Every finding on record at Life Care Center of Michigan City

Based on observation, record review and interview, the facility failed to ensure a resident received the necessary care and treatment related to incorrect oxygen flow rate for 1 of 3 residents reviewed for respiratory care. (Resident E) Finding includes: On 10/27/25 at 1:13 p.m., Resident E was observed lying in her bed. She had a nasal cannula on and oxygen was flowing from the concentrator at 4 liters per minute (lpm). On 10/28/25 at 9:15 a.m., the resident was seated in her room with the nasal cannula on and oxygen flowing at 4 lpm. The resident indicated she was supposed to be on 2 lpm of oxygen. The resident's record was reviewed on 10/27/25 at 1:00 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease, hypertension and chronic cough. The Quarterly Minimum Data Set assessment, dated 10/14/25, indicated the resident was cognitively intact and received oxygen. A Physician's Order, dated 4/3/24, indicated oxygen at 2 lpm continuously. During an interview on 10/28/25 at 1:20 p.m., LPN 1 indicated the resident was on 2 lpm of oxygen. She observed the resident's oxygen concentrator at 4 lpm and adjusted it to the correct flow rate. This citation relates to Intake 2645073. 3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure there was adequate monitoring and interventions implemented for constipation related to a delay in treatment for a resident with no documented bowel movements for over 5 days for 1 of 3 residents reviewed for change in condition. (Resident J) Finding includes:Resident J's record was reviewed on 10/28/25 at 9:15 a.m. Diagnoses included, but were not limited to, hemiplegia and hemiparesis following a cerebral infarction (weakness and paralysis following a stroke) affecting the left non-dominant side and epilepsy. The resident was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment, dated 10/15/25, indicated the resident was cognitively intact. She was occasionally incontinent of bowel and bladder. The Care Plan, dated 10/10/25, indicated the resident was at risk for constipation related to decreased mobility and side effects of medications. Interventions included, but were not limited to, follow facility bowel protocol for bowel management, observe for medication side effects of constipation and keep physician informed of any problems, record bowel movement pattern each day, and observe for and report as needed any signs or symptoms of complications related to constipation such as abdominal distention, vomiting, bowel sounds, abdominal tenderness, guarding, or rigidity. The B&B - Bowel and Bladder Elimination, task indicated the resident had a medium sized bowel movement on 10/9/25 at 10:29 p.m., a medium sized bowel movement on 10/15/25 at 1:03 p.m., a medium sized bowel movement on 10/17/25 at 9:07 a.m., and a medium sized bowel movement on 10/19/25 at 9:14 a.m. There were no bowel movements documented on 10/10, 10/11, 10/12, 10/13, and 10/14/25. The October 2025 Physician's Order Summary indicated docusate sodium (stool softener) oral capsule 100 milligram (mg), 1 capsule once daily as needed for constipation, divalproex sodium oral tablet delayed release 250 mg 2 tablets twice daily for seizure prevention, perampanel oral tablet 4 mg 1 tablet once daily for seizure prevention, lacosamide 100 mg tablet twice daily for seizure prevention, and monitor for side effects of anticonvulsants which included, but were not limited to, dizziness, fatigue, constipation, nausea, or vomiting. The October 2025 Medication Administration Record (MAR) indicated the docusate sodium was administered on 10/15/25 at 1:49 p.m. with follow up code: unknown, 10/18/25 at 8:48 p.m. with follow up code: effective, and 10/19/25 at 10:11 p.m. with follow up code: ineffective. The monitoring for side effects of anticonvulsants indicated there were no side effects observed between 10/9/25 night shift thru 10/20/25 evening shift. A Progress Note, dated 10/12/25 at 7:37 a.m., indicated the resident was complaining of nausea related to medications. The nurse practitioner was notified and sent a new order for Zofran (preventative for nausea and vomiting) 4 milligrams three times days as needed for three days. The resident and family were aware. A Progress Note, dated 10/13/25 at 1:36 p.m., indicated the resident was alert and oriented, vital signs were stable and within normal limits, and bowel sounds were present in all quadrants. A Progress Note, dated 10/15/25 at 2:12 p.m., indicated the initial dose of Miralax (laxative) was administered. The family was informed of the new order and the resident was stating her bowels were not moving like they should. A Physician's Order, dated 10/15/25, indicated Miralax packet (polyethylene glycol 3350), give 1 packet by mouth twice daily for 5 days. The October 2025 MAR indicated Miralax was administered as ordered from 10/15/25 at 5:00 p.m. until 10/20/25 at 9:00 a.m. A Progress Note, dated 10/16/25 at 3:27 p.m., indicated the resident was continuing the Miralax twice daily regimen and had one medium soft bowel movement. A Progress Note, dated 10/17/25 at 4:42 p.m., indicated the resident had not had a bowel movement yet. A Progress note, dated 10/20/25 at 8:30 p.m., indicated the resident complained of increasing abdominal pain and was unable to have a bowel movement. The nurse practitioner (NP) was notified, and new orders were received for a Fleet enema. After the enema, the resident still did not have a bowel movement and complained of worsening pain and stated that she felt like she could have a seizure. 911 was called, the NP and family were notified. A Progress Note, dated 10/21/25 at 8:41 a.m., indicated the resident was admitted to the hospital for proctitis (an inflammation of the anus and the lining of the rectum) and constipation. The CT (computed tomography) of the abdomen and pelvis, dated 10/20/25, indicated there was a large volume of stool throughout the colon and rectum. There was mild wall thickening of the rectum with adjacent inflammatory change concerning for proctitis. Stercoral colitis (rare inflammatory form of colitis that occurs when impacted fecal material leads to distention of the colon) was not excluded. During an interview on 10/28/25 at 10:40 a.m., the Director of Nursing indicated interventions for constipation were to be initiated if a resident had not had a bowel movement in 3 days. She was unable to find any other documentation. A facility policy titled, Bowel Protocol, reviewed on 9/15/25, indicated Procedure 1. Nursing staff will record, in the EHR, each time a resident has a bowel movement. 2. The facility in coordination with the resident's attending practitioner will implement standing orders to address a lack of bowel movement. A. These orders may vary within the facility for each attending practitioner. B. These orders may vary depending on the individual needs of a resident. This citation relates to Intake 2645073. 3.1-37(a)

Based on observation and interview, the facility failed to ensure the residents' environment was clean and in good repair related to dirty floors, bed rails, baseboards, and ceiling vents, loose trim on floors and baseboards, and marred walls and doors in 2 of 2 units. (The East and [NAME] Units)Findings include:During the Environmental Tour on 8/7/25 at 1:35 p.m., with the Maintenance Director and Housekeeping Director, the following was observed:1. East Unita. The floor and floor mat in room [ROOM NUMBER] were dirty and sticky. The bed rail was visibly dirty with a brown substance stuck on it. One resident resided in the room. These observations were consistent with observations made on 8/4/25 at 11:19 a.m.2. [NAME] Unita. In room [ROOM NUMBER], the trim on the floor in the doorway to the bathroom and the baseboard were coming off. One resident resided in the room.b. In room [ROOM NUMBER], the paint was chipped on the wall by bed 2 and the floor mat was torn along the edge. The floor tile was dirty along baseboard in the entry to the room. Two residents resided in the room.c. In room [ROOM NUMBER], the privacy curtain was stained, and the paint was chipped on the wall by bed 2. The floors in the room and bathroom were discolored. There was an accumulation of dirt along baseboard in entry way of room and the bathroom. Two residents resided in the room. d. In room [ROOM NUMBER], the paint was chipped on the wall behind bed 2. The floor tile was dirty along baseboard in the entry to the room and in the bathroom. Two residents resided in the room.e. In room [ROOM NUMBER], there was debris and food crumbs on the floor around the bed. The resident indicated the room had not been cleaned in two days. One resident resided in the room. f. In room [ROOM NUMBER], the paint was chipped on the wall next to bed 1. The bathroom door was marred. There was an accumulation of dirt along baseboard in the entry to the room and in the bathroom. Two residents resided in the room.g In room [ROOM NUMBER], the wall behind the head of the bed was marred. There was an accumulation of dirt along the baseboard in the entry to the room. One resident resided in the room.h. In room [ROOM NUMBER], the room door and bathroom door were scratched and marred. In the bathroom, there was a rust stain in the sink, a buildup of dirt along the baseboards, and discoloration of the floor tile. Two residents resided in the room.i. In room [ROOM NUMBER], the floor and baseboards were dirty. In the bathroom, the floor was marred and discolored, and the ceiling vent had an accumulation of dust. Two residents resided in the room and used the bathroom. j. In room [ROOM NUMBER], the bathroom ceiling vent had an accumulation of dust. Two residents used the bathroom. During an interview on 8/7/25 at 1:52 p.m., the Maintenance Director and Housekeeping Director indicated all of the above areas were in need of cleaning or repair.3.1-19(f)

Based on observation, record review, and interview, the facility failed to store over the counter medications and insulin securely in a locked medication cart for 2 of 2 residents reviewed for medication storage. (Residents 42 and 3)Findings include:1. During random observations on 8/4/25 at 10:00 a.m. and 1:13 p.m. and on 8/5/25 at 9:09 a.m. and 1:55 p.m., Resident 42 was observed in her room and in bed. At those times there was an unopened multi-use vial of Insulin on the resident's nightstand with a label of the resident's name on it. On 8/5/25 at 3:41 p.m., the Nurse Trainer entered the resident's room and observed the insulin vial on top of the nightstand and asked the resident if she could remove it. The record for Resident 42 was reviewed on 8/5/25 at 1:57 p.m. Diagnoses included, but were not limited to, acute respiratory failure, heart disease, heart failure, dementia without behaviors, and high blood pressure. The 6/20/25 Annual Minimum Data Set (MDS) assessment, indicated the resident was not cognitively intact for daily decision making and needed substantial assistance with activities of daily living. There was no care plan the resident could store medications in her room. There was no physician's order for any type of insulin. During an interview on 8/5/25 at 3:55 p.m., the Nurse Trainer indicated the vial of insulin should not have been on the nightstand. During an interview on 8/5/25 at 3:56 p.m., the Director of Nursing indicated the resident had never received insulin during her stay and she had no idea where it could have come from. 2. During random observations on 8/4/25 10:00 a.m. and 1:10 p.m., there was a bottle of over the counter castor oil on Resident 3's over bed table. The resident was not in her room during those times and was at dialysis. During an interview on 8/5/2025 at 10:27 a.m., the resident indicated she used the castor oil for her hair, and did not consume it. During an observation on 8/5/25 at 1:50 p.m., the castor oil was still observed on the over bed table. On 8/5/25 at 3:41 p.m., the Nurse Trainer entered the resident's room and observed the bottle of castor oil on the resident's over bed table. She asked the resident if she could take it and write some information down and then she would bring it back. The resident indicated at that time, she used the oil for her hair only. The record for Resident 3 was reviewed on 8/6/25 at 2:25 p.m. Diagnoses included, but were not limited to, stroke, heart disease, end stage renal disease, high blood pressure, heart failure, major depressive disorder, and dependence on renal dialysis. The Modification of the 6/18/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making. There was no care plan the resident could store over the counter medications in her room. During an interview on 8/5/25 at 3:55 p.m., the Nurse Trainer indicated the castor oil should be in a lock box or kept secured in the room. The current and revised 8/7/23 Storage and Expiration Dating of Medications and Biologicals policy, provided by the Director of Nursing on 8/7/25 at 11:33 a.m., indicated the facility should ensure that all medications and biologicals, including treatment items, were securely stored in a locked cabinet or medication cart. 3.1-25(j)

Based on observation, record review, and interview, the facility failed to ensure residents had physician's orders for medications and an assessment to self-administer their own medications for 1 of 2 residents reviewed for self-administration of medication. (Resident 20)Finding includes:During random observations on 8/4/25 at 10:05 a.m., 8/4/25 at 3:00 p.m., and 8/5/25 at 2:20 p.m., a container with 4 bottles of re-wetting eye drops was observed on Resident 20's bedside table. One of the bottles had an expiration date of 12/2017. The resident indicated he used the eye drops regularly and independently. The resident's record was reviewed on 8/5/25 at 2:44 p.m. Diagnoses included, but were not limited to, chronic kidney disease, lymphoma, and glaucoma.The 7/5/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident had moderate cognitive impairment, and required moderate assistance with activities of daily living (ADLs).The record lacked a self-administration assessment and physician's orders for re-wetting eye drops.During an interview on 8/5/25 at 2:10 p.m., the Assistant Director of Nursing (ADON) indicated a self-administration assessment should be completed and a physician's order obtained for a resident to self-administer medications. A policy titled, Self-Administration of Medications, received as current from the Administrator on 8/7/25 at 3:11 p.m. indicated, . Facility, in conjunction with the interdisciplinary care team, should assess and determine, with respect to each resident, whether self-administration of medications is safe and clinically appropriate, based on the resident's functionality and health condition . Facility should ensure that orders for self-administration list the specific medication(s) the resident may self-administer . Facility should document the self-administration and self-storage of medications in the resident's care plan.3.1-11(a)

Based on record review and interview, the facility failed to promptly notify the resident's physician of multiple refusals of sliding scale insulin for 1 of 5 residents reviewed for unnecessary medication. (Resident 4)Finding includes:The record for Resident 4 was reviewed on 8/6/25 at 8:56 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, stroke, heart disease, high blood pressure, type 2 diabetes, diabetic neuropathy, heart failure, chronic pain, low back pain, major depressive disorder, chronic migraines, and a history of thrombosis (the formation of a blood clot (thrombus) inside a blood vessel, obstructing the normal flow of blood). The admission Minimum Data Set (MDS) assessment, dated 5/15/25, indicated the resident was cognitively intact for daily decision making and received insulin in the last 7 days. The Care Plan, revised on 5/28/25, indicated the resident refused care such as being repositioned, incontinent checks and changes, and skin assessments. The Care Plan, revised on 5/28/25, indicated the resident has diabetes mellitus. The approaches were to educate regarding medications and importance of compliance. A Physician's Order, dated 5/2/25, indicated Humalog Insulin 100 units/milliliter, inject as per sliding scale: if 0 - 150 = 0 units; 151 - 200 = 4 units; 201 - 250 = 6 units; 251 - 300 = 10 units; 301 - 350 = 12 units; 351 - 400 = 15 units every morning, midday, and evening shifts. The 5/2025 Medication Administration Record (MAR) indicated the resident refused the insulin 7 times for the morning dose, 10 times for the midday dose, and 10 times for the evening dose. The 6/2025 MAR indicated the resident refused the insulin 14 times for the morning dose, 12 times for the midday dose and 13 times for the evening dose. There was no documentation in May or June 2025 to indicate the Physician or Nurse Practitioner (NP) was notified of the repeated refusals of the sliding scale insulin. The first documentation of any type of medication refusals was on 7/2/25 at 4:02 p.m., as the NP note indicated patient's blood sugars have been over 200. Patient is very noncompliant with medications During an interview on 8/7/25 at 3:10 p.m., the Director of Nursing indicated she had reviewed her files and there was no documentation the NP was notified of the resident refusing the insulin, however, there was a care plan that indicated she had refused care. During an interview on 8/8/25 at 11:00 a.m., the Director of Nursing indicated she had spoken to the NP on 8/8/25, and she indicated she was not aware the resident had been refusing her insulin for the months of 5/2025 and 6/2025. The revised and current 6/1/24 Resident Medication Rights policy, provided by the Assistant Director of Nursing on 8/7/25 at 3:27 p.m., indicated the facility should notify the physician/prescriber of a resident's refusal of medications for periods greater than 24 hours. 3.1-5(a)(3)

Based on observation, record review, and interview, the facility failed to ensure a wound vacuum and tubing were kept off the floor and treatments were in place for a non-pressure skin area for 1 of 2 residents reviewed for non-pressure skin areas, a resident was treated for constipation for 1 of 1 resident reviewed for constipation and a resident with a NG tube was assessed and monitored for complications for 1 of 1 resident reviewed for hospice. (Residents 90, 4, and 11)Findings include: 1. During an observation on 8/4/25 at 1:00 p.m., Resident 90 was observed in bed. At that time, the resident had a large bandage over the left knee and it was connected to a wound vacuum (a treatment that used suction to help wounds heal). The wound vacuum and tubing were observed on the floor. The resident was also observed with a pink foam bandage on the back of her right hand with a date of 7/28/25. During an interview with the resident, she indicated she had an allergic reaction while in the hospital from a medication and scratched herself so badly the area became open. On 8/4/25 at 2:28 p.m. RN 1 removed the bandage from the resident's right hand and there was a dark discoloration underneath it. At that time, the wound vacuum and tubing were still observed on the floor. During an interview on 8/4/25 2:30 p.m., RN 1 indicated the area underneath the bandage was a bruise and the initials on the bandage were hers. She did not recall why she had placed the bandage on the back of the resident's right hand, as she was sick and off of work the rest of last week (7/28-8/1/25). The record for Resident 90 was reviewed on 8/5/25 at 2:06 p.m. The resident was admitted to the facility on [DATE], was admitted to the hospital on [DATE] and returned to the facility on 7/28/25. Diagnoses included but were not limited to, history of falling, anxiety, osteoporosis, depression, alcohol abuse, cirrhosis of the liver, infection of the skin, and a laceration of the left knee. The 8/5/25 admission Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and had one surgical wound. A Care Plan, revised on 7/29/25, indicated the resident had a break in skin integrity related to a surgical incision to the left lower extremity. There was no care plan for any non-pressure areas such as bruising or skin tears. The admission Assessment, dated 7/28/25, indicated scattered bruises on both arms and top of hands and right leg. A Skin-Wound Note, dated 7/29/25 at 11:48 a.m., indicated the resident had an open surgical wound to the left knee and a wound vacuum was in place and functioning. There was no documentation or an assessment of any other type of wound or non-pressure area to the back of the right hand. There was no Physician's Order for a foam bandage for the back of the right hand. A Physician's Order, dated 7/28/25, indicated to cleanse the left knee with wound cleanser, apply wound vacuum using black foam with a layer of Xeroform directly on the wound bed at 125 mmHg (millimeters of mercury), change two times a week. During an interview on 8/7/25 at 10:15 a.m. the Assistant Director of Nursing indicated the wound vacuum and tubing should not have been on the floor and there were no orders for the foam bandage that was on the back of the resident's right hand. 2. During an interview on 8/4/25 at 10:21 a.m., Resident 4 indicated she was constipated all the time and sometimes it was longer than 3 days before she had a bowel movement. The record for Resident 4 was reviewed on 8/6/25 at 8:56 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, stroke, heart disease, high blood pressure, type 2 diabetes, diabetic neuropathy, heart failure, chronic pain, low back pain, major depressive disorder, chronic migraines, and a history of thrombosis (the formation of a blood clot (thrombus) inside a blood vessel, obstructing the normal flow of blood). The admission Minimum Data Set (MDS) assessment, dated 5/15/25, indicated the resident was cognitively intact for daily decision making and was dependent on staff for toileting. The resident was always incontinent of bowel and was not on any bowel program. The resident received insulin in the last 7 days and also received an opioid medication. A Care Plan, revised on 5/28/25, indicated the resident was at risk for constipation related to decreased mobility and use/side effects of medication. The approaches were to record bowel movement pattern each day. The bowel and bladder elimination record in the CNA task section indicated the resident was coded as having no bowel movement on 7/8, 7/9, 7/11, 7/12, 7/13, 7/14, 7/19, 7/20, 7/29, 7/30, 7/31, 8/1, 8/2, and 8/3/25. There was no documentation and the days were blank on 8/4 and 8/5/25. Physician's Orders, dated 5/2/25, indicated Oxycodone (a narcotic medication) 5-325 milligrams (mg), give one tablet by mouth every four hours as needed for pain and Docusate Sodium (a stool softener medication) 100 mg, give one capsule by mouth as needed daily for constipation. A Physician's Order, dated 6/26/25, indicated Miralax (an over the counter laxative medication) packet 17 grams, give one packet by mouth daily as needed for constipation. The 5/2025 Medication Administration Record (MAR) indicated the resident received the Oxycodone medication 58 times, the Docusate medication two times and the Miralax one time. The 6/2025 MAR indicated the resident received the Oxycodone 49 times and did not receive the Docusate or Miralax. The 7/2025 MAR indicated the resident received the Oxycodone 66 times and did not receive the Docusate or Miralax. The 8/2025 MAR indicated the resident received the Oxycodone 15 times and did not receive the the Docusate or Miralax. During an interview on 8/7/25 at 11:33 a.m., the Director of Nursing (DON) indicated they were made aware the resident had no bowel movement and when a staff member went down to ask the resident, she said she had one on the 7/30/25. They were made aware she had not had one in the last few days and was told that nursing staff gave her a prn laxative, however, nothing was documented on the MAR, nor was the bowel movement documented. The current and revised Bowel Protocol policy, provided by the DON on 8/7/25 at 2:05 p.m., indicated nursing staff will record in the electronic health record each time a resident has a bowel movement. The facility in coordination with the resident's attending practitioner will implement standing orders to address a lack of bowel movement. 3. During a random observation on 8/6/25 at 9:03 a.m., Resident 11 was observed lying in bed. A nasogastric (NG) tube (a tube inserted through the nose into the stomach) was observed connected to a suction machine. There were dark brown flecks in the tubing. The suction canister was empty. The record for Resident 11 was reviewed on 8/6/25 at 9:54 a.m. Diagnoses included, but were not limited to, cancer of the rectum and liver, colostomy, and intestinal obstruction. The 7/21/25 admission Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and required substantial assistance with ADLs and transfers. A 7/15/25 Physician's Order indicated the resident was to have the NG tube to low intermittent suction, and to have nothing by mouth. The record indicated an NG output of 10 milliliters on 7/21/25. All other documented outputs were zero. The record lacked documentation of verification of correct NG tube placement, correct functioning equipment, and inspection of the skin for medical device-related pressure injury. The record lacked a care plan for the resident having an NG tube. During an interview on 8/6/25 at 11:16 a.m., RN 2 indicated the nurses' only responsibility related to the NG tube was to document the output amount, but there had not been any. Hospice managed the NG tube. During an interview on 8/7/25 at 10:30 a.m., the Director of Nursing (DON) indicated the NG tube was managed by hospice, who came three times a week. During an interview on 8/8/25 at 11:05 a.m., the DON indicated although hospice was supposed to manage the NG tube, the nursing care for the resident having the NG should still be in place. A policy titled, Nasogastric or orogastric tube monitoring, received as current from the DON on 8/7/25 at 12:30 p.m. indicated, . Effective NG or OG tube care requires meticulous monitoring of the patient and the equipment. Patient monitoring involves assessing GI function, including the volume and appearance of NG or OG tube drainage (if applicable); equipment monitoring involves verifying correct tube placement and function . Inspect the skin around the NG or OG tube by lifting and repositioning the tube gently at least daily to prevent medical device-related pressure injury . confirm accurate NG or OG tube placement regularly . using at least two bedside techniques . Special Considerations. NG or OG tubes can become clogged or incorrectly positioned . If no drainage appears in the tube, check the suction equipment for proper function . 3.1-37(a)

Based on record review and interview, the facility failed to ensure a resident received routine eye care and was seen by an Optometrist for 1 of 1 resident reviewed for vision. (Resident 4) Finding includes:During an interview on 8/4/25 at 10:14 a.m., Resident 4 indicated she needed to see the eye doctor to have another cataract surgery. She had the first one in 1/2025. The record for Resident 4 was reviewed on 8/6/25 at 8:56 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, stroke, heart disease, high blood pressure, type 2 diabetes, diabetic neuropathy, heart failure, chronic pain, low back pain, major depressive disorder, chronic migraines, and a history of thrombosis (the formation of a blood clot (thrombus) inside a blood vessel, obstructing the normal flow of blood). The admission Minimum Data Set (MDS) assessment, dated 5/15/25, indicated the resident was cognitively intact for daily decision making and had adequate vision with no corrective lens. A signed consent, dated 5/5/25, indicated the resident wished to have optometry care at the facility. During an interview on 8/6/25 at 11:00 a.m., the Social Service Director (SSD) indicated she was unaware the resident needed to see the eye doctor. During an interview on 8/6/25 at 12:54 p.m., the SSD indicated the optometrist was last at the facility on 6/12/25 and the resident was not seen. The list was finalized on 6/5/25, however, she was unaware the resident wanted to be seen. She indicated she did not follow up with the resident after the consent had been signed. 3.1-39(a)(1)

Based on record review and interview, the facility failed to ensure residents received foot care and routine visits with the podiatrist for 1 of 1 resident reviewed for foot care. (Resident 4) Finding includes:During an interview on 8/4/25 at 10:16 a.m., Resident 4 indicated she had told staff she wanted to see a podiatrist at the time of admission. The record for Resident 4 was reviewed on 8/6/25 at 8:56 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, stroke, heart disease, high blood pressure, type 2 diabetes, diabetic neuropathy, heart failure, chronic pain, low back pain, major depressive disorder, chronic migraines, and a history of thrombosis (the formation of a blood clot (thrombus) inside a blood vessel, obstructing the normal flow of blood). The admission Minimum Data Set (MDS) assessment, dated 5/15/25, indicated the resident was cognitively intact for daily decision making. A signed consent, dated 5/5/25, indicated the resident wished to have podiatry care at the facility. During an interview on 8/6/25 at 11:00 a.m., the Social Service Director (SSD) indicated the resident was on the list to be seen by the Podiatrist for 8/7/25. She had not seen one since admission. Their normal Podiatrist was out of the country and they were using a different one and were having some issues with them, as they were behind on the visits. During an interview on 8/6/25 at 12:54 p.m., the SSD indicated the last time a Podiatrist was in the facility was on 5/29/25 and the resident was not seen. 3.1-47(a)(7)

Based on record review and interview, the facility failed to ensure psychological services were offered for a resident exhibiting signs and symptoms of depression for 1 of 1 resident reviewed for mood and behavior. (Resident 5)Finding includes:During an interview on 8/4/25 at 9:53 a.m., Resident 5 indicated she had some feelings of depression. She indicated she did not receive an antidepressant but she would like to talk to somebody. The resident indicated that she told the Speech Therapist but she didn't know if the therapist told nursing. The record for Resident 5 was reviewed on 8/7/25 at 3:42 p.m. Diagnoses included, but were not limited to, displaced comminuted fracture of the shaft of the left femur and depression. The admission Minimum Data Set (MDS) assessment, dated 3/31/25, indicated the resident was cognitively intact and had no mood issues. The Quarterly MDS assessment, dated 6/30/25, indicated the resident had moderate cognitive impairment and she had little interest or pleasure in doing things and she was also feeling down, depressed, or hopeless 2-6 days during the assessment reference period. The resident had no behaviors and was not receiving an antidepressant. A Care Plan, dated 4/29/25 and reviewed on 7/22/25, indicated the resident had depression and was not currently taking medications. Interventions included, but were not limited to, observe for and report as needed (PRN) any signs and symptoms of depression including, hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing negative statements, repetitive anxious or health-related complaints, and tearfulness. A Staff Assessment of Resident Mood, dated 6/30/25, indicated the resident had little interest or pleasure in doing things and she was also feeling down, depressed, or hopeless during the last 2-6 days. There was no Social Service progress note addressing the resident's mood on or after 6/30/25. The August 2025 Physician's Order Summary (POS), indicated the resident was not receiving an antidepressant and there was no order for psychological services. During an interview on 8/8/25 at 10:30 a.m., the Social Service Director indicated when new onset mood issues were identified she would notify nursing, the Nurse Practitioner, or the physician and she would ask the resident if they would like psych services. The Social Service Director indicated she would get an order for psych services for the resident. 3.1-34(a)(1)

Based on observation, record review and interview, the facility failed to maintain clinical records that were complete and accurately documented related to a lack of documentation of blisters for 1 of 1 resident reviewed for non-pressure skin conditions (Resident 67), and inaccurate meal consumption documentation for a resident who was NPO (nothing by mouth) for 1 of 1 resident reviewed for hospice. (Resident 11)Findings include: 1. During a random observation on 8/4/25 at 8:41 a.m., Resident 67's legs were wrapped in gauze. At that time, the resident indicated there used to be blisters on her legs, but she was not sure if they were still there.During an observation of treatment on 8/07/25 at 1:11 p.m., a small, dark, circular discoloration was observed to the resident's left shin. At that time, the Assistant Director of Nursing (ADON) indicated it used to be a blister. She indicated the resident used to have multiple small blisters to both legs, but they had healed. The record for Resident 67 was reviewed on 8/5/25 at 3:07 p.m. Diagnoses included, but were not limited to, legal blindness and edema (swelling).The 5/20/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making, and required substantial assistance with ADLs and transfers. A 7/30/25 Physician's Order indicated: cleanse both legs with wound wash, apply Xeroform (a non-adherent dressing), ABDs (a gauze pad), secure with Kerlix (a rolled gauze), one time a day for blisters. The record lacked documentation of the resident having blisters on her legs.During an interview on 8/7/25 at 2:10 p.m., the ADON indicated she had been monitoring the resident's blisters to her legs, but had not been documenting it. 2. During a random observation on 8/6/25 9:03 a.m., Resident 11 was observed lying in bed. A nasogastric (NG) tube (a tube inserted through the nose into the stomach) was observed, connected to a suction machine. The record for Resident 11 was reviewed on 8/6/25 at 9:54 a.m. Diagnoses included, but were not limited to, cancer of the rectum and liver, colostomy, and intestinal obstruction.The 7/21/25 admission MDS assessment indicated the resident was cognitively intact for daily decision making and required substantial assistance with ADLs and transfers.A 7/15/25 Physician's Order indicated the resident was to have the NG tube to low intermittent suction, and to have nothing by mouth.A Care Plan, reviewed 8/5/25, indicated the resident status was NPO (nothing by mouth) except ice chips and small sips of water.In the Tasks section of the record, resident meal intakes were recorded on 7/17/25, 7/21/25, 7/22/25, 7/25/25, 7/27/25, 7/28/25, 7/29/25, 8/1/25, 8/2/25, and 8/3/25. During an interview on 8/7/25 at 10:30 a.m., the Director of Nursing (DON) indicated the resident had not eaten since prior to admission. Meal consumptions should not be documented because the resident did not eat. 3.1-50(a)

Based on observation, record review and interview, the facility failed to ensure infection control practices were in place and implemented related to enhanced barrier precautions (EBP) not followed while assisting a resident who had a Foley catheter to the bathroom and emptying an indwelling Foley catheter during random infection control observations. (Residents 5 and 56)Findings include:1. During a random observation on 8/5/25 at 9:15 a.m., Occupational Therapy Assistant (OTA) 1 was assisting Resident 5 with a toilet transfer. The OTA was wearing gloves but was not wearing an isolation gown. The resident had an indwelling Foley catheter. During a random observation on 8/6/25 at 1:11 p.m., CNA 1 was draining the resident's Foley catheter leg bag. The CNA had donned a pair of gloves, but she was not wearing an isolation gown. The record for Resident 5 was reviewed on 8/7/25 at 3:42 p.m. Diagnoses included, but were not limited to, displaced comminuted fracture of the shaft of the left femur and neuromuscular dysfunction of the bladder (nerve damage that impaired the bladder's ability to store and release urine properly). The Quarterly Minimum Data Set (MDS) assessment, dated 6/30/25, indicated the resident had moderate cognitive impairment and an indwelling catheter. A Care Plan, dated 3/31/25 and reviewed on 7/22/25, indicated the resident had an indwelling Foley catheter related to neurogenic bladder and was at risk for infection. Interventions included, but were not limited to, enhanced barrier precautions (EBP).Enhanced barrier precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with multidrug-resistant organisms (MDRO) as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices).A Physician's Order, dated 7/16/25, indicated the resident had an 18 French 30 cubic centimeter (cc's) indwelling Foley catheter. During an interview on 8/7/25 at 3:10 p.m., the Director of Nursing indicated the CNA had just recently finished her training and she should have worn a gown while emptying the Foley catheter bag and therapy staff should have worn a gown when assisting the resident in the bathroom. 2. During a random observation on 8/6/25 at 1:11 p.m., CNA 1 was observed from the doorway of Resident 56's room emptying her Foley catheter drainage bag which was attached to her leg. The CNA had donned a pair of gloves but was not wearing an isolation gown. A sign on the door to the resident's room indicated she required enhanced barrier precautions (EBP). Enhanced barrier precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with multidrug-resistant organisms (MDRO) as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices).During an interview on 8/7/25 at 3:10 p.m., the Director of Nursing indicated the CNA had just recently finished her training and she should have worn a gown while emptying the Foley catheter bag. 3.1-18(b)

Based on record review and interview, the facility failed to ensure the responsible party was notified of a unwitnessed fall in a timely manner for 1 of 3 residents reviewed for accidents. (Resident B) Finding includes: Resident B's record was reviewed on 3/31/25 at 10:47 a.m. Diagnoses included, but were not limited to, fracture of the left femur, hypertension (high blood pressure), depression, chronic kidney disease, history of falling and dementia. A Nurse's Note, dated 1/8/25 at 12:25 a.m., indicated Resident B was noted on the floor in her room by the CNA. The resident was assessed and was alert and oriented to situation and self. The resident was noted to have a bruise to the left frontal side of her head with a small bump. The resident had also complained of soreness to her left hip and back. The resident refused pain medication and refused to go to the hospital. A message was left to notify the Nurse Practitioner. A Nurse's Note, dated 1/8/25 at 1:04 a.m., indicated medication was given for pain in the left hip and lower back. A Nurse's Note, dated 1/8/25 at 3:12 a.m., indicated the resident's son was called and notified about the situation and indicated to send the resident to the hospital. A Quarterly Minimum Data Set (MDS) assessment, dated 1/13/25, indicated the resident was severely impaired for daily decision making. The resident had impairment on both sides of her lower extremities. Supervision and touching assistance was required for eating, oral hygiene, upper body dressing, and personal hygiene. The resident required substantial/maximum assistance with toilet hygiene, shower/bathing, putting on footwear and lower body dressing. The resident transferred from sit to stand, chair to bed, toilet transfer and roll left to right with partial/moderate assistance. During an interview on 3/31/25 at 2:15 p.m., the Executive Director (ED) indicated she understood the concern regarding delayed notification after a fall. During an interview on 3/31/25 at 2:12 p.m., the Director of Nursing (DON) indicated the nurse at the time of the resident's fall did not feel there was anything concerning regarding the resident's hip, she was more focused on the neurological assessments and that is why she had waited to call the resident's son. She understood the concern and had nothing further to add. The current 2024 Changes in Resident's Condition or Status policy, provided by the Executive Director on 3/31/25 at 10:45 a.m., indicated . A facility must immediately inform the resident, consult with resident's physician, and notify, consistent with his or her authority , the resident representative when there is (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention . This citation relates to Complaint IN00451276. 3.1-5(a)(2)

Based on observation, record review, and interview, the facility failed to ensure fall interventions were updated to prevent injury for a resident with multiple falls for 1 of 3 residents reviewed for accidents. (Resident D) Finding includes: On 3/31/25 at 12:09 p.m., Resident D was not observed in his room. There was a mattress leaning on the side of the wall, there was a touch pad call light, gym shoes by the bedside, and the bed had two half side rails. Resident D's record was reviewed on 3/31/25 at 1:17 p.m. The diagnoses included, but were not limited to, dementia, chronic obstructive pulmonary disease (COPD), hypertension (high blood pressure), stroke, and hemiplegia (paralysis on one side of the body). The Admission Minimum Data Set (MDS) assessment, dated 1/16/25, indicated the resident was severely impaired for daily decision making. The resident required substantial/maximum assistance for bed mobility, transferring and toileting. A Care Plan, last updated on 1/31/25, indicated the resident was at risk for falls related to decreased mobility, weakness, high blood pressure, depression, and hemiparesis/hemiplegia affecting right side of the body. Approaches were to assist with ADL's (activities of daily living) as needed, have a mattress on the floor at bedside, call light within reach, complete a fall risk assessment, and orient resident to room. The last two months were reviewed and the resident had four falls on the following dates: 2/3/25 3/2/25 3/13/25 3/25/25 A Health Status Note, dated 3/2/25 at 11:10 a.m., indicated the resident was seen leaning in her wheelchair and the nurse assisted the resident to sit up in the chair. When the writer walked away and came back several minutes later, the resident was lying on the floor. Assessments were completed and the resident had a small bump to the back of her head. A Health Status Note, dated 3/13/25 at 2:36 p.m., indicated the resident was seen lying on her right side on the floor in front of her wheelchair near the nurse's station. Two nurses assessed the resident and the resident bumped the side of her right head and had a small abrasion to the right outer elbow. A Health Status Note, dated 3/25/25 at 7:26 a.m., indicated the resident was sitting in her wheelchair by the nurses' station and the nurse observed the resident leaning over. Before the nurse could reach the resident, she fell on to her left side and hit her head on the floor. Swelling and bruising were noted to the left forehead. There was no documentation in the resident's record to indicate the facility added interventions to address the resident's wheelchair use or positioning after the resident's multiple falls from her wheelchair. During an interview on 3/31/25 at 2:34 p.m., the Executive Director (ED) indicated there was no updated care plan for Resident D's recurrent falls. The current 2022 Fall Management policy, provided by the Executive Director on 3/31/25 at 10:45 a.m., indicated .4. The interdisciplinary team will review and revise the care plan, if indicated, upon completion of each comprehensive, significant change and quarterly MDS, upon a fall event and as needed thereafter . This citation relates to Complaint IN00451276. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure a discharge summary was completed at the time of discharge for a resident going home who required home health services for 1 of 3 residents reviewed for discharge (Resident B). Finding includes: Resident B's record was reviewed on 9/11/24 at 9:43 a.m. The diagnoses included, but were not limited to, paraplegia (paralysis of lower body), chronic kidney disease stage 3, and high blood pressure. The Discharge Minimum Data Set assessment, dated 9/1/24, indicated the resident was cognitively intact for daily decision making. He was totally dependent on staff for toileting, bathing, and transfers. He had an indwelling catheter and an ostomy (an artificial opening). He was taking antipsychotic, antidepressant, and anticoagulant medications. Resident B's Care Plans upon discharge included, but were not limited to, the resident would be long term care, had an ostomy, required extensive assistance for his activities of daily living (ADL) tasks for bed mobility, transfers, and toileting, had an indwelling Foley (urinary) catheter, and had oxygen therapy. A Physician's Order, dated 7/16/24, indicated the resident was on continuous oxygen therapy at 4 liters per minute via nasal cannula. The Discharge Summary Information assessment, dated 8/28/24 at 4:23 p.m., indicated the resident was discharged to home by ambulance. The reason for discharge was left blank. The clothing and valuables were not marked as received or stored. Physical assessment on discharge and instructions were listed as follows: - Physical and Mental Functioning Status: assist with one with ADLs and bed mobility, mechanical lift for transfers - Nutritional Status: regular diet with thin liquids and feeds self with set up - Special treatments and procedures: Colostomy 2.75 or 70 millimeter size appliance and catheter 20 french with 5 milliliter bulb - Mental, Psychosocial, and Behavior Status: alert and oriented - Continence: incontinent of bladder, resident colostomy with ostomy care per staff - Skin Condition: warm and dry no open areas noted - Resident established his own in home nursing, physical and occupational therapy as well as his own ADL assistance through a home health agency - Medications: Pre-discharge and post-discharge medications that have been reconciled with attached medications to take after discharge from the facility was blank - Recapitulation of Stay: Nursing was blank - Copy of instructions given to: was blank - Name of patient/patient representative giving consent: was blank - Received by and date: was blank The Discharge Summary Information assessment did not address the resident being on oxygen therapy and was incomplete. During an interview on 9/11/24 at 1:04 p.m., the Director of Nursing indicated the Discharge Summary Information assessment should have been completed and oxygen should have been addressed on the form. The resident had set everything up for his own discharge as he decided that he was going to leave that weekend with family. Social Services had talked with the home health company and others involved with his care at home to ensure he had the equipment he needed and was set to move home, however it was not documented. A Policy titled, Area of Focus: Discharge Process and Bed Holds, noted as current, indicated, .How .In the event that the resident requires transfer or discharge the documentation in the medical record should include: .7. A discharge summary must be completed for discharges. This citation relates to Complaint IN00442864. 3.1-36(a)(1) 3.1-36(b)

Based on record review and interview, the facility failed to ensure there was an adequate indication for use of a scheduled antifungal powder for 1 of 3 residents reviewed for non-pressure skin conditions (Resident B) Finding includes: Resident B's record was reviewed on 9/11/24 at 9:43 a.m. The diagnoses included, but were not limited to, paraplegia (paralysis of lower body), chronic kidney disease stage 3, and high blood pressure. The Discharge Minimum Data Set assessment, dated 9/1/24, indicated the resident was cognitively intact for daily decision making. He was totally dependent on staff for toileting, bathing, and transfers. A Physician's Order, dated 7/16/24, indicated nystatin external powder (antifungal powder) 100,000 unit/gram, apply to right and left skin folds topically every shift for skin irritation. The July and August 2024 Medication and Treatment Administration Record indicated the nystatin powder was administered three times each day to the groin area. A Weekly Skin Assessment was completed on 7/20, 7/27, 8/3, 8/10, 8/17, 8/24, and 8/31/24. There were no skin abnormalities noted to the groin or any other areas on the assessments. During an interview on 9/11/24 at 11:22 a.m., the Assistant Director of Nursing indicated she was unable to locate documentation related to any type of skin conditions and the nystatin powder should have just been an as needed order for any new skin condition that was observed. This citation relates to Complaint IN00442864. 3.1-48(a)(4)

Based on observation, record review, and interview, the facility failed to ensure a resident received the assistive devices needed to maintain hearing related to hearing aids not administered to a resident as per the physician's order for 1 of 2 residents reviewed for vision/hearing. (Resident 4) Finding includes: On 6/11/24 at 11:48 a.m., Resident 4 was observed sitting in the dining area with other residents. The resident kept saying huh when other people were talking. The resident did not have hearing aids observed to either ear. On 6/11/24 at 3:08 p.m., Resident 4 was sitting in a wheelchair in his room. The resident indicated he could not hear the questions being asked. The resident did not have hearing aids observed to either ear and was unaware where his hearing aids were. Record review for Resident 4 was completed on 6/11/24 at 3:11 p.m. Diagnoses included, but were not limited to coronary artery disease, heart failure, and hypertension. The Quarterly Minimum Data Set (MDS) assessment, dated 3/26/24, indicated the resident was cognitively impaired. The resident had difficulty hearing and used a hearing aid. The resident required a partial moderate assistance for dressing the upper body. A Care Plan, dated 9/19/23, indicated the resident required extensive assistance from staff to complete his ADL (assistance of daily living) tasks of bed mobility, transfers, and limited assistance for meals. An intervention, dated 1/25/24, included for his hearing aids to be put in his ears in the morning and taken out at night time. A Care Plan, dated 4/2/24, indicated the resident had a communication problem related to hearing deficit. The resident had hearing aids which he removed at times and misplaced them under the bed, under dressers, and his covers. Interventions included to assist with hearing aids (left and right), remove hearing aids and place in container as needed, and search the resident's room if the resident, staff, or visitors report the hearing aids are missing. The June 2024 Physician's Order Summary indicated the following order: - Hearing aids in the morning and out at night time. Document when put in and removal at bedtime. The June 2024 Medication Administration Record and Treatment Administration Record did not have any documentation related to the hearing aid order. During an interview on 6/11/24 at 3:09 p.m., CNA 1 indicated she was unaware if the resident wore hearing aids. During and interview on 6/11/24 at 3:16 p.m., LPN 1 looked into her medication cart and could not find the resident's hearing aids. She indicated she believed the resident's hearing aids were lost and she would go to his room and look for them. The resident would take them out himself sometimes, set them down and lose them. The staff were supposed to put them in and take them out every day and put them in the medication cart. She was unaware if that was supposed to be documented anywhere. During an interview on 6/11/24 at 3::25 p.m., the Director of Nursing (DON) indicated she was not sure why the hearing aid order did not populate for the nursing staff to document the resident's hearing aids were put in and taken out each day. The facility had replaced the resident's hearing aids once because he had lost them. The staff were supposed to be making sure they had documented when they are put in and then taken out, and that they are placed into the medication cart after they are removed. 3.1-39(a)

Based on record review and interview, the facility failed to ensure food consumption logs were completed for residents with a history of weight loss for 3 of 5 residents reviewed for nutrition. (Residents 59, 14, and 42) Findings include: 1. Record review for Resident 59 was completed on 6/12/24 at 3:11 p.m. Diagnoses included, but were not limited to, hypertension, dementia, and failure to thrive. The Quarterly Minimum Data Set (MDS) assessment, dated 5/13/24, indicated the resident was cognitively impaired. The resident required a substantial maximal assistance with eating. A Care Plan, dated 1/11/24, indicated the resident had unplanned/unexpected weight loss related to poor food intake. Interventions included to alert the dietician when consumption was poor for more than 48 hours and to record food intake at each meal. The resident weighed 109 pounds on 11/30/23. A weight obtained on 6/7/24 indicated the resident weighed 97 pounds, which was a 11.01 % (percent) weight loss. The Task Meal Consumption Logs were documented with percentage of meals eaten. The last 30 days lacked documentation for the following meals: - Breakfast on 5/16/24, 5/22/24, 5/25/24, 5/26/24, 5/29/24, 6/1/24, 6/3/24, 6/9/24, 6/10/24, and 6/12/24. - Lunch on 5/18/24, 5/22/24, 6/10/24, and 6/12/24. - Dinner on 5/16/24, 6/9/24, 6/10/24, and 6/11/24. During an interview on 6/13/24 at 1:20 p.m., the Director of Nursing (DON) indicated the CNAs were expected to document meal consumption percentage eaten in the computer under the Task section for Meal Consumption. 48055 2. On 6/13/24 at 12:15 p.m., Resident 14 was observed eating lunch. Resident 14 received a house shake with her lunch. Resident 14 consumed about 75% of her shake and ate about 50% of the food on her plate. The resident's record was reviewed on 6/13/24 at 11:26 a.m. Diagnoses included, but were not limited to, gastroesophageal reflux disease without esophagitis, constipation, and type 2 diabetic mellitus with diabetic neuropathy. The Quarterly MDS assessment, dated 3/12/24, indicated the resident was cognitively impaired. A Care Plan, dated 5/14/24, indicated to record Resident 14's food intake at each meal. Weight Assessments indicated the resident weighed 177 pounds on 1/12/24 and 162 pounds on 6/7/24, which was an 8.47% weight loss. The meal consumption logs indicated the following: 5/17/24 - dinner meal was not documented 5/18/24 - no meals were documented 5/19/24 - breakfast and lunch meals were not documented 5/20/24 - breakfast and dinner were not documented 5/27/24 - dinner meal were not documented 5/31/24 - breakfast and lunch meals were not documented 6/6/24 - breakfast and lunch were not documented 6/7/24 - no meals were documented 6/8/24 - breakfast and lunch were not documented 6/10/24 - no meals were documented During an interview on 6/13/24 at 2:35 p.m., the Assistant Director of Nursing (ADON) indicated the food consumption logs should have been completed for the resident. 48383 3. The record for Resident 42 was reviewed on 6/10/24 at 12:19 p.m. The diagnoses included, but were not limited to, atrial fibrillation (abnormal heart rhythm), dementia, depression, muscle weakness, adult failure to thrive, anxiety, and left shoulder fracture. The Significant Change MDS assessment, dated 5/29/24, indicated the resident was severely impaired for daily decision making. The resident had no impairment of the upper and lower extremities and used a wheelchair. Eating and oral hygiene required supervision or touching assistance. Lower body dressing, toileting and bathing required dependent assistance. A Care Plan, dated 4/12/24, indicated the resident had unplanned/unexpected weight loss related to poor intake. Interventions were to record food intake for each meal, and alert the dietician when supplements were not being consumed for more than 48 hours. The resident weighed 106 pounds on 2/27/24. A weight obtained on 5/24/24 indicated the resident weighed 87 pounds, which was a 28.57% weight loss in 3 months. The meal consumption intake logs indicated the following: - The breakfast meal was not documented on 5/15, 5/21,5/22, 5/25, 5/26, 5/30, 6/1, 6/8, 6/10, 6/11, and 6/12/24. - The lunch meal not documented on 5/22, 5/25, and 6/1/24. - The dinner meal was not documented on 5/18, 5/19, 6/3,6/4, 6/5, 6/9, and 6/10/24. During an interview on 6/13/24 at 1:20 p.m., the DON indicated the CNAs were expected to document meal consumption percentage eaten in the computer under the Task section for Meal Consumption. A current facility policy titled, Nutritional Intake, provided by the Director of Nursing on 6/14/24 at 3:03 p.m., indicated the facility will document the nutritional intake on each individual resident. 3.1-46(a)(1)

Based on observation, record review, and interview, the facility failed to ensure oxygen was at the correct flow rate for 2 of 3 residents reviewed for oxygen use. (Residents 42 and 48) Findings include: 1. On 6/10/24 at 11:25 a.m., Resident 42 was observed lying in bed wearing oxygen via nasal cannula. The oxygen flow rate was set under 2 liters. On 6/10/24 at 12:04 p.m., the resident's oxygen was in place and the flow rate was set under 2 liters. On 6/11/24 at 11:59 a.m., the resident was observed lying in bed and oxygen was in place via nasal cannula. The flow rate was set just under 2 liters. On 6/11/24 at 3:36 p.m., the resident was observed asleep in bed. Oxygen was in place and the flow rate was set below 2 liters. The record for Resident 42 was reviewed on 6/10/24 at 12:19 p.m. The diagnoses included, but were not limited to, atrial fibrillation (abnormal heart rhythm), dementia, depression, muscle weakness, adult failure to thrive, anxiety, and left shoulder fracture. The Significant Change Minimum Data Set (MDS) Assessment, dated 5/29/24, indicated the resident was severely impaired for daily decision making. The resident had no impairment of the upper and lower extremities and used a wheelchair. Eating and oral hygiene required supervision or touching assistance. Lower body dressing, toileting and bathing required dependent assistance. A Care Plan, dated 4/25/24, indicated the resident received oxygen therapy. Interventions were to administer oxygen settings per physician orders and administer medications as ordered. A Physician's order, dated 4/25/24, indicated to administer oxygen via nasal cannula continuously at 2 liters/minute for hypoxia. The June 2024 Medication Administration Record (MAR) indicated oxygen was signed out as being given at 2 liters every shift on the following dates: 6/10/24 and 6/11/24. During an interview on 6/12/24 at 11:34 a.m., the Director of Nursing (DON) indicated she would correct the resident's oxygen flow rate. No additional information was provided. 2. On 6/10/24 at 9:18 a.m., Resident 48 was observed sitting in her wheelchair watching her phone. The resident wore oxygen via nasal cannula and the flow rate was set at 3.5 liters. The oxygen canister had an oxygen sticker label that was marked 2 liters in red. On 6/10/24 at 11:55 a.m., the resident was observed asleep in bed, her nasal cannula was in place and the oxygen flow rate was set at 2.5 liters. On 6/11/24 at 11:58 a.m., the resident's oxygen was in place via nasal cannula and the flow rate was set at 2.5 liters. The record for Resident 48 was reviewed on 6/11/24 at 3:19 p.m. The diagnoses included, but were not limited to, hemiplegia, heart failure, stroke, diabetes, hypertension (high blood pressure), and chronic obstructive pulmonary disease. The Quarterly MDS Assessment, dated 6/6/24, indicated the resident was cognitively intact for daily decision making. The resident had an impairment on one side of her upper and lower extremity. The resident used oxygen and a wheelchair. A Care Plan, dated 6/11/24, indicated the resident received oxygen therapy. Interventions were to administer oxygen settings per physician orders and to administer medications as ordered. A Physician's order, dated 6/3/24, indicated to administer oxygen via nasal cannula continuously at 2 liters/minute for shortness of breath. The June 2024 MAR indicated oxygen was signed out as being given at 2 liters every shift on the following dates: 6/10/24 and 6/11/24. During an interview on 6/12/24 at 11:34 a.m., the DON indicated she would correct the resident's oxygen flow rate. No additional information was provided. 3.1-47(a)(6)

Based on observation, record review, and interview, the facility failed to ensure residents had an assessment and Physician's Orders to self-administer their own medications, for 4 of 4 residents reviewed for self-administration of medication. (Residents C, F, G and H) Findings includes1. During a random observation on 4/1/24 at 1:37 p.m., Resident C was observed in bed and awake. The resident was confused and not oriented to time and place. At that time, there was a tube of Bacitracin ointment on the dresser and 1 over the counter bottle of Genteal tears eye solution. The bottle of eye drops was located on a high top dresser and completely out of reach for the resident. During a random observation, on 4/2/24 at 8:25 a.m., the resident was observed in bed. At that time, the bottle of eye drops was still located on the high top dresser and out of reach for the resident. The record for Resident C was reviewed on 4/1/24 at 3:20 p.m. Diagnoses included, but were not limited to, contusion right lower leg and foot, osteoarthritis, dry eye syndrome, high blood pressure, difficulty walking, and muscle weakness. Physician's Orders, dated 3/28/24, indicated Bacitracin Zinc External Ointment, apply to toes topically one time a day and leave open to air until healed. Physician's Orders, dated 8/20/23, indicated Refresh Tears 0.5%, instill 1 drop in both eyes three times a day for dry eyes. The patient may self-administer. There was no documentation of a self-administration of medication assessment or an order for the Bacitracin ointment to be left at the bedside. During an interview, on 4/2/24 at 11:30 a.m., the Director of Nursing (DON) indicated the resident's son could have brought in the bottle of eye drops and given them to her, however, the Bacitracin ointment should not have been left at the bedside. 2. During a random observation, on 4/1/24 at 1:00 p.m., Resident F was observed sitting on the side of the bed. At that time, the Physical Therapist (PT) was in the room preparing to change the bandages on the left foot. There were 2 medication cups observed on the resident's over bed table with the resident's name written on them. One of the medication cups contained 1 white unidentified pill. During an interview at that time, the resident indicated it was a Melatonin tablet that he had requested last evening, but never took it. The record for Resident F was reviewed on 4/2/24 at 9:25 a.m. The resident was admitted on [DATE] from the hospital. Diagnoses included, but were not limited to, osteomyelitis left ankle and foot, abscess to the left foot, type 2 diabetes, open wound to the left foot, high blood pressure, and peripheral vascular disease. The Admission Minimum Data Set (MDS) assessment, dated 3/8/24, indicated the resident was cognitively intact for daily decision making. The resident was admitted with a diabetic foot ulcer. Physician's Orders, dated 3/12/24, indicated Melatonin 5 milligrams (mg), give 1 tablet by mouth as needed for insomnia. There was no documentation of a self-administration of medication assessment or a Physician's Order to self-administer his own medications. During an interview, on 4/2/24 at 11:30 a.m., the Director of Nursing indicated she was aware of the medication cups with the resident's name on them and the pill that was left inside of one of them. She had them on her desk in her office. The resident had no order to self-administer his own medications or an assessment to do so. 3. During a random observation, on 4/1/24 at 9:50 a.m., Resident G was observed in her bed reading a book. At that time, there was a bottle of eye drops placed inside a medication cup on the over bed table. The resident indicated she administered the eye drops to herself every evening, that way she knew she got them. The record for Resident G was reviewed on 4/2/24 at 11:14 a.m. Diagnoses included, but were not limited to, high blood pressure and type 2 diabetes. Physician's Orders, dated 1/25/23, indicated Latanoprost Ophthalmic Solution 0.005%, instill 1 drop in both eyes at bedtime for ocular hypertension. There was no Physician's Order for the resident to self-administer the eye drops. There was no self-administration of medication assessment to self-administer the eye drops. During an interview, on 4/1/24 at 1:25 p.m., the Director of Nursing indicated there was no order for the resident to administer the eye drops or a self-administration of medication assessment completed. 4. During a random observation, on 4/1/24 at 9:59 a.m., Resident H was seated in a wheelchair with an over bed table. There was a medication cup on that table with 3 white pills on a napkin. During an interview with the resident at that time, she indicated she was taking her water pills. The record for Resident H was reviewed on 4/2/24 at 10:16 a.m. Diagnoses included, but were not limited to, heart disease, high blood pressure, edema, chronic obstructive pulmonary disease. The Care Plan, dated 3/6/24, indicated, the resident had a Physician's Order for self-administration of the following medications: Vicks VapoRub, Saline Nasal Spray, Sore throat spray, [NAME] throat drops, and an inhaler. There was no Physician's Order for the resident to self-administer her daily medications. There was no self-administration of medication assessment to self-administer her daily medications. During an interview, on 4/2/24 at 1:15 p.m., the Director of Nursing indicated the resident had no Physician's Order to self-administer her daily medications and no assessment completed. The current 8/29/24 Self-Administration of Medication policy, provided by the Infection Preventionist on 4/2/24 at 12:54 p.m., indicated the team in consultation with the Physician for the resident will conduct an assessment of the resident's cognitive, physical, and visual ability to carry out this responsibility. The interdisciplinary assessment will be completed in the electronic medication record. This citation relates to Complaint IN00430795. 3.1-11(a)

Based on record review and interview, the facility failed to ensure supervision was provided and fall interventions were in place while a resident was showering resulting in a resident falling and obtaining a pelvic fracture, The facility also failed to complete a thorough investigation after the fall for 1 of 3 residents reviewed for falls in a sample of 5. (Resident #B) Findings include: Resident #B's record was reviewed on 7/30/14 at 10:10 a.m. The resident's [DIAGNOSES REDACTED]. Nursing Progress Notes dated 7/12/14 indicated, "Res (resident) fell this eve (evening) at 8:15 p.m., area to head of 1.0 x 0.1 slight red blood, pressure applied, and scant amt of bleeding noted. Stated to nurse she had 2 surgeries to R (Right) hip previous and needed knee operated on prior to coming here. C/o (complains of) R (right) hip pain. Upon assessment, no rotation noted, legs even in length. Called nurse on call and MD notified, order to send to ER for eval (evaluation). Sister called and notified... Res left LCC (Name of Facility) at 10 p.m. via ambulance...." An Incident Follow-Up & Recommendation Form dated 7/12/14 indicated the following: "Summary of Investigative Facts: Resident was in shower room showering when she fell , she was found on R side. Resident was independent (with) care and ADL's (Activities of Daily Living). Recommendations/ Actions Taken: MD (Physician) & sister notified ... sent to ER, X-rays taken, fx (fractured) pelvis & laceration (cut) head. Res (resident) returned to facility, prn (as needed) q (every) 6 hrs (hours) Norco (pain medicine) ..., PT/OT (Physical Therapy/ Occupational Therapy) orders, toe touch wt (weight) bearing. Follow up: MD, sister notified, safety: low bed only." There was no evidence of any interviews, further investigation, or safety measures for showering indicated in the fall assessment/ investigation. Review of the hospital emergency room MD assessment dated [DATE] included: 1. Fractured bones (two) to right pelvis 2. Contusion and sprain, right wrist An initial Fall Risk Assessment after Resident #B's admission on 4/8/14 indicated the resident had 3 falls in the last 6 months and the fall risk score of 12 placed the resident at risk for falls. A physician's orders [REDACTED]." Nursing Assessment Summaries dated 6/22/14 and 7/6/14 both indicated: "Mental Status: alert & oriented with periods of confusion." The Admission Minimum Data Set (MDS) Assessment, dated 4/15/14, indicated the resident needed one person physical assist for bathing. The MDS further indicated a care plan for ADL's would be developed based on the following supporting documentation: admitted from home, hx. (history) of falls; requires supervision to extensive assist with ADL's, transfers and repositioning. A care plan for fall risk will be developed based on impaired balance, urinary incontinence, and a BIMS (Brief Interview for Mental Status) of 6 which indicated moderate cognitive impairment. Review of Resident #B's ADL flow sheets for April, May, June and July 2014 indicated the resident required supervision to limited assistance (some physical help provided) with bathing. The resident had current care plans in place for cognition, ADL's, and falls: The care plan for cognition initiated 4/23/14 indicated Resident #B "has the potential to experience cognitive difficulty related to BIMS score that shows moderate cognitive impairment." The ADL care plan initiated 4/23/14 indicated a self-care deficit for bathing requiring limited assistance and a goal of only needing supervision for bathing. Approaches included: "Provide the amount of assistance/ supervision that is needed - contact guarding (having one or two hands on the body to help steady the body or help with balance, but providing no other assistance to perform the functional task) ..." The care plan for falls initiated 4/23/14 indicated Resident #B was "At risk for fall related injury due to: previous fall, fall risk factors present as determined by fall screen relating to disease process/ condition, functional problem - limited to extensive, medication usage, and use of assistive devices - walker, w/c (wheelchair)". Approaches included provide/ observe use of adaptive devices, reinforce safety awareness, and appropriate footwear. An interview with the Director of Nursing (DoN) in 7/30/14 at 1:10 p.m., indicated the resident was not supervised in the shower at the time of her fall on 7/12/14. "The resident was independent with ADL's, so that was the normal routine." CNA #1 was interviewed on 7/30/14 at 1:20 p.m. and indicated she was familiar with Resident #B's care. She further indicated the resident was fairly private, so when she helped the resident with showering (in a shower chair) now, she would wait on the other side of the curtain in the shower room. She had not assisted the resident with showering before her fall, but had heard no reports of the resident refusing staff to be present in the shower room and had seen no documentation to that effect. CNA #1 also indicated, "All residents here, in my mind, require some type of supervision and are not truly independent or they would be back at home." During an interview with Resident #B's sister on 7/30/14 at 1:35 p.m., she indicated the facility staff had told her the resident "is so independent that they did allow her to go in the shower alone when she said she didn't need help." A follow up interview with the DoN on 7/30/14 at 3:10 p.m., indicated the resident was wearing flip flops in the shower at the time of her fall which was a concern previously voiced by the resident's sister. She further indicated there were no additional written interviews, statements, other safety assessments or interventions for the fall investigation. Resident #B was interviewed on 7/31/14 at 10:10 a.m. She indicated no staff was present in the shower room at the time of her fall. She had been stepping back to reach the bar on the wall to turn around after completing her shower and "slipped on some soap scum." Resident #B further indicated she was found by another resident "only about 20 seconds" after she fell & the other resident went to get staff to help. She indicated she was not wearing non-skid footwear when she fell . She also indicated she was a private person, but had never specifically asked staff to stay out of the shower room while she was showering. Just prior to the interview, the resident was observed to be seating herself in her wheelchair after using the bathroom and was wearing flat shoes at that time. During an interview with the Nurse Consultant on 7/31/14 at 10:30 a.m., she indicated no resident should be completely unsupervised in the shower room, especially one with a history of falls and [DIAGNOSES REDACTED]. There are shower curtains in the shower rooms to provide privacy while still allowing staff to be present and available to help if needed. She also indicated a more complete investigation should have been done including interviews and a safety review with causative factors and updated interventions. This Federal tag relates to Complaint IN 882. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure adequate supervision was provided related to leaving a resident unattended in the bathroom for 1 of 3 residents reviewed for falls in the sample of 10. This resulted in the resident being sent to the hospital for a head laceration requiring Dermabond (a liquid bonding agent that holds many cuts, wounds, and incisions together as effectively as sutures). (Resident #D) (CNA #1) Findings include: The record for Resident #D was reviewed on 11/30/11 at 10:25 a.m. The resident's [DIAGNOSES REDACTED]. A fall risk evaluation completed on 10/6/11 indicated the resident's score was (14). The evaluation indicated a resident with a score of 10 or above was at high risk for falls. The fall risk evaluation indicated the resident had 1-2 falls in the last 90 days. The 10/31/11 Minimum Data Set (MDS) quarterly assessment indicated the resident required extensive assistance of one staff member for bed mobility, transfers, and toilet use. The assessment also indicated the resident used a walker and wheelchair as mobility devices and had one fall with a major injury since her last assessment. The MDS assessment also indicated the resident was not steady moving on and off the toilet and was only able to stabilize with human assist. Review of a 8/5/11 Physical Therapy Plan of Treatment indicated the resident was seen for Physical Therapy 8/5/11 through 10/31/11. The Discharge Summary indicated the resident had sustained a compression fracture to the lower back from hitting her back when on the toilet. The resident was discharged from skilled therapy due to refusing therapy because of pain. The November 2011 Nurses' Notes were reviewed. An entry made on 11/22/11 at 5:45 a.m., indicated the resident was found on the floor with bleeding from the right side of her head. The entry indicated the resident was having a seizure and fell off the toilet and hit her head. Ice wrapped in towel was applied to the cut on the right side of the resident's forehead and the 911 ambulance was called. The next entry was made at 6:15 a.m. This entry indicated the resident left the facility by ambulance. A care plan initiated on 7/12/2010 indicated the resident was at risk for falls and fall related injuries. The care plan was last updated on 11/7/11. Care plan approaches included staff were not to leave the resident alone in the bathroom. The 11/21/11 Daily Care Guide for the resident indicated the resident was on the Falling Star Program and staff were not to leave the resident unattended in the bathroom. Review of the facility investigation of the 11/22/11 fall indicated CNA #1 was interviewed. The CNA indicated she had answered Resident #D's call light and assisted the resident up and put her on the toilet. The CNA then left to get an incontinence brief for the resident from the resident's closet and heard a noise. The CNA then saw the resident on the floor between the wall and the wheelchair laying on her right side. The CNA indicated blood was observed from a cut on her forehead. The 11/22/11 hospital Emergency Department Record was reviewed. The record indicated the resident arrived at the hospital at 6:40 a.m. The resident was alert and had a 2 centimeter laceration (cut) to the forehead. The 11/22/11 Emergency Physician Record indicated the resident had a laceration to the forehead and bleeding was controlled. The record also indicated the forehead laceration was washed with saline and closed with Dermabond. When interviewed on 11/30/11 at 11:20 a.m., the Director of Nursing indicated the resident had a seizure and fell off the toilet on 11/22/11. The Director of Nursing indicated the CNA was outside of the bathroom at the time as she was obtaining a brief for the resident. The Director of Nursing indicated the resident should not have been left alone in the bathroom as per the plan of care. This Federal tag relates to Complaint IN 394. 3.1-45(a)(2)