Every finding on record at Ignite Medical Resort Crown Point LLC

Based on record review and interview, the facility failed to ensure dependent residents received oral care and toilet transfers, for 2 of 3 residents reviewed for Activities of Daily Living (ADL's). (Residents B and D) Findings include: 1.The record for Resident B was reviewed on 7/15/26 at 9:15 a.m. Diagnoses included, but were not limited to, dysphagia (difficulty swallowing), stroke, aphasia (difficulty speaking) muscle wasting, dementia, and high blood pressure. The 2/26/26 admission Minimum Data Set (MDS) assessment indicated the resident was severely impaired for daily decision-making and required partial to moderate assistance with oral hygiene and personal hygiene. Toilet transfer required substantial to maximum assistance. A Care Plan, dated 2/21/26, indicated the resident had an ADL self-care performance deficit related to limitations in physical mobility. The Task Reports indicated oral care was not signed out as completed on the following dates:3/19, 3/23, 3/25, 3/27, 3/31, 4/3, 4/5, 4/8, 4/15, 4/19, 4/23, 4/26, 4/28, 4/29, 5/2, 5/3, and 5/4/26. Toilet transfers were not signed out as completed on the following dates:3/19, 3/23, 3/25, 3/27, 3/31, 4/3, 4/5, 4/8, 4/15, 4/19, 4/23, 4/25, 4/26, 4/27, 4/28, 4/29, 5/2, 5/3, and 5/4/26. During an interview on 7/15/26 at 3:00 p.m., the [NAME] President of Nursing Services indicated there were holes in the oral care and toilet transfer documentation and she would re- educate the staff. During an interview on 7/16/26 at 11:45 a.m., the General Manager indicated he understood the concerns and had no additional information to provide. 2. The record for Resident D was reviewed on 7/15/26 at 1:45 p.m. Diagnoses included, but were not limited to, stage four pressure ulcer, copd, protein malnutrition, dementia, heart failure, dysphagia (difficulty swallowing), high blood pressure, kidney disease stage three, and, muscle weakness. The 5/18/26 admission Minimum Data Set (MDS) assessment indicated the resident was severely impaired for daily decision-making and had impairment on both sides of the lower extremities. A Care Plan, dated 2/21/26, indicated the resident had an ADL self-care performance deficit related to limitations in physical mobility. Approaches were to provide dependent care for oral hygiene and toilet transfers. The Task Reports indicated oral care was not signed out as completed on the following dates:6/18, 6/19, 6/22, 6/23, 6/24, 6/25, 6/26, 6/30, 7/2, 7/6, and 7/8/26. During an interview on 7/15/26 at 3:00 p.m., the [NAME] President of Nursing Services indicated there were holes in the oral care and toilet transfer documentation and she would re- educate the staff. During an interview on 7/16/26 at 11:45 a.m., the General Manager indicated he understood the concerns and had no additional information to provide. This citation relates to Intakes 2985224 and 3013926. 410 IAC (Indiana Administrative Code) 16.2-3.1-38(a)(2)(C)410 IAC 16.2-3.1(a)(3)(C)

Based on observation, record review, and interview, the facility failed to ensure food was stored and served under sanitary conditions related to dirty food equipment, boxes stored on the floor, dirty dishes stored on food equipment, and lack of sanitation of the food thermometer for 1 of 1 kitchen. (The Main Kitchen) This had the potential to affect the 68 residents who received food from the kitchen. Findings include:1. During the Kitchen Sanitation Initial Tour on 3/29/26 at 9:55 a.m. with [NAME] 1, the following was observed:a. The grill had an accumulation of crumbs and debris on it.b. There was a stack of dirty pans and dishes on top of the flat-top grill.c. There were multiple boxes of food stored on the floor of the walk-in freezer. Some of the boxes were open and tipped over.d. There were multiple boxes of food and non-food items stored on the floor in the dry storage area. Some of the boxes were open and tipped over.e. There were multiple boxes of cups and straws stored on the floor in the hallway outside the kitchen.During an interview at that time, [NAME] 1 indicated all of the above was in need of cleaning. The items should not have been on the floor. They had been there for a few days and no one had put them away like they were supposed to. A facility policy, titled, Dietary Cleaning Policy, indicated, .Staff will use a 'clean as you go' technique to keep the facility and neighborhood kitchen areas clean, functional and attractive.The Retail Food Establishment Sanitation Requirements, dated 11/13/04, indicated .Food storage.Sec. 189. (a). food must be protected from contamination by storing the food as follows: (1) In a clean, dry location. (2) Where it is not exposed to splash, dust, or other contamination. (3) At least six (6) inches (fifteen centimeters) above the floor. Storage of equipment, utensils, linens, and single-service and single-use articles.cleaned equipment and utensils, laundered linens, and single-service and single-use articles must be stored: (1) In a clean, dry location. (2) Where it is not exposed to splash, dust, or other contamination. (3) At least six (6) inches (fifteen centimeters) above the floor. 2. On 4/1/26 at 11:51 a.m., the Sous Chef was observed checking the lunch food temperatures. He had two thermometers in a basin of ice water. He took one thermometer out of the water, wiped it off on a blue towel sitting on steam table, and checked the food temperature of the hamburgers. He took the second thermometer out of the water, wiped it off on the same blue towel, and checked the food temperature of the stuffing. He had not sanitized either thermometer prior to using them to check the food temperatures. He then wiped both thermometers off on the same blue towel and continued to check food temperatures. He wiped the thermometer off in between each food using a paper towel, but had not sanitized the thermometers in between checking each food temperature.During an interview at that time, the Sous Chef indicated he should have been using probe wipes to clean the thermometer between each food temperature, but they did not have any right now. He was unable to ask his manager what he should do because his manager had not shown up to work the past few days and probably no longer worked at the facility. During an interview on 4/1/26 at 2:42 p.m., the Administrator was made aware of the kitchen sanitation concerns. He indicated he had been trying to contact his Dietary Manager for the past few days but had been unable to reach him.A facility policy, titled, Food, indicated, .Food temperatures will be taken using a clean, rinsed and sanitized air-dried metal stem type thermometer, numerically scaled and accurate to plus or minus 2F. Test the temperature of a hot food before serving, insert the thermometer at 45-degree angle to the middle of the food item. Take care not to touch the container or bone, if a meat item. Read the temperature and remove thermometer from food item and immediately wipe and sanitize with alcohol wipe, and air dry .410 IAC (Indiana Administrative Code) 16.2-3.1-21(i)(3)

Based on observation, record review, and interview, the facility failed to keep the kitchen clean and in good repair related to dirty floors and shelved for 1 of 1 kitchen. (The Main Kitchen) Finding includes:Findings include:During the Kitchen Sanitation Initial Tour on 3/29/26 at 9:55 a.m. with [NAME] 1, the following was observed:a. An accumulation of dirt and debris was observed on the floor in front of the oven.b. An accumulation of dirt and debris was observed on the floor in between the oven, grill, and fryer.c. An accumulation of dried food spillage, dirt, and debris was observed on the shelf underneath the grill.d. An accumulation of dried white and pink substance was on the bottom shelf of the prep table.During an interview at that time, [NAME] 1 indicated all of the above was in need of cleaning. A facility policy, titled, Dietary Cleaning Policy, indicated, .Keep floor of kitchen free of debris. Staff will use a 'clean as you go' technique to keep the facility and neighborhood kitchen areas clean, functional and attractive.the following areas and equipment will be cleaned daily.kitchen walls and floors.410 IAC (Indiana Administrative Code) 16.2-3.1-19(f)

Based on record review and interview, the facility failed to ensure the Activities Program was directed by a qualified professional who met required training and certification standards prior to assuming the role of Activities Director. This failure had the potential to affect 69 of 69 residents who relied on the activities program to meet their psychosocial, emotional, and social needs. Finding includes: The employee records were reviewed on 4/1/26. The Activity Director was hired on 10/20/25. There was a certificate, dated 12/31/25, for Hospitality Management Studies. There was no indication she had completed the Activities Director course. During an interview on 4/1/26 at 11:25 a.m., the Activities Director indicated she had a certificate in hotel hospitality and she had not completed the Activity Director course. She indicated she was not aware it was necessary. She did not have 2 years prior experience and was not a therapeutic recreations specialist or an activities professional. The policy and or qualifications was requested from the Director of Nursing (DON). During an interview on 4/2/26 at 8:50 a.m., the DON indicated she did not have a policy related to the Activity Director or qualifications. 410 IAC (Indiana Administrative Code) 16.2-3.1-33(e)

Based on observation, interview, and record review, the facility failed to honor a resident's food preferences for 1 of 2 residents reviewed for food choices. (Resident 104) Finding includes:On 3/29/26 at 1:51 p.m., Resident 104 was observed sitting in his room with his daughter. The resident indicated he wanted soup for lunch and he was told they did not have any. The resident's daughter indicated she had to go upstairs to his Assisted Living apartment to get a can of soup for him to eat for lunch. They both indicated he did not always receive what he ordered from the menu.Record review for Resident 104 was completed on 4/1/26 at 9:02 a.m. The resident was admitted to the facility on [DATE].During an interview on 4/1/26 at 9:08 a.m., the A Unit Manager indicated the resident's daughter filled out his meal tickets for the week and the kitchen had his meal tickets.The Lunch Meal Ticket, dated 4/1/26, indicated the resident chose:-soup of the day-small salad with French dressing-chilled peachesOn 4/1/26 at 1:42 p.m., Resident 104 was observed sitting in his room eating lunch. The resident had a salad and the chilled peaches. The resident did not have any soup. The resident indicated he also wanted soup for lunch but did not receive any. During an interview on 4/1/26 at 1:42 p.m., the Sous Chef indicated he did not make any soup that day and one of the cooks was supposed to make it.During an interview on 4/1/26 at 1:52 p.m., [NAME] 1 indicated [NAME] 2 was supposed to make the soup for the day and she was unsure why she didn't. During an interview on 4/1/26 at 2:39 p.m., the Administrator indicated [NAME] 2 had already left for the day. He called her and she indicated she thought [NAME] 1 was supposed to make the soup and there was confusion on who was supposed to make it, so no one made the soup. 410 IAC (Indiana Administrative Code) 16.2-3.1-3(u)(3)

Based on record review and interview, the facility failed to ensure non-pharmacological interventions were attempted prior to administering as needed (PRN) antipsychotic medication for 1 of 5 residents reviewed for unnecessary medications. (Resident G)Finding includes:Resident G's record was reviewed on 3/31/26 at 8:45 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, dementia, mood disorder and metabolic encephalopathy.The admission Minimum Data Set assessment, dated 2/24/26, indicated the resident had severe cognitive impairment and received antipsychotic medications.A Physician's Order, dated 2/18/26, indicated to give quetiapine fumarate, (an antipsychotic) 12.5 milligrams (mg) every eight hours as needed for agitation. The order was discontinued on 2/20/26.A Physician's Order, dated 2/20/26, indicated to give quetiapine fumarate, 12.5 mg every eight hours as needed for psychotic behaviors for 14 days. The order was discontinued on 2/24/26.A Physician's Order, dated 2/26/26, indicated to give quetiapine fumarate, 12.5 mg every eight hours as needed for psychosis related to dementia with psychotic disturbance for 14 days. The February and March 2026 Medication Administration Record (MAR) indicated the resident received the quetiapine fumarate nine times between 2/26/26 and 3/1/26. There was no documentation in the MAR, nurse's notes, or behavior narrative notes that any non-pharmacological interventions had been attempted prior to giving the medication on 2/19, 2/24, 2/26, 3/1 or 3/7/26. The policy, Psychotropic Medications, reviewed 5/2025, indicated, .Use of alternative non-pharmacologic interventions for psychiatric disorders and problem behaviors related to dementia will be attempted prior to and during administration of antipsychotic medications .During an interview on 4/1/26 at 9:42 a.m., the Director of Nursing indicated non-pharmacologic interventions should have been attempted prior to giving the medication. 410 IAC (Indiana Administrative Code) 16.2-3.1-3(w)

Based on observation, record review, and interview, the facility failed to ensure the Minimum Data Set (MDS) comprehensive assessment was accurately completed related to oxygen use for 1 of 22 MDS assessments reviewed. (Resident M)Finding includes:On 3/29/26 at 11:10 a.m., Resident M was observed lying in bed. The resident had oxygen on via a nasal cannula and attached to a concentrator. The flow rate was set at 4 liters. The resident indicated she had been on 3 liters of oxygen since she was admitted to the facility and was unsure why it was set at 4 liters.Record review for Resident M was completed on 3/30/26 at 2:00 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease, asthma, and respiratory failure. The resident was admitted to the facility on [DATE].A Physician's Order, dated 2/2/26, indicated the resident was to receive oxygen at 3 liters every shift.The admission MDS assessment, dated 2/9/26, indicated the resident was cognitively intact. The assessment did not have checked that the resident received oxygen on admission or as a resident. During an interview on 3/31/26 at 10:35 a.m., MDS Coordinator 1 indicated the resident had been on oxygen since admission and it was not coded on the assessment.410 IAC (Indiana Administrative Code) 16.2-3.1-31(i)

Based on observation, record review, and interview, the facility failed to ensure a care plan was implemented for pressure ulcers for 1 of 2 residents reviewed for pressure ulcers. (Resident F)Finding includes:During an interview on 3/29/26 at 12:59 p.m., Resident F indicated she was receiving treatment for multiple pressure ulcers that were causing a lot of pain and she received antibiotics for an infection in the wounds.On 4/2/26 at 10:23 p.m., Resident F's wound care was observed for the left and right buttocks wounds and the left lateral posterior thigh with the Wound Nurse. The Wound Nurse indicated the wounds had been infected and the resident had been receiving antibiotics for wound infections. The resident was noncompliant with offloading and wound care.Resident F's record was reviewed on 3/30/26 at 1:33 p.m. Diagnoses included, but were not limited to, local infection of skin and subcutaneous tissue.The admission Minimum Data Set (MDS) assessment, dated 2/25/26, indicated the resident was cognitively intact and had two stage IV pressure ulcers, two unstageable pressure ulcers, and two venous/arterial ulcers. The resident was also receiving antibiotic treatment.The Wound Rounds, dated 3/24/26, indicated the resident had a stage IV pressure ulcer to the right buttocks measuring 9.0 cm long by 17.0 cm wide by 2.0 cm deep. She had an unstageable pressure ulcer on the left lateral posterior thigh measuring 9.5 cm long by 5.0 cm wide. She had a stage IV pressure ulcer to the left buttocks measuring 6.5 cm long by 18.0 cm wide by 2.0 cm deep. The pressure ulcers were present on admission.The comprehensive care plan lacked a care plan related to the pressure ulcers that identified needs, including measurable goals, resident involvement and choice, and interventions to heal/prevent pressure ulcers.During an interview on 4/2/26 at 1:12 p.m., the Director of Nursing indicated there was a skin impairment care plan implemented, but there was no care plan implemented related to the pressure ulcers.A facility policy titled, Wound Policy & Procedure, indicated, .Documentation and Care Planning.The wound management program documentation requirements include: Identification of the location and frequency of wound documentation, Required comprehensive description of pressure ulcer weekly at a minimum, Delineation of in-house documentation required and by whom, Goals of the wound care plan collaboratively determined with the resident, family, and interdisciplinary team, Assigned responsibility/accountability for the initial care plan and for subsequent updating, Determined facility time frames for care plan updating; Resident risk factors and interventions are documented including: Impaired mobility, Need for pressure relief such as support surfaces, repositioning, pressure relieving devices, Nutritional status, Incontinence, Skin condition, Complications such as infection and pain, General treatment regimen.410 IAC (Indiana Administrative Code) 16.2-3.1-35(b)(1)

Based on observation, record review, and interview, the facility failed to ensure dependent residents received showers or baths as scheduled for 2 of 2 residents reviewed for activities of daily living (ADL) care. (Residents H and J)Findings include: 1. On 3/29/26 at 11:37 a.m., Resident H was observed in his bed. His hair was uncombed and he was unshaven. The resident was unable to communicate if he had a shower recently or preferred to be clean shaven.Resident H's record was reviewed on 4/1/26 at 3:44 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, metabolic encephalopathy and chronic obstructive pulmonary disease.The admission Minimum Data Set assessment, dated 3/1/26, indicated the resident was rarely or never understood, and was dependent for toileting, bed mobility, and transfers.The ADL Care Plan, dated 2/26/26, indicated the resident had self-care deficits, performance deficit, and limitations in physical mobility. Interventions included, but were not limited to, provide partial to moderate assistance with tub and/or shower transfers.The shower book indicated the resident was scheduled for showers or bed baths on Tuesday and Friday during the day shift. There were no showers or baths documented on 2/27, 3/13, 3/20, or 3/24/26.During an interview on 4/2/26 at 9:43 a.m., the A-Unit Manager indicated there was no additional documentation that the scheduled showers had been completed. 2. On 3/29/26 at 12:51 p.m., Resident J was observed lying in her bed. She indicated she had not had a shower since she had been in the facility.Resident J's record was reviewed on 3/30/26 at 11:57 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, low back pain and atrial fibrillation.The admission Minimum Data Set assessment, dated 3/29/26, indicated the resident was cognitively intact and required partial to moderate assistance for showering and toileting.The shower book did not have a page for the resident. The resident who previously resided in Resident J's room was still in the shower book.During an interview on 3/31/26 at 1:46 p.m., the A-Unit Manager indicated there were no shower sheets for the resident. She would ensure the resident was showered that day.This citation relates to Intake 2729246.410 IAC (Indiana Administrative Code) 16.2-3.1-38(a)(3)

Based on observation, record review and interview, the facility failed to ensure activities were provided to a dependent resident as care-planned for 1 of 1 resident reviewed for activities. (Resident 51)Finding includes: On 3/29/26 at 2:20 p.m., Resident 51 was observed in her bed. She indicated she liked to go to activities, but nobody would take her to them. Resident 51's record was reviewed on 3/30/26 at 2:12 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, acute respiratory failure and morbid obesity. The Leisure Preferences Care Plan, dated 2/12/26, indicated the resident would participate in leisure activities as desired through the review period. Interventions included, but were not limited to, creative arts, music, puzzles and trivia, and music.The admission Minimum Data Set assessment, dated 2/18/26, indicated the resident had moderate cognitive impairment and needed substantial maximum assistance for transfers. During an interview on 3/31/26 at 10:11 a.m., the Activity Director indicated it was difficult to get the resident to activities. The resident liked to come to Friday dinner and a movie with her family. Her family was unable to push her in her wheelchair, but their staff could push her. All activities were documented in the electronic record. The activities log in the resident's electronic record was reviewed for the past 30 days. There was no documentation of any one on one or group activities. During an interview on 4/1/26 at 10:57 a.m., the resident's family member indicated she would like to go to activities, but no one would take her and she was unable to push the wheelchair. During another interview on 4/1/26 at 11:25 a.m., the Activity Director was made aware there were no activities documented in the resident's record for the past 30 days. The Activity Director indicated staff could take her to the activities. 410 IAC (Indiana Administrative Code) 16.2-3.1-33(a)

Based on observation, record review, and interview, the facility failed to ensure weekly weights were obtained as ordered for 1 of 5 residents reviewed for nutrition. (Resident G) The facility also failed to ensure physician's orders were in place for a bandage and an abrasion and a bruise were assessed and monitored for 2 of 3 residents reviewed for non-pressure skin conditions. (Residents K and L)Findings include:1. Resident G's record was reviewed on 3/31/26 at 8:45 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, dementia, diabetes mellitus and dysphagia (difficulty swallowing). A Nutritional Care Plan, dated 2/17/26, indicated the resident had potential for alteration in nutrition and hydration. Interventions included, but were not limited to, obtain and document weights per physician order and facility protocol. A Physician's Order, dated 2/17/26, indicated to obtain a weekly weight every Sunday. A Physician's Order, dated 3/16/26, indicated to weigh the resident in the morning, this was ordered weekly no weight in 30 days documented. There was a weight documented on 2/17/26 and 3/19/26. The admission Minimum Data Set assessment, dated 2/24/26, indicated the resident had severe cognitive impairment and needed supervision or touch assistance for eating. During an interview on 4/1/26 at 9:42 a.m., the Director of Nursing was made aware of the missing weights and indicated she would look into it. No additional information was provided. 2. On 3/29/26 at 10:19 a.m., Resident K was observed lying in bed with her eyes closed. There was an undated white bandage observed to her left inner elbow and a thick black scabbed area to her left forearm. On 4/2/26 at 11:01 a.m., Resident K was observed lying in bed. There was an undated white bandage observed to her left inner elbow and a thick black scabbed area to her left forearm. The resident indicated she was unsure why she had the bandage or how she received the scabbed area. The resident then proceeded to remove the bandage. The skin underneath the bandage was observed with a green discoloration. Record review for Resident K was completed on 3/31/26 at 1:49 p.m. Diagnoses included, but were not limited to, atrial fibrillation, diabetes mellitus, and end stage renal disease. The admission Minimum Data Set (MDS) assessment, dated 2/25/26, indicated the resident was cognitively intact. The resident had an impairment on one side of her upper extremities for a functional limitation in range of motion. The resident required a substantial maximal assistance for upper body dressing. The resident received anticoagulant medication. A Care Plan, dated 2/23/26, indicated the resident received anticoagulant therapy. An intervention included to monitor, document, and report bruising. A Daily Skilled Nursing Evaluation, dated 3/29/26, indicated the skin/wound section was blank. There was a lack of documentation to indicate there was a physician's order for the bandage to the resident's inner elbow or why the bandage was there. There was also a lack of documentation to indicate the resident's scabbed area on her skin was assessed and or monitored. During an interview on 4/2/26 at 11:02 a.m., RN 1 indicated she was unaware of the scabbed area to the resident's arm. She further indicated the resident had probably had blood work completed and that was why there was a bandage. The bandage should not have been on her arm for that many days. 3. Record review for Resident L was completed on 3/31/26 at 1:38 p.m. Diagnoses included, but were not limited, Guillain-Barre syndrome (immune system attacks peripheral nerves), atrial fibrillation, and diabetes mellitus. The resident was admitted to the facility on [DATE]. A Nursing Evaluation, dated 3/18/26 at 3:30 p.m., indicated the resident was admitted from the hospital. The skin color to all extremities were normal and warm. The admission Minimum Data Set (MDS) assessment, dated 3/23/26, indicated the resident was cognitively intact. The resident had an impairment to both sides of his upper and lower extremities for a functional limitation in range of motion. The resident was dependent on staff for toileting, hygiene and transfers. The resident received anticoagulant medication. A Care Plan, dated 3/18/26 and revised 3/25/26, indicated the resident had an ADL (activities of daily living) self-care deficit and limitations in physical mobility related to tetraquadraplegia and ascending paralysis. An intervention included for staff to assist with all ADLs and may use Hoyer lift (mechanical lift) for transfers. A Care Plan, dated 3/24/25, indicated the resident received anticoagulant therapy. An intervention included to monitor, document, and report any adverse reactions of anticoagulant therapy which included bruising. During a random observation on 4/1/26 at 12:01 p.m., Resident L was observed lying in bed. The resident had on a shirt and an incontinence brief. There was large dark purple discoloration observed to his right upper inner thigh from his groin area extended to the middle part of his upper leg. The resident indicated he was unsure how he received it. There was a lack of documentation to indicate the resident's discoloration on his skin was assessed and or monitored. During an interview on 4/1/26 at 12:07 p.m., LPN 2 indicated she was unaware of the discoloration to the resident's leg. During an interview on 4/1/26 at 12:10 p.m., CNA 1 indicated she believed the discoloration to his leg was there since he was admitted but she was unsure. During an interview on 4/1/26 at 2:35 p.m., the A Unit Manager and the Director of Nursing (DON) indicated the resident's discoloration was not there on admission. They believe it may have come from using the Hoyer lift. The staff should have observed the discoloration and assessed it. A facility policy titled, Wound Policy & Procedure and received as current from the facility on 4/2/26, indicated, .Procedure: Accountability The Wound Management Program identifies staff participation and accountability to include .Expectation of all caregivers to observe resident skin integrity during the daily provision of the resident's personal care . This citation is related to Intakes 2729246 and 2786645. 410 IAC (Indiana Administrative Code) 16.2 3.1-37(a)

Based on record review and interview, the facility failed to ensure pressure ulcer care was provided as ordered for 1 of 2 residents reviewed for pressure ulcers. (Resident F)Finding includes:During an interview on 3/29/26 at 12:59 p.m., Resident F indicated she was receiving treatment for multiple pressure ulcers that were causing a lot of pain and she received antibiotics for an infection in the wounds.Resident F's record was reviewed on 3/30/26 at 1:33 p.m. Diagnoses included, but were not limited to, local infection of skin and subcutaneous tissue.The admission Minimum Data Set (MDS) assessment, dated 2/25/26, indicated the resident was cognitively intact and had two stage IV pressure ulcers, two unstageable pressure ulcers, and two venous/arterial ulcers. The resident was also receiving antibiotic treatment.The Wound Round Notes, dated 3/24/26, indicated the resident had a stage IV pressure ulcer to the right buttocks measuring 9.0 cm long by 17.0 cm wide by 2.0 cm deep. She had an unstageable pressure ulcer on the left lateral posterior thigh measuring 9.5 cm long by 5.0 cm wide. She had a stage IV pressure ulcer to the left buttocks measuring 6.5 cm long by 18.0 cm wide by 2.0 cm deep. The pressure ulcers were present on admission.A Physician's Order, dated 2/24/26 and discontinued on 3/25/26, indicated wound care to left buttocks/ischium, irrigate with Vashe (wound cleanser) and normal saline, pack saline moistened roll gauze and cover with bordered gauze, change daily and as needed every day shift.The March 2026 Medication and Treatment Administration Records (MAR/TAR) indicated the wound care for the left buttocks/ischium was not marked as completed on 3/1/26, 3/7/26, 3/8/26, 3/14/26, 3/15/26, 3/21/26, and 3/22/26.A Physician's Order, dated 2/24/26 and discontinued on 3/25/26, indicated wound care to right buttocks/ischium, irrigate with Vashe and normal saline, pack saline moistened roll gauze and cover with bordered gauze, change daily and as needed every day shift.The March 2026 MAR/TAR indicated the wound care for the right buttocks/ischium was not marked as completed on 3/1/26, 3/7/26, 3/8/26, 3/14/26, 3/15/26, 3/21/26, and 3/22/26.A Physician's Order, dated 2/25/26 and discontinued on 3/25/26, indicated wound care to the left lateral posterior thigh, cleanse with Vashe wash, apply Vashe moistened gauze and cover with bordered gauze, change daily and as needed every day shift.The March 2026 MAR/TAR indicated the wound care for the left lateral posterior thigh was not marked as completed on 3/1/26, 3/7/26, 3/8/26, 3/14/26, 3/15/26, 3/16/26, 3/21/26, and 3/22/26.A Physician's Order, dated 3/25/26, indicated wound care to the left buttocks/ishium, irrigate with Vashe or Dakin's 1/4 strength (wound cleanser), pack with MediHoney (antibacterial honey product) and calcium alginate (highly absorbent dressing), cover with bordered gauze, change daily and as needed every day shift.The March 2026 MAR/TAR indicated the wound care for the left buttocks/ischium was not marked as completed on 3/28/26 and 3/29/26.A Physician's Order, dated 3/25/26, indicated wound care to the left lateral posterior thigh, cleanse with Vashe wash, pack with Medihoney and calcium alginate, cover with bordered gauze and change daily and as needed every day shift.The March 2026 MAR/TAR indicated the wound care for the left lateral posterior thigh was not marked as completed on 3/28/26 and 3/29/26.A Physician's Order, dated 3/25/26, indicated wound care to the right buttocks/ischium, cleanse with Vashe wash, pack with Medihoney and calcium alginate, cover with bordered gauze and change daily and as needed every day shift.The March 2026 MAR/TAR indicated the wound care for the right buttocks/ischium was not marked as completed on 3/28/26 and 3/29/26.There were no refusals documented in the medical record.On 4/2/26 at 10:23 p.m., Resident F's wound care was observed for the left and right buttocks wounds and the left lateral posterior thigh with the Wound Nurse. The Wound Nurse indicated the wounds had been infected and the resident had been receiving antibiotics for wound infections. The resident was noncompliant with offloading and wound care.During a follow-up interview on 4/2/26 at 11:12 a.m., the Wound Nurse indicated the nurses who were scheduled during the weekend were supposed to provide the wound care, as she only worked Monday through Friday. The resident was very noncompliant, and it took her a while to convince the resident to allow anyone to do the wound care.This citation relates to Intake 2729246.410 IAC (Indiana Administrative Code) 16.2-3.1-40(a)(2)

Based on observation, record review, and interview, the facility failed to ensure safety was maintained related to fall interventions not in place for 1 of 4 residents reviewed for accidents (Resident 79)Finding includes:On 3/29/26 at 1:30 p.m., Resident 79 was observed lying in bed watching television. There were no floor mats in place on either side of the bed.On 3/30/26 at 9:17 a.m., Resident 79 was observed lying in bed. There were no floor mats in place on either side of the bed.On 3/31/26 at 11:40 a.m., Resident 79 was observed lying in bed. There were no floor mats in place on either side of the bed.Resident 79's record was reviewed on 3/31/26 at 9:34 a.m. Diagnoses included, but were not limited to, hypertension and type 2 diabetes mellitus. The resident was admitted to the facility on [DATE]. She was discharged to the hospital on 3/16/26 and returned to the facility on 3/28/26. The admission Minimum Data Set (MDS) assessment was still in progress.A Baseline Care Plan, initiated on 3/8/26, indicated the resident was at risk for falls. A Fall Note, dated 3/16/26 at 5:15 a.m., indicated the resident was found on the floor next to her bed. She had an abrasion to her left forehead and was guarding her right arm. The resident was sent to the emergency room for evaluation.An Interdisciplinary Team (IDT) Meeting Note, dated 3/16/26 at 9:22 a.m., indicated the resident was found on the floor with an abrasion to her forehead. She was sent to the hospital for evaluation. A mat on the floor would be implemented upon her return.A falls Care Plan was updated on 3/16/26 to include the intervention of floor mat next to the bed.During an interview on 3/31/26 at 2:41 p.m., the Director of Nursing was made aware the fall mat was not in place.During an interview on 4/1/26 at 9:39 a.m., the C Unit Manager indicated the resident had been sent out to the hospital and the floor mat was not put in place upon her return. The resident was no longer attempting to self-transfer, so she didn't think the floor mat was an appropriate intervention.A facility policy, titled, Post Fall Policy, indicated, .Fall is documented on the care plan with interventions to prevent further falls based on the determined causal factors at the time of the initial fall follow up .410 IAC (Indiana Administrative Code) 16.2-3.1-45(a)

Based on observation, record review, and interview, the facility failed to ensure an indwelling urinary catheter bag and tubing was placed below the level of the bladder and not on the floor for 2 of 3 residents reviewed for catheters. (Residents 115 and F)Findings include: 1. On 3/29/26 at 12:04 p.m., Resident 115 was observed seated in her wheelchair in the Main Dining Room. Her catheter bag was hanging from the back rest of her wheelchair, not below the level of the bladder. On 3/29/26 at 1:25 p.m., Resident 115 was observed seated in her wheelchair with family pushing her down the hallway towards her room. Her catheter bag was hanging from the back rest of her wheelchair, not below the level of the bladder. On 3/31/26 at 12:52 p.m., Resident 115 was observed seated in her wheelchair in the Main Dining Room. Her catheter bag was hanging from the bottom of her wheelchair with the bag touching the floor. The record for Resident 115 was reviewed on 3/30/26 at 2:46 p.m. Diagnoses included, but were not limited to, acute kidney failure. A Care Plan, updated 3/25/26, indicated the resident had a urinary catheter. The interventions included check placement of tubing each shift. During an interview on 3/31/26 at 2:41 p.m., the Director of Nursing was made aware the catheter had not been below bladder level and was touching the floor. The facility policy was requested. 2. On 3/31/26 at 11:13 a.m., Resident F was observed lying in bed. Her catheter bag was secured onto the footboard of the bed, above the level of the bladder. On 4/1/26 at 1:42 p.m., Resident F was observed sitting up in a wheelchair eating lunch. The catheter bag was sitting on the floor underneath the wheelchair and the tubing was touching the floor. Resident F's record was reviewed on 3/30/26 at 1:33 p.m. A Care Plan, dated 2/21/26, indicated the resident had a urinary catheter. Interventions included, but were not limited to, check placement of tubing each shift. A Physician's Order, dated 3/20/26, indicated to check placement and patency of the Foley catheter, 16 FR/10 cc balloon (sizing of catheter). During an interview on 4/1/26 at 4:10 p.m., the Director of Nursing indicated she had no further information to provide. A facility policy titled, Urinary Indwelling Catheter Management, indicated, .Additional Care Practices.Securing the catheter to facilitate flow of urine, preventing kinking of the tubing and position below the level of the bladder. 410 IAC (Indiana Administrative Code) 16.2-3.1-41(a)

Based on observation, record review, and interview, the facility failed to ensure to follow-up and implement recommendations from the Registered Dietician for a resident with documented weight loss and lack of documentation of meal intakes for 2 of 4 residents reviewed for nutrition. (Residents F and C)Findings include:1. Resident F's record was reviewed on 3/30/26 at 1:33 p.m.On 3/15/26, the resident weighed 186 pounds (lbs). On 3/20/26, the resident weighed 156 lbs. On 3/29/26, the resident weighed 159 lbs, which was a -14.52% weight loss from 3/15/26 to 3/29/26.A Care Plan, dated 2/23/26, indicated the resident had the potential for alterations in nutrition and hydration. Interventions included, but were not limited to, evaluate any weight changes, determine percentage changed and follow facility protocol for weight change, monitor/record/report to the physician any signs/symptoms of malnutrition, significant weight loss (3 lbs in 1 week, greater than 5% in a month, and greater than 10% in six months); Registered Dietician (RD) to evaluate and make diet change recommendations as needed.A Dietician Evaluation, dated 2/27/26 at 11:18 a.m., indicated the resident was on a regular texture low concentrated sweets/no added salt diet. She was a new admission from the hospital for diabetic ketoacidosis and severe clostridium difficile colitis (gastrointestinal infection), and infected gluteal ulcer. She was receiving intravenous antibiotics. She would benefit from liquid protein 30 milliliters twice daily and double portion protein foods for wound healing. Recommendations included to add liquid protein 30 milliliters twice daily and add double portion protein foods at all meals.There were no physician's orders for the liquid protein or double portion protein foods initiated after the recommendations were made by the RD. During an observation on 3/31/26 at 1:13 p.m., Resident F was observed sitting in bed. A lunch tray was sitting on the bedside table that had two chicken strips, two pieces of bread, a serving of potato wedges, and a dessert. There was not a double serving of protein or a health shake observed on the tray.During an observation on 4/1/26 at 1:42 p.m., Resident F was observed sitting in her wheelchair. A lunch tray was observed on the bedside table that had a single turkey patty, cooked zucchini, and a starch side dish. There was not a double serving of protein or a health shake observed on the tray.The Amount Eaten Point of Care documentation was reviewed for the last 30 days. There were no documented meal entries on 3/4/26, 3/6/26, 3/8/26, and 3/12/26. There was one meal entry on 2/22/26, 2/23/26, 3/3/26, 3/7/26, 3/19/26, 3/21/26, 3/23/26, 3/25/26, and 3/27/26. There were two meal entries on 2/24/26, 2/26/26, 2/27/26, 3/1/26, 3/9/26, 3/10/26, 3/13/26, 3/16/26, and 3/29/26.During an interview on 4/1/26 at 9:42 a.m., the C Wing Unit Manager indicated she reviews all the RD's recommendations once the RD sends them over via email. Resident F was never listed as a resident who was reviewed by the RD on her visit before or after 2/27/26 when her note was entered in the resident's record. The recommendations were missed and not entered as new orders in the Physician's Order Summary.During an interview on 4/2/26 at 1:12 p.m., the Director of Nursing indicated the scales had recently been recalibrated as they were finding errors with residents' weights. The resident weighed 62 kilograms (136.7 pounds) on 2/18/26 per the hospital paperwork. A Work History Report provided at the time indicated that preventative maintenance was completed on the resident scales, and the calibration was checked on the scales on 3/18/26. The RD's recommendations were due to wound healing and not for weight loss as the resident had not actually had a large weight loss. 2. Resident C's record was reviewed on 3/31/26 at 12:51 p.m.On 2/13/26, the resident weighed 250 pounds (lbs). On 3/29/2026, the resident weighed 218 lbs which was a -12.8% weight loss.A Dietician Evaluation, dated 3/13/26 at 2:18 p.m., indicated the resident required hemodialysis and had history of osteomyelitis (bone infection) and left great toe amputation with complications. Diet was adequate to meet needs, but additional protein was indicated for wound healing. Eating 50-100% of meals. Per the chart, obesity was documented. The resident was receiving two Nepro (supplement) a day. Recommendations were given to decrease to one Nepro daily with 30 milliliters of liquid protein.The Amount Eaten Point of Care documentation was reviewed for the last 30 days. There were no documented meal entries on 3/9/26, 3/11/26, 3/20/26, 3/22/26, 3/23/26. There was one meal entry on 3/8/26, 3/12/26, 3/14/26, 3/16/26, 3/19/26, 3/25/26, and 3/27/26. There were two meal entries on 3/6/26, 3/7/26, 3/10/26, 3/13/26, and 3/29/26.During an interview on 4/1/26 at 4:10 p.m., the Director of Nursing indicated each meal should have been documented.During a follow-up interview on 4/2/26 at 1:12 p.m., the Director of Nursing indicated the scales had recently been recalibrated as they were finding errors with residents' weights.A facility policy was requested and not received.410 IAC (Indiana Administrative Code) 16.2-3.1-46(a)

Based on observation, record review, and interview, the facility failed to ensure residents received the necessary respiratory care and treatment related to incorrect oxygen flow rate and not monitoring oxygen saturation levels every shift as ordered for 2 of 5 residents reviewed for respiratory care (Resident 51 and C) and 1 of 5 residents reviewed for unnecessary medications. (Resident M) The facility also failed to ensure pre and post nebulizer assessments were completed and the licensed nurse remained with the resident during the nebulizer treatment for one resident observed during medication pass (Resident 51) and 1 of 5 residents reviewed for unnecessary medications. (Resident M)Findings include:1. On 3/29/26 at 2:20 p.m., and 3/30/26 at 9:00 a.m., Resident 51 was observed in her bed with her oxygen on via nasal cannula. The oxygen concentrator was flowing at 1 liter per minute (lpm). The resident's record was reviewed on 3/30/26 at 2:12 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, acute respiratory failure with hypoxia (low oxygen saturation), pleural effusion (fluid build up between the lungs and chest wall) and pneumonia. The admission Minimum Data Set assessment, dated 2/18/26, indicated the resident had moderate cognitive deficits and used oxygen. An Oxygen Care Plan, dated 2/12/26, indicated the resident required oxygen. Interventions included, but were not limited to, administer oxygen per physician's order and monitor vital signs as ordered (skin color, pulse oximetry, airway functioning and degree of restlessness which may indicated hypoxia). A Physician's Order, dated 2/17/26, indicated oxygen at 2 lpm every shift. A Physician's Order, dated 2/17/26, indicated to monitor Resident 51's oxygen saturation every shift. The oxygen saturation log in the vital signs section of the electronic record was reviewed for the previous two weeks. The log was missing entries on 3/18, 3/20, 3/23, 3/25, 3/26, and 3/28. On 3/31/26 at 9:46 a.m., the A Unit Manager observed the oxygen concentrator and indicated it was flowing at 1 lpm. She indicated it should be on 2 lpm. She asked a family member present who had turned the oxygen down. The family member said someone had turned it down about a week ago. The A Unit Manager checked the resident's record and indicated there were no new orders or documentation the oxygen had been changed. During an interview at that time., the A Unit Manager was made aware there were missing oxygen saturation in the vital signs. No additional information was provided. 2. On 3/29/26 at 11:10 a.m., and again on 3/30/26 at 2:03 p.m., Resident M was observed lying in bed. The resident had oxygen on via a nasal cannula and attached to a concentrator. The flow rate was set at 4 liters. The resident indicated she had been on 3 liters of oxygen since she was admitted to the facility and was unsure why it was set at 4 liters. Record review for Resident M was completed on 3/30/26 at 2:00 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease, asthma, and respiratory failure. The resident was admitted to the facility on [DATE]. The admission MDS assessment, dated 2/9/26, indicated the resident was cognitively intact. The assessment did not have checked that the resident received oxygen on admission or as a resident. A Care Plan, dated 2/2/26, indicated the resident required oxygen therapy. An intervention included to administer oxygen and nebulizers per the physician's orders. The March 2026 Physician's Order Summary (POS) indicated orders for the following:-ipratropium-albuterol inhalation solution, inhale 3 ml (milliliters) every 4 hours for wheezing-oxygen at 3 liters every shift. The February and March 2026 Medication Administration Records (MARs) indicated the resident received the inhalation medication every day. There was not a respiratory assessment section included on the MARs with each time the medication was administered. There was a lack of documentation to indicate respiratory assessments were completed prior to or after the inhalation medication was administered. During an interview on 3/30/26 at 2:04 p.m., LPN 1 indicated the resident was supposed to be on 3 liters of oxygen. During an interview on 3/31/26 at 10:11 a.m., the Director of Nursing (DON) indicated the resident should have been on 3 liters of oxygen. The nurses should be completing and documenting respiratory assessments prior to and after the inhalation medication treatments. She would fix the section on the MAR to include the respiratory assessments. 3. During a medication administration pass on 3/31/26 at 9:51 a.m., LPN 2 was observed preparing Resident 51's medications, which included a Duoneb solution (inhalation breathing treatment medication solution). The nurse poured the solution into the mask's chamber, applied the mask to the resident, and then left the room. The nurse then proceeded to move down the hallway with her medication cart. The nurse did not complete a respiratory assessment prior to administering the inhalation medication. During an interview at the time of the observation, LPN 2 indicated she does not complete respiratory assessments prior to administering the inhalation medication. She always left the residents' rooms during the breathing treatments and did not stay with them. She would go back to the resident's room in 15 minutes to check to see if the breathing treatment was completed. During an interview on 3/31/26 at 9:58 a.m., the DON indicated the nurses should be doing respiratory assessment prior to administering the breathing treatments and they should be staying in the resident's room during the breathing treatments. A facility policy titled, Nebulizer Use and received as current from the DON on 3/31/26, indicated, .Infection Prevention and Control .4. Respiratory pre and post assessment to be completed .Documentation Staff must document in the medical record: .Pre and post assessment Time spent in guest room . 4. On 3/29/26 at 1:10 p.m., Resident C was observed sitting in bed. He had oxygen infusing via a nasal cannula. The oxygen concentrator was set to 2 liters per minute. On 4/1/26 at 9:01 a.m., Resident C was observed lying in bed. He had oxygen infusing via a nasal cannula. The oxygen concentrator was set to 2 liters per minute. Resident C's record was reviewed on 3/31/26 at 12:51 p.m. A Physician's Order, dated 3/4/26, indicated continuous oxygen via nasal cannula at 4 liters per minute every shift. A Care Plan, dated 2/12/26, indicated the resident required oxygen therapy. Interventions included, but were not limited to, administer oxygen per physician's orders. During an interview on 4/1/26 at 4:10 p.m., the Director of Nursing had no further information to provide. A facility policy titled, Oxygen, indicated, General: Ensure residents are receiving oxygen per physician orders. Provide Guidance to Staff and Family of any precautions or oxygen use upon entering patients rooms.Guideline: 1. Residents who are admitted on oxygen or have new orders for oxygen should be assessed to ensure it is required. 2. Order for oxygen should be obtained by a qualified provider.4. Oxygen orders should include rate of administration and how they are receiving it. 5. Order should be written in the EMR and signed out by the nursing staff each shift to ensure resident is tolerating oxygen therapy. 410 IAC (Indiana Administrative Code) 16.2-3.1-47(a)(6)

Based on record review and interview, the facility failed to timely address a pharmacy recommendation as requested for 1 of 5 residents reviewed for unnecessary medications (Resident L). Finding includes:Record review for Resident L was completed on 3/31/26 at 1:38 p.m. Diagnoses included, but were not limited, heart failure, Guillain-Barre syndrome (immune system attacks peripheral nerves), and atrial fibrillation. The resident was admitted to the facility on [DATE].A Consultant Pharmacist Recommendations to Nursing form, dated 3/20/26, indicated the resident's current order for sacubitril-valsartan (heart medication) 24/26 mg (milligrams) was for once a day. Per the hospital discharge summary, the resident was to receive the medication twice a day. Please clarify with the prescriber and update accordingly.There was a lack of documentation to indicate the recommendation was clarified with the prescriber and updated until 3/31/26.During an interview on 3/31/26 at 2:46 p.m., the Director of Nursing (DON) indicated the pharmacy recommendation had not been completed until 3/31/26. The medication should have been clarified with the physician when the resident was admitted from the hospital.A facility policy titled, Pharmacy Recommendations and received as current from the DON on 4/1/26, indicated, .The facility requires that all pharmacy recommendations be: .Reviewed, acted upon, or acknowledged by the prescriber in a timely manner .410 IAC (Indiana Administrative Code) 16.2-3.1-25(i)

Based on record review and interview, the facility failed to ensure clinical records were complete and accurately documented related to a Qualified Medication Aide documenting administration of injectable medications for 2 of 2 residents reviewed for anticoagulant administration. (Residents B and D)Findings include:1. Resident B's closed record was reviewed on 3/31/26 at 2:16 p.m.The Discharge Minimum Data Set (MDS) assessment, dated 3/13/26, indicated the resident was cognitively intact and received anticoagulant and antiplatelet medications while a resident.A Care Plan, dated 1/29/26, indicated the resident received anticoagulant medications. Interventions included, but were not limited to, administer anticoagulant medications as ordered by the physician.A Physician's Order, dated 1/15/26, indicated Lovenox (anticoagulant) injection solution prefilled syringe 40 milligrams/0.4 milliliters, inject 0.4 milligrams (mg) once a day for blood clot prevention.The January and February 2026 Medication Administration Record (MAR) indicated QMA 1 marked the Lovenox injection as administered on 1/24/26, 1/25/26, 1/26/26, 2/2/26, 2/18/26, and 2/20/26 at 6:00 a.m. During a telephone interview on 4/2/26 at 1:03 p.m., QMA 1 indicated when she was administering medications and someone required an injectable medication that she was not qualified to administer, she would go get the nurse to administer that medication. She did not give any injections or intravenous medications. On her computer, she would have two separate MARs open, one logged in under her own username and another that was logged in with the nurse's username. When the nurse administered the medication, she would open her own MAR (on QMA 1's computer) and then mark the medications as administered, however sometimes the nurses would open the wrong window and falsely documented the administration under QMA 1's username.During an interview on 4/2/26 at 1:23 p.m., the Director of Nursing indicated she had no further information to provide. 2. Resident D's closed record was reviewed on 3/31/26 at 3:58 p.m.The Discharge Minimum Data Set assessment, dated 2/24/26, indicated the resident was cognitively intact and received anticoagulant medications while a resident.A Care Plan, dated 1/15/26, indicated the resident received anticoagulant medications. Interventions included, but were not limited to, administer anticoagulant medications as ordered by the physician.A Physician's Order, dated 1/14/26, indicated Lovenox (anticoagulant) injection solution prefilled syringe 40 milligrams/0.4 milliliters, inject 0.4 milligrams (mg) once daily.The January and February 2026 Medication Administration Record (MAR) indicated QMA 1 marked the Lovenox injection as administered on 1/16/26, 1/17/26, 1/24/26, 1/25/26, 1/26/26, 1/31/26, and 2/21/26 at 6:00 a.m. During a telephone interview on 4/2/26 at 1:03 p.m., QMA 1 indicated when she was administering medications and someone required an injectable medication that she was not qualified to administer, she would go get the nurse to administer that medication. She did not give any injections or intravenous medications. On her computer, she would have two separate MARs open, one logged in under her own username and another that was logged in with the nurse's username. When the nurse administered the medication, she would open her own MAR (on QMA 1's computer) and then mark the medications as administered, however sometimes the nurses would open the wrong window and falsely documented the administration under QMA 1's username.During an interview on 4/2/26 at 1:23 p.m., the Director of Nursing indicated she did not believe the QMA was administering the injectables, but there was incorrect documentation.This citation relates to Intake 2785715.410 IAC (Indiana Administrative Code) 16.2-3.1-50(a)(2)

Based on observation, record review and interview, the facility failed to ensure infection control practices were in place and implemented related to guidelines for residents in EBP (Enhanced Barrier Precautions), and staff not wearing a gown during a PICC (peripherally inserted central catheter) medication administration during random infection control observations. (Residents L, 104, and E) Findings include:1. On 3/29/26 at 11:47 a.m., Resident L was observed lying in bed. There were no signs on the doorway or in the room that indicated the resident was on any infection control precautions.Record review for Resident L was completed on 3/31/26 at 1:38 p.m. Diagnoses included, but were not limited, Guillain-Barre syndrome (immune system attacks peripheral nerves), and urinary tract infection in the past 30 days. The resident was admitted to the facility on [DATE].The admission MDS assessment, dated 3/23/26, indicated the resident was cognitively intact. The resident had an impairment to both sides of his upper and lower extremities for a functional limitation in range of motion. The resident was dependent on staff for toileting hygiene and transfers. The resident received antibiotic medication.A Physician Progress Note, dated 3/20/26 at 3:23 p.m., indicated the resident had a urinary tract infection with MDRO (multidrug-resistant organisms) with ESBL (extended spectrum beta-lactamase) production. The resident's antibiotic was to be continued through 3/20/26.There was a lack of documentation to indicate the resident had been put under any infection control precautions for the ESBL infection.During an interview on 4/1/26 at 8:40 a.m., the Director of Nursing (DON) indicated the resident should have had EBP in place due to the history of ESBL in his urine. 2. On 3/29/26 at 1:51 p.m., Resident 104 was sitting in a wheelchair in his room. There were no signs on the doorway or in the room that indicated the resident was on any infection control precautions.On 3/30/26 at 9:40 a.m., Resident 104's door was closed and he had a sign on the door for droplet precautions.Record review for Resident 104 was completed on 4/1/26 at 9:02 a.m. The resident was admitted to the facility on [DATE].A Health Status Note, dated 4/1/26 at 11:33 a.m., indicated the resident was asymptomatic related to previous RSV (respiratory syncytial virus) diagnoses. The resident was asymptomatic and would be removed from strict isolation and entered into EBP isolation related to a history of ESBL in urine.There was a lack of documentation to indicate the resident had been placed under precautions prior to 3/30/26.During an interview on 4/1/26 at 8:40 a.m., the DON indicated the resident did not require droplet precautions anymore related to having RSV, but the resident should have been placed on EBP after admission due to the history of ESBL in his urine. 3. During a medication administration on 4/1/26 at 10:24 a.m., LPN 3 was observed preparing Resident E's medications, which included an antibiotic medication to be administered through the resident's PICC line. The resident's doorway had a sign that indicated EBP was to be used. The nurse went into the resident's room, washed her hands, applied gloves, but did not put on a gown. She then proceeded to administer the medication through the PICC line. Interview at the time of the observation with the nurse indicated she was unsure if she should wear a gown when administering a medication through a PICC line.During an interview on 4/1/26 at 11:21 a.m., the DON indicated the nurse should have worn a gown when she administered the resident's medication through the PICC line.The EBP policy for MDROs was not provided. 410 IAC (Indiana Administrative Code) 16.2-3.1-18(b)

Based on observation, record review and interview, the facility failed to care for a midline catheter (inserted into a vein in the upper arm for intravenous [IV] treatments) in accordance with professional standards of practice related to flushing orders and flushing of the catheter, medications administered as ordered, documentation of the insertion and discontinuation of the catheter, assessments of the catheter line with dressing changes and after discontinuing the catheter, for 3 of 3 residents reviewed for midline/PICC (peripherally inserted central catheter) care. (Residents B, C, and F)Findings include:1. Resident B's closed record was reviewed on 9/8/25 at 9:56 a.m. The diagnoses included, but were not limited to, urinary tract infection and bladder cancer. A Care Plan, dated 6/2/25, indicated IV medication was being administered. The interventions included, the dressing for the site was to be changed daily and the observations of the site were to be recorded and the IV line was to be flushed per the Physician's Orders.A Physician's Order, dated 6/2/25, indicated the dressing on the midline was to be changed every seven days for midline maintenance per the midline maintenance protocol.The Medication Administration Record (MAR), dated 6/2025, had initials as completed on June 2, 10, 26, and 24, 2025. There was no assessment of site and length of the IV line documented.A Physician's Order, dated 6/2/25, indicated piperacillin-tazobactam (antibiotic) 3-0.375 grams was to be administered per the IV in 100 milliliters (ml) of normal saline every eight hoursThe Medication Administration Record (MAR), dated 6/2025, indicated the last dose of the antibiotic had been administered on 6/10/25 at 2:00 p.m. A Physician's Order, dated 6/2/25 and discontinued on 6/30/25, indicated a normal saline flush solution, 10 mls was to be used to flush the midline before and after the medication was infused. The MAR, dated 6/2025, indicated the flush was scheduled as needed and had not been administered from 6/2/25 to 6/30/25.A Nurse Practitioner's (NP) Progress Note, dated 6/3/25 at 2:37 p.m., indicated the IV antibiotic was to be discontinued on 6/9/25. An admission Minimum Data Set (MDS) assessment, dated 6/7/25, indicated a moderately impaired cognitive status, and indwelling urinary catheter was present, had a urinary tract infection in the last 30 days, and an IV was present.There was no documentation on the MAR or the Nurses' Progress Notes that indicated the IV line had been flushed before and after the medication and after the IV antibiotics had been discontinued.A Nurse's Progress Note, dated 6/25/25 at 7:07 p.m., indicated the midline in the right upper arm had been removed per the NP orders. There was no bleeding or signs of infection. The resident had tolerated the procedure well.There was documentation in the Nurse's Progress Note that indicated the length of the IV line and the condition of the tip of the catheter.During an interview on 9/8/25 at 12:05 p.m., the Director of Nursing (DON), indicated the midlines/PICC lines were usually discontinued when it was determined there would be no further treatment. When the line was no longer in use, it was to be flushed with 10 ml normal saline twice a day.During an interview on 9/8/25 at 1:25 p.m., the DON indicated she was trying to find the flush orders for before and after the antibiotic was administered and assumed it had been done per the as needed order when the medication had been administered. She acknowledged there was no assessment of the length of the line and the tip condition with dressing changes and when the line had been discontinued. 2. During an observation on 9/8/25 at 8:25 a.m., Resident C was lying in bed and had an IV line in her upper left arm. The dressing that covered the insertion site had a date of 9/5/25.Resident C's record was reviewed on 9/8/25 at 1:37 p.m. The diagnoses included, but were not limited to urinary tract infection.A Physician's Order, dated 9/4/25, indicated meropenem (antibiotic) one gram was to be administered per the IV every 12 hours for seven days due to a urinary tract infection.A Physician's order, dated 9/5/25, indicated a midline IV was to be inserted for the antibiotic treatment.The MAR, dated 9/2025, indicated the meropenem had not been administered as ordered on 9/5/25 at 9:00 a.m., 9/6/25 at 9:00 p.m. and 9/7/25 at 9:00 p.m.There were no Physician's Orders for the weekly dressing change, assessment of the site, or the normal saline flushes before and after the antibiotic until 9/8/25 at 8:53 a.m.An NP Progress Note, dated 9/4/25 at 3:25 p.m., indicated, a urinary tract infection was present secondary to the urinary catheter. Cipro (antibiotic) had been initiated for seven days, pending the final sensitivity report.A MAR Note, dated 9/5/25 at 9:00 a.m., indicated the meropenem had not arrived from the pharmacy and had not been administered.An NP Progress Note, dated 9/5/25 at 4:21 p.m. and written on 9/6/25 at 12:22 p.m., indicated meropenem per IV had been ordered due to the sensitivity indicating the organism was resistant to the Cipro. A heperin lock (IV insertion) had been placed in the antecubital for IV access and a midline catheter had been ordered.A MAR Note, dated 9/6/25 at 8:57 p.m., indicated the meropenem had not been administered. No reason was documented.A MAR Note, dated 9/7/25 at 10:07 p.m., indicated the meropenem had not been administered. No reason was documented.There was no documentation who had inserted the heparin lock and when the midline had been inserted.During an interview on 9/8/25 at 2:22 p.m., the DON indicated the NP had inserted the heparin lock. There was no documentation who had placed the heparin lock and no documentation when the midline had been administered.During an interview on 9/8/25 at 3:19 p.m., the DON indicated the nurses had attempted to place the heparin lock and were unable to place, so the NP had placed the lock. The meropenem had not arrived from the pharmacy. The facility did have the medication available in the EDK 9emergency frug kit). The nurse had not looked in the EDK for the medication. The physician had not been notified. The flush orders and care of the mid-line had not been written at the time of the insertion. The first dose of the meropenem had been administered through the heparin lock on 9/5/25 at 10:00 a.m.3. Resident F's record was reviewed on 9/8/25 at 3:03 p.m. The diagnoses included, but were not limited to, rhabdomyolysis and peripheral vascular disease.A Care Plan, dated 5/20/25 and revised on 8/11/25, indicated IV medication was being received. The interventions included, the dressing would be changed weekly and the observation of the IV site was to be recorded. The IV would be flushed as ordered.A Physician's Order, dated 7/23/25 and discontinued on 8/13/25, indicated the IV midline dressing change was to be completed every seven days per midline protocol.A Physician's Order, dated 7/23/25 and discontinued on 8/13/25, indicated a flush of normal saline, 10 ml was to be completed before and after the IV medication was given.A Physician's Order, dated 7/23/25 and discontinued on 8/6/25, indicated meropenem one gram was to be administered every 8 hours for a urinary tract infection for 14 days. (42 doses)The MAR, dated 7/2025, indicated the meropenem had not been administered on 7/23/25 at 10:00 p.m. and 7/24/25 at 6:00 a.m. and was marked as refused.A Physician's Order, dated 7/23/24, indicated daptomycin (antibiotic) 476 milligrams as to be administered every 24 hours for 14 day, for the urinary tract infection.The MAR, dated 7/2025, indicated the daptomycin dose on 7/24/25 had not been given at 11:22 a.m.The MAR's, dated 7/2025 and 8/2025, indicated the dressing change had been completed on 7/26/25, 8/2/25, 8/10/25, 8/16/25, and 8/24/25. There was no documentation of the mid-line's length.A Physician's Order, dated 8/14/25, indicated the midline IV was to be discontinued.There was no documentation the mid-line had been discontinued, the length of the line or the status of the line's tip.During an interview on 9/9/25 at 10 a.m., the DON indicated the full dosages of the antibiotics were not administered and there was no documentation of the mid-line being discontinued and the assessment of the site and line had not been completed.The facility's central line care policy, dated 12/2024 and received from the DON as current, indicated general instructions after insertion of all PICC line treatments and dressings required a physician's order. A physician's order was required for flushing the line prior to and post administration of the medication, maintenance of the lines and routine line care. The removal of the line was to be documented in the record. The measurement of the line will be obtained by measuring the entire length of the line and was to be recorded. The measurement was to be compared to the insertion measurement. Assessment of the insertion site was to be completed every shift for seventy-two hours.This citation relates to Intake 1839939.3.1-47(a)(2)

Based on observation, record review, and interview, the facility failed to ensure residents who were admitted with open areas and at risk for further pressure sore development, received the necessary treatment and services to prevent pressure ulcers for 2 of 3 residents reviewed for pressure ulcers. (Residents D & C) This resulted in a second unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed) pressure ulcer developing from a leg brace for a resident who had already acquired an unstageable pressure ulcer from the leg brace. (Resident D) Findings include: 1) During an observation with Wound Nurse 1 and CNA 4 on 4/26/21 at 9:45 a.m., Resident D was lying in bed on a low air loss mattress. There was a dressing on the left heel and a brace on the left leg from the mid thigh to the the ankle area. There were anti-pressure boots worn on both lower extremities. Wound Nurse 1 adjusted the left leg brace at that time. During an observation with Wound Nurse 1 on 4/27/21 at 7:45 a.m., Resident D was lying in bed, there was a wedge under the left leg. Wound Nurse 1 indicated the wedge had come with the resident when she was admitted and was not on the bed on 4/26/21 due to the resident was being bathed. The left leg brace was on and there were two metal bars on the sides of the brace. Wound Nurse 1 indicated the resident's legs jerk and cause the the brace to become dislodged. The Orthopedic Physician's Office had been notified and had not returned the call. She had called them on 4/26/21 around 1 p.m. The Nurse Practitioner was aware of the area, though would not override the Orthopedic Physician. The Wound Physician had been in this morning and assessed the wounds. During an interview on 4/27/21 at 7:50 a.m., Resident D indicated the staff would come in when she rang her call light and informed them the brace was hurting her. They would then adjust the brace. She indicated the pressure sores and the brace can be painful. One nurse took the brace off, adjusted it and loosened the bandage. The regular nursing staff did not look underneath the brace. The Wound Nurses only had looked underneath the brace. Resident D's record was reviewed on 4/26/21 at 3:25 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission Minimum Data Set assessment, dated 3/13/21, indicated her cognition was intact, she required extensive assistance of two for bed mobility and transfers, was dependent for bathing, had two stage 3 (full thickness of skin) pressure ulcers, and received Physical and Occupational Therapy. A Braden Scale Assessment, dated 3/9/21, indicated she was a high risk for pressure ulcers. A Care Plan, dated 3/9/21, indicated potential for skin integrity impairment related to impaired mobility, leg brace, and paraplegic. The interventions included, on 3/9/21 - the skin was to be observed during routine care and any alteration was to be reported to the nurse, and on 3/10/21 - leg brace applied as ordered. A Care Plan, dated 3/9/21, indicated the resident had pressure ulcers. The interventions, dated 3/9/21, indicated a pressure redistribution or low air loss mattress was applied, the wound and healing progress was to be assessed and documented weekly and as needed, the pressure ulcers were to be assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Registered Dietician Consult, dated 3/10/21, indicated the resident had multiple surgical areas to the left and right legs, an unstageable area on the right heel, a stage three area on the sacrum and the right buttock on admission to the facility. A multivitamin and liquid protein supplement was ordered. The Treatment Administration Record (TAR), dated 3/2021, indicated from 3/9/21 to 3/31/21 the skin integrity assessment under the left leg brace was documented as completed every shift, except 3/22/21 on the night shift. The TAR, dated 4/2021, indicated the skin integrity assessment under the left leg brace was completed daily on all three shifts from 4/1/21 through 4/26/21. A Wound Report, dated 4/5/21, indicated an unstageable pressure ulceration was identified on the left heel. The wound was deep maroon in color over 80% of the ulcer and bright beefy red over 20% of the ulcer. The wound measured 3 cm (centimeters) by 5 centimeters with depth unknown. The Progress Note indicated a leg brace was worn at all times on the left leg. The heel was resting on the hard part of the brace. The resident and staff were advised to make sure the the brace was applied properly. Treatment orders were obtained and the Nurse Practitioner was aware of the pressure ulcer. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR, dated 4/2021, indicated the treatment to the left heel was completed daily from 4/6/21 through 4/13/21. The Registered Dietician Assessment, dated 4/5/21, indicated the current diet was a no added salt and she received liquid protein twice a day and a multivitamin. She received 100% of dietary allowance for vitamins/minerals. She received increased protein for the wounds. The meal consumption was 76-100%. There were no further recommendations. A Nurse Practitioner's Progress Note, dated 4/5/21 at 2:48 p.m., indicated the resident was sitting in a wheelchair. Her pain was controlled at this time. The left lower extremity brace was in place. The Wound Care Team was following the wounds of the buttock, left medial knee, right buttock, and right heel. A Nurse's Progress Note, dated 4/13/21 at 1:37 p.m., indicated during wound care, the resident complained of posterior heel pain. The area was assessed and a new wound was observed. The wound appeared to have been caused by the metal stabilization bar on the medial side of the brace. The wound was cleansed and dressed. The brace stabilizer was adjusted and reapplied in the correct position. The Nurse Practitioner was made aware of the second pressure ulcer caused by the leg brace. The Wound Assessment, dated 4/13/21, indicated posterior left heel pressure ulceration was unstageable. The wound was 50% non-granulating and was covered with 50% of loosely adherent slough. The measurement of the wound was 1 cm by 1 cm with depth unknown. The assessment note indicated the left heel area had an increase of the eschar. New orders received. Area to the posterior left heel was caused by the leg brace. The hard bar on the brace continues to press against the heel. The bar was adjusted at the time of the observation and the brace was applied appropriately after the adjustment. The resident was on a low air loss mattress, received supplements, and was compliant with wearing off loading boots on her heels. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nurse Practitioner Progress Note, dated 4/13/21 at 12:57 p.m., indicated there was left leg pain and had improved with the leg brace metal bar customized. Left leg immobilizer brace was in place. The Wound Care team was following the wounds of the buttocks, left medial knee, right buttock, and right heel. A Nurse Practitioner Progress Note, dated 4/14/21 at 12:32 p.m., indicated there was left leg pain and the had improved with the leg brace metal bar customized. Left leg immobilizer brace was in place. The Wound Care team was following the wounds of the buttocks, left medial knee, right buttock, and right heel. A Nurse's Progress note, dated 4/26/21 at 1:41 p.m., indicated Wound Nurse 1 placed a call to the Orthopedic Physician's Office and was awaiting a return call. A Nurse Practitioner's Progress Note, dated 4/26/21 at 4:14 p.m., indicated the resident was sitting in a chair. She continued to participate in therapy sessions, complained of pain to the left leg due to the brace. A call was made to the Orthopedic Physician's Office about the brace. Pain was controlled at the time of the assessment. The left lower leg immobilizer brace was in place. The Wound Care Team was following the resident for wound of the buttock, left medial knee, right buttock, and right heel. A Physical Medicine & Rehabilitation Follow-up Evaluation, dated 4/26/21 at 8:15 p.m., indicated the resident was asked to be seen by the primary team to optimize therapy, pain control, and discharge planning. Resident was sitting upright in the bed and appeared uncomfortable. She had pain affecting the left lower extremity and improved pain with pain medication. Discussed open sore of the left heel with the Wound Care Team on 4/26/26. Nursing was to contact the Orthopedic Physician's Office today about the wound. There was no documentation in the resident's record to indicate the Orthopedic Physician had been notified of the first or second pressure areas, believed to be caused by the leg brace, prior to 4/26/21. During an interview on 4/26/21 at 3:48 p.m., Wound Nurse 2 indicated the brace on the left leg needed to be checked often. The areas on the left heel were from the brace. The brace should be checked every shift and the Wound Nurses also checked the brace. During the skin assessments, the pressure areas on the left heel were noted where the metal bar from the brace rested on the heel. The Orthopedic Physician's Office was called today to see if a smaller brace could be applied and had not called back. The Wound Physician was scheduled to see the resident on 4/27/21 around 5 a.m. During an interview on 4/27/21 at 8 a.m., Wound Nurse 1 indicated the interventions initiated after the first unstageable wound on 4/5/21 was found on the left heel were to re-educate the staff for the brace placement, adjustment, and checking of the skin. She could not find any documentation in the record to indicate the Orthopedic Physician was notified of the initial pressure ulcer found on 4/5/21, determined to be caused by the brace, or the second ulcer found on 4/13/21 also determined to be caused by the brace. She indicated the bar on the brace was adjusted on 4/13/21. She was unable to find documentation of any interventions initiated after the cause of the first unstageable pressure ulcer was determined to be the leg brace on 4/5/21, other than re-education of the staff. The Care Plan had not been updated with interventions. During an interview on 4/27/21 at 9:05 a.m., the Therapy Director indicated the resident was no longer receiving therapy as of 4/23/21. Physical Therapist 3 and the Therapy Director indicated they were unaware of any issues with the left lower extremity brace. Physical Therapist 3 indicated the immobilizer had not been removed by therapy due to they were not mobilizing the left lower extremity. During an phone interview on 4/27/21 at 9:37 a.m., the Orthopedic Physician's Office nurse indicated there was no documentation in the Physician's Notes about any pressure area to the resident's left heel. The first call from the facility to their office regarding the resident was on 4/26/21. The Wound Physician's Progress Notes, dated 4/27/21 and received from Wound Nurse 1 on 4/27/21 at 9:45 a.m., indicated left heel was unstageable and necrotic. The measurement was 1.5 cm by 5.5 cm with light serous exudate. The wound was 70% black necrotic tissue and 30% granulated tissue. The nature of the wound was at the lower contact point of the left leg brace with [CONDITION(S)]. [CONDITION(S)] was present. The treatment was to apply oil [MEDICATION(S)], a hydrogel gauze, and dry protective dressing daily. The exam indicated the resident was oriented to person, place, time and situation. The left and right foot had limited sensation. No [CONDITION(S)] of the the left and right lower extremities. Both lower extremities were warm and the dorsalis pedis and posterior tibial pulses were detected by a portable doppler. An addendum note from the Wound Physician, dated 4/27/21, indicated the unstageable wound of the posterior heel was likely due to the brace, which was required to be worn by the Orthopedic Physician. The resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The wound developed quickly within an eight hour shift and could have developed within two hours. Due to these factors, the wound was unavoidable. A Guideline for Determination of a clinical Unavoidable Skin Condition, dated 4/13/21 and received from Wound Nurse 1 on 4/27/21 at 9:45 a.m., after the interview on 4/27/21 at 8 a.m., indicated the resident had chronic bowel incontinence, [CONDITION(S)], and a non-removable device. The head of the bed was elevated the majority of the day due to medical necessity.Based upon the above assessment, it is determined the resident is a risk for a clinically unavoidable skin condition. The form was signed by Wound Nurse 1 and the Nurse Practitioner on 4/13/21. Wound Nurse 1 indicated this was an internal form and had not been kept in the resident's record, nor brought up in any prior interview. During an interview on 4/27/21 at 10:16 a.m., Wound Nurse 1 indicated the Wound Physician measured the two left heel areas as one area. The Unavoidable Pressure Assessment indicated the brace was non-removable, though it should have been removed for treatments and skin checks as ordered. 2. During an observation with Wound Nurse 1 and CNA 2 on 4/26/21 at 9:20 a.m., Resident C was lying in bed. The resident indicated the dressings on the buttocks did not always get changed daily. CNA 2 removed the incontinence brief and rolled the resident on to her right side. There were 2 pressure ulcers on the resident's coccyx/sacrum area. There was no dressing noted on either pressure ulcer. CNA 2 indicated she had last changed the resident at 6:30 a.m. and had not paid attention to the wounds to know if the dressings were on at that time. There were no dressings located in the brief. Wound Nurse 1 staged both pressure areas as stage two (partial thickness of skin lost). Wound Nurse 1 then dressed the pressure areas with a foam dressing after cleansing them. The dressings were not dated. Wound Nurse 1 indicated the facility policy is not to date the dressings. Resident C's record was reviewed on 4/26/21 at 11 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission Minimum Data Set assessment, dated 4/20/21, indicated there was no cognitive impairment. A Care Plan, dated 4/14/21, indicated there were pressure ulcers of the coccyx and sacrum. The interventions included, the pressure ulcers were to be assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This Federal tag relates to Complaints IN 248 and IN 256. 3.1-40(a)(1) 3.1-40(a)(2)

Based on record review and interview, the facility failed to ensure a resident was properly transferred which resulted in a fracture for 1 of 4 residents reviewed for accidents. (Resident C) Finding includes: The closed record for Resident C was reviewed on 8/10/20 at 9:45 a.m. The resident was admitted to the facility on [DATE] and discharged on [DATE]. [DIAGNOSES REDACTED]. A Skilled Look Back Note dated 8/2/20 at 9:51 a.m., indicated the resident was alert and oriented to person, place and time and needed two person extensive assistance for transfer mobility. Physician Assistant Narrative, dated 8/3/20 at 12:59 p.m., indicated, .The patient was seen today in her room sitting up in chair. She reports acute pain to the left anterior/posterior shoulder and neck that started last night attributed to injury on transfer .X-ray of left shoulder order per staff with preliminary findings of clavicle fracture Progress Note, dated 8/3/20 at 3:02 p.m., indicated the Physician ordered the resident to be sent to hospital for evaluation and treatment of [REDACTED]. During an interview with Physical Therapist (PT) and Occupational Therapist (OT) on 8/11/20 at 9:45 a.m., the OT indicated the resident was a two person maximum assistance for transfers. They had initially recommended a Hoyer (mechanical lift). The Transfer Communication sheet was completed on 8/2, but had not been taken to the nurses station until 8/3. The OT indicated she gave CNA 1 verbal instructions on 8/2 on how to transfer the resident using two person maximum assistance. During an interview with CNA 1 on 8/11/20 at 10:03 a.m., she indicated she had been instructed by the OT that the resident was a two person max assist for transfers. She would have given a verbal report to oncoming staff how to transfer; she did not remember who she gave verbal report to the evening of 8/2/20. During a telephone interview with QMA 1 on 8/10/20 at 2:25 p.m., she indicated she had been called in to the resident's room by CNA 4 on 8/2/20 for transfer assistance. It was evening shift, but she was unsure of the time. QMA 1 indicated the resident's wheelchair was next to the bed. The QMA placed her hands around her waist, and the resident put her arms around her neck, and the resident stood up. As soon as she stood up, the resident began yelling the QMA broke her arm. She sat her onto the bed. CNA 4 went to get an ice pack and QMA 1 notified RN 3 at that time what had happened. CNA 4 did not assist with the transfer at any time. During an interview with the Administrator on 8/11/20 at 9:35 a.m., she indicated she believed the resident's fracture was caused by an improper transfer. This Federal tag relates to Complaint IN 414. 3.1-45(a)

Based on observation, record review, and interview the facility failed to ensure pressure ulcers were assessed weekly, interventions were in place as ordered, the Registered Dietician was notified of a pressure ulcer, and a treatment was obtained for an open area, resulting in worsening of the pressure ulcers for 3 of 4 residents reviewed for pressure ulcers of the 8 who met the criteria for pressure ulcers. This failure resulted in a right outer ankle wound first being assessed at a Stage 3 pressure ulcer and an open area to the coccyx worsening to an unstageable pressure ulcer. (Residents #70, #245, and #247) Findings include: 1. On 7/11/16 at 9:33 a.m. Resident #70 was observed in her room seated in her wheelchair. She had soft foam boots in place to both feet. On 7/11/16 at 2:33 p.m. Resident #70 was observed lying in bed. LPN #2 removed the dressings from the resident's right lateral ankle and right heel. The bottom of the resident's right heel was observed to have a quarter sized black hardened scabbed area. The skin surrounding the black scabbed area was observed to be pink. The resident's right lateral ankle was observed to have a pea sized open area. The skin surrounding the open area was observed to be pink. LPN #2 cleaned the areas with wound cleanser, applied medi honey and a 4x4 piece of gauze, then wrapped the areas with kerlix. The record for Resident #70 was reviewed on 7/6/16 at 1:07 p.m. The resident's [DIAGNOSES REDACTED]. The resident was readmitted to the facility from the hospital on [DATE]. The 6/23/16 Admission Minimum Data Set (MDS) assessment indicated the resident was at risk for pressure ulcers, currently had one unstageable deep tissue injury pressure ulcer and one stage 2 pressure ulcer that were present on admission. The resident required an extensive assist of one person for her Activities of Daily Living (ADLs). The resident had a care plan for alteration in skin integrity related to a pressure ulcer to the right lateral ankle and the right heel as well as vascular wounds to the left dorsal foot and right foot 2nd digit. The nursing interventions included, .assess and document wound healing progress weekly and prn (as needed), daily skin checks during care heel protectors as ordered . Review of the Admission Clinical Evaluation, dated 6/16/16, indicated the resident had a blister to the R (right) third toe, treatment to the R (right) heel, x (times) 3 discolorations to L (left) abdomen, and discoloration to R (right) upper inner arm. Review of the hospital discharge summary, dated 6/16/16, indicated orders for .right heel: wound care daily dressing change. Cleanse foot and RLE (right lower extremity) with sage bath wipes. Apply remedy skin repair cream to foot. Apply [MEDICATION NAME] to heel eschar. Cover with ABD (a treatment pad) and secure with gauze roll. Prevalon (a heel protector type boot) boot when in bed. Review of the 6/2016 Treatment Administration Record (TAR) indicated the resident received the following treatment from 6/17/16 to 7/1/16: [MEDICATION NAME] to R (right) heel, cover secure with kerlix daily, foam to heel for padding every day shift. The treatment was not signed out as completed on 6/20/16, 6/21/16, and 6/25/16. Review of the TAR lacked indication the wound treatment had been completed as ordered by the hospital and the heel protector boots had been put in place as ordered by the hospital. Review of the 7/2016 TAR indicated heel protector boots were put in place on 7/1/16. The record lacked indication any heel protector boots had been put in place prior to 7/1/16. Review of a Progress Note, dated 7/1/16, indicated .skin/wound assessment completed, md (physician) notified of skin concerns new orders received, guest and family updated. Review of the Wound Rounds Wound Summary, dated 7/1/16, indicated the resident had a suspected deep tissue injury to the right heel that was listed as present on admission measuring 3.5 centimeters (cm) x (by) 4.5 cm x unknown depth. The predominant tissue type was listed as necrotic/hard/firm. The resident also had a right lateral ankle stage 3 pressure ulcer that was listed as present on admission measuring 0.3 cm x 0.4 cm x unknown depth. The predominant tissue type was listed as slough. The record lacked indication the right heel pressure ulcer had been assessed, staged, or measured prior to 7/1/16. The record lacked indication the right lateral ankle pressure ulcer had been assessed, staged, or measured prior to being found at a stage 3 on 7/1/16. Interview with the DON on 7/8/16 at 10:46 a.m. indicated the heel protector boots had not been put in place until 7/1/16. She indicated the right heel area had not been assessed until 7/1/16. She indicated the right heel area was staged as a deep tissue injury in the Wound Rounds system initially because the program would not let them change the staging to an unstageable, only to a stage 1, 2, or 3. She indicated she had spoken with the Wound Nurse Consultant who had indicated the right heel area should have been staged as an unstageable pressure ulcer, not a deep tissue injury. She indicated the right lateral ankle area had not been found or assessed until 7/1/16 and was then staged as a stage 3 pressure ulcer. She indicated the Wound Nurse Consultant had indicated the right lateral ankle area should have been staged as an unstageable on 7/1/16 because it was 100% slough. She indicated the resident had a previous area to the right lateral ankle on her prior admission but it was not listed on the 6/16/16 admission assessment so it must have healed previously. She further indicated the pressure areas should have been assessed upon admission and weekly. 2. The record for Resident #245 was reviewed on 7/6/16 at 1:23 p.m. The resident's [DIAGNOSES REDACTED]. The resident's admitted was 6/24/16 from the hospital. Review of the Admission assessment dated [DATE] indicated an open area to the coccyx (tailbone) with no staging or measurements noted. Review of a Wound assessment dated [DATE], indicated a stage 3 pressure ulcer to the coccyx. A Wound assessment dated [DATE], indicated an unstageable pressure ulcer to the coccyx. Review of a Nurse Progress Note from the hospital dated 6/20/16, indicated a sheared injury to buttocks with a yellow center. A duoderm (dressing) was applied. Review of the facility's Nurse Progress Notes from 6/24/16-6/29/16, lacked an indication of a treatment, measurements and description of the coccyx open area. Physician order [REDACTED]. The 5 day Minimum Data Set (MDS) assessment dated [DATE], indicated the resident was cognitively intact and was a physical 1 person assist for transfers, dressing, and toileting. Interview with the Wound Nurse on 7/6/16 at 2:52 p.m., indicated only the Wound Nurse is allowed to assess and measure wounds. He further indicated the resident was not assessed and a treatment order was not in place until 6/28/16. Interview with the Director of Nursing (DON) on 7/7/16 at 2:30 p.m., indicated the nurse that completed the resident's admission should have notified the Physician of the lack of a wound treatment plan in place upon discharge from the hospital. 3. On 7/11/16 at 1:38 p.m., Resident #247 was observed receiving a wound treatment by the Wound Nurse. The resident had a pressure area to the right heel. The area was approximately the size of a nickel and had a brown scab over the area. Record review for Resident #247 was completed on 7/6/16 at 2:05 p.m. The residents [DIAGNOSES REDACTED]. The 5 Day Minimum Data Set (MDS) assessment completed on 6/29/16 indicated the resident had an unstageable pressure ulcer. A Care Plan initiated on 6/14/16 indicated the resident had a pressure ulcer to the right heel. The resident was admitted to the facility on [DATE]. The Hospital Transfer Form completed on 6/2/16 indicated the resident had a pressure sore to the heel. An Admission Assessment completed on 6/2/16 indicated the resident was a readmission to the facility. The assessment indicated the resident had a right heel ulcer with a blister that was open to air and healing. A Physician Note completed on 6/3/16 at 10:57 a.m., indicated the resident did not have any wounds or pressure ulcers noted. A Registered Dietician (RD) evaluation of Nutritional Risk admission assessment completed on 6/10/16 indicated the resident was not on current wound reports. A Wound Assessment Detail completed on 6/13/16 indicated the resident had an intact blister on the right heel that was staged at an unstageable. The area measured 1.6 cm (centimeters) x 1.6 cm. A physician's orders [REDACTED]. Cleanse with wound cleanser, apply skin prep (protective barrier for skin), and cover with a foam dressing every 3 days and as needed for wound care. An RD evaluation of Nutritional Risk assessment was completed again on 6/29/16. The assessment indicated the resident had an unstageable right heel pressure area. The RD suggested to start Juven (nutritional protein drink) twice a day and Prostat (liquid protein supplement) daily for wound healing. The record lacked any indication the Physician or RD had been notified of the pressure area that was documented on the admission assessment on 6/2/16. The record lacked any indication there was a treatment in place or any further assessments completed of the pressure area until 6/13/16. Interview with the Director of Nursing (DON) on 7/8/16 at 1:26 p.m., indicated when the resident was admitted to the facility, the interventions in place for pressure area prevention were a pressure reducing mattress and have the resident's heels floated while in bed. She indicated she was unable to find any documentation the pressure area itself had a treatment put into place until 6/13/16. She further indicated the pressure area was not staged correctly on the 6/13/16 wound report. The area should not have been staged as an unstageable due to it being an intact blister. A policy titled, Skin Care Prevention, was received as current from the Administrator on 7/7/16 at 3:52 p.m. The policy indicated, .Guideline: 1. The Skin Care Coordinator will review all new admissions to put a plan in place for prevention. 3. All residents will be evaluated daily for changes in their skin condition. 14. If appropriate, consult dietary for a dietary supplement and/or evaluation . 3.1-40(a)(2)

Based on observation, record review, and interview, the facility failed to ensure proper fall interventions were in place as ordered for a resident, resulting in a resident falling and obtaining a subdural hematoma (a collection of blood outside the brain) for 1 of 1 residents reviewed for accidents. (Resident #269) Finding includes: Interview with LPN #3 on 7/6/16 at 10:33 a.m. indicated Resident #269 had a fall on 7/5/16 and was sent to the emergency room . She further indicated the resident was currently at the hospital and the hospital had reported the resident had an acute right subdural hematoma. On 7/7/16 at 10:25 a.m. Resident #269 was observed siting in her wheelchair in her room watching television. She had a chair alarm in place to her wheelchair. The record for Resident #269 was reviewed on 7/8/16 at 12:33 p.m. The resident's [DIAGNOSES REDACTED]. Review of the 6/28/16 Admission Minimum Data Set (MDS) assessment indicated the resident required an extensive assist with a 2 person physical assist for bed mobility and transfers. Review of the 7/2016 Physicians Order Summary indicated orders for a bed alarm and a chair alarm. Resident #269 had a care plan for risk for injury from falls. The nursing interventions included, .bed alarm as ordered, chair alarm as ordered . Review of an initial incident investigation form dated 7/5/16 at 10:15 a.m. indicated Resident #269 was found lying on the floor in her room on her back with her upper body under the bed. The resident was unable to explain how the fall occurred and was sent to the emergency room for evaluation. Review of the follow up incident investigation form dated 7/8/16 indicated upon investigation of the fall, it was found the resident's bed alarm had not been properly placed under the resident after she had been assisted to bed by LPN #4. The follow up indicated LPN #4 had been counseled regarding alarm placement. It further noted, after evaluation of the resident, the emergency room noted a right-sided subdural hematoma. The resident returned to the facility from the hospital on [DATE]. A hospital imaging result, CT (computed tomography, a series of x-ray images) of the head/brain, dated 7/5/16 at 12:27 p.m., indicated Impression: Tiny right-sided acute subdural hemorrhage with no significant mass effect . A Corrective Action Notice Form included in the investigation follow up dated 7/5/16 indicated, LPN #4 was assisting a resident to bed and failed to properly place the ordered bed alarm under guest resulting in a fall with injury . Interview with the DON (Director of Nursing) on 7/8/16 at 10:30. indicated the resident had fallen out of bed. She further indicated upon investigation, it was found the resident's bed alarm had not been properly placed. She indicated staff was counseled regarding the incident. 3.1-45(a)(2)