opened, unsealed and undated: a box of cooked sausage crumble, chicken Kiev portions, pate scones, cookies and green beans. There was also an opened unsealed bag of carrots open dated [DATE] and [NAME] fish dated [DATE]. During an interview on [DATE] at 9:17 A.M., the Dietary Supervisor indicated the food should be dated when open and sealed. On [DATE] at 3:24 P.M., the Administrator provided a policy titled, PRODUCTION, PURCHASING, STORAGE, FOOD AND SUPPLY STORAGE, dated ,d+[DATE], and indicated the policy was the one currently used by the facility. The policy indicated, .Most but not all products contain an expiration date. The words sell-by, best-by, enjoy by or use-by should precede the date. The sell-by date is the last date that food can be sold or consumed; do not sell products in retail areas or place on patient trays/resident plates past the date on the product. Foods past the used-by, sell-by, best-by, or enjoy-by date should be discarded. Cover, label and date unused portions and open packages. Complete all sections on a [NAME] orange label or use the Medvantage/Freshdate labeling system. Products are good through the close of business on the date noted on the label. 3. During a follow up observation in the kitchen, on [DATE] at 11:10 A.M.,the Sous Chef 2 was pureeing zucchini and pasta. The Sous Chef had a mustache and a goatee, approximately ,d+[DATE] inch long, neatly trimmed, without a hair restraint. During an interview on [DATE] at 11:26 A.M., the Sous Chef indicated he did not have to wear a hair restraint because he kept it short. The State allowed it. The Project Manager handed him a hair restraint. On [DATE] at 12:10 P.M., the Project Manager provided a policy titled, Safety and Sanitation, Hair Restraints/Beard Guards, revised ,d+[DATE], and indicated the policy was the one currently used by the facility. The policy indicated .Beards* are not recommended for any team member who handles food however if a team member had a beard/Facial Hair ,d+[DATE]' growth or more than a beard guard must be worn at all times while in the kitchen and/or handing food. *Please refer to the local state requirements . 4. During a dining room observation on [DATE] at 12:05 P.M., Resident 4 was given his tray with the food covered. At 12:15 P.M., the resident's food was uncovered and CNA 3 sat down to assist the resident with his meal of sandwich and chips. CNA 3 was observed feeding the resident his sandwich and potato chips with her bare hands. During an interview on [DATE] at 12:24 P.M., CNA 3 indicated she should be wearing gloves when assisting with finger-foods, however, the DON had informed her they were not to wear gloves outside the resident's rooms. CNA 3 indicated she was confused regarding when she should be wearing gloves. On [DATE] at 3:29 P.M., the DON indicated they did not have a policy on assisting with meal service with dependent residents or the passing of trays. 5. During an observation on [DATE] at 10:07 A.M., St. John's nourishment refrigerator contained a covered dinner plate with a note stating SAVE containing a chef's salad, a store bag with 4 containers of Okio brand yogurt without a label or date. 6. During an observation on [DATE] at 10:08 A.M., the St. Mark's refrigerator/freezer contained three resident's treatment ice packs in the freezer with ice cream cups. The Project Manager did not know why the treatment ice packs were in the freezer with food items. 7. During an observation on [DATE] at 10:11 A.M., the St. Luke's unit freezer contained had 4 resident's treatment ice packs, along with an unlabeled frozen dinner and ice cream cups. 8. During an observation on [DATE] at 10:18 A.M., the St. [NAME] Way refrigerator contained a cardboard pizza box, dated [DATE] and labeled [first name]. The Project Manager indicated it was a staff member's pizza. 9. During an observation on [DATE] at 10:21 A.M., the St. Paul's refrigerator contained take out containers from the store of chicken [NAME] and 2 salads with Resident 16's name on it, all undated. During an interview on [DATE] at 10:23 A.M., the Project Manager indicated food brought in by the residents needed to be labeled with their name and the date. Employee foods should not have been in the resident refrigerator and residents' treatment ice packs caused cross contamination. On [DATE] at 11:28 A.M., the Project Manager provided a policy titled, Use and STORAGE OF FOOD BROUGHT TO RESIDENTS FROM THE OUTSIDE. revised ,d+[DATE], and indicated the policy was the one currently used by the facility. The policy indicated .The outside food must be stored in a container with a tight-fitting lid, clearly labeled with the residents name and room number, the date the food was brought to the resident, and the use-by date . On [DATE] at 12:55 P.M., the Project Manger provided a policy titled, Cleaning of Refrigerators, revised [DATE], and indicated the policy was the one currently used by the facility. The policy indicated .3. Food for colleagues shall not be stored in the resident refrigerator . 3XXX,d+[DATE](i)(3)

Based on interview and record review, the facility failed to provide the resident or representative, a notice of transfer/discharge or a copy of the bed hold policy for 1 of 1 resident reviewed for hospitalization s. (Resident 65) Finding includes: During an interview, on 5/14/24 at 10:29 A.M., Resident 65 indicated he was hospitalized a couple of weeks ago but could not recall why. A record review for Resident 65 was conducted on 5/16/24 at 9:31 A.M. Diagnoses included, but were no limited to, partial amputation of right foot and diabetes mellitus. A Five Day Minimum Data Set assessment, dated 4/19/24, indicated Resident 65 had an intact cognition Nursing Progress Notes, dated 5/1/24, indicated Resident 65 was sent to the emergency room for a change in condition and was admitted to the acute care center with a diagnosis of pneumonia. The record lacked documentation a notice of transfer/discharge or a bed hold policy was given to the resident when he was sent to the emergency room . During an interview, on 5/17/24 at 2:23 P.M., the DON indicated she was unable to find tdocumentation Resident 65 was provided a notice of transfer/discharge or a copy of the bed hold policy for the 5/1/24 admission to the hospital. On 5/20/24 at 3:24 P.M., the DON provided a checklist form for transfers and indicated there was not a policy that addresses documents that should be sent when a resident goes to the hospital but she did provide a checklist. 3.1-12(a)(25)(26)

Based on record review and interview, the facility failed to develop a person-centered care plan addressing depression for 1 of 21 residents whose care plans were reviewed. (Resident 53) Finding includes: A record review was completed on 5/15/2024 at 12:22 P.M. for Resident 53. Diagnoses included, but were not limited to major depressive disorder, chronic obstructive pulmonary disease, and heart failure. A Care Plan, dated 4/29/2024, indicated Resident 53 had mood and behavior concerns related to depression. Interventions included: administer medications as ordered; provide a calm and quiet environment; monitor for triggers of mood changes and provide appropriate interventions as needed. There were no specific interventions to address what specific triggers the resident exhibited or what appropropriate interventions were planned for Resident 53. During an interview, on 5/20/2024 at 10:08 A.M., the Assistant Director of Nursing indicated Resident 53 did not have person-centered interventions for her Care Plan. A policy for developing person-center care plans was requested from the Director of Nursing, on 5/20/2025 at 10:30 A.M. During an interview on 5/20/2024 at 1:22 P.M., the Director of Nursing indicated the facility did not have a policy for person-centered care plans. 3.1-35(a)

Based on record review, and interview, the facility failed to ensure care plans were revised and care conferences were held quarterly for 2 of 3 residents reviewed for care planning. (Resident 37 & 58) Finding include: During an observation, on 5/14/2024 at 3:18 P.M., Resident 37's right hand was contracted and there was no splint on the resident's right hand. During an observation, on 5/15/2024 at 9:16 A.M., Resident 37 was wearing a soft splint to her right hand. During an observation, on 5/17/2024 at 9:11 A.M., Resident 37 was not wearing a soft splint to her right hand. A Physicians Order, dated 8/31/2019, indicated to apply a soft resting hand splint to the right hand daily, place on prior to bed and take off upon rising. A Care Plan, dated 5/22/2020, indicated the following: -I have right side hemiparesis related to cardiovascular accident. Interventions included: I wear a soft splint to my right hand, on in AM, off HS (hour of sleep). -I have self care deficits associated with need for assistance with activities of daily living (ADL's). Interventions included: right soft resting hand splint to right hand daily ON PB (prior to bed). - I am at risk for skin breakdown. Interventions included: right soft resting hand splint to right hand daily, on prior to bed, off at hour of sleep. During an interview, on 5/17/24 at 1:26 P.M., LPN 14 indicated Resident 37's soft right hand splint got put on in the evening prior to bed time and removed upon waking. She indicated the care plan needed to be revised. On 5/20/24, at 3:31 P.M., a policy for revising care plans was requested and one was not provided prior to the survey exit. During an interview, on 5/15/24 at 9:18 A.M., Resident 37's family indicated it had been more than a year since they had been invited to a care conference. A record review was completed on 5/16/24 at 9:56 A.M., for Resident 37. Diagnosis included, but were not limited to: Type 2 diabetes, aphasia, major depressive disorder, and dementia. There was no documentation in the record to indicate Resident 37 had a care conference conducted since 3/30/2023. During an interview, on 5/20/24 at 3:25 P.M., the DON indicated Resident 37 had not had a care conference in the last year and should have. 2. A record review was completed, on 5/16/24 at 3:12 P.M., for Resident 58. Diagnoses included, but were not limited to scoliosis, hypertensive heart disease, adjustment disorder with anxiety and depressed mood, and insomnia. During an interview, on 5/14/24 at 10:03 A.M., Resident 58's family indicated it had been 6-9 months since they were invited to a care conference. There was no documentation int he record to indicate Resident 58 had a care conference conducted between 6/27/23 and 3/21/24. During an interview, on 5/20/24 at 3:25 P.M., the DON indicated Resident 37 and Resident 58 did not have a care conference every quarter and should have had one scheduled. On 5/20/24, at 3:28 P.M., a policy for care conferences was requested and one was not provided prior to the survey exit. 3.1-35(d)(2)(B)

Based on observation, interview, and record review, the facility failed to provide assistance with Activities of Daily Living (ADLs) related to bed baths, shaving, and turning and positioning per standards of care for 2 of 3 residents reviewed for ADL care. (Resident 37 & 46) Finding includes: 1. During an observation, on 5/14/24 at 3:18 P.M., Resident 37's fingernails were long and dirty. During an observation, on 5/15/2024 at 9:16 A.M., Resident 37's fingernails remained long and dirty. During an observation, on 5/16/2024 at 10:19 A.M., Resident 37's fingernails remained long and dirty. A record review was completed on 5/16/2024 at 9:56 A.M. for Resident 37. Diagnoses included, but were not limited to hemiplegia and hemiparesis, type 2 diabetes, major depressive disorder, dementia, and aphasia. A Quarterly Minimum Data Set (MDS) assessment, dated 3/6/2024, indicated that Resident 37 had severely impaired cognition and was dependent on staff with bed mobility, transfers, dressing, toileting, hygiene and bathing, and required a mechanical lift (hoyer) with two staff for transfers. A current Care Plan, dated 8/8/2019, was provided and indicated Resident 37 required staff assistance with deficits of activities of daily living (ADLs) with a current intervention of Assist with personal hygiene. On 5/20/2024 at 10:30 A.M., Resident 37's shower record from 3/8/2024 to 5/16/2024 was provided by the Administrator. Resident 37 received one bed bath between 4/16/2024 and 4/30/2024, and one bed bath between 5/3/2024 and 5/13/2024, with no refusals of care documented for that time period. During an interview, on 5/16/24 at 11:01 A.M., CNA 13 indicated during a sponge bath warm water and soap were used and staff washed the resident's entire body. Nail care was included in sponge baths and whenever staff observed the resident needed it. During an interview, on 5/21/24 at 09:11 A.M., the DON indicated the resident should have had additional bed bath during the timeframe where there were large gaps between dates. 44111 2. During an interview on 5/15/2024 at 9:25 A.M., Resident 46 indicated that he never gets shaved unless CNA 12 worked, she was the only one who shaved him. When he lived at home, he shaved every day, and he preferred to be shaved daily. He was observed to be unshaven at the time of the interview During an observation on 5/15/2024 at 2:56 P.M., he was remained unshaved. During an observation and interview on 5/16/2024 at 10:44 A.M., Resident 46 indicated he had not been washed up yet or shaved today and his call light was on to be changed. During an observation and interview on 5/16/2024 at 3:05 P.M., Resident 46 indicated he was not shaved today, facial hair was present. During an observation on 5/17/2024 at 9:15 A.M., Resident 46 was unshaven. During an observation on 5/17/2024 at 2:08 P.M., Resident 46 was unshaven. During an observation and interview on 5/20/2024 at 9:24 A.M. Resident 46 indicated he had not been shaved all weekend, he had an increased growth of whiskers. During an observation on 5/21/2024 at 9:35 A.M., Resident 46 was unshaven. A record review was completed on 5/17/2024 at 9:05 A.M. for Resident 46. Diagnoses included, but were not limited to cardiovascular accident, hemiplegia, hemiparesis, peripheral vascular disease and depression. A Quarterly Minimum Data Set Assessment, dated 4/24/2024, indicated Resident 46 was dependent for oral hygiene, personal hygiene, shower/bath, upper and lower body dressing, toileting, transfers and bed mobility. He had limited range of motion on one side to the upper and lower body extremity. A Care Plan, dated 2/12/2019, for self care deficit associated with need for assistance with ADL's related to history of cerebrovascular accident resulting in left sided weakness, included a goal the for the resident to be neat, clean and well-groomed. A Resident Summary on activities of daily living care/bathing, dated 1/3/2022, indicated Resident 46 was extensive assist of 2 with a hoyer lift for transfers and bed mobility, supervision with eating, assist with oral care twice daily, expressed a shower preference of twice a week and had full dentures. On 5/17/2024 at 11:30 A.M., the DON indicated resident preferences could be found on the resident's summary. During an interview on 5/16/2024 at 1:42 P.M., CNA 5 indicated when she completed morning care, she washed the resident's underarms and peri-area, brushed the resident's teeth, applies lotion, combed the resident's hair and made the bed. During an interview on 5/16/2024 at 2:01 P.M., CNA 6 indicated that when she completed morning care, she provided a bed bath, applied lotion, assisted with dressing, brushed the resident's teeth, combed the resident's hair and offered a shave. During an interview on 5/17/2024 at 9:18 A.M., CNA 7 indicated that when she completed morning care, she washed the resident's upper body, then peri-area, put on a brief, assisted with dressing, and brushed the resident's teeth. During an interview on 5/20/2024 at 11:13 A. M., the Director of Nursing indicated she did not have a policy on activities of daily living or shaving. During an interview on 5/15/2024 at 9:25 A.M., Resident 46 indicated that the staff did not turn him every two hours. He indicated he would like to get the pressure off his buttock, he became sore at times and rarely got out of bed. During an observation and interview on 5/16/2024 at 10:44 A.M., Resident 46 indicated he had not been washed up yet or shaved today and his light was on to be changed. Resident 46 was lying in a supine position in bed. During an observation on 5/16/2024 at 3:05 P.M., Resident 46 was on his back in bed. During an observation on 5/17/2024 at the following times: 9:15 A.M., 10:28 A.M., 11:48 A.M., 1:18 P.M., 2:08 P.M., resident was in bed positioned on his back. During an interview on 5/17/2024 at 11:48 A.M., Resident 46 indicated no one has turned and repositioned him today. During an observation on 5/20/2024 at the following times: 9:24 A.M., 11:50 A.M. and 2:37 P.M. the resident was lying on his back in bed. During an observation on 5/21/2024 at 9:35 A.M., the resident was lying on his back in bed. The CNA documentation on turn and reposition for Resident 46 in the electronic medical record indicated the following:: 5/14/2024 1:51 P.M. 5/14/2024 9:13 P.M. 5/15/2024 3:20 A.M. 5/15/2024 11:29 A.M. 5/15/2024 2:25 P.M. 5/16/2024 12:10 A.M. 5/16/2024 2:08 P.M. 5/16/2024 3:46 P.M. 5/16/2024 11:52 P.M. 5/17/2024 10:35 A.M. 5/17/2024 9:49 P.M. 5/18/2024 12:43 A.M. 5/18/2024 12:59 P.M. 5/18/2024 7:13 P.M. 5/19/2024 5:40 A.M. 5/19/2024 9:23 P.M. 5/20/2024 3:59 A.M. 5/20/2024 10:50 A.M. 5/20/2024 9:25 P.M. 5/21/2024 12:14 A.M. A Care Plan, dated 2/12/2019, for risk for skin breakdown related to left side hemiparesis, weakness, and history of cerebrovascular accident, with an intervention to assist with turning and repositioning as directed on resident summary. A Resident Summary for Resident 46, , on mobility/specialized devices dated 9/16/2021, indicated to ensure resident is lying in the middle of the bed, and position the legs and feet to prevent pressure injuries. Skin care dated 9/16/2021 indicated care of the supra pubic catheter to prevent skin breakdown. During an interview on 5/17/2024 at 11:40 A.M., CNA 7 indicated when she took care of a dependent resident, she would turn and reposition them every two hours, and do range of motion, provided a drink of water, if nothing by mouth (NPO) she would provide oral care every time she changed them. During an interview on 5/17/2024 at 11:43 A.M., CNA 8 indicated when she took care of a dependent resident, she checked and changed them every two hours and assisted with meals if needed. During an interview on 5/21/2024 at 9:11 A.M., the DON indicated the resident summary did not mention turning and repositioning the resident, she would expect her staff to do rounds every couple of hours to keep residents clean and repositioned. The staff were not charting in the kiosk like she would prefer regarding turning and repositioning of residents. She indicated there needed to be more information be added to the resident summary. On 5/20/2024 at 11:13 A.M., the DON indicated they did not have a policy regarding turning and repositioning or completing the resident summary. 3.1-38(a)(3)(D) 3.1-38(a)(3)(E)

Based on record review and interview, the facility failed to ensure a resident with diabetes was monitored with blood sugars as ordered by the physician which resulted in a hospitalization with an elevated blood sugar of 1080 that required IV (intravenous) insulin for management of diabetic ketoacidosis for 1 of 3 residents reviewed for physicians orders. (Resident N) Finding Includes: A record review was conducted, on 12/7/2020 at 12:36 P.M., and indicated Resident N was admitted to the facility on [DATE] and her [DIAGNOSES REDACTED]. Physician orders [REDACTED]. An admission MDS (Minimum Data Set) assessment, dated 9/2/2020, indicated Resident N had severe cognitive impairment and she had a [DIAGNOSES REDACTED]. The MAR (medication administration record) for Resident N for the month of August lacked documentation to indicate glucometer checks had been completed before meals and at bedtime. The MAR for Resident N for the month of September lacked documentation to indicate glucometer checks were completed before meals and at bedtime. There were no labs present in Resident N's clinical record for review. A progress note, dated 9/30/2020 at 1:32 P.M., indicated Resident N was more sleepy than usual, was not responding appropriately, was unable to eat or take fluids herself and had appeared weak and lethargic. She was not participating in therapy and required extensive assist with transfers. Her B/P (blood pressure) was132/68, P (pulse) 128 and her T (temperature) was 96.8. The progress note indicated BS (blood sugar) extremely (high) w/o readings. The NP (Nurse Practitioner) assessed her at that time and she was sent to the ER (emergency room ). The H&P (History & Physicial) from the hospital, dated 9/30/20 at 4:49 P.M., indicated Resident N had a blood sugar of 1080, with a normal range being 80-130. The assessment indicated she had diabetic ketoacidosis, with underlying type 2 diabetes and required an IV (intravenous) insulin drip to resolve the elevated blood sugar. Resident N was hospitalized to diabetic ketoacidosis resolution from 9/30/2020 to 10/10/2020. During an interview, on 12/7/2020 at 3:02 P.M., the DON (Director of Nursing) indicated Resident N did not have blood glucose monitoring done during her stay at the facility as the order for the glucose monitoring was overlooked when the resident was admitted . During an interview, on 12/8/2020 at 10:36 A.M., the rehab CCC (Clinical Care Coordinator) indicated when the nurse gets a new admission she puts the orders in as a draft, a second nurse checks the orders for completeness and the CCC checks the orders again the next day or on Monday if it is a weekend admission. She indicated she would not automatically check blood sugars on a resident with a [DIAGNOSES REDACTED]. During an interview, on 12/8/2020 at 12:40 P.M., the NP (Nurse Practitioner) indicated she would expect a resident with a [DIAGNOSES REDACTED]. On 12/9/2020 at 10:58 A.M., the ADON (Assistant Director of Nurses) provided a policy, titled, Diabetic Care and Management, dated May 2008, and indicated the policy was the one currently being used by the facility. The policy indicated .Each individual resident/elder will have a plan for the diabetic management that is determined by the elder, their family or responsible party, their physician and their care team to best meet their needs and wishes This Federal Tag relates to Complaint IN 531.

1. Based on observation, interview and record review, the facility failed to provide incontinence care to prevent redness and excoriation in a peri area causing pain and facial grimacing for 1 of 3 residents reviewed for hygiene service. (Resident #20) 2. Based on observation, interviews and record reviews the facility failed to ensure communication between the facility and the [MEDICAL TREATMENT] center was being conducted for 1 of 1 residents reviewed for [MEDICAL TREATMENT] care. (Resident #6) Findings include: 1. a. During an interview on 09/02/2016 at 9:57 A.M., Resident #20 indicated that she had not had assistance to the restroom all day. She indicated she stays wet for long periods of time. She was observed to have had an episode of incontinence. During an observation on 09/02/2016 at 2:30 P.M., Resident #20 was lying in bed on her back with a brief on. Her brief was observed to be wet with urine. Resident #20 indicated she was incontinent during the day because she puts on her call light and they don't come soon enough so she experiences incontinence. She indicated they change her in the morning and then don't come back for hours. A clinical record review was completed on 09/08/2016 at 3:14 P.M., and indicated Resident #20 was admitted on [DATE]. [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment, dated 8/15/16, indicated Resident #20 scored 15 on the Brief Interview for Mental Status (BIMS), no cognitive impairment. A review of care plans for Resident #20 indicated no care plans to address current incontinence needs. A closet care plan, (care plan located on the inside door of the resident's closet), dated 9/5/2016, indicated Resident #20 was to receive continence care every shift. A form titled Resident Bowel and Bladder by Shift Report indicated Resident #20 had not been receiving incontinence services on all shifts. The form indicated Resident #20 received incontinence care on one shift a day. During an interview on 09/08/2016 at 3:17 P.M., two of Resident #20's family members indicated they had been at the facility with Resident #20 and had observed she had gone from before breakfast until after dinner without receiving incontinence services. Resident #20 indicated she had not been assisted to the restroom since she woke up in the AM and she usually only gets assistance with her incontinence in the morning before breakfast and then again in the evening before bed. She further indicated there are many times she is wet all day and her bottom is sore and red. On 09/08/2016 at 4:45 P.M., Resident #20's peri area was observed with LPN (Licensed Practical Nurse) #59. The resident complained of pain in the labia and had a grimacing expression on her face. The labia was reddened and covered with a thick white substance. During an interview on 09/08/2016 at 5:04 P.M., Resident #20 indicated she had rated the pain to her peri area at an 8 on 09/07/2016, and she rated her pain a 6 on 09/08/2016. The ratings used were referring to a scale from 1-10 levels of pain (1 the least and 10 the worst). During an interview on 09/08/2016 at 5:02 P.M., the DON (Director of Nursing) indicated Resident #20's peri area was red. She further indicated she believed Resident #20 was developing a yeast infection. A procedure was provided by the DON (Director of Nursing) on 09/08/2016 at 4:30 P.M., titled Perineal care of the female patient, dated October 02, 2015, and indicated this was the procedure the facility currently follows. The procedure indicated .Perineal care, which includes care of the external genitalia and the anal area, should be performed during the daily bath and if the patient is incontinent after urination and bowel movements. The procedure promotes cleanliness and prevents infection. It also removes irritating and odorous secretions, such as smegma, a cheese-like substance that collects on the inner surface of the labia. For a patient with perineal skin breakdown, frequent bathing followed by application of a moisture-barrier skin protectant aids healing This information was printed from Lippincott Procedures-Perineal care of the female patient. 2. a. On 9/6/16 at 10:32 A.M., a review of the clinical record for Resident #65 was conducted. The record indicated the resident was admitted on [DATE] and readmitted on [DATE]. The resident's [DIAGNOSES REDACTED]. The Admission MDS (Minimum Data Set) assessment, dated 8/9/16, indicated the resident's Brief Interview Mental Status (BIMS) was 15 (normal cognition). The assessment did not indicate the resident had received specialized services, such as [MEDICAL TREATMENT]. An August 2016 Treatments form indicated an order was received, on 8/11/16 to check the fistula (vascular assess) for a bruit and thrill. The form indicated on 8/29/16 an order was received for resident to have [MEDICAL TREATMENT] 3 times a week, the resident was to be picked up at 10 A.M., and taken per stretcher and transported to the [MEDICAL TREATMENT] center via a local ambulance service. The form indicated the resident would receive [MEDICAL TREATMENT] on the 29th and 31st of August. The September 2016 Treatments form indicated the resident's fistula was being assessed by checking for the bruit and thrill and the resident received [MEDICAL TREATMENT] on 9/2/16 and 9/5/16. During an interview, on 9/6/16 at 11:16 A.M., the MDS Coordinator indicated the resident went to the hospital on [DATE] and returned to the facility on [DATE]. She indicated the resident had a fistula but had not started [MEDICAL TREATMENT] until she returned to the facility and the first day of [MEDICAL TREATMENT] was on 8/29/16. She indicated there was no care plan for the resident's [MEDICAL TREATMENT] services to date. During an interview, on 9/6/16 at 1:44 P.M., the resident's nurse, LPN #4 indicated the Treatment Record indicated to assess the resident's fistula every shift. She indicated the dates the resident went to [MEDICAL TREATMENT] were on a calendar. LPN #4 indicated the resident had a [MEDICAL TREATMENT] communication log book, however LPN #4 indicated the forms were blank. LPN #4 indicated the [MEDICAL TREATMENT] log book was sent with the resident but the [MEDICAL TREATMENT] center was not entering the resident's pre/post [MEDICAL TREATMENT] weight or any other documentation. LPN #4 indicated the only communication she sends with the resident was a face sheet, which did not contain vitals, medications the resident was being administered or blood sugar results prior to breakfast and/or going to the [MEDICAL TREATMENT] center. During an interview, on 9/6/16 at 2:09 P.M., Resident #65 indicated she leaves the facility around 10:00 A.M. on Monday, Wednesday and Friday to go to the [MEDICAL TREATMENT] center and returns between 3:00 and 4:00 P.M. The resident indicated she had never received a sack lunch and/or a snack from the facility and the [MEDICAL TREATMENT] center did not provide her a lunch, so on [MEDICAL TREATMENT] days she indicated she doesn't get to eat lunch. The resident was observed to have a dressing on her right upper arm. The resident indicated her fistula was underneath the dressing, as she just returned from having a procedure completed on her fistula. On 9/6/16 at 4:10 P.M., an interview was conducted with the Director of Nursing (DON) and the Administrator. The DON indicated the [MEDICAL TREATMENT] center wouldn't allow the resident to eat at their facility. She also indicated the facility still had time to develop a [MEDICAL TREATMENT] care plan. The Administrator indicated the [MEDICAL TREATMENT] center might possibly be feeding the resident lunch. They both indicated the facility had no policy determining what information would be exchanged between the facility and the [MEDICAL TREATMENT] center. On 9/7/16 at 9:42 A.M., the DON provided a form titled [MEDICAL TREATMENT] Communication Log and indicated the log was found in the resident's belongings. She could not confirm if the nurses had reviewed the communication log after the resident's [MEDICAL TREATMENT] treatments. During an interview, on 9/7/16 at 9:52 A.M., the Nurse Manager from the [MEDICAL TREATMENT] center indicated Resident #65 was attending their facility for [MEDICAL TREATMENT] 3 times a week. The Nurse Manager indicated the facility had never contacted them about the resident eating at the center. The Nurse Manager indicated the resident could bring a light sack lunch or snack as they do not provide any food at the center. The Nurse Manager indicated the resident had brought a communication log with her to the center. The only information they have received from the facility was a face sheet. On 9/7/16 at 10:03 A.M., the Administrator provided a policy titled [MEDICAL TREATMENT] Care, dated May 2008, and indicated the policy was the one currently used by the facility. The policy indicated .4. Assure that the [MEDICAL TREATMENT] center that the resident receives care from is listed in the medical record and care plan. Indicate [MEDICAL TREATMENT] days and times, method of transportation how meals/snacks may be coordinated during this time. List the phone number for the [MEDICAL TREATMENT] center and emergency number to contact with complications or bleeding 3.1-37(a)

Based on record review and interviews, the facility failed to accurately assess a resident who incurred a burn, had recurring complaints of pain and resulted in hospitalization 10 days post occurrence. (Resident "B") Finding includes: The record of Resident "B" was reviewed on 08/20/13 at 10:35 a.m. Resident "B" was admitted to the facility, on 08/09/07, with [DIAGNOSES REDACTED]. Review of the most recent quarterly MDS (Minimum Data Set: a tool to assist in assessing resident care needs), dated 07/03/13, indicated Resident "B" understood, required supervision (oversight, supervision and cueing) for eating, and required extensive assistance of 1 for transfers, dressing, bathing, and toileting. Review of a facility reportable event, provided by the Administrator on 08/20/13 at 1:00 p.m., indicated Resident "B" normally ate in the dining room and occasionally took her meals in her room without incident. Resident "B" chose to eat her evening meal, on 07/13/13, in her room and was found by a CNA to have spilled hot tea on her person. Review of "Clinical Notes Report" indicated: "07/13/13 10:40 p.m. The CNA went to change resident, found a huge pink area to genital (1%). Right leg towards the groin area (4.5%), left leg (1%)....Dr. notified, ordered [MEDICATION NAME] (medication specific to burns) to apply BID (twice daily) until healed. Cold ice water poured to the area." "07/14/13 9:40 a.m. [MEDICATION NAME] applied to burn areas as ordered....several fluid filled blisters present on periarea (sic) and right upper thigh with redness covering large area. PRN pain medication given at this time for comfort. Resident keeping clothes off to lower body as precaution to not irritate area further...." "07/14/13 12:53 p.m. (Physician's name) on call for (Resident's physician's name) notified..., also informed of residents burn to peri area and right upper thigh. Requested routine pain medication for comfort X 10 days. (Physician's name) states use PRN pain med at this time and have (Resident's physician's name) review tomorrow (sic). No new orders received." "07/14/13 8:00 p.m. ...burn areas on her groin and upper thigh still pink with several blisters present and intact...." "07/15/13 9:44 a.m. In to asses (sic) residents burn to her (right) thigh. It measures 21 X (times) 5.2 right lateral non pubis and on the right upper thigh from outer to inner aspect it measures 35.8 X 9.9. There are 4 fluid filled blisters noted two on the anterior upper thigh, one in the posterior thigh that appears to be draining some fluid, and one on the inner aspect of the thigh. Resident c/o (complains of) of pain...Silvadine applied to area....Will continue to monitor resident." "07/15/13 10:52 a.m. Administered 1 PRN (as needed) [MEDICATION NAME] tablet with morning med pass. Reassessed pain and rated at 4/10 from 6/10 upon rising (pain scale of 1 to 10 with 10 being the worst) ...Called (Physician's name) office...left message with current pain medication orders and requested a stronger [MEDICATION NAME]." "07/16/13 2:33 p.m. N.O. (New Order) received Keflex (antibiotic) 500 mg PO (Per Os: by mouth) X 5 days for UTI (Urinary Tract Infection)...." "07/20/13 10:45 p.m. [MEDICATION NAME] applied to burnt areas to bilateral legs. Blisters yellow and pink towards the edges...." "07/21/13 1:28 a.m. ...areas remain redden (sic) and some are open...treatment cont (continued) is uncomfortable with turns. Will monitor for pain control...." "07/22/13 10:17 p.m. New order to apply [MEDICATION NAME] to burnt areas on right groin, right leg, left leg, cover with [MEDICATION NAME] pad twice daily, per (Physician's name)...Treatment done to burnt areas no s/s (Signs and Symptoms) of infection noted. Wound bed to open blisters remains yellow...." "07/24/13 11:35 p.m. New order to cleanse burnt areas on right groin, right leg and genital with saline, apply [MEDICATION NAME] BID and leave open to air until healed....(Physician's name) stated she would come to see the patient in course of the week." "07/25/13 2:17 p.m. Resident seen by (Physician's name). N.O. (New Order) to sent pt (patient) to (hospital name) for a direct admit...." The resident was admitted to the ACF (Acute Care Facility - hospital) on 07/25/13. Review of the physician's hospital H&P (History & Physical) for Resident "B" indicated: "07/25/13...CHIEF COMPLAINT: Burn to the leg....I had seen her about 10 days ago on a routine visit. She, however, approximately one week ago spilled a cup of coffee in her lap. I was called that she had [MEDICAL CONDITION] the inguinal and peri region....I went by this morning to see another client there and stopped in to look at her wounds...found to have a very large area of burn in her right lower quadrant, inguinal, right perineal region and extending down most of her right inner thigh it looked quite red, inflamed extremely painful to her. There are some areas of eschar in the thigh that looks as though it needs debridement. I am questioning also she might need a skin graft as the areas is quite extensive...." The Administrator and the DNS (Director Nursing Services) were interviewed on 08/21/13 at 1:15 p.m. The DNS indicated physician's had been notified in relation to the [DIAGNOSES REDACTED]. The Administrator indicated the physician for Resident "B" was updated by the staff and new orders received. This Federal tag relates to Complaint IN 780. 3.1-37(a)

Based on record review and interviews, the facility failed to provide supervision for a resident with a [DIAGNOSES REDACTED]. This deficiency affected 1 of 1 residents reviewed for accidents in a sample of 6. (Resident "B") Finding includes: The record of Resident "B" was reviewed on 08/20/13 at 10:35 a.m. Resident "B" was admitted to the facility, on 08/09/07, with [DIAGNOSES REDACTED]. Review of the most recent quarterly MDS (Minimum Data Set: a tool to assist in assessing resident care needs), dated 07/03/13, indicated Resident "B" understood, required supervision (oversight, supervision and cueing) for eating, and required extensive assistance of 1 for transfers, dressing, bathing, and toileting. Review of a facility reportable event, provided by the Administrator on 08/20/13 at 1:00 p.m., indicated Resident "B" normally ate in the dining room and occasionally took her meals in her room without incident. Resident "B" chose to eat her evening meal, on 07/13/13, in her room and was found by a CNA to have spilled hot tea on her person. Review of "Clinical Notes Report" indicated: "07/13/13 10:40 p.m. The CNA went to change resident, found a huge pink area to genital (1%). Right leg towards the groin area (4.5%), left leg (1%)....Dr. notified, ordered silvadene (medication specific to burns) to apply BID until healed. Cold ice water poured to the area." "07/14/13 9:40 a.m. ...silvadene applied to burn areas as ordered....several fluid filled blisters present on periarea (sic) and right upper thigh with redness covering large area. PRN pain medication given at this time for comfort. Resident keeping clothes off to lower body as precaution to not irritate area further...." "07/14/13 12:53 p.m. (Physician's name) on call for (Resident's physician's name) notified..., also informed of residents burn to peri area and right upper thigh. Requested routine pain medication for comfort X 10 days. (Physician's name) states use PRN pain med at this time and have (Resident's physician's name)review tomorrow (sic). No new orders received." "07/14/13 8:00 p.m. ...burn areas on her groin and upper thigh still pink with several blisters present and intact..." "07/15/13 9:44 a.m. In to asses (sic) residents burn to her (right) thigh. It measures 21 X (times) 5.2 right lateral non pubis and on the right upper thigh from outer to inner aspect it measures 35.8 X 9.9. There are 4 fluid filled blisters noted two on the anterior upper thigh, one in the posterior thigh that appears to be draining some fluid, and one on the inner aspect of the thigh. Resident c/o (complains of) of pain...Silvadine applied to area....Will continue to monitor resident." "07/15/13 10:52 a.m. Administered 1 PRN ibuprofen tablet with morning med pass. Reassessed pain and rated at 4/10 from 6/10 upon rising (pain scale of 1 to 10 with 10 being the worst) ...Called (Physician's name) office...left message with current pain medication orders and requested a stronger analgesic...." "07/16/13 2:33 p.m. N.O. (New Order) received Keflex (antibiotic) 500 mg PO (Per Os: by mouth) X 5 days for UTI (Urinary Tract Infection)..." "07/20/13 10:45 p.m. Silvadene applied to burnt areas to bilateral legs. Blisters yellow and pink towards the edges...." "07/21/13 1:28 a.m. ...areas remain redden (sic) and some are open...treatment cont (continued) is uncomfortable with turns. Will monitor for pain control...." "07/22/13 10:17 p.m. New order to apply silvadene to burnt areas on right groin, right leg, left leg, cover with telfa pad twice daily, per (Physician's name)...Treatment done to burnt areas no s/s of infection noted. Wound bed to open blisters remains yellow...." "07/24/13 11:35 p.m. New order to cleanse burnt areas on right groin, right leg and genital with saline, apply silvadene BID (twice daily) and leave open to air until healed....(Physician's name) stated she would come to see the patient in course of the week." "07/25/13 2:17 p.m. Resident seen by (Physician's name). N.O. (New Order) to sent pt (patient) to (hospital name) for a direct admit...." The resident was admitted to the ACF (Acute Care Facility - hospital) on 07/25/13, 10 days following the burn. Review of the physician's hospital H&P (History & Physical) for Resident "B" indicated: "07/25/13...CHIEF COMPLAINT: Burn to the leg....I had seen her about 10 days ago on a routine visit. She, however, approximately one week ago spilled a cup of coffee in her lap. I was called that she had some burns in the inguinal and peri region....I went by this morning to see another client there and stopped in to look at her wounds...found to have a very large area of burn in her right lower quadrant, inguinal, right perineal region and extending down most of her right inner thigh it looked quite red, inflamed extremely painful to her. There are some areas of eschar in the thigh that looks as though it needs debridement. I am questioning also she might need a skin graft as the areas is quite extensive...." The Administrator and the DNS (Director Nursing Services) were interviewed on 08/21/13 at 1:15 p.m. The DNS indicated physician's were notified in relation to the [DIAGNOSES REDACTED]. The Administrator indicated the physician for Resident "B" was updated by the staff and new orders received. Review of the facility investigation indicated the resident stated to the staff she spilled her tea. The investigation indicated the facility was unable to determine the time lapse from the spill to the discovery which was documented in the investigation as 07/13/13 at 7:00 p.m. This Federal tag relates to Complaint IN 780. 3.1-45(a)(2)