Every finding on record at Ignite Medical Resort Chesterton

Based on observation, record review, and interview, the facility failed to ensure care plans were developed for residents related to perentral fluids/medications, urinary catheter usage, and risk for constipation, for 2 of 7 residents reviewed for care plans. (Residents C and E) Findings include: 1. During an observation on 7/27/26 at 9:45 a.m., Resident C was ambulating with his walker. A urinary catheter and a peripheral intravenous (IV) line were observed. Resident C's record was reviewed on 7/27/26 at 10:39 a.m. The diagnoses included, but were not limited to, dehydration, fractures of the sacrum and spine, urinary retention, and constipation. a) The Physician's Order dated 7/7/26 to 7/9/26, indicated hydrocodone-acetaminophen (narcotic pain medication) 5-325 milligrams (mg), one to two tablets every four hours as needed for pain. A Physician's Order, dated 7/9/26, indicated oxycodone (narcotic pain medication) five mg every four hours. A Physician's Order, dated 7/14/26 to 7/22/26, indicated Tramadol (narcotic pain medication) 50 mg, one tablet every 12 hours for pain. The bowel movement record, dated 7/2026 indicated there had been no bowel movement from 7/8/26 through 7/24/26. There was no care plans for the risk of constipation due to the narcotic pain medications and no bowel movements. b) An admission Minimum Data Set (MDS) assessment, dated 7/9/26, indicated an indwelling urinary catheter was present. A Physician's Order, dated 7/13/26, indicated an indwelling urinary catheter was present and output was to be recorded every shift. There was no care plan for the indwelling urinary catheter. During an interview on 7/28/26 at 2:16 p.m., the Nurse Consultant indicated the care plans were not completed. 2. The record for Resident E was reviewed on 7/28/26 at 9:36 a.m. Diagnoses included, but were not limited to, COPD, hypertension (high blood pressure), chronic kidney disease, and tremors. The Baseline Care Plan, dated 7/20/26, indicated the resident was moderately impaired for daily decision making. The resident required partial to moderate assistance for toileting. A Physician's Order, dated 7/20/26, indicated to check intravenous (IV) dressing every shift. A Physician's Order, dated 7/20/26, indicated to change the peripherally inserted central catheter (PICC) line dressing every seven days. A Physician's Order, dated 7/20/26, indicated to administer two Bisacodyl (laxative) tablets by mouth two times a day for a laxative. The Bowel and Bladder Elimination Task for the past 30 days indicated the resident did not have a bowel movement (BM) from 7/19/26 through 7/28/26. The current Care Plan did not address the resident's IV/PICC line or constipation. During an interview on 7/28/26 at 4:00 p.m., the Nurse Consultant indicated she understood the concerns regarding resident E's care plans. The care plans would be updated. This citation relates to Intake 3110454. 410 IAC (Indiana Administrative Code) 16.2-3.1-35(a)

Based on record review and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards related to bowel management and treatment to a non-pressure wound, for 3 of 7 residents reviewed for quality of care. (Residents C, D, and E) Findings include: 1. Resident C's record was reviewed on 7/27/26 at 10:39 a.m. The diagnoses included, but were not limited to, constipation. An admission Minimum Data Set (MDS) assessment, dated 7/9/26, indicated an intact cognitive status, dependent for toileting, and always continent of bowel movement. A Physician's Order, dated 7/7/26, indicated polyethylene glyco (laxative) 17 grams daily for constipation. The bowel movement record, dated 7/2026, indicated there had been no bowel movement from 7/8/26 through 7/24/26. A Physician's Progress Note, dated 7/21/26 at 2:22 p.m., indicated the resident had not had a bowel movement since 7/3/26 and denies any abdominal pain, nausea or vomiting. A Physician's Order, dated 7/21/26, indicated bisacodyl suppository (laxative) 10 milligrams (mg) was to be administered every 24 hours as needed for constipation and Senna oral tablet (laxative) 8.6 mg, 1 tablet twice a day was to be initiated for constipation. A Nurse's Progress Note, dated 7/21/26 at 5:03 p.m., indicated the resident has been administered stool softeners and polyethylene gloyco for constipation and he has not had a bowel movement. A suppository was administered. If there was no bowel movement after the suppository, he has requested to go to the hospital. A Nurse's Progress Note, dated 7/21/26 at 6:18 p.m., indicated the resident had a bowel movement. There was no documentation of the amount/size of the resident's bowel movement. A Nurse's Note, dated 7/21/26 at 7:05 p.m., indicated the resident insisted on going to the emergency room (ER). Orders were obtained to transfer to the ER. The Hospital Progress Notes, dated 7/21/26 through 7/22/26, indicated the resident had not had a bowel movement since 7/3/36. He had mild abdominal discomfort and diminished appetite. An enema and good bowel regimen was recommended. The CT of the abdomen indicated moderate to large volume of stool throughout the colon. The resident had a large bowel movement. There was no assessment of bowel sounds documented from 7/7/26 to 7/21/26. The physician had not been notified of the resident's constipation until 7/21/26. During an interview on 7/28/26 at 2:16 p.m., the Nurse Consultant indicated there had been no physical assessments of the resident with no bowel movement and no documentation the physician had been notified. The physician was aware of the no bowel movements. A facility bowel management policy, dated 4/2026 and received from the Nurse Consultant as current, indicated the facility was to maintain an effective bowel management program that included assessment, monitoring, documentation, intervention and evaluation of bowel function for each resident. The physician was to be notified if there was no bowel movement for more than three days unless otherwise ordered. Bowel movements were to be documented. 2. The record for Resident D was reviewed on 7/27/26 at 12:27 p.m. Diagnoses included, but were not limited to, acquired absence of leg above the knee, chronic pain syndrome, osteomyelitis left femur, assistance with personal care, and difficulty walking. The Medicaid 5-day Minimum Data Set (MDS) assessment, dated 7/21/26, indicated the resident was cognitively intact for daily decision making. Toileting, shower/bathing, and lower body dressing required substantial/maximum assistance. A Care Plan, dated 7/16/26, indicated the resident moved in with a left above the knee amputation (LAKA). Interventions were to treat per physician orders and assess per facility policy. A Physician's Order, dated 7/16/26, indicated to cleanse the LAKA with saline and pat dry, apply maxorb to the wound bed and cover with a dry dressing every day shift for wound care. The Treatment Administration Record (TAR) indicated the wound treatment had not been signed out on 7/25/26. During an interview on 7/27/26 at 4:45 p.m., the Nurse Consultant indicated the resident's wound treatment should have been signed out. 3. Resident E was observed on 7/28/26 at 10:20 a.m. sitting in his wheelchair waiting for therapy. The resident indicated nah when asked if he had been having bowel movements. The record for Resident E was reviewed on 7/28/26 at 9:36 a.m. Diagnoses included, but were not limited to, COPD, hypertension (high blood pressure), chronic kidney disease, and tremors. The Baseline Care Plan, dated 7/20/26, indicated the resident was moderately impaired for daily decision making. The resident required partial to moderate assistance for toileting. The Bowel and Bladder Elimination Task for the past 30 days indicated the resident did not have a bowel movement (BM) from 7/19/26 through 7/28/26. A Physician's Order, dated 7/20/26, indicated to administer two Bisacodyl (laxative) tablets by mouth two times a day for a laxative. A Physician's Order, dated 7/20/26, indicated to administer one Bisacodyl suppository rectally every 24 hours as needed for laxative. The was no documentation that the physician was notified of the resident lack of BMs. There was no care plan for constipation. The Medication Administration Record indicated the rectal suppository was not given during the month of July 2026. During an interview on 7/28/26 at 3:55 p.m., the Assistant Chief Nursing Officer (ACNO) indicated the physician had been made aware of the resident's constipation and he would receive a suppository today. This citation relates to Intakes 3074217 and 3110454. 410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on observation, record review and interview, the facility failed to ensure an intravenous (IV) access and fluids were initiated timely, flush orders were obtained from the physician, the flush was completed per policy, and the insertion site was monitored for signs and symptoms of adverse reaction, for 1 of 3 residents reviewed for parenteral fluids. (Resident C)Finding includes:During an observation on 7/27/26 at 11:50 a.m., RN 1 entered Resident C's room with a 10 cubic centimeters (cc) syringe of 0.9% normal saline (NS). She indicated the tubing needed to be flushed due to observing blood in the tubing. The resident was lying in bed and IV fluids were infusing at 60 cc's an hour into a peripheral IV access site in the right forearm. The dressing on the insertion site was dated 7/22/26. The IV fluid bag of 1000 cc's of 0.9% NS was almost empty. RN 1 indicated a new IV bag of 0.9% NS needed to be administered. RN 1 then detached the IV tubing from the insertion tubing, inserted the syringe of NS into the insertion tubing without using an alcohol prep pad to clean the port, and administered the 10 cc's of 0.9% NS flush. She then clamped the tubing, obtained a new 1000 cc bag of 0.9 NS and tubing. She primed the tubing and set the rate at 60 cc per hour, used an alcohol prep pad to clean the insertion tubing and attached the IV tubing.During an interview on 7/27/26 at 12:15 p.m., RN 1 indicated she had not used the alcohol prep pad with the flush because it was a closed system.Resident C's record was reviewed on 7/27/26 at 10:39 a.m. The diagnoses included, but were not limited to, dehydration.A Physician's Progress Note, dated 7/21/26 at 2:22 p.m., indicated the lips, mucosa, and tongue were normal. The mucosa appeared dry, the skin turgor was normal. IV fluids of 1000 cc NS was to be administered over 24 hours and then re-evaluate. The Blood Urea Nitrate (BUN) levels were progressively going up secondary to dehydration.A Nurse's Progress Note, dated 7/21/26 at 6:18 p.m., indicated the physician had visited and an IV of 1000 cc's normal saline was to be administered for 24 hours. The PICC (central line) team would come to insert the peripheral line.A Nurse's Progress Note, dated 7/21/26 at 7:05 p.m., indicated the resident requested to be transferred to the hospital due to constipation and a Physician's Order was obtained.A Nurse's Progress Note, dated 7/21/26 at 9:10 p.m., indicated the resident was transferred to the hospital at 9:10 p.m.A Nurse's Progress Note, dated 7/22/26 at 2:59 p.m., indicated the resident returned from the Hospital Emergency Room.There was no documentation to indicate a peripheral IV had been initiated prior to the resident's transfer to or upon return to the facility from the Emergency Room.There was no documentation the peripheral IV had been initiated on 7/22/26 per the dressing date.A Physician's Order had not been written until 7/23/26 for NS 0.9% at 100 cc's and hour per IV one time a day for urinary tract infection symptoms. There was no documented diagnosis of a urinary tract infection symptoms.A Nurse's Progress Note, dated 7/23/26 at 1:25 p.m., indicated the IV had been initiated in the right forearm and IV fluids of 0.9% NS was initiated at 100 cc per hour as ordered.A Nurse Practitioner's (NP) Progress Note, dated 7/23/26 at 1:38 p.m., indicated the resident returned from the hospital Emergency Room. IV fluids were initiated per orders on 7/23/26.The Medication Administration Record (MAR), dated 7/2026, indicated the 0.9% NS had been administered on 7/23/26. There was no time documented when the IV had infused.There was no Physician's Order for the IV NS flush or dressing changesThere was no documentation the IV had been discontinued after the initial bag of NS had been infused.There was no documentation the IV had been flushed for patency or assessments of the IV insertion site.A Physician's Order, dated 7/26/26, indicated NS 0.9% was to be infused at 60 cc's per hour every shift for dehydration.The MAR indicated the IV fluids of 0.9% NS at 60 cc per hour had been initiated on 7/26/26 on the night shift.There were no assessments of the insertion site after the IV dluids of 0.9% NS at 60 cc's per hour had been initiated.During an interview on 7/28/26 at 2:16 p.m., the Nurse Consultant indicated the IV insertion site should have been assessed every shift. The resident was transferred to the hospital on 7/21/26 when the original order had been received and she was unsure why the fluids had not been started upon return from the hospital. She was unable to validate if the IV had remained inserted from 7/23/26 to 7/26/26 and, if it remained inserted, was unable to validate what care had been completed. She also acknowledged there were no flush orders for the IV site.A facility peripheral IV policy, dated 4/2026 and received from the Nurse Consultant as current, indicated, staff was to complete verification of the physician's order and clinical indication upon insertion. The site was to be assessed each shift, before and after medication administration and during continuous infusions. The IV was to be removed upon completion of therapy or if the catheter was no longer clinically indicated. The removal of the IV was to be documented.This citation is related to Intake 3110454.410 IAC (Indiana Administrative Code) 16.2-3.1-47(a)(2)

Based on observation, record review and interview, the facility failed to ensure pain management regimens were followed as ordered by the physicians and failed to provide a pain medication in a timely manner upon request, for 3 of 3 residents reviewed for pain. (Residents C, G, and D)Findings include: 1. During an interview on 7/27/26 at 9:45 a.m., Resident D indicated he was supposed to receive oxycodone (narcotic pain medication) every four hours, the medication was received late on several occasions and sometimes he did not get the medication at all. Resident C's record was reviewed on 7/27/26 at 10:39 a.m. The diagnoses included, but were not limited to, fractured sacrum and wedge compression fractures of the spine. A Care Plan, dated 7/7/26, indicated an alteration in the musculoskeletal status related to a fracture of the sacrum and spinal wedge fractures. The interventions included pain medication would be administered as ordered by the physician. An admission Minimum Data Set (MDS) assessment, dated 7/9/26, indicated an intact cognitive status, no behaviors, and pain was frequently present that effected his sleep, therapy activities, and day to day activities. The pain was rated a 5 out of 10 and he received opioid medications daily. A Nurse Practitioner's (NP) Progress Note, dated 7/9/26 at 5:45 p.m., indicated the resident reported severe sacral pain due to a sacral fracture. The worst the pain had been rated was a 10 out of 10. Frequent opioid analgesics were required. The pain medication was switched to oxycodone five milligrams (mg) every four hours for better pain control. A Physician's Order, dated 7/9/26, indicated oxycodone five mg was to be administered every four hours for pain due to fractures. The oxydocone was scheduled for 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. and the pain was to be evaluated with the administering of the medication. Review of the administration details for the oxycodone with the actual administration times, received on 7/27/26 at 3:00 p.m. from the Nurse Consultant, indicated the oxycodone was administered and the pain assessment at the following times for July 2026:- 7/12/26 the 4:00 a.m. dose was administered at 5:32 a.m. with a pain rating of four.- 7/12/26 the 4:00 p.m. dose was administered at 5:51 p.m. with a pain rating of zero.- 7/12/26 the 8:00 p.m. dose was administered at 10:53 p.m., five hours between doses, with a pain rating of eight.- 7/13/26 the 12:00 a.m. dose was administered at 11:50 p.m., less than an hour from the from the 8:00 p.m. dose.- 7/13/26 the 4:00 p.m. dose was administered at 6:14 p.m. with a pain rating of seven.- 7/13/26 the 8:00 p.m. dose was given at 9:01 p.m., 2 3/4 hours since the last administration, with a pain rating of four. - 7/14/26 the 8:00 a.m. dose was administered at 9:16 a.m. with a pain rating of four.- 7/14/26 the 12:00 p.m. dose was administered at 1:28 p.m. with a pain rating of seven.- 7/14/26 the 4:00 p.m. dose was administered at 5:40 p.m. with a pain rating of zero.- 7/14/26 the 8:00 p.m. dose was administered at 10:30 p.m. with a pain rating of four.- 7/15/26 the 12:00 a.m. dose was administered at 12:35 a.m., two hours between doses, with a pain rating of four.- 7/15/26 the 4:00 a.m. dose was administered at 6:05 a.m., five and a half hours between doses, with a pain rating of three.- 7/15/26 the 8:00 a.m. dose was offered at 11:28 a.m. and documented as refused.- 7/17/26 the 8 a.m. dose was documented as administered at 8:25 a.m., the oxycodone had not been signed out on the narcotic record that would indicate the resident received the medication.- 7/18/26 the 4:00 a.m. dose was administered at 4:04 a.m. with a pain rating of seven.- 7/18/26 the 8:00 a.m. dose was administered at 11:53 a.m., seven hours between doses, with a pain rating of zero.- 7/18/26 the 12:00 p.m. dose was administered at 12:15 p.m., less than a half hour between doses, with a pain rating of 3.- 7/18/26 the 4:00 p.m. dose was administered at 5:27 p.m., the pain was not assessed.- 7/18/26 the 8:00 p.m. dose was administered at 11:24 p.m., six hours between doses, with a pain rating of two.- 7/19/26 the 12:00 a.m. dose was administered at 12:45 a.m., one hour and 15 minutes between doses, with a pain rating of four.- 7/24/26 the 8:00 a.m. dose was administered at 10:39 a.m. and the pain rating was not assessed.- 7/24/26 the 12:00 p.m. dose was administered at 11:48 a.m., one hour and nine minutes between doses. The pain was not assessed.- 7/26/26 the 12:00 p.m. dose was administered at 11:39 a.m., with a zero pain rating.- 7/26/26 the 4:00 p.m. dose was administered at 6:21 p.m., over six hours form last dose, with a zero pain rating.- 7/26/26 the 8:00 p.m. dose was administered at 7:45 p.m., one hour and 15 minutes between doses, with the pain rated at an eight. During an interview on 7/27/26 at 9:30 a.m., Resident C indicated if the pain medications were administered at the correct time, he could push through his pain. It made the pain easier to live with. Sometimes he received the pain medications too close together and sometimes he never received them at all. If the pain medications were not administered as ordered, the pain was often unbearable. During an interview on 7/28/26 at 10:30 a.m., QMA 1 indicated when they are preparing the medications for administration, they check off the medication on the Medication Administration Record (MAR), the medications are then administered, and the save button on the MAR is clicked when they return to the medication cart to indicate the medications had been administered. During an interview on 7/28/26 at 2:16 p.m., the Nurse Consultant indicated the first time located on the medication administrative details was the time the medication was administered. No further information was provided after going over the documented times of the administration of the oxycodone. 2. During a morning medication pass observation on 7/28/26 at 8:25 a.m., Resident G indicated he was having pain and asked QMA 3 for Tylenol and indicated the Tylenol relieved the pain in the past. QMA 3 exited the room, looked in the medication cart, and indicated the resident had no Tylenol available. She then reported to RN 1 that the resident was in pain and requested Tylenol and the resident had no Tylenol available. RN 1 then checked the Emergency Drug Kit (Pixus) and indicated there was no Tylenol available. RN 1 then assessed the resident's pain at an eight out of 10 located in his back. She indicated she would notify the physician to get something stronger than Tylenol since the pain was rated at an eight. RN 1 texted the Nurse Practitioner and requested a pain medication order. RN 1 then notified the Physician at 8:45 a.m. and received an order for ibuprofen. At 8:50 a.m., RN 1 indicated there was no ibuprofen in the Pixus. The Assistant Director of Nursing notified the Physician on 7/28/26 at 9:05 a.m., that the ibuprofen was not available and requested another pain medication. Resident G's record was reviewed on 7/28/26 at 1:00 p.m. The diagnoses included, but were not limited to, stroke. A Care Plan, dated 6/8/26, indicated a potential for pain. The interventions indicated they would respond immediately to any complaint of pain and identify the resident's previous response to analgesia including pain relief. An admission MDS assessment, dated 6/11/26, indicated a moderately impaired cognitive status and no pain. A Physician's Order, dated 7/2/26, indicated acetaminophen (Tylenol) 650 mg, one tablet every four hours as needed for pain. The MAR, dated 7/2026, indicated the acetaminophen 650 mg had been administered on 7/26/26 at 3:50 a.m. for a pain level of four out of 10 and was effective. A Physician's order was received on 7/28/26 at 9:26 a.m. for hydrocodone -acetaminophen (narcotic pain medication), one 5-325 mg tablet was to be administered every four hours as needed for pain. The MAR, dated 7/2026, indicated QMA 3 had administered the medication on 7/28/26 at 9:30 a.m. During an interview on 7/28/26 at 1:42 p.m., the Nurse Consultant indicated the acetaminophen was not stocked in the Pixus since it was an over the counter medication and she was unsure where the acetaminophen 650 mg was obtained from on 7/26/26 at 3:50 a.m. A pain management policy, dated 5/2023 and received as current from the Nurse Consultant, indicated optimal management of the resident experiencing pain enhanced the healing and promoted both physical and psychological wellness. A medication administration policy, dated 4/2026 and received as current from the Nurse Consultant, indicated to .Click 'confirm on the EMAR once the medication is removed form the package . 3. During a random observation on 7/27/26 at 4:20 p.m., Resident D was sitting in the dining room waiting for dinner. She indicated she was in pain and needed her fentanyl patch changed, she pulled her shirt over her left shoulder, and her fentanyl patch was dated 7/23/26. At 4:25 p.m., the Assistant Chief Nursing Officer (ACNO) and the Nurse Consultant asked the resident to see her fentanyl patch and confirmed it was dated 7/23/26 and should have already been removed. The record for Resident D was reviewed on 7/27/26 at 12:27 p.m. Diagnoses included, but were not limited to, acquired absence of leg above the knee, chronic pain syndrome, osteomyelitis left femur, assistance with personal care, and difficulty walking. The Medicaid 5-day Minimum Data Set (MDS) assessment, dated 7/21/26, indicated the resident was cognitively intact for daily decision making. Toileting, shower/bathing, and lower body dressing required substantial/maximum assistance. A Care plan, reviewed on 7/16/26, indicated the resident received opioid medication. Interventions were to administer analgesic medication as ordered by a physician and assess if pain intensity was acceptable to resident. A Physician's Order, dated 7/23/26, indicated for a Fentanyl patch to be administered transdermally (on the skin) one time a day, every three days. Remove the old patch before a new patch was applied and record the site of the old patch. Remove per schedule. The MAR for 7/2026 was signed out as an eight for removal and placement on 7/26/26, which indicated the resident was nauseated. During an interview on 7/28/26 at 4:00 p.m., the Nurse Consultant indicated the old patch was removed and a new patch was placed on the resident. This citation relates to Intake 3110454. 410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on observation, record review and interview, the facility failed to ensure residents were provided with routine medications by the contracted pharmacy as ordered by the physician related to medications not available to be administered, for 2 of 7 residents reviewed for medications. (Residents G and H)Findings include:1. During a morning Medication Pass Observation on 7/28/26 at 8 a.m., QMA 3 prepared Resident G's medication. The Certivite (supplement) one tablet and vitamin B12 (supplement) 500 micrograms (mcg) were not found in the cart and were unavailable to administer.QMA 3 indicated the Certivite was last received on 7/14/26 and only 14 doses were sent, the vitamin B12 was last received on 7/9/26 and only 13 doses were received. She was unable to find where the medications had been re-ordered when the supply lessened.QMA 3 reported this to RN 1. RN 1 then went to the Emergency Drug Kit (Pixus) and was unable to find the medications in the Pixus.RN 1 notified the pharmacy and indicated they would send the medication out with next order. 2. During a morning Medication Pass Observation on 7/28/26 at 8:25 a.m. Resident G indicated he was having pain and asked QMA 3 for Tylenol and indicated the Tylenol relieved the pain in the past. QMA 3 exited the room, looked in the Medication Cart, and indicated the resident had no Tylenol available. She then reported to RN 1 the resident was in pain and requested Tylenol and the resident had no Tylenol available. RN 1 then checked the Emergency Drug Kit (Pixus) and indicated there was no Tylenol available. RN 1 then assessed the resident's pain at an eight out of 10 and it was located in his back. She indicated she would notify the Physician to get something stronger than Tylenol since the pain was rated at an eight. RN 1 texted the Nurse Practitioner and requested a pain medication order. RN 1 then notified the Physician at at 8:45 a.m. and received an order for ibuprofen. At 8:50 a.m., RN 1 indicated there was no ibuprofen in the Pixus.The Assistant Director of Nursing notified the Physician on 7/28/26 at 9:05 a.m., that the ibuprofen was not available and requested another pain medication.Resident G's record was reviewed on 7/28/26 at 1:00 p.m. The diagnoses included, but were not limited to, stroke.A Care Plan, dated 6/8/26, indicated a potential for pain. The interventions indicated they would respond immediately to any complaint of pain and identify previous response to analgesia including pain relief.An admission MDS assessment, dated 6/11/26, indicated a moderately impaired cognitive status and no pain.A Physician's Order, dated 7/2/26, indicated acetaminophen (Tylenol), 650 mg, one tablet every four hours as needed for pain.The MAR, dated 7/2026, indicated the acetaminophen 650 mg had been administered on 7/26/26 at 3:50 a.m. for a pain level of four out of 10 and was effective.A Physician's order was received on 7/28/26 at 9:26 a.m. for hydrocodone -acetaminophen (narcotic pain medication), one 5-325 mg tablet was to be administered every four hours as needed for pain.The MAR, dated 7/2026, indicated QMA 3 had administered the medication on 7/28/26 at 9:30 a.m.During an interview on 7/28/26 at 1:42 p.m., the Nurse Consultant indicated the acetaminophen was not stocked in the Pixus since it was an over the counter medication and was unsure where the acetaminophen 650 mg was obtained from on 7/26/26 at 3:50 a.m. 2. During a morning Medication Pass Observation on 7/28/26 at 10:25 a.m., QMA 1 prepared Resident H's medication. She indicated the Mirilax (laxative) 17 grams, thiamine (supplement) 100 milligrams (mg), and the Lasix (diuretic) 40 mg was not available to administer and would need to be re-ordered.During an interview on 7/28/26 at 1:42 p.m., the Nurse Consultant indicated the Pharmacy used to send a 30 day supply out, then they went to a 15 day supply with auto-refill and she was unsure if this had been changed.During an interview on 7/28/26 at 3:58 p.m., the Nurse Consultant indicated there was no policy for medication deliveries. The pharmacy had changed the procedure and was no longer doing auto refill but sending only a 15 day supply. They had not informed the facility the auto refill was discontinued.This citation relates to Intake 3110454.410 IAC (Indiana Administrative Code) 16.2-3.1-25(a)

Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5% for 1 of 7 residents observed during medication pass. Five errors were observed during 33 opportunities for errors during medication administration. This resulted in a medication error rate of 15.151%. (Resident H)Finding includes: During an observation on 7/28/26 at 10:35 a.m., QMA 1 prepared Resident H's morning medications, which consisted of the following medications per the labels:atorvastatin (cholesterol medication) 40 milligrams (mg), one tablet by mouthnifedipine (heart medication) 30 mg, one tablet by mouthOcuvite (supplement), one tablet by mouthEliquis (blood thinner) 2.5 mg, one tablet by mouthCarvedilol (anti-hypertensive) 3.25 mg two tablets by mouthomeprazole (stomach medication) 20 mg, two tablets by mouthpotassium chloride (supplement) liquid, 20 milliequivalents (meq), 15 cubic centimeters (cc) by mouththiamine (supplement) 100 mgLasix (diuretic) 40 mg, one tablet by mouthQMA 1 indicated the thiamine and Lasix were not available and needed to be reordered. She placed the atorvastatin, nifedipine, Ocuvite, Eliquis in the medication cup. She placed only one tablet of the Carvedilol and omeprazole in the medication cup. She then poured 20 cc's of potassium chloride in the a plastic medication cup and indicated she was ready to administer the medications.QMA 1 counted six tablets in the medication cup and was stopped prior to the administration. During the interview, she indicated there should be two Carvedilol and omeprazole medications and placed another tablet of each in the cup. She indicated the resident was to receive 20 cc's of the potassium chloride, then re-read the order and indicated the dosage was 15 cc's. Upon re-counting of the medication she indicated there were eight tablets in the medication cup. She then indicated the medications needed to be crushed. The medications were crushed and placed in applesauce and administered to the resident.Resident H's medication orders were reviewed on 7/28/26 at 11:45 a.m. The Physician's Orders indicated ferrous sulfate (iron) 325 mg one tablet and lactobacillis (supplement) one tablet was also to be administered. The ferrous sulfate and lactobacillis had been omitted.Review of the Medication Administration Record, dated 7/2026, indicated QMA 1 had documented the medications as administered at the same time of the other medications, though they had not been administered.A facility administration of medication policy, dated 4/2026, and received from the Nurse Consultant as current, indicated the medication was to be removed from the drawer and the label read upon removal from the drawer, upon pouring the medication and after pouring the medication. A physician or nurse practitioner order is required for administration of all medications The order was to be read entirely, check the medication for the right medication, right dose, right route, right patient and time.This citation relates to Intake 3110454.410 IAC (Indiana Administrative Code) 16.2-3.1-48(c)(1)

Based on record review and interview, the facility failed to ensure a resident was provided with ordered laboratory services related to a wound culture not completed as ordered for 1 of 3 residents reviewed for laboratory services. (Resident E) Finding includes: The record for Resident E was reviewed on 7/28/26 at 9:36 a.m. Diagnoses included, but were not limited to, COPD, hypertension (high blood pressure), chronic kidney disease, and tremors. The Baseline Care Plan, dated 7/20/26, indicated the resident was moderately impaired for daily decision making. The resident required partial to moderate assistance for toileting. A Care Plan, dated 7/19/26, indicated the resident was admitted with a surgical incision to the abdomen and left flank. Intervention was to treat per physician orders. A Physician's Order, dated 7/26/26, indicated a culture and sensitivity of wounds may be obtained if indicated. A Skin/Wound Note, dated 7/26/26 at 5:15 p.m., indicated the wound culture needed to be obtained before intravenous (IV) antibiotics could be started. A Skin/Wound Note, dated 7/26/26 at 4:38 p.m., indicated the resident was having green drainage from his wound vac located on his left rib. The physician assessed the wound and ordered a wound culture and vancomycin and aztreonam (IV antibiotics). The wound culture to be collected on 7/26/26 was cancelled due to a red cap viral tube being used instead of the appropriate pink cap culture swab. The wound was not re-cultured. During an interview on 7/28/26 at 11:26 a.m. the Wound Nurse indicated she would get a hold of the physician that day and get an order to have the wound re-cultured. It was cancelled because they sent the culture in the wrong tube. She had just swabbed the fluid for a culture but not the surgical site. She thought it had been completed and she would need to obtain a new order. The resident could not start his antibiotics without the culture being completed. During an interview on 7/28/26 at 4:00 p.m., the Nurse Consultant indicated she understood the concerns regarding resident E's wound culture and had no additional information to provide. This citation relates to Intake 3074217. 410 IAC (Indiana Administrative Code) 16.2-3.1-49(c)

Based on record review and interview, the facility failed to ensure a dependent resident received bathing at least twice a week, daily hygiene and oral care, for 1 of 4 residents reviewed for activities of daily living (ADL's). (Resident D) Finding includes:Resident D's closed record was reviewed on 7/7/26 at 6:58 a.m. The diagnoses included, but were not limited to, paraplegia related to trauma.A Care Plan, dated 6/17/26, indicated the resident was dependent for oral care, bathing, and hygiene.A Care Plan, dated 6/18/26, indicated the bathing type of preference was a shower.An admission Minimum Data Set assessment, dated 6/22/26, indicated maximum assistance was required for oral hygiene, set up assistance was required for hygiene, and was dependent for bathing.The CNA tasks record indicated hygiene had not been completed on June 20, 21, 28, and 30, 2026. Oral hygiene had not been completed on June 20, 21, 28, and 30, 2026.Bathing record forms were provided by the Nurse Consultant and indicated the type of bathing had not been documented on the bathing record form for 6/19/26, 6/24/26, and 6/30/26. The resident had been bathed only one time from 6/21/26 to 6/30/26.The ADL concern was was discussed with the Nurse Consultant on 7/7/26 at 4:50 p.m., no further information was provided.This citation relates to Intakes 3012845, 3055048 and 3064613.410 IAC (Indiana Administrative Code) 16.2-3.1-38(a)(3)410 IAC 16.2-3.1(a)(3)(C)

Based on record review and interview, the facility failed to ensure a resident received an intravenous antibiotic as ordered by the physician for 1 of 3 residents reviewed for antibiotic use. (Resident H) Finding includes:Resident H's record was reviewed on 7/8/26 at 10:17 a.m. The diagnoses included, but were not limited to, cellulitis of right lower limb. A Care Plan, dated 6/9/26, indicated an antibiotic was being administered. The interventions included the antibiotic would be administered as ordered by the physician.A Physician's Order, dated 6/23/26, indicated piperacillin sod - tozobactam (antibiotic) 3-0.375 grams (g) was to be administered intravenously (IV) every six hours for seven days.The Medication Administration Record, dated 6/2026, indicated the antibiotic had not been administered on 6/24/26 at 12:00 p.m. with no reason documented and on 6/30/26 at 12:00 a.m. due to the resident was sleeping.During an interview on 7/8/26 at 12:35 p.m., the Nurse Consultant acknowledged the antibiotic had not been administered.This citation relates to Intakes 3055048 and 3064613.410 IAC (Indiana Administrative Code) 16.2-3.1-37

Based on record review and interview, the facility failed to ensure residents with pressure ulcers received the necessary treatment and services to promote healing related to treatments not completed, a protein supplement not provided, and antibiotic medication not administered for a wound infection as ordered for 3 of 3 residents reviewed for pressure ulcers. (Residents D, E, and F)Findings include: 1. Resident D's closed record was reviewed on 7/7/26 at 6:58 a.m. The diagnoses included, but were not limited to, infected unstageable (unable to determine depth of ulcer) sacral pressure ulcer and stage three (full thickness of skin loss) pressure ulcer of the heel. A Care Plan, dated 6/17/26, indicated impairments to the skin were present. The interventions indicated the areas would be treated as ordered by the physician. A Care Plan, dated 6/18/26, indicated an antibiotic was to be administered related to infection. The interventions indicated the antibiotic would be administered as ordered by the physician. An admission Minimum Data Set (MDS) assessment, dated 6/22/26, indicated there were unhealed pressure areas on admission. There was one stage three and four unstageable wounds on admission. a) A Physician's Order, dated 6/17/26, indicated piperacillin sod-tazobactam (antibiotic) 3.375 grams was to be administered intravenously every six hours for infection for 14 days. The MAR, dated 6/2026, indicated the antibiotic had not been administered on 6/24/26 at 12:00 p.m. and 6/29/26 at 6:00 p.m. The MAR, dated 7/2026, indicated the antibiotic had not been administered on 7/1/26 at 12:00 p.m. and at 6:00 p.m. b) A Physician's Order, dated 6/18/26, indicated Critical Care Active Protein supplement, 30 milliliters (ml) was to be provided twice a day to promote wound healing. The Medication Administration Record (MAR), dated 6/2026, indicated the supplement had not been administered on 6/29/26 at 5:00 p.m. The MAR, dated 7/1/16, indicated the supplement had not been administered on 6/1/26 at 5:00 p.m. c) A Physician's Order, dated 6/18/26, indicated the pressure area on the left gluteal (buttocks) was to be cleansed with saline, patted dry, a nickel size of Santyl (debriding agent) was to be applied and covered with a moist gauze and then a dry dressing applied every day shift. The Treatment Administration Record (TAR), dated 6/2026, indicated the treatment had not been completed on 6/19/26. A Physician's Order, dated 6/18/26, indicated betadine was to be applied to the left heel pressure area then cover the area with roll gauze daily and as needed. The TAR, dated 6/2026, indicated the treatment to the left heel had not been completed on 6/19/26 and 6/20/26. A Physician's Order, dated 6/18/26, indicated Santyl was to be applied to the coccyx area after cleansing and the area was to be covered by a moist gauze and dry dressing every day shift. The TAR, dated 6/2026, indicated the treatment to the coccyx had not been completed on 6/19/26 and 6/20/26. A Physician's Order, dated 6/18/26, indicated Santyl was to be applied to the sacrum pressure area every day shift after cleansing, then covered with a moist gauze and dry dressing. The TAR, dated 6/2026, indicated the sacrum treatment had not been completed on 6/19/26. A Physician's Order, dated 6/20/26, indicated the sacrum wound was to be cleansed with saline, patted dry, skin prep was to be applied to the peri-wound, and a wound vac was to be applied and changed every Tuesday, Thursday, and Saturday and as needed. The TAR, dated 6/2026, indicated the wound vac treatment had not been completed on 6/20/26. A Physician's Order, dated 6/30/26, indicated Iodosorb External Gel 0.9% (antimicrobial gel) was to be applied to the left heel every day shift and covered with a dry dressing. The TAR, dated 7/2026, indicated the left heel treatment had not been completed on 7/1/26. During an interview with the Nurse Consultant on 7/7/26 at 4:50 p.m., no further information was provided. An undated facility pressure wound policy, received as current on 7/7/26 at 3:48 p.m. from the Administrator, indicated implementation of appropriate interventions were to be documented and supplements were to be utilized as ordered. 2. The record for Resident E was reviewed on 7/7/26 at 9:43 a.m. Diagnoses included, but were not limited to, muscle weakness, acute kidney failure, and hypertension (high blood pressure). The 7/4/26 admission Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making and had a stage three pressure ulcer on admission. A Nursing Progress Note, dated 6/30/26 at 8:09 a.m., indicated the resident's admitting assessment revealed a pressure injury to the coccyx. There was slough (moist, yellowish or white stringy dead tissue) and pale pink tissue noted. Orders were received and initiated. A Care Plan, dated 6/30/26, indicated the resident had been admitted to the facility with a pressure injury to the coccyx. Approaches were to treat per physician orders, and measure and assess per facility policy. A Physician's Order, dated 7/1/26, indicated to apply topical external triad paste to the coccyx every day shift for wound care. The Treatment Administration Record (TAR) for June and July 2026 indicated wound treatments were not signed out on the following dates: 6/30/26 7/1/26 7/4/26 7/6/26 During an interview on 7/8/26 at 11:33 p.m., the Nurse Consultant indicated she understood the concerns and had no further information to provide. 3. Resident F's record was reviewed on 7/7/26 at 2:35 p.m. The diagnoses included, but were not limited to, muscle weakness, abnormal gait and mobility, aphasia (difficulty speaking), obstructive and reflux uropathy (blockage and backward flow of urine), adjustment disorder, anemia (low iron), and hypertension (high blood pressure). The 6/16/26 admission Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision-making and had a pressure injury. A Care Plan, dated 6/10/26, indicated the resident had actual impairment to skin integrity. Approaches were to evaluate and treat per physician's orders and follow facility protocol for treatment of injury. A Care Plan, dated 6/10/26, indicated the resident was in Enhanced Barrier Precautions (EBP) related to wounds. Approaches were to provide EBP as indicated, and use of personal protective equipment (PPE), specifically gowns and gloves during high contact resident care. A Physician's Order, dated 6/11/26 at 7:00 a.m., indicated to cleanse the left inner glute with saline, pat dry, apply medical honey to the wound bed and cover with a dry dressing every day shift and as needed. The Treatment Administration Record (TAR) for June 2026 indicated wound treatments were not signed out on the following dates: 6/11 6/14 6/20 6/21 6/22 6/26 6/27 During an interview on 7/8/26 at 11:33 p.m., the Nurse Consultant indicated she understood the concerns and had no further information to provide. This citation relates to Intakes 3055048 and 3064613. 410 IAC (Indiana Administrative Code) 16.2-3.1-40(a)(2)

Based on observation, record review, and interview, the facility failed to ensure Foley (urinary) catheter care was provided, urine output was recorded and catheter bags and tubing were kept off of the floor for a resident with a Urinary Tract Infection (UTI) for 2 of 3 residents reviewed for catheters. (Residents E and F) Findings include: 1. On 7/7/26 at 10:30 a.m., Resident E was observed lying in bed. He had a Foley catheter that hung off the side of the bed. The record for Resident E was reviewed on 7/7/26 at 9:43 a.m. Diagnoses included, but were not limited to, muscle weakness, acute kidney failure, and hypertension (high blood pressure). The 7/4/26 admission Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision-making and had a urinary catheter. A Care Plan, dated 6/29/26, indicated the resident had a urinary catheter. The approaches were to check placement of the tubing every shift, monitor/document pain or discomfort, and monitor/record/report signs and symptoms of a UTI. A Physician's Progress Note, dated 6/30/36 at 9:26 p.m., indicated the resident had a suspected UTI and recommended hot and cold packs to reduce abdominal/back pain associated with a UTI. A Physician's Order, dated 7/1/26, indicated to administer foley catheter care every shift and as needed. The Treatment Administration Record (TAR) for July 2026 lacked documentation that Foley catheter care had been provided from 7/1/26-7/7/26.During an interview on 7/8/26 at 11:33 p.m., the Nurse Consultant indicated the order had never transferred to the TAR and she would have the issue resolved. 2. During random observations on 7/7/26 at 8:35 a.m., 12:16 p.m. and 12:50 p.m., Resident F was observed sitting in a wheelchair. The bottom of the resident's urinary catheter bag was observed on the floor under the wheelchair. Resident F's record was reviewed on 7/7/26 at 2:35 p.m. The diagnoses included, but were not limited to, muscle weakness, abnormal gait and mobility, aphasia (difficulty speaking), obstructive and reflux uropathy (blockage and backward flow of urine), adjustment disorder, anemia (low iron), and hypertension (high blood pressure). The 6/16/26 admission Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision-making and had a urinary catheter. A Care Plan, dated 6/10/26, indicated the resident had a urinary catheter. The approaches were to check placement of the tubing every shift, monitor/document pain or discomfort, and monitor/record/report signs and symptoms of a UTI which included urinary frequency, foul smelling urine, no output, fever, chills, cloudiness, mental status changes, and blood-tinged urine. A Care Plan, dated 6/12/26, indicated the resident was on antibiotic therapy. Approaches were to administer medications as ordered by a physician and monitor and report adverse reactions. A Physician's Order, dated 6/17/26 indicated to record output every shift. A Physician's Order, dated 6/17/26 indicated to change the Foley catheter drainage bag as needed. A Physician's Order, dated 6/26/26, indicated to obtain a urinalysis and culture (urine laboratory tests). The Urine Culture results, dated 6/29/26, indicated a urine infection was present. A Physician's Order, dated 6/30/26, indicated to administer Ciprofloxacin 500 milligrams (mg), one tablet by mouth every 24 hours for 10 days for infection. A Physician's Order, dated 7/7/26 at 7:00 a.m., indicated Foley catheter care to include anchoring tubing and checking skin integrity every shift. The record lacked Foley catheter care orders until 7/7/26. A Physician's Order, dated 7/7/26 at 7:00 a.m., indicated to check/ensure the Foley catheter was in place and intact. A Physician's Progress Note, dated 7/6/26 at 10:24 a.m., indicated the resident had a UTI and was on Ciprofloxacin (antibiotic) until 7/10/26. The June and July Treatment Administration Record (TAR) indicated there was no Foley catheter care recorded for June through July 7th, 2026. The urine output was not recorded on the following dates:6/17/26 - am and pm6/18/26 - pm shift6/19/26 - pm shift6/20/26 - am shift6/21/26 - am and pm shift6/22/26 - am shift6/23/26 - am and pm shift6/24/26 - am shift6/25/26 - am and pm shift6/26/26 - am shift6/27/26 - am shift6/29/26 - am and pm shift6/30/26 - am and pm shift7/4/26 - am shift7/5/26 - am and pm shift7/6/26 - pm shift The current 2025 Catheter policy, provided by the Nurse Consultant on 7/7/26 at 3:48 p.m., indicated .provide routine perineal hygiene according to facility protocol . During an interview on 7/7/26 at 2:21 p.m., the Nurse Consultant indicated the resident's Foley bag should not have been on the floor. During an Interview on 7/8/26 at 11:33 a.m., the Nurse Consultant indicated she understood the output should have been documented and the catheter care orders should have been placed sooner. She had no further information to provide. This citation relates to Intakes 3055048 and 3064613. 410 IAC (Indiana Administrative Code) 16.2-3.1-41(a)(2)

Based on record review and interview, the facility failed to provide colostomy care and assess the colostomy and skin surrounding the ostomy, for 1 of 1 resident with a colostomy. (Resident D)Finding includes:Resident D's closed record was reviewed on 7/7/26 at 6:58 a.m. The diagnoses included, but were not limited to, paraplegia related to trauma and colostomy.A Care Plan, dated 6/17/26, indicated an ostomy was present. The interventions included the stoma would be monitored for changes and ostomy care would be provided.An admission Minimum Data Set assessment, dated 6/22/26, indicated a colostomy was present.There was no documentation in the record that indicated colostomy care had been provided, the collection bag had been changed, stoma care had been completed, and the ostomy site had been assessed.There were no Physician's Orders for the care of the colostomy.During an interview 7/7/26 at 11:05 a.m., the Nurse Consultant had no further information on the care of the colostomy.A facility undated colostomy policy, received from the Administrator on 7/7/26 at 3:48 p.m., indicated a resident with a colostomy would receive care in accordance with physician's orders, the care plan, infection prevention standards, and accepted nursing practice. The stoma was to be assessed with care and as needed. The peristomal skin was to cleansed with warm water and dried thoroughly. the stoma assessment was to be documented with output characteristics, skin condition, appliance changes, resident tolerance, and any abnormalities.This citation relates to Intakes 3055048 and 3064613.410 IAC (Indiana Administrative Code) 16.2-3.1-47(a)(3)

Based on observation, record review, and interview, the facility failed to care for peripherally inserted central catheters (PICC) (inserted into a vein in the upper arm for intravenous [IV] treatments) in accordance with professional standards of practice related to lack of measurements of the catheter length, dressing changes to the site, assessments of the site and flushes of the catheter for 3 of 3 residents reviewed with a PICC. (Residents G, H, and D)Findings include:1. During an observation on 7/8/26 at 10:30 a.m., LPN 1 administered Resident G's antibiotic through the PICC line in the left upper arm after flushing the line with 10 milliliters (ml) of normal saline. The dressing covering the PICC insertion site was dated 6/26/26. The Nurse Consultant verified the date at 6/26/26 and indicated the dressing was to be changed every seven days.Resident G's record was reviewed on 7/8/26 at 12:51 p.m. The diagnoses included, but were not limited to, urinary tract infection.The Nursing admission Assessment, dated 6/27/26 at 6:53 p.m., indicated a peripheral IV was present. A PICC line was not indicated.A Care Plan, dated 6/27/26, indicated the resident received IV medications. The interventions included the site would be observed every shift, the dressing would be changed every week, and the IV would be flushed per the physician's orders.An admission Minimum Data Set (MDS) assessment, dated 7/3/26, indicated the resident received an antibiotic, had IV medications and an IV access.There were no physician's orders for the PICC line flush or dressing changes.There was no documentation the the PICC insertion site had been assessed, flushes had been completed, or the dressing had been changed every seven days. 2. During an observation on 7/8/26 at 1 p.m., the dressing over the PICC site on Resident H's right upper arm was dated 7/7/26.Resident H's record was reviewed on 7/8/26 at 10:17 a.m. The diagnoses included, but were not limited to, cellulitis of right lower limb. A Nursing admission Assessment, dated 6/8/26 at 7:23 p.m., indicated there was no venous access present.A PICC Insertion Form from the nursing service who inserted the PICC line, dated 6/16/26, indicated a line had been placed in the left upper arm. The size of the line and the length of the line and arm circumference were documented. The directions indicated a dressing change was to be completed 24 hours after insertion and then every seven days and as needed.There was no documentation that indicated the dressing had been changed 24 hours after the PICC line was inserted.A Physician's Order, dated 6/19/26, indicated the PICC line was to be flushed with 10 ml of normal saline every shift to keep the line patent.The Medication Administration Record (MAR) indicated the flush had not been completed on the day and night shifts on 6/29/26.There were no physician orders for changing the dressing.There was no documentation the dressing had been changed every seven days.A Care Plan, dated 7/2/26, indicated the resident received IV medications. The interventions included, the insertion site and dressing was to be assessed every shift, the dressing was to be changed weekly, and flushes were to be completed per the physician's orders.There were no assessments of the insertion site until 7/5/26 at 2:10 p.m. A Nurse's Note, dated 7/5/26 at 2:10 p.m., indicated the PICC line had been pulled out approximately 1/2 inch and the insertion site was reddened. The nursing service for PICC line insertion was notified.A new PICC line was inserted on 7/5/26 at 5:55 p.m. by the nursing service.There was no documentation that indicated the PICC line dressing had been changed 24 hours after the insertion on 7/5/26.There were no further assessments of the PICC insertion site.During an interview on 7/8/26 at 2:30 p.m., the Nurse Consultant indicated there were no orders to change the dressing every seven days or assessments completed. 3. Resident D's closed record was reviewed on 7/7/26 at 6:58 a.m. The diagnoses included, but were not limited to, infected unstageable (unable to determine depth of ulcer) sacral pressure ulcer and stage three (full thickness of skin loss) pressure ulcer of the heel. The Nursing admission Assessment, dated 6/17/26 at 6:00 p.m., indicated there was no venous access.A Physician's Order, dated 6/17/26, indicated piperacillin sod-tazobactam (antibiotic) 3-0.375 grams was to be administered intravenously every six hours.A Care Plan, dated 6/18/26, indicated the resident received IV medications. The interventions included, the dressing was to be observed every shift and the dressing was to be changed every seven days.A Physician's Order, dated 6/19/26 indicated the PICC line was to be flushed with 10 ml of normal saline every shift to keep the line patent.There was no documentation when the PICC line was inserted or when the dressing changes had been completed. There was no documentation of the PICC line insertion site assessments.An undated central line (PICC) policy, received from the Nurse Consultant on 7/8/26 at 11:30 a.m., indicated the dressing change was to be completed every seven days and as needed.This citation relates to Intakes 3055048 and 3064613.410 IAC (Indiana Administrative Code) 16.2-3.1-47(a)(2)

Based on observation, interview, and record review, the facility failed to ensure infection control practices were in place and implemented related to Enhanced Barrier Precautions (EBP) not followed and no glove change from dirty to clean care for 1 of 3 residents reviewed for infection control. (Resident E) Finding includes: During random observations on 7/7/26 at 10:30 a.m. and 12:11 p.m., Resident E was observed lying in bed. There was no Enhanced Barrier Precautions (EBP) sign on the door or inside the resident's room. On 7/7/26 at 10:32 a.m., CNA 1 was observed providing incontinence care to Resident E. CNA 1 had put gloves on and positioned the resident lying down. She indicated the resident had a bowel movement and needed to be changed. She removed the resident's brief and realized he did not have a bowel movement but provided peri care and a new brief. The resident had a wound dressing on his coccyx which remained intact. The CNA then began to get the resident dressed for therapy; she put his pants on and buttoned his shirt up and assisted the resident to his wheelchair. CNA 1 did not change her gloves after completing peri care to transfer into the wheelchair. The resident was supposed to be in enhanced barrier precautions due to having a catheter, feeding tube and a wound, and the CNA had only worn gloves during care. During an interview at the time, CNA 1 indicated she had never cared for Resident E and if he was in enhanced barrier precautions she would wear a gown, gloves, and a mask. She had indicated there was no EBP sign on the door. The record for Resident E was reviewed on 7/7/26 at 9:43 a.m. Diagnoses included, but were not limited to, muscle weakness, acute kidney failure, and hypertension (high blood pressure). The 7/4/26 admission Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision-making and had a urinary catheter. A Care Plan, dated 6/29/26, indicated the resident was in Enhanced Barrier Precautions (EBP) related to wounds. Approaches were to provided EBP as indicated, and use of personal protective equipment (PPE), specifically gowns and gloves during high contact resident care. A Care Plan, dated 6/30/26, indicated the resident had been admitted to the facility with a pressure injury to the coccyx. Approaches were to treat per physician orders, and measure and assess per facility policy. A Physician's Order, dated 7/5/26, indicated the resident was in enhanced barrier precautions related to a wound. During an interview on 7/7/26 at 11:23 a.m., the Nurse Consultant indicated CNA 1 should have followed enhanced barrier precautions and changed her gloves after care. During an interview on 7/8/26 at 11:33 a.m., the Nurse Consultant indicated they had an infection control staff member, but she had been off for a while. They were going to check and ensure all doors were updated with appropriate signage. A facility policy titled, Enhanced Barrier Precautions and received as current from the Nurse Consultant on 7/7/26 at 3:48 p.m., indicated, .Gowns and gloves are used during high contact activities with increased risk for MDRO transmission to staff clothing and hands including but not limited to: dressing, bathing/showering, and transferring . This citation relates to Intakes 3055048 and 3064613. 410 IAC (Indiana Administrative Code) 16.2-3.1-18(b)

Based on observation, record review and interview, the facility failed to ensure posted staffing information was current and failed to retain the posted daily nurse staffing data for a minimum of 18 months. This had the potential to affect all residents who reside in the facility.Finding includes:During an observation on 7/7/26 at 4:00 a.m., the posted staffing information was located at the front door. The date on the posting was 7/2/26.During an interview on 7/7/26 at 5;50 a.m., the Nurse Consultant indicated the posted information was to be changed out daily.During an interview on 7/7/26 at 4:55 p.m., the Nurse Consultant indicated the Scheduler had been shredding the daily postings. She started the position in February and was unaware she was required to keep the posting.This citation relates to Intakes 3012845 and 3055048.

Based on record review and interview, the facility failed to ensure weights were monitored as ordered and/or reweights were checked for significant weight changes for 5 of 8 residents reviewed for nutrition. (Residents 5, 27, 58, 6 and 17)Findings include: 1.Resident 5's record was reviewed on 2/20/26 at 10:09 a.m. Diagnoses included, but were not limited to, dependence on renal dialysis and heart failure. The resident was admitted on [DATE]. A Physician's order, dated 1/31/26, indicated to weigh the resident one time a day for three days, then once a week for four weeks, then monthly. The only weight recorded in vitals since admission was on 1/31/26. During an interview on 2/20/26 at 2:00 p.m., the Director of Nursing (DON) indicated weights wouldn't be documented anywhere else and she was aware there were issues with weights not being monitored as scheduled. 2. Resident 27's record was reviewed on 2/19/26 at 10:10 a.m. Diagnoses included, but were not limited to, protein calorie malnutrition and dementia. The Quarterly Minimum Data Set assessment, dated 2/6/26, indicated the resident had moderate cognitive impairment, had weight loss and needed set up assistance for eating. The resident's weight on 8/21/25 was 166 pounds. The resident's weight on 9/22/25 was 149.8 pounds, a loss of 16.2 pounds in one month. There was no reweigh completed at that time. The next monthly weight was recorded on 10/24/25 and was 149 pounds. During an interview on 2/20/26 at 2:00 p.m., the Director of Nursing (DON) indicated weights wouldn't be documented anywhere else and she was aware there were issues with weights not being monitored as scheduled. If there was a significant weight change within a short period of time, a reweigh should be completed as soon as possible. 3. Resident 58's record was reviewed on 2/20/26 at 9:07 a.m. Diagnoses included, but were not limited to, adult failure to thrive and diabetes mellitus. A Physician's order, dated 12/27/25, indicated to weigh the resident one time a day for three days, then once a week for four weeks, then monthly. The resident's weight on 12/30/25 was 215.2 pounds. The resident's weight on 1/11/26 was 201.4 pounds, a loss of 13.8 pounds in less than two weeks. There was no documentation the resident was reweighed. During an interview on 2/20/26 at 2:00 p.m., the Director of Nursing (DON) indicated weights wouldn't be documented anywhere else and she was aware there were issues with weights not being monitored as scheduled. If there was a significant weight change within a short period of time, a reweigh should be completed as soon as possible. The current Weight Policy was provided by the DON on 2/20/26 and indicated, 1. Resident will be weighed upon admission, readmission, weekly for the first 4 weeks and then at least monthly and, .5. Weights, upon completion, will be given to the DON or designee to determine a list of reweighs 4. Record review for Resident 6 was completed on 2/20/26 at 9:18 a.m. Diagnoses included, but were not limited to, heart failure, hypertension, and end stage renal disease. The resident was discharged to the hospital on 2/18/26. The resident's weights indicated that on 12/5/25 the resident weighed 191.1 pounds. On 1/11/26 the resident weighed 175.6 pounds which was a weight loss of 8.11%. There was a lack of documentation to indicated the resident was re-weighed after the significant weight loss on 1/11/26. During an interview on 2/23/26 at 2:27 p.m., the Director of Nursing (DON) indicated the weight taken on 1/11/26 was incorrect. The staff should have done a re-weight on 1/11/26 since there was a significant weight loss. 5. Resident 17's record was reviewed on 2/19/26 at 11:15 a.m. The resident admitted to the facility on [DATE]. On 2/2/26, the resident weighed 265.6 pounds (lbs). On 2/17/26, the resident weighed 237.6 lbs which was a -10.54% loss. A Care Plan, revised on 2/11/26, indicated the resident had potential for alterations in nutrition and hydration. Interventions included, but were not limited to, monitor/record/report to the physician as needed any signs or symptoms of malnutrition including emaciation, muscle wasting, or significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months, obtain and document weights per orders and facility protocol. A Physician's Order, dated 1/31/26, indicated weights one time a day for three days, then one time a day every seven days for four weeks and then one time a day every month. The resident's weight was recorded on 1/31/26 with a weight of 265.6 lbs, on 2/2/26 with a weight of 265.6 lbs and on 2/17/26 with a weight of 237.6 lbs. There was no weight documented on 2/1/26 or any weights following 2/17/26 after a 10.54% weight loss was documented. During an interview on 2/23/26 at 2:27 p.m., the Director of Nursing indicated any weights that seemed abnormal should have been stricken from the record and there was a problem with obtaining weights by the CNAs as they were not weighing the residents correctly each time, so there were discrepancies with some of the resident's weights. A facility policy titled, Weight Policy, indicated, .1. Residents will be weighed upon admission, readmission, weekly for the first 4 weeks and then at least monthly. 2. Weekly weights will be done with a physician order or as the facility deems appropriate .3. Short term residents with a diagnosis of CHF will be weighed twice weekly unless otherwise ordered by the physician .5. Weights, upon completion, will be given to the DON or designee to determine a list of reweights. 6. Once reweighs have occurred any resident with an unexplained significant to insidious weight loss will be reviewed and intervention implemented by the DON or designee . 3.1-46(a)

Based on observation, record review and interview, the facility failed to label insulin pens with open dates in 1 of 2 medication carts observed. (Cart C1)Finding includes:On 2/23/26 at 11:50 a.m., Medication Cart C1 was observed with LPN1. There were 12 various insulin pens in plastic baggies that were labeled Refrigerate Until Opened. There were stickers on each insulin pen with space provided to write an opened-on date, none of the pens had opened-on dates documented. The LPN indicated there should be dates written on the pens when opened, and should be refrigerated if not opened. During an interview on 2/23/26, the Administrator indicated all the insulin pens had been opened but did not have opened-on dates. A document titled, Information Regarding Insulin Storage and Switching Between Products in an Emergency, was provided by the Director of nursing on 2/24/26 and indicated, .Insulin products .may be left unrefrigerated at a temperature between 59 and 86 degrees Fahrenheit for up to 28 days and continue to work 3.1-25(j)

Based on observation, record review, and interview, the facility failed to ensure residents were assessed for self-administration of medications and had a physician's order to self-administer medications for 1 of 1 resident reviewed for self-administration of medication. (Resident 68)Finding includes:During an observation on 2/18/26 at 1:40 p.m., Resident 68 was observed sitting in his room. There were latanoprost eye drops on the bedside. The resident indicated he administered the eye drops himself.Resident 68's record was reviewed on 2/20/26 at 11:38 a.m. A Physician's Order, dated 2/10/26, indicated latanoprost ophthalmic emulsion 0.005% instill one drop in both eyes at bedtime for eye pressure. There was a lack of any Physician's Orders for self-administration of medications or any assessment for self-administration of medications.During an interview on 2/23/26 at 9:22 a.m., the Director of Nursing indicated she had no further information at the time.A facility policy titled, Self-Administration of Medications and Treatments, indicated, .1. If it is determined by a member of the interdisciplinary team, or if the resident requests to self-administer, it is documented in the chart, and the physician is called for an order to self-administer medications and keep the medications at bedside. 2. Assessment of the ability to self-administer medications will be done by nursing using the tool assessment for self-administration of medications. The assessment will review if the resident is fully capable, able with assist, or unable to perform assessment criteria .3.1-11(a)

Based on observation, record review and interview, the facility failed to ensure care plans were in place and implemented related to hypotension and splint use for 2 of 25 resident care plans reviewed. (Residents 5 and 38)Findings include:1.The record for Resident 5 was reviewed on 2/20/26 at 10:09 a.m. Diagnoses included, but were not limited to, heart failure and dependence on renal dialysis. A Physician's Order, dated 2/16/26, indicated to give midodrine (a medication used to treat hypotension) 10 milligrams, three times a day related to hypotension. A Hypotension Care Plan was initiated on 2/1/26, however, there were no goals or interventions included. During an interview on 2/20/26 at 2:00 p.m., the Director of Nursing was made aware the care plan was not completed. There was no additional information provided. 2. On 2/17/26 at 11:42 a.m. and 3:30 p.m., and 2/20/26 at 1:29 p.m., Resident 38 was observed sitting in a wheelchair and had a splinting device on her left hand. Resident 38's record was reviewed on 2/19/26 at 2:31 p.m. Diagnoses included, but were not limited to, hemiplegia (weakness or paralysis) of the left non-dominant side. The admission Minimum Data Set assessment, dated 1/30/26, indicated the resident was moderately cognitively impaired and had an impairment in range of motion on one side of the upper and lower extremities. A Physician's Order, dated 1/24/26, indicated apply brace to left hand at bedtime and remove in the morning every day. The record lacked any care plans related to the resident's limited range of motion with splint use. During an interview on 2/23/26 at 9:33 a.m., the Director of Nursing indicated she had no further information to provide. 3.1-35(a)

Based on observation, record review and interview, the facility failed to ensure medications were administered as ordered for 1 of 5 residents reviewed for unnecessary medications, (Resident 5) and 1 of 2 residents reviewed for urinary catheter. (Resident 66) The facility also failed to ensure a physician's order was in place for a compression device for 1 of 3 residents reviewed for range of motion. (Resident 4)Findings include:1.Resident 5's record was reviewed on 2/20/26 at 10:09 a.m. Diagnoses included, but were not limited to, dependence on renal dialysis and heart failure. The admission Minimum Data Set assessment, dated 2/2/26, indicated the resident was cognitively intact and received renal dialysis. A Physician's Order, dated 2/16/26, indicated to give midodrine, (a medication used to treat hypotension) 10 milligrams, three times daily, for hypotension. Hold if blood pressure was greater than 130/90. The February 2026 Medication Administration Record (MAR) indicated the midodrine was given on the following days when the systolic pressure was greater than 130: 2/17 blood pressure 150/86 2/18 blood pressure 150/86 2/18 blood pressure 146/59 2/20 blood pressure 141/78 On 2/19, the medication was not given when the blood pressure was 119/64. The Medication Note indicated the blood pressure was outside of parameters. During an interview on 2/20/26 at 2:00 p.m., the Director of Nursing indicated the midodrine orders and parameters came from the hospital discharge orders. She indicated the parameters should be revised to hold the medication if the systolic was greater than 130 and the current order wasn't clear. She indicated some education needed to be provided to nursing staff. 2. On 2/18/26 at 1:22 p.m., Resident 4 was observed sitting in a wheelchair in his room. There were compression leg wraps folded up in a clear plastic bag on his bed. There was also a machine with tubes hooked to the end of the bed that connected to the compression leg wraps. The resident indicated he was unaware who brought them and placed them on his bed. He was unaware if he was supposed to apply them or if the facility staff were to apply them to his legs. On 2/19/26 at 2:35 p.m., Resident 4 was not in his room. The compression leg wraps were opened up and laying on the resident's bed. They were hooked to the tubing and the machine at the end of his bed. Record review for Resident 4 was completed on 2/19/26 at 1:02 p.m. Diagnoses included, but were not limited to, diabetes mellitus and left tibia fracture. The Quarterly Minimum Data Set (MDS) assessment, dated 2/3/26, indicated the resident was cognitively intact. The resident had an impairment on both sides of his lower extremities. The resident received diuretic and anticoagulant medications. A Care Plan, dated 10/31/25, indicated the resident was on diuretic therapy related to edema. A Care Plan, dated 10/31/25, indicated the resident was on anticoagulant therapy related to DVT (deep vein thrombosis) (blood clot) prevention. There was lack of documentation for Physician Orders for the compression leg wraps. During an interview on 2/19/26 at 2:36 p.m., RN 1 indicated she was unaware there were compression leg wraps on the resident's bed. He did not have an order for them and she would have to look into it. During an interview on 2/19/26 at 2:50 p.m., the Director of Nursing (DON) indicated the resident was supposed to wear the legs wraps for swelling in his legs. The company must have dropped them off in his room and did not let the staff know. There should have been an order in the computer for the compression leg wraps. 3. Resident 66's record was reviewed on 2/20/26 at 10:32 a.m. Diagnoses included, but were not limited to, heart failure. A Physician's Order, dated 1/31/26, indicated midodrine (treatment for low blood pressure) oral tablet 2.5 milligrams, one tablet by mouth three times a day, hold medication if systolic blood pressure (top number) is greater than 110. The February 2026 Medication Administration Record indicated the midodrine was administered on the following dates and times with a systolic blood pressure (bp) greater than 110. - 2/2/26 at 8:00 a.m., bp 123/75 - 2/2/26 at 12:00 p.m., bp 136/74 - 2/3/26 at 8:00 a.m., bp 135/87 - 2/3/26 at 12:00 p.m., bp 129/72 - 2/6/26 at 12:00 p.m., bp 117/63 - 2/6/26 at 5:00 p.m., bp 117/63 During an interview on 2/23/26 at 2:20 p.m., the Director of Nursing indicated she had no further information to provide. 3.1-37(a)

Based on observation, record review and interview, the facility failed to ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers related to not routinely repositioning a dependent resident for 1 of 3 residents reviewed for pressure ulcers. This resulted in the development of 2 Deep Tissue Injury (DTI) ulcers. (Resident G) Finding includes: On 4/26/21 at 9:40 a.m., Resident G was observed in his bed. He indicated he had some sores on his backside, which are not surprising, because I have just been laying in bed all day. On 4/27/21 at 12:15 p.m., the resident was observed in bed. He was alert and indicated he was able to turn himself in bed. He turned his upper body from side to side, however his buttocks did not lift from the mattress. There was an air mattress on his bed. The resident's record was reviewed on 4/27/21 at 9:25 a.m. The resident was admitted to the facility on [DATE] for therapy after falling and fracturing his left ankle. He was non-weight bearing to his left leg. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set Admission assessment, dated 4/18/21, indicated the resident needed extensive two person assist for bed mobility and transfers, had no pressure ulcers and was cognitively intact. A Physical Therapy evaluation, dated 4/12/21, indicated the resident needed maximum assistance of two persons to roll and sit in while in bed. An admission Skin Assessment, completed on 4/11/21, indicated the resident was at high risk to develop skin issues. A Skin Integrity Care Plan, initiated on 4/12/21, indicated the resident was at risk for skin impairment. The two interventions in place were to observe skin during routine care and report alterations to Nurse, and to provide peri-care and barrier cream as needed. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no orders or interventions to routinely reposition the resident. A Progress Note, dated 4/22/21, indicated the resident had increased confusion. Nursing Notes, dated 4/22/21 through 4/25/21, indicated the resident continued to be confused and was diagnosed with a UTI. On 4/25/21, a CNA noted there was skin impairment on the resident's buttocks. A Wound Assessment, dated 4/26/21, indicated the resident had a deep tissue injury (DTI) measuring 0.8 x 1.0 centimeters (cm) on his left buttock and a DTI measuring 3.0 x 1.4 cm on his right buttock. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no orders or interventions to reposition the resident. Interview with Unit Manager 1 on 4/27/21 at 12:20 p.m., indicated there was not an order to reposition the resident every two hours, only as needed. She indicated he was a maximum assist and could reposition himself. Staff were to reposition during care or as requested. Interview with the Administrator on 4/27/21 at 1:15 p.m., indicated the resident's skin risk assessment had improved since admission. On 4/14/21 he was assessed at moderate risk for skin impairment. She indicated the resident's mobility fluctuated. She did not know why the resident wasn't on a repositioning schedule, but would contact the Wound Nurse to find out as the Wound Nurse had left and was not available. Interview with Occupational Therapist 1 on 4/27/21 at 2:05 p.m., indicated the resident had made some improvement since admission with his bed mobility, but had recently been diagnosed with a UTI and had declined. He was a maximum to moderate assist with bed mobility. This Federal Tag relates to Complaint IN 753. 3.1-40

Based on record review and interview, the facility failed to ensure residents were free from avoidable pain related to not providing an effective pain management program to include continued pain assessment, physician notification, altered interventions and effectiveness follow-up resulting in ongoing excruciating pain which affected a resident's psychological state and daily ability to function (Resident 44) and the lack of timely administration of pain medications (Resident 256) for 2 of 3 residents reviewed for pain. Findings include: 1. Interview with Resident 44 on 7/30/19 at 8:41 a.m., indicated she had acute and chronic pain. She was being treated by a pain specialist prior to admission for her chronic pain issues. Upon her original admission, dated 7/4/19, she was taking [MEDICATION NAME] (a narcotic pain medication), [MEDICATION NAME] (a narcotic pain medication), and [MEDICATION NAME]es (a [MEDICATION NAME]) to help manage her pain. Her pain was in her right lower back, pelvic area, and genital area and her pain level was above 7, on a pain scale of 1 - 10. She indicated the pain was excruciating and affected her ability to function on a daily basis. Since 7/26/19, she had only received Tylenol which did not help. The [MEDICATION NAME] and [MEDICATION NAME] had been discontinued. She had refused the Tylenol medication at times because it did not provide relief, however, she had taken it out of desperation for relief since she did not have anything else. She had requested on multiple occasions to have her [MEDICATION NAME] re-ordered since 7/26/19 and had not received any follow up related to her requests. Interview with Resident 44 on 7/31/19 at 2:47 p.m., indicated she had reported to RN 3 that morning she was in pain after having a PICC (Peripherally Inserted Central Catheter) line (for provision of intravenous medications) insertion procedure and would like something else due to no relief. She had already taken Tylenol 650 mg (milligrams). The nurse indicated she would page the doctor. On 8/1/19 at 9:40 a.m., the resident was observed in her room with the lights off and the window shade closed. Interview at the time indicated her pain level was a 9 out of 10 located in her pelvic area, back, and genital area. She was in a depressed mood due to the excruciating pain and did not know what else to do. The record for Resident 44 was reviewed on 7/30/19 at 2:50 p.m. The resident was admitted to the facility on [DATE] from the hospital. She was discharged back to the hospital on [DATE] and returned on 7/20/19. [DIAGNOSES REDACTED]. The 5-Day Minimum Data Set (MDS) assessment, dated 7/27/19, indicated the resident was cognitively intact, had pain frequently which affected her sleeping and daily activities and had not received any non-medication intervention for pain. The Care Plan, dated 7/20/19, indicated the resident had pain, the interventions included, but were not limited to, monitor/record/report to nurse any signs and symptoms of non-verbal pain, changes in breathing vocalizations, and mood/behavior. The 7/2019 physician's orders [REDACTED]. - pain assessments every shift - [MEDICATION NAME] 50 mg, give 1 tablet by mouth every 6 hours as needed for pain, dated 7/6/19 -7/20/19 - [MEDICATION NAME] 10-325 mg, give 1 tablet by mouth every 12 hours as needed for Severe pain, dated 7/4/19 - 7/11/19 - [MEDICATION NAME] 10-325 mg, give 1 tablet by mouth every 4 hours as needed for pain for 5 days, dated 7/20/19 -7/25/19 - [MEDICATION NAME], apply to affected area topically in the morning 1 time a day for 12 hours and remove per schedule, dated 7/6/19 - 7/20/19 - Tylenol 325 mg, give 2 capsules by mouth every 4 hours as needed for pain, dated 7/5/19 -7/20/19 - Tylenol 325 mg, give 2 capsules by mouth every 4 hours as needed for pain, dated 7/20/19 - [MEDICATION NAME] 30 mg, give 1 capsule by mouth one time a day for pain, dated 7/6/19 - 7/20/19 - [MEDICATION NAME] 30 mg, give 1 capsule by mouth one time a day for pain, dated 7/29/2019 The resident's Pain Assessments, dated 7/20/19 - 8/1/19, indicated pain greater than 7 out of 10 on 9 out of 12 days. An eMAR- Medication Administration Note, dated 7/28/2019 at 1:45 a.m., indicated Tylenol Capsule 325 MG: Give 2 capsule by mouth every 4 hours as needed for Pain; Fever/Elevated Temperature offered Tylenol at this time for pain, patient refused saying, 'it doesn't work.' There was no documentation to indicate the Physician was notified related to the resident's continued complaints of pain or of any non-pharmacological interventions being attempted. Interview with RN 2 on 8/1/19 at 8:28 a.m., indicated she had reported the resident's complaints of pain. The [MEDICATION NAME] was not re-ordered because the resident's pain remained the same with the [MEDICATION NAME] and Tylenol. The Physician would only treat acute pain and not chronic pain. Interview with the Director of Nursing (DON) on 8/1/19 at 10:08 a.m., indicated the resident was placed on [MEDICATION NAME] for her pain. There should have been documentation to indicate the Physician was notified related to the resident's continued complaints of pain. There should have been an effective plan of care in place to address the resident's uncontrolled pain. 2. During an interview on 7/29/19 at 9:58 a.m., Resident 256 indicated she was admitted to the facility for pain management and antibiotic therapy. The Tylenol and the [MEDICATION NAME] gel help a lot but I wish it was given more timely. During an interview on 7/31/19 at 9:15 a.m., the resident indicated she went to the doctor yesterday and her pain was addressed. The cream needs to be on time and I will be ok. The record for Resident 256 was reviewed on 7/31/19 at 9:37 a.m. The resident was admitted on [DATE]. [DIAGNOSES REDACTED]. A Pain Evaluation, dated 7/18/19, indicated the resident was having pain now to the right and left iliac crest. The pain was acute and throbbing during movement, turning, resting, sitting, and therapy. The plan was to initiate a pain care plan. A Care Plan, dated 7/19/19, indicated the resident was at risk for alteration in comfort related to discitis and arthritis. The approaches were to administer medication as ordered and monitor for effectiveness of relief. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. The Medication Administration Record [REDACTED] The 7/2019 MAR, indicated the Tylenol extra strength twice a day for pain, was administered on 7/19/19 at 9:44 p.m., 7/20/19 at 9:30 a.m., 7/21/19 9:58 a.m., 7/22/19 at 9:47 a.m., 7/24/19 at 9:48 p.m., 7/25/19 11:02 a.m., and 7/25/19 at 11:48 p.m. The Tylenol 325 mg three times a day for pain was administered on 7/29/19 at 9:15 p.m. Interview with the Director of Nursing on 7/31/19 at 11:00 a.m., indicated the [MEDICATION NAME] gel and the Tylenol were not administered in a timely manner. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure residents were safe and free from accidents and hazards related to the use of oxygen in the beauty salon for 1 of 1 resident observed in the salon. (Resident 301). This had the potential to affect 4 residents on oxygen therapy who received services in the salon. The immediate jeopardy began on 4/28/17 at 2:10 p.m., when Resident 301 was observed seated in her wheelchair with oxygen flowing through a nasal cannula. The portable oxygen tank was observed anchored to the handles of the wheelchair. The Administrator and the Director of Nursing were informed of the immediate jeopardy on 4/28/17 at 4:02 p.m. Finding includes: On 4/28/17 at 2:10 p.m., Resident 301 was observed in the beauty salon. She was wearing a nasal cannula which was infusing oxygen at 3 liters per minute. Interview with the resident at the time indicated her oxygen was currently flowing through the nasal cannula. Interview with the beautician at the time, indicated she was not aware residents could not enter the salon with their oxygen infusing. The record for Resident 301 was reviewed on 5/1/17 at 9:52 a.m. [DIAGNOSES REDACTED]. The 4/24/17 Admission Minimum Data Assessment (MDS) indicated the resident was alert and oriented and required the use of oxygen. A physician's orders [REDACTED]. The 4/26/17 hair salon appointment log indicated two residents, which required oxygen, were provided services in the salon. The 4/28/17 hair salon appointment log indicated three residents, which required oxygen, were provided services in the salon. Interview with Resident 299 on 5/1/17 at 9:20 a.m., identified by the Administrator as being alert and oriented, indicated she received salon services on 4/26/17 and her portable oxygen tank was permitted in the salon during those services. Interview with Resident 306 on 5/1/17 at 9:25 a.m., identified by the Administrator as being alert and oriented, indicated she received salon services on 4/28/17 and her portable oxygen tank was permitted in the salon during those services. Interview with the Administrator on 4/28/17 at 2:15 p.m., indicated she was not aware residents were receiving salon services while receiving oxygen. No resident receiving oxygen therapy should be provided salon services while on oxygen. The current Oxygen Cylinder Safety Guidelines policy, dated 11/2014 and provided by the Administrator on 4/28/17 at 2:40 p.m., indicated, Never permit oil, grease or flammable materials to come in contact with oxygen cylinders, valves, gauges, or regulators of fittings. Do not store oxygen cylinders in a closet near heaters, radiators or any heat source as well as near elevators. Do not store cylinders where the temperature is above 125 degrees. The policy did not address oxygen use in the beauty shop and the administrator indicated there was no other facility policy which addressed this issue. The immediate jeopardy that began on 4/28/17, was removed on 5/2/17 after the facility reopened their beauty salon. There were no observations of residents receiving oxygen therapy while being provided services. Facility wide interviews were conducted related to the updated policy, which included, but was not limited to, Life Safety code regulations states that the resident nasal cannula or face mask must be at least 1 foot away from the heating element (NFPA 99 section 8-2.1.2.3) AS A RESULT, no oxygen equipment will be permitted in the beauty salon. Interviews also included fire extinguisher safety. The deficient practice was corrected on 4/28/17, after the facility identified and removed Resident 301 from the salon and assessed her for injuries. A sign was placed outside of the salon's door advising no oxygen use in the salon, the salon's beautician as well as facility staff were in-serviced on the safety hazards caused by oxygen in the salon, and the use of oxygen was no longer permitted in the salon. The salon appointment binder was also updated to include identifying guests who require the use of oxygen. 3.1-45(a)(2)