Every finding on record at Majestic Care of Deming Park

Based on record review and interviews, the facility failed to ensure a resident's right to be free of sexual abuse was protected for 1 of 3 residents reviewed for abuse (Resident G). The deficient practice was corrected 12/10/25, prior to the start of the survey, and was therefore past noncompliance. Findings include:On 1/15/26 at 11:00 a.m., a review of an Indiana Department of Health reportable incident document dated, 12/9/25 at 4:44 p.m., indicated a hospice staff member who was a Certified Nursing Assistant (CNA) 13, entered the room of Resident H and found resident G sitting on the bed of resident H, with her pants down to her knees. The CNA observed resident H's hands were in resident G's brief. The residents were immediately separated, and Resident H was placed on one to one supervision and an investigation was initiated. 1. On 1/15/26 at 10:30 a.m., the medical record of Resident G was reviewed. The resident was admitted to the facility on [DATE]. admission diagnosis included dementia (the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), muscle weakness and convulsions (a sudden, violent, irregular movement of a limb or of the body, caused by involuntary contraction of muscles and associated especially with brain disorders). On 12/9/25 after the incident with the male resident the staff completed a head to toe assessment of resident G. In addition, she was seen by a Nurse Practitioner and a psychological evaluation was completed by psych services. No concerns were identified. A quarterly MDS, dated [DATE], indicated the resident was cognitively impaired. A care plan dated 12/12/25 indicated that the resident exhibited behavioral symptoms of seeking companionship with other residents. Interventions included but were not limited to. One to one initiated on 12/12/25. The record indicated the resident was placed on 15 minute checks from 12/12/25 to 12/28/25. On 1/15/26 at 1:35 a.m., during an interview the Director of Nursing (DON) indicated the facility started 15 minute checks starting on 12/12/25 because they did not think there was a concern between Resident G and other residents. When the facility determined she was seeking the male resident it was determined the resident looked like her husband, and she associated the resident to her husband. She was placed on 15 minute checks, and the care plan was updated. The DON indicated there were no other residents who wander in other residents' rooms. She indicated there had not been any other issues with resident since the initial occurrence. Review of the education and audit tools indicated abuse education of all staff was completed on 12/10/25. The facility completed daily room rounds and weekly interviews from 12/9/25 to current date. 2. Resident H's record was reviewed on 1/16/26 at 11:10 a.m. The profile indicated the resident's diagnoses included but were not limited to, schizophrenia (a severe mental illness causing distorted thinking, perceptions (hallucinations), and behavior, psychotic disorder with hallucinations (involve loss of touch with reality, where individuals perceive things not actually present most commonly hearing voices, but also seeing, feeling, or smelling things that are not there), and adult failure to thrive. Facility census information indicated Resident H admitted to the facility on [DATE]. An admission Minimum Data Set (MDS) assessment, dated 11/7/25, indicated the resident was cognitively intact and received anti-psychotic medication. A care plan, dated 12/10/25, indicated the resident had a history of schizophrenia and psychotic disorder with hallucinations.the resident could exhibit behaviors to include inappropriate sexual interactions with others. Interventions included, but were not limited to, 1:1 started on 12/9/25 and ended on 12/12/25, every 15-minute checks, room change 12/12/25, document behaviors per behavior management program, psych services as ordered. A change in condition evaluation form, dated 12/9/25 at 2:46 p.m., indicated Resident H had exhibited sexual behavior changes today. A tele visit note with psychiatry, dated 12/10/25, indicated Resident H had inappropriate behavior with a female resident. Resident H indicated to the nurse practitioner that nothing happened during the incident in question. Resident H indicated a resident entered his room unexpectedly. Treatment would be to continue with one-on-one observation for a minimum of 72 hours. May discontinue one on one after completion of investigation. A social service note, dated 12/10/25 at 8:54 a.m., indicated Resident H was in his room and indicated Resident G had entered his room and sat on his bed. He indicated Resident G was not making any sense when she spoke and was quoted to say, she is not my type, he denied any sexual behaviors or distress. An acute psych visit note, dated 12/11/25 at 11:59 p.m., indicated Resident H denied anything happening with Resident G on 12/9/25. Review of Interdisciplinary Team (IDT) note dated 12/11/25 at 3:55 p.m., Resident H indicated he would like to move rooms so that he would be further away from a female resident who wandered. Resident H would be moved to a new room per his request today. Review of written statement, dated 12/9/25, a hospice staff member who was a Certified Nursing Assistant (CNA) 13 indicated she was at the facility and during her visit she entered Resident H's room to provide care. The curtain was pulled when she entered the room, and she slowly pulled the curtain back. She saw Resident H and Resident G sitting on the side of the bed, both were leaning back. Resident H was fully dressed, but Resident G had her pants down to the knee area, and she was wearing a gray brief, the brief was pulled to the side. CNA 13 noted Resident H's hands were near Resident G's vaginal area. CNA 13 summoned facility staff to assist as she had the residents in sight at the doorway. Facility staff immediately came to assist CNA 13. Review of written statement, dated 12/9/15, a hospice staff member who was also a CNA 14 indicated she was at the facility to provide resident care. CNA 14 followed CNA 13 into Resident H's room. CNA 14 saw Resident H on the edge of his bed and he was fully dressed. She indicated she saw a female resident sitting on the edge of the bed also and she could visualize the top of her thighs; it appeared her pants were down to the knee area. She left the room and immediately went to get help from the facility staff. Review of written statement, dated 12/9/25 the Director of Nursing (DON) indicated she had spoken with Resident G about the reported event with the presence of a police officer. Resident G indicated she knew who Resident H was and that he resided at the facility but denied she had seen Resident H today. She indicated she was doing great and had no concerns at this time. Review of written statement dated 12/9/25, the DON indicated she had spoken to Resident H about the reported even with the presence of a police officer. Resident H indicated he knew who Resident G was and that she resided at the facility. Resident H indicated that Resident G was in his room earlier that day, he indicated they were talking and standing close to each other. He denied any concerns at this time. Review of written statement, dated 12/9/25, Licensed Practical Nurse (LPN) 6 indicated she did not observe any inappropriate behaviors between Resident G and H on 12/9/25. Review of written statement, dated 12/9/25, Qualified Medication Aide (QMA) 10 indicated at approx. 1:30-2:00 p.m. she saw Resident H in his room with the hospice staff members and Resident G walking around the hallways per usual. During an interview, on 1/15/26 at 1:35 p.m., the Director of Nursing (DON) indicated both residents were separated immediately once the incident was reported by the hospice staff member and Resident H was started on one-on-one observations (and continued to be on every 15-minute checks at this time). The police department was called, and an officer was present at the facility the evening of 12/9/25. The officer interviewed both Resident G and H separately in the DON's office. Neither resident admitted to any concerns. No charges were filed by the police officer. The DON indicated during their investigation they observed Resident G seeking Resident H. Resident G thought Resident H was her husband because they both had a beard and both were smokers. DON denied Resident H ever expressing sexual behaviors before this incident. 32 residents were interviewed by staff on 12/10/25 and denied any resident in the facility had touched them inappropriately. Review of the in-service sign-up sheet, dated 12/10/25, indicated staff were educated on resident rights, abuse, neglect, and sexual expression and intimacy. The sign-up sheet contained 68 staff signatures. On 1/15/26 at 2:30 p.m., the Director of Nursing provided a document, dated 7/1/25, titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation, and indicated it was the policy currently being used by the facility. The policy indicated, .b.3. If a resident/patient is accused or suspected. The facility will ensure other residents/patients are protected as determined by the circumstances, which may include but are not limited to, increased supervision of the alleged perpetrator and/or other residents/patients, room or Care Team Member changes, and immediate transfer or discharge, if indicated. On 1/15/26 at 2:30 p.m., the Director of Nursing provided a document, dated 12/12/23, titled, Resident Rights, and indicated it was the policy currently being used by the facility. The policy indicated, .8. Safe environment. The resident has the right to a safe, clean comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safety. The deficient practice was corrected by 12/10/25 after the facility implemented a systemic plan that included the following actions: Resident H was placed on 1:1 care, interviews were conducted on all resident with a BIMS (Brief Interview for Mental Status) over 8, all residents with BIMS below 8 had head to toe assessment completed, in-servicing education to staff related to abuse, neglect, resident rights, and sexual expression and intimacy, and ongoing monitoring by Quality Assurance and Performance Improvement (QAPI). This citation relates to Intake 2689100. 3.1-27(a) 3.1-27(b)

Based on interview and record review, the facility failed to report an allegation of resident-to-resident abuse to the Indiana Department of Health in a timely manner for 2 of 4 residents reviewed for abuse (Resident B and C). This deficient practice was corrected by 11/3/25 prior to the start of the survey and was therefore Past Noncompliance. Findings include: A Facility Reported Incident form, submitted by the Interim Administrator on 10/30/25, indicated, on 10/8/25 at 8:45 a.m., Resident B was sitting in the back west hallway with a female resident sitting close by, when Resident C came down the hall and yelled at Resident B to leave her alone. Resident B then yelled at Resident C in response. The residents were immediately separated. During an interview on 11/12/25 at 2:04 p.m., the Social Services Director (SSD) indicated the morning of 10/8/25, she heard yelling down the hallway. As she turned the corner to where the noise was coming from, she observed multiple staff members separating Resident B and Resident C. She spoke with all residents involved and then went to the former Administrator and reported the incident. The former Administrator indicated to her that she wanted to reach out to someone prior to the SSD entering a progress note regarding the incident. She indicated to the SSD she would let her know when to proceed with documentation. The SSD indicated she noticed later, the former Administrator had left the facility for the day. She proceeded to enter the progress notes regarding the incident at that time. She had thought the incident had been reported to the Indiana Department of Health, as Resident B had threatened Resident C. A progress note, dated 10/8/25 at 3:23 p.m., entered by the SSD, indicated she had heard yelling down the hall. When she arrived, Resident B was being moved by a staff member away from another resident. When Resident B was asked what had happened, he indicated Resident C had told him not to touch the female resident, and Resident B responded he would lay him out and fuck him up. The SSD had reported the incident to the Administrator. A current facility policy, revised 6/5/25, titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation, provided by the Director of Nursing on 11/12/25 at 3:38 p.m., included the following: .E. Initial Reporting .2) Department of Health. a) If abuse is alleged or Serious Bodily Injury. If any form of abuse is alleged (e.g., physical verbal, etc.) ., the Administrator or his/her designee will notify the Department of Health immediately, but not later than 2 hours after the allegation is made. This deficient practice was corrected by 11/3/25 prior to the start of the survey and was therefore Past Noncompliance. The facility implemented a systemic plan that included staff education, skin assessments, and wound care plan audits, and ongoing monitoring was in place. This tag relates to Intake 2657794. 3.1-28(c)

Based on interview and record review, the facility failed to protect the resident's right to be free from neglect, when staff failed to visualize a confused resident during their shift resulting in the resident eloping from the facility for 1 of 3 residents reviewed for neglect (Resident B). The immediate jeopardy began on 10/11/25 when the facility failed to protect the resident's right to be free from neglect when a resident with a traumatic brain injury and at risk of elopement was able to exit the facility sometime after 9:30 p.m., on 10/11/25, or early morning, on 10/12/25, despite wearing a WanderGuard (a type of wander management system used in senior living communities and healthcare facilities to prevent residents at risk of wandering from leaving the premises unsupervised) bracelet. The facility alarm system failed to alert staff of the resident exiting with a WanderGuard. The night shift nurse and night shift Certified Nurse Aide (CNA), on 10/11/25, failed to visualize the resident during their eight hour shift. On 10/12/25, around 7:00 a.m., the day shift staff were unable to locate the resident and started the elopement process. The resident was located approximately 0.6 miles away from the facility. She had a temperature of 95 degrees Fahrenheit and abnormal vitals. The Administrator was notified of the immediate jeopardy on 10/30/25 at 11:39 a.m. The immediate jeopardy was removed on 10/31/25, but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include:A facility reported incident form, dated 10/12/25, indicated the Administrator was notified Resident B could not be located at 7:11 a.m. The elopement procedure was initiated, and the resident was brought back to the facility. The resident's WanderGuard bracelet was checked and found functional and intact. An incident file included the following documents: -A document titled, Nursing Education/Expectations to Prevent Elopements, indicated, You are expected to lay eyes on all your residents that are under your direct care at minimum of 1-2 times per shift. For safety concerns. The goal is to check on them every 2 hours as you are making rounds to change/medicate them. After you get report for your shift, it is best practice to round your assignment and look in and lay eyes on all the residents and make sure they are accounted for. -A statement from CNA 20 indicated, .When I worked over the weekend I did not go into [Resident B's] room, as she was not on my assignment. I worked 6p [p.m.] to 6a [a.m.] that day and did not see [Resident B] out of her room or see anyone go in there. -A statement from RN 21 indicated, .On 10/11 to 10/12 I worked [unit name]. I didn't see anyone wandering halls. No alarms sounded on the entire shift. I left at 6:30 a.m., arrived at 2200 [10:00 p.m.] on the 11th. -A statement from RN 19 indicated, .I.was [Resident B's] nurse from 10p [10:00 p.m.] to 6a [a.m.].I did not see [Resident B] on my shift, nor did I enter her room at any time during my shift. -A statement from CNA 14 indicated, I.had put [Resident B] to bed on 10/11/25 at 9:30 p.m. The last time I have seen her was 9:40 p.m. when I walked the halls to check on the residents. -A statement from CNA 7 indicated, .I.received a verbal report on [Resident B] when coming on shift for night shift. I did not lay eyes on the resident during report and no call light was used from resident's room during the night. -A statement from CNA 22 indicated I.did not hear any alarms nor did I see [Resident B] the night/morning in questioning [sic]. During an interview, on 10/29/25 at 11:43 a.m., Resident B's family member indicated the facility called him around 8:00 a.m., on 10/12/25, and notified him of the incident. The family member went to the facility, and the resident seemed confused when he arrived. It was cold in the 40's that morning. The resident was found by the school down the road, about a half mile from the facility. The family member was not sure how the resident was able to get out of the facility. The family member was not sure how long the resident was out of the facility. During an interview, on 10/29/25 at 1:24 p.m., Registered Nurse (RN) 4 indicated she was the nurse, on 10/12/25, day shift. She received report from the night shift nurse and was reviewing information for the day. The night shift nurse reported Resident B was fine. RN 4 indicated she went to Resident B's room to check her blood sugar, and her wheelchair was gone and just a sheet was on the bed. She went out into the hallway and asked the aide if she had seen Resident B, but she had not. The staff completed a room to room check of the facility. When they did not find Resident B, RN 4 called the Administrator and sent staff outside to look for the resident. One of the staff members went into a nearby business, and an employee reported seeing someone who fit the resident's description on a bench near the school. The staff found the resident and brought her back to the facility. RN 4 indicated she thought the resident had on long pants and a sweater with tennis shoes, but she was not sure. The resident had her wheelchair full of stuff with her. Residents should have been checked on at least every two hours. RN 4 was not sure how long Resident B was out of the building. When the resident returned to the facility she had been incontinent of urine and had a low body temperature. The resident complained of back and leg pain but stated she had not fallen. The resident reported she was trying to go to her house. During an interview, on 10/29/25 at 1:30 p.m., CNA 5 indicated she worked day shift on 10/12/25, but she was not directly assigned to Resident B. When she did shift-to-shift report she usually tried to go room to room and see each resident, but she had not done that on 10/12/25. She was not sure what time Resident B got out of the facility. Residents should have been checked on at least every two hours, especially if they were confused. CNA 5 indicated staff was not really made aware of which residents were at risk for elopement, and she was not sure how they would find out. The staff had assignment sheets, but elopement risk was not included on the assignment sheet. CNA 5 indicated she thought if a resident with a WanderGuard got too close to an exit door an alarm would sound, however the noise of the alarm was not loud enough to hear throughout the building. The night shift aide told CNA 5 they had not seen the resident during their shift. During an interview, on 10/29/25 at 1:40 p.m., Qualified Medication Aide (QMA) 6 indicated they normally walked up and down the hall during shift-to-shift report. Residents should have been checked on at least every two hours, especially if they were confused. QMA 6 arrived for her shift at 6:00 a.m., on 10/12/25. They realized the resident was missing around 7:00 a.m., and they found her around 7:50 a.m. Staff was not really notified which residents were an elopement risk, and she was not sure how they would find out. Elopement risks were not included on their assignment sheets. They received training after the elopement, but it only included what to do when a resident eloped, but not how to manage residents who were elopement risks. If a resident's WanderGuard set off the door alarm, then the door alarm was not able to be turned off until someone put in the override code. If the pharmacy staff member knew the door code they would have been able to open the front door without staff. The functionality of the WanderGuards was checked regularly. Night shift staff had not seen Resident B all night, so she was not sure how long the resident was out of the facility. During an interview, on 10/29/25 at 2:04 p.m., CNA 7 indicated he was assigned to Resident B, on 10/12/25, night shift. He worked 10:00 p.m. to 6:00 a.m. CNA 7 indicated he did not remember seeing Resident B during his shift. Residents were normally checked on every two hours. CNA 7 indicated he had not heard any alarms that shift, and he had not seen the resident go sit in the lobby. During an interview, on 10/29/25 at 3:04 p.m., the Administrator indicated the staff called her early on the morning of 10/12/25 and told her Resident B was missing. The Administrator instructed the staff to check every room in the facility, and she immediately went to the facility. When she arrived at the facility, the resident was still missing. The Administrator sent the staff out in the community in pairs to search for the resident. The staff called in every two blocks and stayed in communication with her throughout the search. A staff member found the resident near the school. The resident reported she wanted to go feed her cat and was looking for her grandchildren. When the resident returned to the facility, she had a low body temperature, got in bed, and went to sleep. She expected staff to check on residents every two hours, and the aides to do a walking shift-to-shift report where they visualized residents at shift change. The last time staff saw the resident, as far as she found through the investigation, was the night before, on 10/11/25. During the investigation, they were unable to determine exactly how the resident left the facility. There had been a pharmacy delivery that night but no other visitors entering or exiting through the front door. The resident should not have been able to open the door because she had a WanderGuard. The WanderGuard forced the door to stay locked when the resident was nearby. They were working on getting annunciators throughout the facility to make the door alarm audible in all areas. She had the company inspect the door and WanderGuard system. They found an issue with the latch at the top of the door, and it was not always latching effectively. The mag-lock was not functioning appropriately, and repairs were completed. As a result, it was possible the door alarm had not activated effectively. They re-set everything, and now it was set up so that the door alarm sounded after being left open for 74 seconds. The Administrator was not sure if the pharmacy staff had the front door override code, but they should not have known it. They changed the code after the incident. If a resident received a new WanderGuard, there was a communication form sent out. The WanderGuard/elopement risk should have been noted on the point of care tasks so the aides were aware of which residents were elopement risks. During an interview, on 10/31/25 at 1:36 p.m., LPN 25 indicated residents should have been checked on every two hours regardless of how much care they required. Staff should have checked on residents whether or not they turned their call light on. During an interview, on 10/31/25 at 1:38 p.m., CNA 16 indicated all residents should have been checked every two hours regardless of how much physical care they required. They should be checking on all residents whether or not the residents turned on their call lights. During an interview, on 10/31/25 at 1:40 p.m., Restorative Aide 16 indicated all residents should have been checked on every two hours, not just when they turned on their call light. All residents should have been checked on even if they did not require very much physical assistance. Resident B's record was reviewed on 10/29/25 at 10:30 a.m. Census information indicated the resident was admitted to the facility on [DATE]. Diagnoses on the resident's profile included, but were not limited to, diffuse traumatic brain injury) an injury to the brain caused by an external physical force, such as a blow, hit, fall, or blast), attention and concentration deficit following other cerebrovascular disease (a group of conditions that affect the blood vessels in the brain), and Parkinson's disease (a progressive neurodegenerative disorder that affects movement). A quarterly Minimum Data Set (MDS) assessment, dated 8/4/25, indicated the resident had a severe cognitive impairment, required supervision/touching assistance for toileting hygiene, and was occasionally incontinent of bladder. A care plan, initiated 3/15/25, indicated the resident was at risk for falls and fall related injury due to impaired cognition, impaired mobility, visual impairment, urinary incontinence, traumatic brain injury, subdural hematoma (a collection of blood that accumulates between the brain and the outer layer of tissue covering the brain), and seizure activity. Interventions included, but were not limited to, assist with toileting and transfers as needed. A personal preferences care plan, initiated on 3/17/23, indicated the resident wanted to be dressed and in bed between 8:00 p.m. and 9:00 p.m. and preferred to crawl on the floor at times for mobility. A care plan, initiated on 3/28/25 and last revised on 10/12/25, indicated the resident was an elopement risk due to exit seeking behaviors, impulsivity, impaired safety awareness, and diagnosis of traumatic brain injury. Interventions, dated 3/28/25, indicated assess the resident for unmet needs when wandering/exit seeking such as needing to toilet, pain, hunger, thirst, and intervene as needed, elopement risk assessment quarterly and as needed, place the resident's profile in the elopement book, and redirect the resident when she was wandering or exit seeking by providing a diversional activity such as playing games on her phone, providing a snack or beverage, or visits with cats. Interventions, dated 10/12/25, indicated check the WanderGuard placement every shift and the function daily. A care plan, initiated on 5/8/24, indicated the resident had a severe cognitive impairment and traumatic brain injury. A progress note, dated 9/4/25, indicated the resident was found wandering aimlessly outside. Staff intervened and walked her back into the building. The resident stated she was looking for her keys and car to leave. The resident was offered snacks, fluids, and re-oriented to her surroundings but continued to exit seek and stated she wanted to leave. The Director of Nursing (DON) and Administrator instructed the staff to place a WanderGuard on the resident for safety. The resident verbalized understanding and was educated on the importance and need for WanderGuard for safety. An elopement risk assessment, dated 9/4/25, indicated the resident's elopement risk factors included the resident made statements to staff, family, or other residents that they planned to leave the facility in an unsafe manner, wandered aimlessly, and had a history of or was currently exit seeking. The assessment indicated the resident did not have a history of elopement. A physician's order, dated 9/4/25, indicated check WanderGuard placement to the resident's left ankle every shift. A physician's order, dated 9/5/25 and discontinued 10/14/25, indicated check the function of the WanderGuard every day shift. A nursing progress note, dated 10/12/25 at 8:30 a.m., indicated the nurse assisted the resident from the vehicle after she was located by staff. The resident stated her back was hurting, and she was cold. The WanderGuard was in place on the resident's left ankle and was functioning. The WanderGuard alarmed with the resident was brought back in through the ambulance entrance. Upon assessment, the resident's temperature was 95.7 degrees Fahrenheit (normal range between 97 and 99 degrees Fahrenheit), heart rate 115 beats per minute (bpm) (normal range between 60 and 100 bpm), blood pressure 188/111 (normal 120/80 or below). The resident was unable to answer any questions regarding her back but stated it, really hurts. A nonverbal pain scale assessment six out of a maximum of ten. The resident was administered acetaminophen, gabapentin (nerve pain medication), and cyclobenzaprine (muscle relaxant). A full skin assessment was completed, and the resident had blanchable erythema (a temporary reddening of the skin that disappears when pressure is applied that can be caused by heat or cold exposure) to the tips of toes, fingers, nose, and ears. The resident was changed into warm clothing, covered with blankets, and given hot chocolate and coffee. Fifteen minutes later the resident's temperature was 98.0 degrees Fahrenheit, pulse 101 bpm, and blood pressure 120/93. According to the article, Vital Signs, dated 1/1/2025, was retrieved on 10/31/25 from MedlinePlus's medical encyclopedia website at https://medlineplus.gov/ency/article/002341.html. The guidance indicated, . vital sign ranges for the average healthy adult while resting are.Blood pressure: between 90/60 mmHg and 120/80 mmHg.Pulse: 60 to 100 beats per minute.Temperature: 97.7 F to 99.1 F . average 98.6 F. A nursing progress note, dated 10/12/25 at 8:32 a.m., indicated the nurse went to the resident's room to check her blood sugar. Upon entrance, the resident was not in the room, the bed was made, and the wheelchair was gone. The nurse checked the resident's bathroom and immediately notified staff to search the building for the resident. The Administrator was notified at 7:11 a.m. of the possible elopement. The DON was notified at 7:18 a.m. The building search was completed at 7:20 a.m., and staff were sent out in pairs to search for the resident going north, south, east, and west. The resident's family member was notified at 7:26 a.m. Staff checked in at 7:30 a.m. and had not found the resident yet. A staff member checked in at 7:53 a.m. and stated they found the resident. The resident stated she was walking to her mom's and needed to see her family. A head to toe assessment was completed with no negative outcome. Pain medication was given for complaints of back pain. One-on-one observation was initiated for 72 hours. The Nurse Practitioner (NP) planned to evaluate the resident later in the day. A social services progress note, dated 10/12/25 at 10:20 a.m., indicated at 7:11 a.m., the Administrator was notified the resident was not in the facility. The facility staff had started a ground search, including all rooms and the outside property. A staff member went into a nearby business, and one of the business staff member's stated they saw someone fitting the resident's description walking down the street, towards the facility. The staff went down that street immediately and found the resident by a school. The resident got into the staff member's vehicle without incident and was returned to the facility. The resident stated she was looking for her ex-husband and kids and wanted to feed her cat. The WanderGuard was in place on the resident's left ankle and was functioning. A social services progress note, dated 10/12/25 at 3:22 p.m., indicated the Social Services Director (SSD) added an elopement task to the resident's point of care (POC). A physician's order, dated 10/15/25, indicated check the function of the WanderGuard everyday shift for safety. The order included the serial number and expiration date of the WanderGuard. The facility's website at https://www.majesticcare.com/location/[NAME]-park/, retrieved on 10/31/25, indicated, .[NAME] Care of [NAME] Park provides a warm, welcoming environment and highly individualized skilled nursing care. Specializing in short-term rehabilitation and long-term care, we provide a full range of care services. The [NAME] Care website at https://www.majesticcare.com/care-services/long-term-care/, retrieved on 10/31/25, indicated, .Long-Term Care is offered at all locations for any needs that our residents may have. We design individual care plans for each resident to address their needs and our compassionate caregivers provide 24-hour nursing care. An Article titled, Abuse & Neglect, from the National Consumer Voice for Quality Long-Term Care was retrieved on 10/31/25 from the Indiana Department of Health website at https://www.in.gov/health/files/abuse-and-neglect.pdf. The article indicated: .Neglect is the failure to care for a person in a manner, which would avoid harm and pain, or the failure to react to a situation which may be harmful. Neglect may or may not be intentional . Nursing homes are required by federal law to have intervention strategies and regular monitoring to prevent neglect and abuse. The nursing home must reevaluate these measures on a regular basis. On 10/30/25 at 8:18 a.m., the Administrator provided a document, titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation, dated 6/5/2025, and indicated it was the policy currently being used by the facility. The policy indicated, .3. Definitions.Neglect is the failure of the facility, its Care Team Members, or facility service providers to provide goods and services to a resident/patient necessary to avoid physical harm, pain, mental anguish, or emotional distress. On 10/30/25 at 8:18 a.m., the Administrator provided a document titled, Incidents, Accidents, and Supervision, dated 1/2/24, and indicated it was the policy currently being used by the facility. The policy indicated, .DEFINITIONS: 'Accident' refers to any unexpected unintentional incident, which results or may result in injury or illness to a resident.'Hazards' refers to elements of the resident environment that have the potential to cause injury or illness.PROCEDURE.6. In the event of an incident or accident, immediate assistance will be provided to ensure the safety and environment are secured for anyone with the potential to be affected.SUPERVISION: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes.4. Monitoring for effectiveness and modifying interventions when necessary. 1. Supervision-Supervision is an intervention and a means if mitigating risk. The facility will provide adequate or increased supervision to prevent accidents. Adequacy of supervision: a. Defined by type and frequency. b. Based on the individual resident's assessed needs and identified hazards in the resident environment. The immediate jeopardy that began on 10/11/25 was removed on 10/31/25, when the facility ensured a systemic plan to include education and monitoring of staff to ensure staff provided supervision and required care to all residents residing at the facility. The noncompliance remained at the lower scope and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need for continued monitoring. This citation relates to Intake 2642220. 3.1-27(a)(3)

Based on record reviews, interviews, and observation, the facility failed to supervise and prevent a confused resident at risk of elopement from eloping from the facility sometime after 9:30 pm on 10/11/25 into the early morning of 10/12/25 (Resident B). A resident with a traumatic brain injury and at risk of elopement was able to exit the facility sometime after 9:30 p.m. on 10/11/25 or early morning on 10/12/25 despite wearing a WanderGuard bracelet (a type of wander management system used in senior living communities and healthcare and healthcare facilities to prevent residents at risk of wandering from leaving the premises unsupervised). The facility alarm system failed to alert staff of the resident exiting with a WanderGuard. The night shift nurse and night shift CNA on 10/11/25 failed to visualize the resident during their 8-hour shift. On 10/12/25 around 7 a.m. the dayshift staff were unable to locate the resident and started the elopement process. The resident was located approximately 0.6 miles away from the facility. She had a temperature of 95-degree Fahrenheit and abnormal vitals. The Administrator was notified of the immediate jeopardy on 10/30/25 at 11:39 a.m. The immediate jeopardy was removed on 10/31/25, but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy.Findings include: Review of a reported facility incident, dated 10/12/25 indicated Resident B was found to be missing when the dayshift nurse could not locate her the morning of 10/12/25 at 7:11 a.m. The Administrator was notified at 7:11 a.m. on 10/12/25 and initiated the elopement protocol. Resident B was located and brought back to the facility. Upon returning to the facility the resident had an intact functioning WanderGuard on. On 10/30/25 at 8:45 a.m., Resident B's medical record was reviewed, her diagnosis included, but were not limited to, traumatic brain injury (an injury to the brain caused by an external force, such as fall, car accident, or assault), Parkinson's disease, (a progressive neurological disorder that affects movement) and type 2 diabetes (a chronic condition where the body does not use insulin effectively or does not produce enough insulin). Census information indicated the resident admitted the facility on 3/15/23. A quarterly Minimum Data Set (MDS) assessment, dated 8/4/25, indicated Resident B had severe cognitive impairment, was occasionally incontinent of urine, and required supervision/touching assistance with toileting. The resident was coded as having one fall since the previous MDS assessment. A care plan, dated 3/28/23 and revised on 4/3/23, indicated Resident B was at risk for elopement due to exit seeking behaviors, impulsiveness, and impaired safety awareness due to diagnosis of traumatic brain injury. Interventions included, but were not limited to, redirect the resident when wandering or was exit seeking by providing a diversional activity, WanderGuard to left ankle, and check placement of WanderGuard every shift and functionality daily. A care plan, dated 3/25/23 with a revised date of 10/12/25, indicated Resident B was at risk for falls or fall related injury due to impaired cognition, impaired mobility, and visual impairment related to diagnosis of traumatic brain injury. Interventions included, but were not limited to, encourage the resident to wear appropriate nonskid footwear, keep call light and frequently used personal items within reach, assist with toileting as needed, and assist with transfers as needed. Review of Morse Fall Scale (a tool used to assess a resident's risk of falling) documentation, dated 9/30/25 at 2:25 p.m., indicated Resident B was a high risk for falls with a score of 65. A score over 45 indicated a resident was a high risk. Review of an elopement risk assessment, dated 9/4/25 at 5:00 p.m., indicated Resident B was at risk for elopement with a score of 3. The resident had a history of or currently exiting seeking and was wandering aimlessly. A progress note, dated 9/4/25 at 5:15 p.m., the note indicated Resident B was wandering aimlessly outside. Staff intervened and walked with her back into the building. The resident indicated she was looking for her keys and the car so that she could leave. The resident was settled into her room and re-oriented to surroundings, but she proceeded to exit seek and indicated she wanted to leave. A WanderGuard was placed on the resident's left lower extremity. A progress note, 10/12/25 at 8:30 a.m., the note indicated Resident B was located outside of the facility and brought back in a facility employee vehicle. The WanderGuard was noted on her left ankle and was functioning properly. The alarm sounded when the resident was brought back into the building through the ambulance bay. The resident was assessed, and the following vitals were obtained: Oral temperature 95.7 degrees Fahrenheit, heart rate 115, respirations 20, blood pressure 188/111, and oxygen saturation 97% on room air. Nonverbal pain scale of 6 out of 10 for back pain. The resident was changed into warm clothing and was given a blanket, hot chocolate and coffee to drink. Repeat vitals were obtained 15 minutes later and the resident had a oral temperature of 98 degrees Fahrenheit, heart rate 101, respirations 18, blood pressure 128/93, and oxygen saturation 98% on room air. A late entry progress note, 10/12/25 at 8:32 a.m., the note indicated Resident B's nurse went to her room to check her blood glucose (sugar) level and the resident was not in her room. The resident's bed was made, and her wheelchair was gone. The nurse checked the bathroom and immediately notified staff to start searching the building for the resident. The Administrator was notified at 7:11 a.m. and the Director of Nursing (DON) was notified at 7:18 a.m. of a possible elopement. The building search was completed at 7:20 a.m. and pairs of two staff were sent to search the north, south, east, and west neighboring blocks. The Resident's family member was notified at 7:26 a.m. of possible elopement. Staff members checked in at 7:53 a.m. and indicated they had found the resident. The resident indicated she was walking to her mom's house. A head-to-toe assessment was completed and no negative outcomes noted to the resident. A blood glucose level was checked and insulin given to the resident, along with pain medication for complaints of back pain. The facility initiated 1:1 supervision for the resident for the next 72 hours. The nurse practitioner would be in the facility to assess the resident. A social service note, dated 10/12/25 at 10:20 a.m., the note indicated the Administrator was notified at 7:11 a.m. that Resident B was not in the facility. The administrator arrived at the facility at 7:14 a.m. and instructed them to begin elopement procedure and search the surrounding area. The Registered Nurse called the resident's family member and the DON. The family member indicated that his mom was not with him. A laundry staff member indicated they had seen someone fitting the resident's description walking down the street. The resident was found by a middle school. The resident was brought back to the facility via a facility employee's vehicle. The WanderGuard was in place and functioning on the resident's left ankle. Resident's son was at the facility when she arrived. He was aware his mom was an elopement risk and indicated she would sit with his mom for a while. Review of nurse practitioner progress note, dated 10/13/25 at 12:59 a.m., the note indicated Resident B was seen for routine monthly visit as well as an elopement. The resident was noted to be missing on morning rounds. The facilities security cameras were not working due to power outage; the resident was wearing the WanderGuard that did work when she re-entered the building. The facility thinks the resident must have exited the building sometime after the pharmacy staff left the facility approximately around 3-3:30 a.m. The facility staff thought the door just did not get shut all the way, therefore did not set off the alarm. Pharmacy staff denied seeing any residents in the lobby when they left. Resident B was found several blocks from the facility. An Interdisciplinary Team (IDT) note, dated 10/13/25 at 2:42 p.m., indicated the team had met to discuss the elopement that occurred on 10/12/25. Resident B continued to be at risk for elopement per follow up assessment related to decrease safety awareness and pain/discomfort. Resident continued to be 1:1 at that time and exhibited no further exit seeking behaviors thus far. IDT team reviewed and updated care plan with new interventions for diversional activities. Will continue current plan of care. A physician order, dated 5/30/24, indicated to monitor for the following behaviors: .elopement.every shift. A physician order, dated 9/4/25, indicated to check placement of WanderGuard to left ankle every shift. A physician order, dated 10/14/25, indicated to check under skin of left ankle where WanderGuard is placed every shift for prevention. A physician order, dated 10/15/25 indicated to check function of WanderGuard every day on dayshift for safety. During an interview, on 10/29/25 at 1:30 p.m., CNA 5 indicated that when she gets report from the night shift CNA and they would go room to room and should lay eyes on each resident. On the day of the elopement, she was not assigned to the hall that Resident B's room was on. She indicated residents were checked on depending on how much care they need, and if they were confused. Staff should check on residents every 2 hours, especially if they were confused residents. CNA 5 was not sure how to find if a resident was an elopement risk and indicated it was not on the CNA assignment sheet. Resident B told CNA 5 that she had gone to bed around 10:00 p.m. the night of 10/11/25 but had gotten up at 1:00 a.m. and went to front lobby to sit. CNA 5 was told by others at the facility that the medication delivery person had entered the facility and left around 4:00 a.m., but the door was not latched completely closed. CNA 5 doesn't think the WanderGuard alarm was loud enough for everyone to hear it even if the alarm had sounded. During an interview, on 10/29/25 at 1:40 p.m., QMA 6 indicated residents should be checked on every 2 hours especially if they are confused. She was not aware of where to find out who was all an elopement risk in the building, it was not on the CNA assignment sheet. QMA 6 worked the dayshift at the facility and was not assigned to the unit Resident B resides on, but she was one of the staff members that helped bring her back to the facility on [DATE]. Resident B doesn't walk well and had a lot of pain, QMA 6 was concerned the resident could have fallen while out of the facility. Resident B had taken her rollator walker (a walker that had a seat to sit on if needed) with her, and it was full of bags that had various personal items in them. The resident could not sit on the seat of the walker because she had so much stuff with her. The resident was found down the road on a bench by a middle school. She indicated the resident was wearing a sweater, pants that were wet, and shoes, she also had a blanket, but she felt cold when they found her outside. She believed the outside temperature was in 40's that morning. Review of a verbal statement, dated 10/12/25, indicated employee 18 did not see Resident B ambulating in the halls during her shift from 10:00 p.m. to 6:00 a.m. She also indicated she did not hear any alarms sounding on the west wing during her shift. She did hear a buzzer when the pharmacy staff arrived, but no other alarms were turned off. She thought the pharmacy staff member was at the facility for about 20-30 minutes. Review of a verbal statement, dated 10/12/25, indicated Certified Nurse's Assistant (CNA) 7 received a verbal report on Resident B at the start of his shift at 10:00 p.m. on 10/11/25. He did not lay eyes on the resident during report, and no call light was used in the resident's room during the night. Review of a verbal statement, dated 10/12/25, indicated Registered Nurse (RN) 19 was the nurse for the night shift on 10/11/25 until the morning of 10/25/25. She did not see Resident B during her shift, nor did she enter her room at any time during her shift. Review of a verbal statement, dated 10/12/25, indicated CNA 14 had placed Resident B in bed at 9:30 p.m. and the last time she laid eyes on her would have been 9:40 p.m. the evening of 10/11/25. Review of a verbal statement, undated, indicated CNA 3 worked the dayshift on 10/12/25 and was told in report from nightshift the resident was in her room at 6:00 a.m., but she did not lay eyes on the resident at that time. Review of verbal statement, dated 10/12/25, indicated the DON had spoken to the lead pharmacist and he indicated the pharmacy driver had arrived at the facility on 10/12/25 at 2:30 a.m. to 3:00 a.m. and was at the facility for roughly 30 minutes. The driver exited the facility through the front door per self. Review of a verbal statement, indicated RN 21 she arrived at the facility on 10/11/25 at 11:00 p.m. and left at 6:30 a.m. on 10/12/25. During her shift she did not see anyone wandering the halls and no alarms sounded the entire shift. Review of a verbal statement, dated 10/14/25, indicated CNA 20 indicated she had worked 6:00 p.m. on 10/11/25 until 6:00 a.m. on 10/12/25, during her shift she did not see Resident B out of her room, and she did not see any other staff enter the room. She was not assigned to the hall that Resident B resides in. During an interview, on 10/29/25 at 1:20 p.m., the DON indicated the facility did have cameras, but the backup battery pack had malfunctioned and caused the cameras to all go down. They were only able to see a black screen and no recordings were able to be viewed. She was not aware of how long the cameras were not functioning properly since the video was in the Administrator's office and she had been out with an injury at that time. If the cameras had been functioning, they would have been able to view the halls and the doorways. During an interview, on 10/29/25 at 2:04 p.m., CNA 7 indicated he doesn't remember seeing Resident B during his night shift on 10/11/25. He was not aware the resident was not at the facility until he received a call saying that she was missing. He did not hear any alarms during his shift that night either. During an observation, on 10/29/25 at 3:00 p.m., the front door to the facility had an alarm that was activated and the alarm sounded for 74 seconds when the door was held open. An unused WanderGuard was placed by the front door to simulate a resident getting by the door and it prevented the front door from opening. The Maintenance Director used an override code to open the door. While the alarm was sounding, a visitor walked to the 200 hall and could not hear the alarm, and 2 other visitors were unable to hear the alarm while in the service hallway, the alarm was heard down the 100 hall, but only at approximately 25 feet down the hall. The Maintenance Director indicated the facility had investigated ordering enunciators to ensure the alarm could be heard throughout the facility. During the observation the Maintenance Director opened and closed the front door and was noted to be closing completely and latched closed. The Administrator indicated the mag locks had been re-drilled to ensure the door would close properly. During an interview, on 10/29/25 at 3:01 p.m., the DON indicated that during the night shift the are no lights in the front lobby and it would be dark. If a resident was sitting in a chair with a WanderGuard in the front lobby they would not be close enough to the door to sound the alarm. It would also be difficult to see the residents sitting in the dark, especially if you weren't really paying attention or expecting someone to be there. During an interview, on 10/29/25 at 3:05 p.m., the Administrator indicated she was not aware if the pharmacy driver had the bypass code for the door alarm to get out the front door, but there was a possibility that driver had the code since no staff indicated they had helped her out of the building. The Administrator and Maintenance Director are the only two employees that now know the bypass code to the door alarm. The visitors and vendors would no longer have access to the codes. The facility was unable to verify that any staff members had entered Resident B's room during the night shift of 10/11/25 into the morning of 10/12/25. It was the administrator's expectation that staff would check on residents at least every 2 hours during their shift. The facility could only speculate on how Resident B got out of the building and they had no idea how long she was out of the building. During an interview, on 10/30/25 at 9:20 a.m., The Maintenance Director indicated before the elopement incident he was doing each exterior door check and courtyard door weekly. Since the elopement he had been doing them daily. He tried over 30 times to recreate the instance of the elopement and could not re-create it. The front door was latching correctly during his weekly and daily checks. The facility did have a company come out and run different tests and they were not able to recreate it either. The magnet lock at the top of the door was the only thing they could come up with that was even a possibility that may not have latched completely. The only thing the Maintenance Director noticed was if there was any pressure placed on the top part of the door when it was opened, there was sometime a tiny gap at the top. The facility had the mag lock repaired just to ensure it could not happen again. Review of exterior and courtyard door check logs, dated 8/15/25 until 10/30/35, it was logged by the Maintenance Director that all the doors were functioning as they should. During an interview, on 10/30/25 at 2:08 p.m., RN 17 indicated that when she checks the WanderGuard, she would have a resident who was wearing one go close to a door and see if the alarm goes off. If the alarms sound, then she would document in the Treatment Administration Record (TAR) that it was functioning. During an interview, on 10/30/25 at 2:10 p.m., CNA 14 indicated she was told if a resident had a WanderGuard and they walked up to a door a different alarm would sound. She was educated on the alarms, but she was not sure when but thought it may have been during her orientation. During an interview, on 10/30/25 at 2:13 p.m., Qualified Medication Aide (QMA) 12 indicated she was not aware if it was within her scope of practice to check the WanderGuard functioning. During an interview, on 10/30/25 at 2:14 p.m., Licensed Practical Nurse (LPN) 11 indicated she would check the WanderGuard by verifying it was in place. If Resident B tried to open a door it would sound an alarm and she also thought it would sound if she got too close to the door. During an interview, on 10/30/25 at 2:15 p.m., CNA 13 indicated she had been told about the WanderGuard and the alarm recently, but she was unsure when. During an interview, on 10/30/25 at 2:16 p.m., CNA 16 indicated she did not know if the elopement information was on the point of care tasks in the medical record or not.Reviewed a list of resident's who were identified as being an elopement risk from the facility, the list identified Residents B, C, D, and E were at risk. Review of the point of care tasks in the medical record on 10/29/25 at 3:30 p.m., lacked documentation of Residents C, D, and E were an elopement risk. On 10/30/25 at 8:18 a.m., the Administrator provided a document, titled, Alarm Use, dated 12/12/23, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure.1.e. Wander/elopement alarms - includes devices such as bracelets, pins/buttons worn on the resident's clothing, sensors in shoes, or building/unit exit sensors worn/attached to the resident that alert staff when the resident nears or exits an area or building. This includes devices that are attached to the residents' assistive device (e.g., walker, wheelchair, cane) or other belongings.3. Identification of risk. A. Each resident shall be assessed for fall are elopement risk upon admission and periodically thereafter as part of the comprehensive assessment process.5. Implementation of interventions.d. Interventions shall be communicated to all relevant staff, including frequency/time frames and responsibility. 6. Monitoring and modification.b.ii. Verifying alarms are working properly.On 10/30/25 at 8:18 a.m., the Administrator provided a document, titled, Elopement and Wandering, dated1/2/2024, and indicated it was the policy currently being used by the facility. The policy indicated, .This facility ensures that the residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents.Procedure 1. The facility is equipped with door locks/alarms to help avoid elopements.3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering.implementing interventions to reduce hazards and risks, and monitoring for effectiveness.4. Monitoring and Managing Residents at Risk for Elopement or Unsafe wandering.c. Interventions to increase staff awareness of the resident's risk, modify the residents' behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff.d. Adequate supervision will be provided to help prevent accidents or elopements.5. Procedure for Locating Missing Resident.c. If the resident is not located in the building or the grounds, Administrator or designee will notify the police department and serve as the designated liaison between the facility and the police department.On 10/30/25 at 8:18 a.m., the Administrator provided a document, titled, Incidents Accidents and Supervision, dated 2/2/24, and indicated it was the policy currently being used by the facility. The policy indicated, .Definitions.Accident refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident.Hazards refers to elements of the resident environment that have the potential to cause injury or illness.6. IN the event of an incident or accident, immediate assistance will be provided to ensure the ensure the safety and environment are secured for anyone with the potential to be affected.Supervision.The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes.4. Monitoring for effectiveness and modifying interventions when necessary.1. Supervision-Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate or increased supervision to prevent accidents.The immediate jeopardy that began on 10/11/25 was removed on 10/31/25, when the facility ensured a systemic plan to include education and monitoring of staff to ensure staff provided supervision and required care to all residents residing at the facility. The noncompliance remained at the lower scope and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need for continued monitoring.3.1-45(a)

Based on record review and interview, the facility failed to ensure a dedicated Infection Preventionist (IP-a healthcare professional who specializes in preventing the spread of infections within healthcare facilities) was designated to oversee the facility's Infection Prevention program. Findings include: During the entrance conference, on 6/19/25 at 10:00 a.m., Registered Nurse (RN) 11's certification of completion of the IP curriculum was provided. The RN was indicated as the dedicated IP for the facility. Review of entrance conference document of QAPI (Quality Assurance and Performance Improvement, the data-driven approach used, especially in healthcare settings like nursing homes, to ensure safety and improve the quality of care and services) Committee Membership lacked documentation of the IP being part of the QAPI Committee. The Facility Assessment, dated 3/2025 through 3/2026, indicated the IP was to be an RN and be a full-time employee. The QAPI Committee Meeting sign-in sheets, dated 4/29/25 and 5/27/25, lacked documentation that a dedicated IP was in attendance at the meetings. During an interview, on 6/25/25 at 9:46 a.m., the Director of Nursing (DON) indicated RN 11 was the facility's IP. She was a full-time nurse that works 4-5 days a week on the floor. She worked both on the floor and as the IP. On the days when they had enough floor nurses, the RN was able to focus on the infection control program fully. She would do the best she could on the days when she had to work the floor as well. During an interview, on 6/25/25 at 9:49 a.m., the Administrator (ADM) indicated she was aware that the facility assessment indicated the IP nurse should be full-time in the building. RN 11 had elected to step away from the IP position about two and one-half months ago and had went to be a nurse on floor full-time. The RN was attempting to do both jobs until they found someone to assume the IP position. The corporate nurse consultant was IP certified and was in the building 1-2 days a week, but had to focus on other things rather than fully the IP program. The corporation did have a IP consultant. He would be at the facility from time-to-time, but not regularly. During an interview, on 6/25/25 at 10:22 a.m., the DON indicated they had been using the corporate nurse consultant and the corporate IP nurse to maintain the facility's infection control program. When the corporate IP was in the building, he did focus specifically on the IP program, but he was not at the facility all that often. The nurse consultant was in the building more frequently, but focused on other issues along with IP when she was present. During an interview, on 6/25/25 at 10:52 a.m., RN 11 indicated she had stepped down from the IP position in early April. She was currently helping as she was able by answering questions, but her primary duty was working as a nurse on the floor. She had attended the QAPI meetings until she stepped down as the IP. The nurse Consultant was the one that currently maintained the binder, but when she was at the facility she did have other responsibilities than the infection control program. During an interview, on 6/25/25 at 11:37 a.m., the ADM indicated the facility policy was that the would follow the regulation regarding having a IP to manage the facility's infection control program.

Based on observation, interview, and record review, the facility failed to ensure a sanitary area for handwashing, the dishwasher functionality was effectively checked, foods were covered when stored, and foods were discarded once past the best if used by date. This deficient practice had the potential to effect 61 of 61 residents who received food from the kitchen. Findings include: During a kitchen observation, on 6/19/25 at 10:05 a.m., with the Culinary Manager, the handwashing sink had a trash cans nearby, but the trash can had a lid affixed to the top with no hands free way to open the trash can. The Culinary Manager indicated the dishwasher sanitized dishes through chemical sanitation. When the functionality of the dishwasher was tested, the Culinary Manager placed a thermometer in the dishwasher to check the highest temperature reached during the run cycle. The thermometer registered 121.4 degrees Fahrenheit (F) as the highest temperature reached. The Culinary Manager indicated there were no chemical test strips available to check the parts per million (ppm) concentration of the sanitizing agent in the dishwasher, and he had not been told it needed to be checked. He normally just checked the highest temperature reached with each meal. There were no dishwasher testing logs readily available in the kitchen. During the same kitchen observation, the reach in cooler contained strawberry yogurt, opened on 5/27/25, with a best if used by date of 5/29/25. A bowl of vegetable soup was dated sometime in April with an illegible day. A dish of spaghetti sauce was made on 6/12/25, with a remove by date of 6/16/25. An open and uncovered package of mozzarella cheese. A dish of food with an employee's name on it was undated. An unopened package of broccoli had a best if used by date of 6/6/25. The walk in cooler contained an opened container of pesto with a best if used date of 6/18/25. A container of mixed vegetables had a best if used by date of 6/13/25. A container of garlic in oil had a best if used by date of 5/25/25. A box of fresh broccoli was folded over but not completely covered. A container of alfredo sauce had a best if used by date of 6/13/25. An opened can of cheddar sauce had an arrival date of 5/22/25 but did not indicate what date it was opened or when it needed to be used by. At the same time, the Culinary Manager indicated food items should have been dated upon arrival and when opened and should have been discarded when they reached the best if used by date. On 6/19/25 at 3:09 p.m., the Administrator provided a document titled, Low Temperature Dish Machine Log, and indicated it was the documentation the dishwasher had been checked. From 6/1/25 to 6/19/25, the dishwasher was checked with each meal. Every check indicated the wash and rinse temperatures were 120 degrees F, and the chemical concentration was 50 ppm. During a second dishwasher observation, on 6/20/25 at 9:02 a.m., the Culinary Manager used a chemical test strip and checked the chemical concentration of the sanitizer in the dish machine during a run cycle. The Culinary Manager indicated the strip showed the sanitizer was between 50 and 100 ppm, which was the level it was required to be. On 6/20/25 at 1:40 p.m., the Administrator provided an Safety Data Sheet and indicated it was for the chemical used in the dishwasher to sanitize dishes. The Safety Data Sheet was for chlorine sanitizer. On 6/20/25 at 1:40 p.m., the Administrator provided an undated document titled, Culinary & Nutrition Services Dish Machine Operations Skills Validation, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure Steps: Dishes and cookware will be washed after each use to assure they are clean and sanitary. Skill .3. Verifies chemical levels (detergent, sanitizer) and proper temperatures .9. Uses test strips to verify sanitizer level meets standards On 6/23/25 at 12:11 p.m., the Administrator provided a document titled, Kitchen Sanitation, dated 1/2/24, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy: The Dietary Manager will be responsible for overseeing the provision of safe food to all residents. Procedure .Dishwashing procedures and techniques will be understood by staff and carried out in compliance with the state and local health codes On 6/23/25 at 2:05 p.m., the Administrator provided a document titled, Safe Food Handling, last revised on 2/5/25, and indicated it was the policy currently being used by the facility. The policy indicated, .1. Purpose: To provide Care Team Members the best practices for handling of food .4. Policy .F .Leftover foods will be protected, labeled and dated with the date of original preparation and date of discard 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure an insulin pen medication was labeled to indicate date opened during 1 of 2 medication cart observations (Resident 29). Findings include: On 6/25/25 at 9:05 a.m., observed the East back hall medication cart, with Licensed Practical Nurse (LPN) 4. Observed an insulin pen labeled Lantus Insulin prescribed for Resident 29. The insulin pen (an injection device that you can use to deliver preloaded insulin into your subcutaneous tissue, the innermost layer of skin in your body) was dispensed from the pharmacy on 5/31/25. The pen had been opened and used and was not dated. On 6/25/25 at 9:08 a.m., during an interview LPN 4 acknowledged the insulin pen must be dated when opened. On 6/25/25 at 9:54 a.m., the medical record of Resident 29 was reviewed. The resident was admitted to the facility on [DATE]. Admitting diagnosis included but was not limited to Type 2 diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high). A physician order, dated 5/31/25, indicated to administer Lantus SoloStar 100 unit/ml (milliliter) solution pen-injector inject 15 units sub-Q (subcutaneous ) twice daily for diabetes. On 6/25/2025 at 11:14 a.m., the Administrator provided a document titled, Labeling of medication, dated 2/1/2028, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure .3) Multi-dose medication vials/devices .a. Should be labeled with date opened/accessed .ii. Once opened/accessed the vial/device should be dated and discarded within 28 days unless manufacturer specifies a different (shorter or longer) date for vial/device after opened/accessed 3.1-25(j) 3.1-25(m) 3.1-25(n)

Based on record review and interview, the facility failed to ensure a physician's order was accurately transcribed from a pharmacy recommendation for 1 of 5 residents reviewed for unnecessary medications (Resident 38). Findings include: Resident 38's record was reviewed on 6/23/25 at 9:50 a.m. Diagnoses on the resident's profile included, but were not limited to, panic disorder, anxiety disorder, and post traumatic stress disorder (PTSD) (a mental health condition that can develop after experiencing or witnessing a traumatic event). A quarterly Minimum Data Set (MDS) assessment, dated 3/28/25, indicated the resident was cognitively intact and received an antianxiety medication during the assessment look-back period. A care plan, last revised on 9/11/24, indicated the resident exhibited behavior symptoms of paranoia, anxiety, and depression. Interventions included, but were not limited to, administer medications as ordered. A pharmacy recommendation, dated 6/3/25, indicated the resident received lorazepam (antianxiety medication) 1 milligram (mg) twice daily for panic disorder, anxiety disorder, and PTSD. The pharmacist recommended a gradual dose reduction (GDR) to lorazepam 0.5 mg twice daily. The Nurse Practitioner (NP) agreed with the recommendation and signed the form on 6/4/25. A physician's order, dated 12/4/24 and discontinued on 6/4/25, indicated lorazepam 1 mg twice daily for panic disorder, anxiety disorder, and PTSD. A physician's order, dated 6/4/25, indicated lorazepam 0.5 mg once daily at bedtime for anxiety. A progress note, dated 6/14/25, indicated the resident had anxiety related to the GDR of his lorazepam. The resident was anxious, pacing, and nervous. A progress note, dated 6/15/25 at 11:03 a.m., indicated the resident had been resting that morning and refused to go to an activity he normally enjoyed related to his anxiety. A progress note, dated 6/15/25 at 5:24 p.m , indicated the resident was anxious related to the GDR of his lorazepam. The resident was anxious, pacing, and nervous. During an interview, on 6/23/25 at 3:28 p.m., the Director of Nursing (DON) indicated she reviewed the lorazepam GDR, and there had been a transcription medication error. The physician's order should have been written for lorazepam 0.5 mg twice daily, as indicated on the pharmacy recommendation, but it was instead written for lorazepam 0.5 mg once daily at bedtime. On 6/24/25 at 10:07 a.m., the DON provided a document titled, Medication Error, dated 1/2/24, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure: 1. The facility shall ensure medications will be administered as follows: a According to physician's orders 3.1-25(i)

Based on observation and interview, the facility failed to ensure infection control procedures were followed to prevent possible contamination of work surfaces with potential to affect residents for 1 of 1 glucometer (a small, portable device that measures the amount of glucose (sugar) in your blood) test observation. (Resident 39 Findings include: On 6/24/25 at 11:30 a.m., observed Licensed Practical Nurse (LPN) 8 administer a blood sugar assessment with a glucometer machine to Resident (39). The nurse obtained the glucometer device and donned (put on) clean gloves. She placed the glucometer on the resident's overbed table. The nurse failed to place a barrier between the glucometer and the resident's overbed table. The nurse completed the blood sugar assessment and cleaned the resident's finger of residual blood. The nurse picked up the glucometer and placed it on the top of the medication cart without a barrier between the glucometer and the cart. She removed her soiled gloves and discarded them into the trash. She opened a canister of Micro Kill One wipes. She left the wipes canister open to the air with several wipes outside of the canister and returned to the medication cart. She wiped the glucometer off for 5 seconds and wrapped the same wipe around the device and set the glucometer aside. She then sanitized her hands with disinfectant spray but did not sanitize the top of the medication cart. On 6/24/25 at 11:35 a.m., during an interview LPN 8 acknowledged she should have placed a barrier under the glucometer on the overbed table and the medication cart. She indicated the device must be cleaned for 2 minutes with the disinfecting wipe and then wait 5 minutes before using the glucometer again for another resident. On 6/24/25 at 11:40 a.m., during an interview the unit manager acknowledged the Micro Kill wipes must be covered. She acknowledged the glucometer must be cleaned and remain visibly wet for 1 minute. The micro Kill disinfecting wipes directions of use indicated. Prepare the Surface: Remove any visible debris or soil from the surface you intend to disinfect. Open the canister of Micro Kill wipes. Remove one wipe and thoroughly wipe the surface, ensuring it remains visibly wet for the required contact time of 1 minute. Depending on the specific organism you are targeting, the contact time may vary from 30 seconds to 3 minutes. Refer to the product label for specific instructions. Allow to Air Dry: Do not rinse or wipe off the disinfectant. Allow the surface to air dry completely. On 6/24/2025 at 12:04 p.m., the Director of Nursing (DON) provided a document, titled, Glucometer Cleaning, dated 2/1/2025, and indicated it was the policy currently being used by the facility. The policy indicated, .4. Policy A. [NAME] Care will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident/patient use .5 .G. Remove and discard gloves, perform hand hygiene prior to exiting the room .I. Retrieve (2) disinfectant wipes from container. J. using first wipe, clean first to remove heavy soil, blood and /or other contaminants left on the surface of the glucometer. K. After cleaning, use second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, following the manufacturer's instructions 3.1-18(a)

Based on observation, record review, and interview, the facility failed to ensure nail care was provided for a resident who required assistance with activities of daily living (ADLs) for 1 of 24 residents reviewed for ADLs (Resident B). Findings include: On 6/19/25 at 11:23 a.m., Resident B was observed lying in bed. The resident's fingernails on both hands were untrimmed with dark debris underneath them. At the same time, the resident indicated the staff did not clean her nails very often. On 6/23/25 at 9:04 a.m., Resident B was observed lying in bed. The resident's fingernails on both hands were untrimmed with dark debris underneath them. On 6/25/25 at 9:21 a.m., Resident B was observed lying in bed. The resident's fingernails on both hands were untrimmed with dark debris underneath them. Resident B's record was reviewed on 6/24/25 at 1:37 p.m. Diagnosis on the resident's profile included, but were not limited to, multiple sclerosis (chronic, debilitating disease that affects the central nervous system). A care plan, initiated on 5/3/25, indicated the resident required assistance with ADLs. Interventions included, but were not limited to, nail care on bath day and as necessary. A quarterly Minimum Data Set (MDS) Assessment, dated 5/20/25, indicated the resident had a moderate cognitive impairment and was dependent for ADLs. Shower sheets indicated the resident was bathed on 6/3/25, 6/6/25, 6/10/25, 6/13/25, 6/17/25, and 6/20/25. The shower sheets indicated the resident received nail care on 6/3/25, 6/13/25, and 6/17/25. The shower sheets, dated 6/6/25, 6/10/25, and 6/20/25, lacked documentation nail care was offered or refused. Progress notes, dated June 2025, lacked documentation the resident refused nail care. During an interview, on 6/25/25 at 9:23 a.m., Licensed Practical Nurse (LPN) 7 indicated nail care should have been done with each bath and as needed. On 6/25/25 at 9:48 a.m., the Administrator provided a document titled, Fingernails/Toenails, Care of, revised in February of 2018, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections .General Guidelines: 1. Nail care includes daily cleaning and regular trimming .Steps in the Procedure .10. Gently, remove the dirt from around and under each nail with an orange stick .Documentation: The following information should be recorded in the resident's medical record: 1. The date and time that nail care was given This citation relates to Complaint IN00460327. 3.1-38(a)(3)(E)

2. During the initial pool interview, on 6/19/25 at 11:12 a.m., Resident E indicated he was supposed to get two showers a week and had not had any this current week and only one the week before. The aides were asking him to sign off the shower sheet even though he was not getting one. Resident E's record was reviewed on 6/23/25 at 10:11 a.m. The profile indicated the resident had been admitted to the facility on [DATE], for diagnoses which included, but were not limited to, hemiplegia and hemiparesis due to cerebral infarction (weakness or paralysis on one side of the body caused by damage to the brain from a stroke). An admission Minimum Data Set (MDS) assessment, dated 6/6/25, indicated the resident had no cognitive deficit and no documentation for refusal of care. A care plan, dated 6/11/25, indicated the resident required assistance with activities of daily living (ADLs-basic tasks that individuals perform to maintain their daily life and care for themselves). Interventions included, but were not limited to, required staff assistance with bathing/showering and personal hygiene. An activity interview for daily and activity preferences document, dated 6/6/25, indicated the resident felt it was very important to choose between a tub bath, shower, bed bath, or sponge bath. A resident preference task document indicated the resident showers preference were on Tuesday and Friday evenings. The point of care (POC) documentation in the medical record (documentation recorded by the Certified Nursing Assistant [CNA] which documented the care that was provided to the resident), indicated the resident was scheduled to have 7 showers administered from 6/1/25 to 6/24/25. The record indicated the resident had received 3 completed showers, had refused 2 showers, and had 1 shower marked NA (not applicable) with no justification for the mark of NA. Review of shower sheets, provided by the Administrator, on 6/24/25 at 2:10 p.m., indicated the following: a. 6/2/25: The document indicated the resident had refused the shower request. The resident had signed the document. b. 6/6/25: The document indicated the resident had refused the shower request. The document lacked a signature from the resident. c. 6/10/25: The document indicated the resident had refused the shower request. The resident had signed the document. d. 6/12/25: The document indicated the resident had refused the shower request. The resident had signed the document. e. 6/13/25: The document indicated the resident had received a shower. The resident had signed the document. f. 6/17/25: The document indicated the resident had refused the shower request. A handwritten note on the document indicated the resident had refused due to the preference of aide. The document indicated the resident had refused to sign. g. 6/19/25: The document indicated the resident had received a shower. The resident had signed the document. h. 6/20/25: The document indicated the resident had refused the shower request. The document lacked a signature from the resident. 3. During observation of the lunch meal service, on 6/19/25 at 12:50 p.m., Resident C was observed with dark debris under her fingernails. Resident C's record was reviewed on 6/23/25 at 11:14 a.m. The record indicated the resident's diagnoses included, but were not limited to, paroxysmal atrial fibrillation (where episodes of irregular heart rhythm start and stop suddenly, either on their own or with treatment, and typically last for less than 7 days) and congestive heart failure (CHF-when the heart muscle doesn't pump blood as efficiently as it should, leading to a buildup of fluid [congestion] in the body). A significant change Minimum Data Set (MDS) assessment, dated 1/17/25, indicated the resident had moderate cognitive deficit and had no documented rejection of care behaviors. A care plan, with a revision dated of 2/5/25, indicated the resident required assistance with activities of daily living (ADLs-basic tasks that individuals perform to maintain their daily life and care for themselves). Interventions included, but were not limited to, required staff assistance with bathing/showering and personal hygiene. A resident preference task document indicated the resident preference was for bed baths on Mondays day shift and a shower on the day shift every Friday. The point of care (POC) documentation in the medical record (documentation recorded by the Certified Nursing Assistant [CNA] which documented the care that was provided to the resident), indicated the resident was scheduled to have 9 bed baths/showers administered from 5/26/25 to 6/23/25. The record indicated the resident had received 5 bed baths and 2 showers during that time period. The record lacked documentation of any refusals of care. Review of shower sheets, provided by the Administrator, on 6/24/25 at 2:10 p.m., indicated the following: a. 6/2/25: The document indicated the resident had received a bed bath, was shaved, and linens were changed. The resident had refused a shower, nail care or having her hair washed. The document indicated the resident was unable to provide a signature. b. 6/6/25: The document indicated the resident had received a bed bath, nail care, and linens were changed. The resident had refused a shower or having her hair washed. The document indicated the resident was unable to provide a signature. c. 6/9/25: The document indicated the resident had received a bed bath. The resident had refused a shower or having her hair washed. The document indicated the resident was unable to provide a signature. d. 6/13/25: The document indicated the resident had received a bed bath. The resident had refused a shower or having her hair washed. The document indicated the resident was unable to provide a signature. e. 6/16/25: The document indicated the resident had received a bed bath, nail care, and linens were changed. The resident had refused a shower or having her hair washed. The document indicated the resident was unable to provide a signature. f. 6/20/25: The document indicated the resident had received a bed bath, nail care, had her hair washed, and linens were changed. The document indicated the resident was unable to provide a signature. The record lacked documentation that the resident had not had her hair washed from 5/26/25 to 6/16/25. The record lacked documentation that the resident had nail care completed from 5/26/25 to 6/13/25. During an interview, on 6/23/25 at 3:18 p.m., the ADM indicated the shower sheets, completed by the CNA's were not a part of the medical record , but were kept separately for internal tracking. During an interview, on 6/24/25 at 9:10 a.m., CNA 5 indicated the aides complete both a shower sheet and would also put the information in the POC system. The dates for the shower sheets and the POC should always match the dates the residents received their showers or bed baths and other care was provided. During an interview, on 6/24/25 at 9:22 a.m., CNA 6 indicated the CNAs would put the shower/bed bath information on both shower sheets and into the POC system. Nail care, washing the resident's hair, and changing bed linen, were all part of the shower/bed bath process. During an interview, on 6/24/25 at 9:46 a.m., Unit Manager 7 indicated the resident were all scheduled for 2 showers a week, but if they requested more, the staff would make sure they received what they wanted. On 6/24/25 at 10:40 a.m., the Director of Nursing (DON) provided a document, dated 1/2/24, titled, Showers, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure: 1. Residents will be provided showers as per request or as per facility schedule protocols This citation relates to Complaint IN00460327. 3.1-3(u)(1) Based on record review and interview, the facility failed to ensure showers were provided to residents based on their preferences for 3 of 24 residents reviewed for choices (Residents B, E, and C). Findings include: 1. Resident B's record was reviewed on 6/24/25 at 1:37 p.m. Census information indicated the resident was admitted to the facility on [DATE]. Diagnosis on the resident's profile included, but were not limited to, multiple sclerosis (chronic, debilitating disease that affects the central nervous system) and nondisplaced transverse fracture (a break in a bone where the two pieces remain aligned and haven't moved out of place) of left patella (knee cap). A care plan, initiated on 5/3/25, indicated the resident required assistance with ADLs. A quarterly Minimum Data Set (MDS) assessment, dated 5/20/25, indicated the resident had a moderate cognitive impairment and was dependent for activities of daily living (ADLs). A physician's order, dated 5/22/25, indicated the resident was to receive a bed bath only, no showers. The current bathing tasks section of the resident's electronic medical record indicated the resident was scheduled for a shower on Tuesdays and Fridays on day shift. The bathing task history, dated June 2025, lacked documentation the resident received any showers. Shower Sheets indicated the resident received a bed bath on 6/3/25, 6/6/25, 6/13/25, 6/17/25, 6/20/25, and a shower on 6/10/25. Progress notes, dated June 2025, lacked documentation the resident refused showers. During an interview, on 6/24/25 at 2:08 p.m., the Director of Nursing (DON) indicated the physician's order for the resident to receive bed baths only was old and should have been removed from the chart. It was in place after the resident was admitted due to her being being post operative after the repair of her patella fracture, but she was cleared by the orthopedic doctor to shower. The DON indicated they asked each resident or their representative how often and what shift the resident wanted to be showered and updated the information in the tasks section of the electronic medical record. The shower schedule in the tasks portion of the chart was the resident's stated preference. During an interview, on 6/25/25 at 9:23 a.m., Licensed Practical Nurse (LPN) 7 indicated the resident was not scheduled for showers and received bed baths only. She did not indicate why the resident's stated preference indicated she wanted showers twice weekly in the tasks section of the chart if she only received bed baths. During an interview, on 6/25/25 at 9:56 a.m., the Administrator indicated there was no specific facility policy for how resident preferences were documented, but the tasks section of the record should have been consistent with the resident's stated bathing preference.

Based on observation, record review, and interview, the facility failed to ensure a resident's call light was kept within their reach for 1 of 24 residents reviewed for call lights (Resident B). Findings include: On 6/19/25 at 11:24 a.m., Resident B was observed lying in bed. The resident's call light was hanging off the side of the bed, nearly touching the floor. At the same time, the resident indicated she was not sure where the call light was or how she would call for assistance if needed. On 6/23/25 at 9:04 a.m., Resident B was observed lying in bed with the call light within reach. At the same time, the resident indicated she used the call light to call for assistance when needed and grabbed the call light to demonstrate. On 6/25/25 at 9:21 a.m., Resident B was observed lying in bed. The resident's call light was hanging off the side of the bed, approximately halfway to the floor. At the same time, the resident indicated she was not sure where her call light was and felt around with her right hand but was unable to find it. Resident B's record was reviewed on 6/24/25 at 1:37 p.m. Diagnosis on the resident's profile included, but were not limited to, multiple sclerosis (chronic, debilitating disease that affects the central nervous system). A quarterly Minimum Data Set (MDS) assessment, dated 5/20/25, indicated the resident had a moderate cognitive impairment and was dependent for activities of daily living (ADLs). A care plan, initiated on 6/3/25, indicated the resident was at risk for falls. Interventions included, but were not limited to, keep call light within reach. During an interview, on 6/25/25 at 9:23 a.m., Licensed Practical Nurse (LPN) 7 indicated the resident was able to use the call light to call for assistance, and it should have been kept within her reach. During an interview, on 6/25/25 at 9:56 a.m., the Administrator indicated call lights should have been kept within reach. On 6/25/25 at 10:48 a.m., the Administrator provided a document titled, Call Lights, dated 1/2/24, and indicated it was the policy currently being used by the facility. The policy indicated, .5. Staff will ensure the call light is within reach of resident and secured, as needed This citation relates to Complaint IN00460327. 3.1-3(v)(1)

Based on record review and interview, the facility failed to ensure a resident was transferred in a safe manner for 1 of 1 residents reviewed for transfers (Resident C). Findings include: Resident C's record was reviewed on 8/20/24 at 10:47 a.m. The profile indicated the resident's diagnoses included, but were not limited to, traumatic subdural hemorrhage (a type of traumatic brain injury [TBI] that occurs when blood leaks into the subdural space between the brain and the skull after a head injury), history of motor vehicle accident with multiple injuries, and generalized muscle weakness. A quarterly Minimum Data Set (MDS) assessment, dated 7/22/24, indicated the resident had no cognitive deficit and required the extensive assistance of 2 or more persons with transfers. A care plan, dated 12/31/23, indicated the resident required assistance with activities of daily living (fundamental skills required to independently care for oneself, such as eating, bathing, and mobility) due to limited mobility related to multiple fractures related to a motor vehicle collision. Interventions included, but were not limited to, staff assistance with transfers and use Pivot Disk (a device that helps individuals with limited mobility transfer from one chair to another with minimal physical effort) to maximize independence with transferring. A functional abilities and goals assessment, dated 4/25/24, indicated the resident was substantial/maximal assistance with chair to bed or bed to chair transfers. Review of the Point of Care (POC) Response History (documents the amount of transfer support provided to the resident), dated 7/22/24 through 8/19/24, indicated out of 69 documented transfer attempts, 41 transfers were documented as 2-person transfers, 3 transfers were documented a 1-person transfer, and 25 attempts were documented as activity did not occur. A CNA Assignment sheet, with an updated date of 8/9/24, indicated the resident required extensive assistance and Pivot Disk with transfers. A risk management fall document was provided by the Director of Nursing (DON) on 8/20/24 at 2:26 p.m. The document, dated 7/25/24 at 6:28 p.m., indicated a CNA was transferring the resident from bed to wheelchair when the resident became unsteady, and the CNA attempted to her regain her balance. The CNA lost his balance and attempted to pivot back to the bed, but the bed moved causing both the resident and CNA to fall. A skin tear on the resident had been measured and covered. The resident's family, physician, and the DON had been notified. The document lacked any documentation of 2 staff providing the transfer assistance or of a Pivot Disk being used during the transfer. During an interview, on 8/20/24 at 12:01 p.m., CNA 3 was in Resident E's room at the time of the interview. She indicated they had problems with the older beds locking for transfers. At the same time, she gave a demonstration of Resident E's bed lock mechanism, and the bed locking mechanism failed to lock into place. She had reported that many of the bed locks were not working properly, but she was not sure anything had ever been done. She indicated that Resident C was to be a 2-person transfer. She denied ever using the Pivot Disk when transferring Resident C. During an interview, on 8/20/24 at 12:05 p.m., CNA 4 indicated she too had problems with some of the beds not locking into place. She had worked with Resident C in the past and explained that the resident was an assist of 2 with transfers and the use of a gait belt. She had never used a pivoting device when transferring the resident. During an interview, on 8/20/24 at 12:08 p.m., Resident C indicated the CNAs don't use the pivot device when transferring her. At the same time, the wheels on the resident's bed were observed to be in the locked position, and the locking mechanism was functional. During an interview, on 8/20/24 at 1:05 p.m., the Maintenance Director indicated he had only been working at the facility for a few weeks. In that time, he had been notified of and repaired one bed lock. He indicated often the lock pins sheer off due to the beds being so old. He would repair any that would be brought to his attention by a work order. During an interview, on 8/20/24 at 2:27 p.m., the DON indicated the resident was a 2-person transfer. On some days she would be strong enough for 1 person to assist her. The staff no longer used the pivot device because the resident was not steady enough to use the device safely. She was not aware about concerns that the beds were not locking appropriately. During a telephone interview, on 8/20/24 at 2:59 p.m., Certified Occupational Therapy Assistant (COTA) 9 indicated the therapy staff had trained the nursing staff on use of the Pivot Disk. However, the resident would only allow the therapy staff to use the device on her. She was fearful about allowing anyone else to use the device with her. During an interview, on 8/20/24 at 3:28 p.m., the Administrator (ADM) indicated staff should always use the proper number of staff designated for a resident, when transferring the resident. If the MDS assessment indicated the resident was a two-person transfer, two persons should be used. On 8/20/24 at 3:05 p.m., the ADM provided a document, dated 12/12/23, titled, Transfer & Mechanical Lifts, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize the risk of injury and to provide and promote a safe, secure, and comfortable experience for the resident .Procedure: .5. Handling aids may include gait belt, transfer boards, and other devices .14. Resident lifting and transferring will be performed according to the resident's individual plan On 8/20/24 at 3:05 p.m., the ADM provided a document, dated July 2017, titled, Safe Lifting and Movement of Residents, and indicated it was the policy currently used by the facility. The policy indicated, .Policy Interpretation and Implementation .3. Nursing staff in conjunction with the rehabilitation staff, shall assess individual residents need for transfer assistance on an ongoing basis .4. Staff responsible for direct resident care will be trained in the use of .lifting devices This citation relates to complaint IN00439730. 3.1-45(a)(2)

Based on interview and record review, the facility lacked documentation of showers being provided related to resident preferences for 3 of 24 residents reviewed for choices (Residents 57, 14, and 11). Findings include: 1. During an interview, with Resident 57's wife, on 6/3/24 at 2:05 p.m., she indicated the resident was not getting the number of showers that he and she preferred. He should be getting 2 showers a week but most often he had only been getting 1 per week. Resident 57's record was reviewed on 6/6/24 at 11:09 a.m. The profile indicated the resident had been admitted on [DATE], for diagnoses which included, but were not limited to, fracture of the right pubis (a type of crack or break in a person's pelvis), cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). An admission Minimum Data Set (MDS) assessment, dated 4/17/24, indicated the resident had severe cognitive deficit and required extensive assistance with his activities of daily living (ADLs-activities related to personal care). The MDS lacked documentation of any behaviors for rejection of care. A care plan, with a revision date of 6/4/24, indicated the resident had personal preferences. A goal with a target date of 8/13/24, indicated staff would honor the resident's preferences. Interventions included, but were not limited to, the resident would like a shower on Monday and Friday evenings, as he prefers. The resident's April and May 2024 shower sheets lacked documentation of any showers being provided or of any refusals of care. The shower sheets indicated the following: a. A bed bath without washing the resident's hair was provided on 4/12/24. b. A bed bath without washing the resident's hair was provided on 4/19/24. c. A bed bath without washing the resident's hair was provided on 4/22/24. d. A bed bath without washing the resident's hair was provided on 4/29/24. e. A bed bath without washing the resident's hair was provided on 5/6/24. On 6/6/24 at 10:45 a.m., review of the March through May 2024, Resident Council meeting minutes indicated concerns had been raised by the Council members about residents not receiving their showers. During an interview, on 6/6/24 at 11:56 a.m., Unit manager 14 indicated the resident did not wish to get out of bed for a shower, so he was given a bed bath. She was not aware why the shower sheets did not indicate he had refused to get out of bed. She believed the staff needed to be educated on how to accurately document shower sheets. During an interview, on 6/7/24 at 2:19 p.m., the Executive Director (ED) indicated that the issue of the resident's showers had been taken on as a performance improvement project (PIP) for the Quality Assurance Performance Improvement (QAPI) committee as an area of concern. 49068 2. During the initial interview with Resident 14, on 6/3/24 at 1:48 p.m., she indicated staff had not been providing her showers very often, and her last shower was on 5/27/24. Her shower days were supposed to be in the evenings on Tuesdays and Saturdays. At one point she had gone about a month without a shower because staff would tell her they would return to give her one, and never came back. Resident 14's record was reviewed on 6/6/24 at 9:48 a.m. Her diagnoses included, but were not limited to, dementia (loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) with late onset, unspecified lack of coordination (poor muscle control that causes clumsy movements that can affect walking and balance), and unsteadiness on feet (a pattern of walking that is unstable). A care plan, dated 11/28/23, indicated staff would honor the personal preferences the resident had indicated to be important to her. The interventions included, but were not limited to, Resident 14 preferred to have a shower on Tuesdays and Saturdays in the evenings. A Minimum Data Set (MDS) assessment completed for payment assessment, dated 5/20/24, indicated Resident 14's brief interview for mental status (BIMS) score was 11, which indicated moderate cognitive impairment. The MDS assessment indicated that she had not exhibited behaviors for rejecting care. 3. During the initial interview with Resident 11, on 6/4/24 at 9:53 a.m., he indicated that he only received showers when staff thought he should, not when he wanted to. Staff would tell him they were going to give him a shower, and then never did. He indicated his shower days were Mondays and Thursdays. Resident 11's record was reviewed on 6/6/24 at 9:17 a.m. His diagnoses included, but were not limited to, difficulty walking, repeated falls, need for assistance with personal care, dizziness and giddiness (a feeling of being unbalanced or lightheaded), Alzheimer's disease with late onset (brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), and fusion of the spine, lumbar region (a surgery technique that connects two or more pieces of the lower back bones). A care plan, dated 8/17/23, indicated staff would honor the personal preferences the resident had indicated to be important to her. The interventions included, but were not limited to, Resident 11 preferred to have a shower on Mondays and Thursdays in the evenings. A quarterly Minimum Data Set (MDS) assessment, dated 4/10/24, indicated Resident 11's brief interview for mental status (BIMS) score was 13, which indicated he was cognitively intact. The MDS assessment indicated that he had not exhibited behaviors for rejecting care. On 6/5/24 at 3:45 p.m., the Assistant Director of Nursing (ADON) provided shower records reports from 3/7/24 to 6/5/24 and indicated all shower/bath documentation was completed electronically. The record lacked documentation of shower/bath completion, or refusal, for 4/4/24 and 5/9/24. During an interview with Unit Manager 14, she indicated that if there were blanks in the shower records, it could have been missed charting, not necessarily that they missed the shower entirely. If a resident had refused their shower, they were to document three attempt refusals. Resident council meeting minutes, dated 3/25/24, indicated that showers were still an issue in old business. In the new business, multiple residents had concerns about not getting showers and bed baths. The response from the department manager, signed by the Administrator (ADM) on 3/30/24 and the Director of Nursing Services (DNS) on 4/1/24, indicated they would look into individual complaints of no showers and that residents should fill out individual grievances. Resident council meeting minutes, dated 4/29/24, indicated that multiple residents had concerns about not getting showers. The response from the department manager, signed by the ADM and DNS on 5/15/24, indicated shower audits were being conducted. Resident council meeting minutes, dated 5/28/24, indicated that multiple residents had concerns about not getting showers. The response from the department manager, signed by the DNS on 5/29/24, indicated individual shower complaints needed to be made and grievance forms were to be handled individually. On 6/6/24 at 1:57 p.m., the DNS provided an undated document, titled, Resident Rights, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy Explanation and Compliance Guidelines . 2. Planning and implementing care . b. The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to . iv. The right to receive the services and/or items included in the plan of care 3.1-3(u)(1)

A. Based on observations, record reviews, and interviews, the facility failed to complete a respiratory assessment on a resident prior to receiving a nebulizer treatment for 1 of 1 resident observed (Resident 8) B. Based on observations, record reviews, and interviews, the facility failed to ensure proper storage of respiratory equipment for 3 of 3 residents reviewed for respiratory care. (Residents 8, 14, and 54). C. Based on observations, record reviews, and interviews, the facility failed to obtain a physician order for oxygen supplementation for 1 of 3 residents reviewed for respiratory care (Resident 14). Findings include: A. During a medication administration observation, on 6/5/24 at 9:15 a.m., Registered Nurse (RN) 13 administered an albuterol nebulization solution (medication used to treat wheezing and shortness of breath caused by breathing problems such as asthma) breathing treatment to Resident 8. The RN did not complete a respiratory assessment prior to administering the nebulizer treatment. Resident 8's record was reviewed on 6/5/24 at 9:45 a.m. The profile indicated the resident's diagnosis included, but were not limited to, chronic obstructive pulmonary disease (COPD- a group of diseases that cause airflow blockage and breathing related problems). A quarterly Minimum Data Set (MDS) assessment, dated 4/27/24, did not indicate the resident was receiving respiratory treatments. A care plan, dated 11/2/23, indicated the resident was at risk for respiratory distress related to COPD. Interventions included, but were not limited to, administer medications as ordered and observe for effectiveness and adverse side effects, administer nebulizer treatments as ordered, and notify medical doctor of changes in respiratory status. A physician order, dated 12/2/23, indicated to administer albuterol sulfate nebulization solution, 2.5 milligrams (mg)/ 3 milliliters (ml) 0.83%., 1 vial orally via nebulizer three times a day. A physician order, dated 11/2/23, indicated to document pulse, respiratory rate, breath sounds, oxygen saturation, and minutes before and after the nebulizer treatment every 6 hours as needed. Resident 8's Medication Administration Record (MAR) lacked documentation of pre and post assessments being completed for the month of May and June 2024. During an interview, on 6/5/24 at 10:00 a.m., Licensed Practical Nurse (LPN) 12 indicated the nursing staff should assess a resident's lungs prior to and after administering a breathing treatment. During an interview, on 6/5/24 at 11:00 a.m., Resident 8 indicated the nursing staff did not assess her lungs before or after administering a breathing treatment. On 6/5/24 at 10:35 a.m., the Assistant Director of Nursing Services (ADNS), provided an undated document as a current facility policy, titled, Nebulizer Therapy. The policy indicated, .6. Obtain resident's vital signs and perform respiratory assessment to establish a baseline .Documentation .4. Resident vital signs and respiratory assessment. 5. Resident's response to treatment B1. On 6/5/24 at 11:00 a.m., Resident 8's unbagged nebulizer mouthpiece and tubing were observed on her bed next to the nebulizer machine. The resident was sitting in her wheelchair next to her bed. On 6/5/24 at 1:26 p.m., Resident 8's unbagged nebulizer mouthpiece and tubing were observed on her bed next to the nebulizer machine. The resident was not currently in her room. On 6/5/24 at 2:59 p.m., Resident 8's unbagged nebulizer mouthpiece and tubing were observed on her bed next to the nebulizer machine. The resident was sitting in her wheelchair next to her bed. On 6/7/24 at 8:44 a.m., Resident 8's unbagged nebulizer mouthpiece and tubing were observed on her bed next to the nebulizer machine. The resident was sitting in her wheelchair next to her bed. On 6/7/24 at 11:57 a.m., Resident 8's unbagged nebulizer mouthpiece and tubing were observed on her bed next to the nebulizer machine. The resident was not currently in her room. Resident 8's record was reviewed on 6/5/24 at 9:45 a.m. The profile indicated the resident's diagnosis included, but were not limited to, chronic obstructive pulmonary disease (COPD- a group of diseases that cause airflow blockage and breathing related problems). A care plan, dated 11/2/23, indicated the resident was at risk for respiratory distress related to COPD. Interventions included, but were not limited to, administer medications as ordered and observe for effectiveness and adverse side effects, administer nebulizer treatments as ordered, and notify medical doctor of changes in respiratory status. A physician order, dated 12/2/23, indicated to administer albuterol sulfate nebulization solution, 2.5 milligrams (mg)/ 3 milliliters (ml) 0.83%, 1 vial orally via nebulizer three times a day. During an interview, on 6/5/24 at 10:00 a.m., Licensed Practical Nurse (LPN) 12 indicated respiratory equipment should be stored in a clear plastic bag after use. 49068 B2. During an initial interview with Resident 54 on 6/4/24 at 11:00 a.m., observed her nebulizer (device that can change liquid medication into a mist) machine on the nightstand table, the assembled mouthpiece and tubing were observed to be sitting on top of the table, unbagged and undated. The resident indicated she had recently received a nebulizer treatment and staff retrieved the mouthpiece and tubing from her when she was finished and placed it on the table. The resident indicated she was unable to reach the nightstand or get out of bed without assistance. On 6/5/24 at 12:01 p.m., observed Resident 54's assembled nebulizer mouthpiece and tubing on the nightstand table, unbagged and undated. On 6/6/24 at 11:56 a.m., observed Resident 54's assembled nebulizer mouthpiece and tubing on the nightstand table, unbagged and undated. On 6/7/24 at 10:07 a.m., observed Resident 54's assembled nebulizer mouthpiece and tubing on the nightstand table, unbagged and undated. On 6/7/24 at 10:59 a.m., observed Resident 54's assembled nebulizer tubing and mouthpiece on the nightstand table with the IP, she indicated that she could not find a dated label or bag for the mouthpiece and tubing, and it should have had both. Resident 54's record was reviewed on 6/6/24 at 2:37 p.m. Her diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD- a group of diseases that cause airflow blockage and breathing related problems), and shortness of breath). A physician's order, dated 1/23/24, indicated to administer albuterol sulfate (a medication used to treat COPD and shortness of breath) nebulization solution, 2.5 milligrams (mg)/ 3 milliliters (ml) 0.083%. Administer 3 ml, inhale orally via nebulizer every six hours as needed for shortness of breath. A physician's order, dated 1/24/24, indicated to replace and date nebulizer tubing and mouthpiece/mask every night shift every Sunday. A care plan, dated 12/31/23, indicated Resident 54 was at risk for respiratory distress related to COPD and inability to lie flat due to causing shortness of breath. Interventions included, but were not limited to, nebulizer treatments as ordered. A quarterly Minimum Data Set (MDS) assessment, dated 4/25/24, indicated Resident 54's brief interview for mental status (BIMS) score was 15, which indicated she was cognitively intact. The MDS indicated the resident required extensive assistance, requiring physical assistance of two or more persons, for transfers. During an interview with Unit Manager 14 on 6/6/24 at 10:30 a.m., she indicated that when nebulizer and oxygen tubing get replaced, staff should put the date on the bag for when it was changed, and the tubing will have tape on it with the date it was changed. During an interview with the Infection Preventionist on 6/7/24 at 10:46 a.m., she indicated that staff should know how to maintain nebulizer and oxygen equipment. Education was provided by method of forms and demonstration for where to put the equipment, how to hook everything up, and how to date everything. The dates were to be written on tape and placed on the tubing. The tubing, masks, and mouth pieces were to be put in the plastic respiratory bag, that were to also be dated. All oxygen and nebulizer supplies were replaced every Sunday evening for all residents. On 6/5/24 at 10:35 a.m., the Director of Nursing Services (DNS) provided an undated document, titled, Nebulizer Therapy, and indicated it was the policy currently being used by the facility. The policy indicated, .It is the policy of this facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using proper technique and standard precautions . Care of Equipment . 3. Disassemble parts after every treatment. 4. Rinse the nebulizer cup and mouthpiece with sterile or distilled water. 5. Shake off excess water. 6. Air dry on an absorbent towel. 7. Once completely dry, store the nebulizer cup and the mouthpiece in a zip lock bag. 8. Change nebulizer tubing every seventy-two hours or per facility policy. C. During an initial interview with Resident 14 on 6/3/24 at 1:48 p.m., she was observed sitting up in bed receiving oxygen via nasal cannula. The oxygen concentrator was observed to be set at 3 Liters (L). Her assembled nebulizer mask, and separate mouthpiece were observed sitting on the lamp table at the foot of the bed, unbagged and undated. The resident indicated she could not get out of bed without assistance and that staff were responsible for giving her breathing treatments. On 6/5/24 at 1:34 p.m., observed Resident 14's assembled nebulizer mask, machine, and tubing sitting on the foot of the bed, unbagged and undated. The mouthpiece was observed to be sitting on the lamp table at the foot of the bed. The oxygen concentrator was observed to be on and delivering 3 L of oxygen to the resident via nasal cannula. She indicated she had only received oxygen since her last trip to the hospital the week before. On 6/6/24 at 10:19 a.m., observed Resident 14's assembled nebulizer mask, mouthpiece, and tubing sitting on the lamp table at the foot of the bed, unbagged and undated. On 6/7/24 at 11:04 a.m., observed Resident 14's assembled nebulizer mask, mouthpiece, and tubing sitting on the lamp table at the foot of the bed with the IP, she indicated that she could not find a dated label or bag or tubing, and it should have had both. The resident was no longer wearing oxygen. Resident 14's record was reviewed on 6/6/24 at 9:48 a.m. Her diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD- a group of diseases that cause airflow blockage and breathing related problems), and shortness of breath) and chronic diastolic heart failure (your heart's main pumping chamber becomes stiff and unable to fill properly). A physician's order, dated 4/28/24, indicated to administer ipratropium-albuterol solution 0.5-2.5, 3 milligrams (mg)/ 3 milliliters (ml). Administer 3 ml, inhale orally every four hours as needed for shortness of breath or wheezing, via nebulizer. Resident 14's record lacked documentation of a physician's order for oxygen administration. Resident 14's care plan, dated 11/15/23, indicated she was at risk for respiratory distress related to COPD. Interventions included, but were not limited to, nebulizer treatments as ordered with a goal that she would be free from respiratory distress through the next review date. A Minimum Data Set (MDS) assessment completed for payment assessment, dated 5/20/24, indicated Resident 14's brief interview for mental status (BIMS) score was 11, which indicated moderate cognitive impairment. The MDS assessment indicated that she had not exhibited behaviors for rejecting care. During an interview with Unit Manager 14 on 6/6/24 at 10:30 a.m., she indicated that when nebulizer and oxygen tubing get replaced, staff should put the date on the bag for when it was changed, and the tubing will have tape on it with the date it was changed. During an interview with the Nurse Practitioner (NP) on 6/6/24 at 2:58 p.m., she indicated the resident went to the emergency roiagnom on [DATE], she would consider orders to be obtained as soon as practicable to be within one week. On 6/5/24 at 10:35 a.m., the Director of Nursing Services (DNS) provided an undated document, titled, Nebulizer Therapy, and indicated it was the policy currently being used by the facility. The policy indicated, .It is the policy of this facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using proper technique and standard precautions . Care of Equipment . 3. Disassemble parts after every treatment. 4. Rinse the nebulizer cup and mouthpiece with sterile or distilled water. 5. Shake off excess water. 6. Air dry on an absorbent towel. 7. Once completely dry, store the nebulizer cup and the mouthpiece in a zip lock bag. 8. Change nebulizer tubing every seventy-two hours or per facility policy. On 6/6/24 at 1:57 p.m., the DNS provided an undated document, titled, Oxygen Administration, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences . Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control 3.1-47(a)(6)

Based on observation, record review, and interview, the facility failed to ensure refrigerator temperatures were up to date, and outdated food was discarded during 2 of 3 kitchen observations. Findings include: During the initial kitchen tour with [NAME] 2, on 6/3/24 at 7:20 a.m., observed the June temperature logs posted on the outside of each unit for the potato freezer, vegetable and meat freezer, and the ice cream freezer. The records lacked both a.m. and p.m. temperature log documentation for 6/1/24 and 6/2/24. During a follow up kitchen tour with the Dietary Manager, on 6/3/24 at 8:34 a.m., observed the reach-in refrigerator with an opened gallon of milk that had an expiration date of 6/2/24, and hard-boiled eggs dated 5/29/24. When asked, the Dietary Manager indicated that the milk had passed the expiration date, and the hard-boiled eggs were passed the use by date, then indicated that was enough and shut the door preventing further observations inside the refrigerator. Observed, for the second time, the June temperature logs for the potato freezer, vegetable and meat freezer, and ice cream freezer, the missing documentation had been filled in. The Dietary Manager indicated that the temperatures were to be logged twice daily, and the temperatures did not get written down anywhere else besides the logs on the outside of each refrigerator or freezer unit. During an interview on 6/5/24 at 10:52 a.m., the Dietary Manager indicated that she had instructed [NAME] 2 to fill in the missing June temperature logs with [NAME] 20's initials for 6/1/24 and 6/2/24. When asked how she knew what the temperatures were for those dates, the Dietary Manager indicated it was an educated guess, and since the refrigerators and freezers had been working, she did not think it would hurt. On 6/6/24 at 1:56 p.m., the Director of Nursing Services (DNS) provided an undated document, titled, Monitoring of Cooler/Freezer Temperature, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy Explanation and Compliance Guidelines .1 .a. Temperatures will be checked and logged at least twice per day by designated personnel .11. Refrigerated food shall be labeled, dated, and monitored so that it is used by the use by date, frozen, or discarded, whichever is applicable On 6/6/24 at 1:56 p.m., the DNS provided an undated document, titled, Date Marking for Food Safety, and indicated it was the policy currently being used by the facility. The policy indicated, .The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food .Policy Explanation and Compliance Guidelines for Staffing .2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded . 6. The Head Cook, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly 3.1-21(i)(3)

Based on observations, record reviews, and interviews, the facility failed to ensure proper administration of inhaled medication during the medication administration pass for 2 of 4 residents observed, resulting in a medication error rate of 11.54 percent and 3 errors out of 26 opportunities for errors (Resident 8 and 13). Findings include: 1. During a medication administration observation, on 6/5/24 at 9:07 a.m., Registered Nurse (RN) 13 was administering a Symbicort (contains an inhaled corticosteroid know as budesonide to reduce inflammation in the lungs) inhaler (small handheld devices that allows you to breath medicine through your mouth, directly to your lungs) to Resident 8. The resident handed the inhaler back to the nurse and the nurse immediately gave the resident an Incruse Ellipta (inhaled medication that works by relaxing the muscles around the airways in the lungs to help you breathe easier) inhaler to use. The resident did not rinse and spit with water after the use of the first inhaler nor did the nurse wait in between administering the two inhaled medications. Resident 8's record was reviewed on 6/5/24 at 9:45 a.m. The profile indicated the resident's diagnosis included, but were not limited to, chronic obstructive pulmonary disease (COPD- a group of diseases that cause airflow blockage and breathing related problems). A physician order, dated 12/2/23, indicated to administer Symbicort Aerosol 160-4.5 mcg (micrograms) two puffs inhale orally two times a day for cough/congestion. Rinse mouth after each use. A physician order, dated 11/3/23, indicated to administer Incruse Ellipta 62.5 mcg one puff inhale orally one time a day for COPD. A care plan, dated 11/2/23, indicated the resident was at risk for respiratory distress related to COPD. Interventions included, but were not limited to, administer medications as ordered and observe for effectiveness and adverse side effects. 2. During a medication administration observation, on 6/5/24 at 9:30 a.m., Registered Nurse (RN) 13 was administering Trelegy Ellipta (a combination of 3 medications which includes a corticosteroid in one inhaler that helps control symptoms of chronic obstructive pulmonary disease [COPD]) to Resident 13. The resident did not rinse and spit with water after use of the inhaler. Resident 13's record was reviewed on 6/5/24 at 10:00 a.m. The profile indicated the resident's diagnosis included, but were not limited to, chronic obstructive pulmonary disease (COPD- a group of diseases that cause airflow blockage and breathing related problems). A physician order, dated 12/6/23, indicated to administer Trelegy Ellipta 100-62.5-25mcg (micrograms) one puff inhale orally one time a day for COPD. A care plan, dated 5/21/24, indicated the resident was at risk for respiratory distress related to COPD. Interventions included, but were not limited to, administer medications as ordered. During an interview, on 6/5/24 at 9:45 a.m., Licensed Practical Nurse (LPN) 12 indicated the resident should rinse and spit with water after use of inhaled medications and the nurse should wait several minutes in between administering inhaled medications to the same resident. During an interview, on 6/5/24 at 9:49 a.m., LPN 11 indicated the nurse should wait 5 minutes in between administering inhaled medications to the same resident and the resident should rinse and spit with water after use of the inhaled medications. On 6/5/24 at 10:35 a.m., the Assistant Director of Nursing Services (ADNS), provided an undated document as a current facility policy, titled, Administration of Metered-Dose Inhaler. The policy indicated, .16. If a resident is using a corticosteroid, allow resident to rinse and gargle with water .to remove medication from mouth and back of throat .17. If resident is using a corticosteroid and a bronchodilator, administer the bronchodilator first then wait 5 minutes before administering the corticosteroid 3.1-48(c)(1)

A. Based on interview and record review, the facility failed to ensure a dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) resident received a tray for meals missed while at dialysis for 1 of 1 residents reviewed for dialysis (Resident 27). B. Based on record review and interview, the failed to ensure documentation of an assessment of a residents arteriovenous (AV) dialysis fistula (a connection that's made between an artery and a vein for dialysis access) for 1 of 1 residents observed for dialysis (Resident 27). Findings include: Resident 27's record was reviewed on 6/6/24 at 1:27 p.m. The profile indicated the resident's diagnoses included, but were not limited to, end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life) and arteriovenous dialysis fistula. An admission Minimum Data Set (MDS) assessment, dated 3/1/24, indicated the resident had no cognitive deficit, was supervision with set-up for eating, had no nutritional issues, and received dialysis. A care plan, dated 3/1/24, indicated the resident required adequate nutrition to promote overall good health related to risk of weight changes and fluid changes due to dialysis services three days a week on Monday, Wednesday, and Friday. A care plan, dated 3/19/24, indicated the resident received dialysis due to end stage renal disease. Interventions included, but were not limited to assess AV dialysis fistula located in right arm, every shift for bruit (the abnormal sound generated by turbulent flow of blood in an artery due to either an area of partial obstruction or a localized high rate of blood flow through an unobstructed artery) and thrill (a thrill or buzz is like a vibration caused by blood flowing through the fistula and can be felt by placing your fingers just above your incision line), swelling, pain, change in temperature, or bleeding. A. During an interview, on 6/4/24 at 11:23 a.m., Resident 27 indicated he did not get his lunch trays when he returned from dialysis. A physician's order, dated 3/14/24, indicated the resident was to receive a regular diet with mechanical soft texture and thin consistency. A Dietician assessment, dated 3/1/24, indicated the resident was able to feed self after tray set-up. He tolerated his diet with a good intake and had no chewing or swallowing issues. The resident required adequate nutrition to promote overall good health, strength and stamina. During an interview, on 6/7/24 at 8:44 a.m., the Dietary Manager indicated the resident was able to make his needs known and had chosen to eat 2 soft fried eggs for every meal. He often would come to the kitchen doorway and ask for 2 cartons of milk to take back to his room with him. She understood that he went to dialysis 3 days a week. She had spoken with her staff and determined that the resident was not getting his lunch meal when he returned from dialysis. She and her staff were not made aware when the resident returned from dialysis. During an interview, on 6/7/24 at 8:54 a.m., the Executive Director (ED) indicated residents should be provided meals any time they were out of the building and missed a meal service. On 6/7/24 at 8:54 a.m., the ED provided a document, with a revision date of February 2023, titled, Frequency of Meals, and indicated it was the policy currently used by the facility. The policy indicated, .Policy Explanation and Compliance Guidelines: .2. Alternative mealtimes will be specified .in accordance with the resident's need, preferences, and requests B. A physician's order, dated 2/26/24, indicated to assess the dialysis AV fistula, located in the right arm, every shift for thrill and bruit, swelling, pain, change in temp and/or bleeding. Review of the resident's Treatment Administration Records (TARs) from March, April, and May 2024, indicated the following: a. The March 2024 TAR lacked documentation of the assessment of the resident's dialysis AV fistula on the day shifts of 3/14/24 and 3/24/24. b. The April 2024 TAR lacked documentation of the assessment of the resident's dialysis AV fistula on the evening shift of 4/25/24. c. The May 2024 TAR lacked documentation of the assessment of the resident's dialysis AV fistula on the day shift of 5/19/24 and the evening shift of 5/23/24. During an interview, on 6/7/24 at 10:40 a.m., the Director of Nursing Services (DNS) indicated she had observed there were holes in the TARs and they were looking into the situation through their QAPI program. On 6/7/24 at 10:40 a.m., the DNS provided a document, with a revision date of February 2023, titled, Hemodialysis, and indicated it was the policy currently being used by the facility. The policy indicated, .Compliance Guidelines: .14. The nurse will ensure that the dialysis access site .is checked before and after dialysis treatments and every shift for patency by auscultating for a bruit and palpating for a thrill 3.1-37(a)

Based on observations, interviews, and record reviews, the facility failed to ensure medications were labeled properly and the facility failed to ensure expired medications were disposed of for 2 of 2 medication storage rooms reviewed for medication storage (Resident 43). Findings include: 1. On 6/5/24 at 9:52 a.m., the 200-hall medication storage room refrigerator contained an undated and opened multi- use vial of Aplisol (a clear, colorless solution for injection as an aid in the diagnosis of tuberculosis) solution. The label on the medication box indicated it was for facility stock and was delivered to the facility on [DATE] from the pharmacy. During an interview, on 6/5/24 at 9:55 a.m., Licensed Practical Nurse (LPN) 11 indicated she was not aware of how long the Aplisol solution was good for once the vial was opened but indicated it should contain and open date once opened for use. During an interview, on 6/5/24 at 10:02 a.m., Registered Nurse (RN) 13 indicated she was not aware of how long the Aplisol solution was good for once opened. During an interview, on 6/5/24 at 10:03 a.m., Unit Manager 14 indicated she was not aware of how long the Aplisol solution was good for once opened. During an interview, on 6/5/24 at 10:05 a.m., LPN 11 indicated she had spoken with management and the Aplisol was good for 30 days once opened. 2. On 6/5/24 at 10:03 a.m., the 100-hall medication storage room refrigerator contained a COVID vaccine (helps our bodies develop immunity to the virus that causes COVID-19 without us having to get the illness). The pharmacy bottle contained a label that indicated it was for Resident 43. The bottle also contained a pharmacy label that indicated the vaccine expired on 3/27/24. During an interview, on 6/5/24 at 10:04 a.m., Unit Manager 14 indicated the vaccine was expired and the Infection Preventionist (IP) nurse was the one that handled the vaccines and Aplisol solutions for the facility. The vaccine should have been disposed of. On 6/5/24 at 11:12 a.m., the Assistant Director of Nursing Services (ADNS), provided an undated document as a current facility policy, titled, Aplisol. The policy indicated, .Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency On 6/5/24 at 11:13 a.m., the ADNS, provided a document as a current facility policy, titled, Medication Administration, revised date of 10/30/18. The policy indicated, .Policy: To ensure all prescription drugs/medications are labeled appropriate expiration dates according to manufacturer recommendations and in compliance with State and Federal regulations and that all expired drugs/medications are removed from medication storage areas for proper disposal . i. Expired medication(s) will be removed from use and destroyed per facility policy and procedure 3.1-25(j) 3.1-25(o)

Based on observation, record review, and interview, the facility failed to ensure an indwelling urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) bag and tubing were prevented from contact with the floor for 1 of 2 residents reviewed for catheter/UTI (urinary tract infection-an infection in any part of the urinary system)(Resident 56), and to ensure that indwelling urinary catheter care (clean the area where the catheter exits your body and the catheter itself with soap and water every day) was for 2 of 2 residents reviewed for catheter/UTI documented (Residents 56 and 41). Findings include: 1. During a random observation, on 6/3/24 at 1:16 p.m., the resident was sitting in the hallway next to the smoking area. Her catheter bag was in contact with the floor. During a random observation, on 6/5/24 at 10:38 a.m., the resident was propelling herself in the 100 hall outside of the dining room. Her catheter tubing was dragging the floor. During a random observation, on 6/5/24 at 4:07 p.m., the resident was sitting outside in the smoking area. Her catheter tubing was in contact with the ground. During a random observation, on 6/6/24 at 8:36 a.m., the resident was sitting in the hallway waiting to go out to smoke. Her catheter bag was in contact with the floor. During a random observation, on 6/6/24 at 10:22 a.m., the resident was sitting at a table in the dining room eating a snack. Her catheter bag and tubing were in contact with the floor. During a random observation, on 6/6/24 at 9:12 a.m., the resident was outside sitting in the smoking area with the smoking group. Her catheter bag and tubing were in contact with the ground. During a random observation, on 6/7/24 at 8:43 a.m., the resident was in her bed asleep, lying on her right side. The bed was observed in a lower position and the catheter bag was in contact with the floor. Resident 56's record was reviewed on 6/5/24 at 12:09 p.m. The profile indicated the resident's diagnoses included, but were not limited to, obstructive and reflux uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow and can be either structural or functional). A 5-day Minimum Data Set (MDS) assessment, dated 2/5/24, indicated the resident had moderate cognitive deficits, required extensive assistance with 2 plus (+) persons with her activities of daily living (ADLs-activities related to personal care), and had a urinary catheter. A care plan, dated 1/31/24, and revised on 5/13/24, indicated the resident was at risk for infections/complications related to an indwelling urinary catheter. A physician's order, dated 1/31/24 with an end date of 2/21/24, indicated to perform catheter care every shift. The resident's February 2024, Treatment Administration Record (TAR) lacked documentation of catheter care being completed on the day shifts of 2/6/24 and 2/14/24, and on the evening shifts of 2/2/24, 2/9/24. 2/13/24, and 2/16/24. The resident's TARs lacked documentation of orders for catheter care from 2/21/24 to 3/1/24. A physician's order, dated 3/1/24, indicated to perform catheter care every shift and document milliliters (mls) output. The resident's March 2024, TAR lacked documentation of catheter care being completed on the day shift of 3/2/24. The resident's April 2024, TAR lacked documentation of catheter care being completed on the evening shifts of 4/12/24, 4/19/24, 4/20/24, and 4/24/24. The resident's May 2024, TAR lacked documentation of catheter care being completed on the day shift of 5/12/24, and on the evening shifts of 5/3/24 and 5/4/24. 2. Resident 41's record was reviewed on 6/5/24 at 9:34 a.m. The profile indicated the resident's diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction (hemiplegia is defined as paralysis of partial or total body function on one side of the body, whereas hemiparesis is characterized by one-sided weakness, but without complete paralysis) and neuromuscular dysfunction of the bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems). An admission Minimum Data Set (MDS) assessment, dated 4/12/24, indicated the resident had moderate cognitive deficit, required extensive assistance of 2 + with her activities of daily living (ADLs-activities related to personal care) and had an indwelling urinary catheter. A care plan, dated 4/2/24 and revised on 5/14/24, indicated the resident was at risk for infection/complications related to an indwelling urinary catheter. Interventions included, but were not limited to, catheter care at least every shift and as needed. A physician's order, dated 4/2/24, with an end date of 5/14/24, indicated to perform catheter care every shift every shift for neurogenic bladder and document milliliters (mls) output. A physician's order, dated 5/14/24, with an end date of 5/30/24, indicated to perform catheter care every shift every shift for neurogenic bladder and document mls output. A physician's order, dated 5/30/24, indicated to perform catheter care every shift every shift for neurogenic bladder and document mls output. The resident's May 2024, TAR lacked documentation of catheter care being completed on the day shifts of 5/1/24, 5/7/24, and 5/19/24, and on the evening shift of 5/23/24. During an interview, on 6/5/24 at 11:06 a.m., the Infection Preventionist (IP) indicated she had noted an increase in the number of UTIs in February and March of 2024. She had not determined a specific root cause for the increase. Education to the nursing staff on catheter care had been provided on 12/20/23. During an interview, on 6/5/24 at 2:07 p.m., Certified Nursing Assistant (CNA) 6 indicated when catheter care was completed, the procedure should be documented in the medical record. During an interview, on 6/5/24 at 2:16 p.m., CNA 7 indicated any procedure, including catheter care, should always be documented when it was completed. During an interview, on 6/5/24 at 2:18 p.m., CNA 8 indicated catheter care should be documented in the medical record when completed. On 6/5/24 at 12:20 p.m., the IP provided a document, with a revision date of September 2014, titled, Catheter Care, Urinary, and indicated it was the policy currently being used by the facility. The policy indicated, .Infection Control .2 .b. Be sure that catheter tubing and drainage bag are kept off the floor .Documentation. The following information should be recorded in the resident's medical record: 1. The date and time that catheter care was given 3.1-41(a)(2)

Based on interview and record review, the facility failed to assess and treat a resident's urinary catheter and follow-up on continued hematuria resulting in immediate jeopardy when the resident with a history of UTI and septic shock did not have a follow-up with a Urologist for continued hematuria and blood clots, had a change in condition with his urinary catheter, and was sent to the hospital several hours later in septic shock and respiratory failure for 1 of 5 residents reviewed for change in condition (Resident B). The immediate jeopardy began on [DATE] when Resident B, with a history of urinary catheter, severe sepsis with septic shock, and urinary tract infection (UTI) on [DATE], had a distended abdomen and low urine output in the foley drain bag on [DATE] at 10:19 p.m. The catheter was changed, and bloody urine was returned. The physician was not notified, and no assessment or vital signs were obtained. On [DATE] at 4:30 a.m. Resident B had black emesis, blood clots from the catheter, and bloody urine. The resident's vital signs were blood pressure of ,d+[DATE], pulse of 107, and temperature of 96.9. Resident B was sent to the hospital at 5:10 a.m. At the hospital Resident B was diagnosed with septic shock, respiratory failure, UTI, bladder hemorrhage with probable cystitis, pneumonia, and anemia. Resident B had to be intubated to protect the airway due to massive amount of projectile vomiting. Resident B expired on [DATE] at 1:15 a.m. The Executive Director (ED) and the Director of Nursing were notified of the immediate jeopardy at 1:20 p.m. on [DATE]. The immediate jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: On [DATE] at 3:00 p.m., Resident B's medical record review was reviewed. Resident B was admitted to the facility on [DATE]. Diagnoses included but were not limited to, chronic obstructive pulmonary disease (COPD) (a group of diseases that cause airflow blockage and breathing-related problems) added [DATE], breakdown (mechanical) of other urinary catheter (a thin, flexible catheter used especially to drain urine from the bladder) added on [DATE], severe sepsis with septic shock (a serious condition in which the body responds improperly to an infection causing a dramatic drop in blood pressure that can damage the lungs, kidneys, liver, and other organs) added on [DATE], neuromuscular dysfunction of bladder unspecified (issues with urinating are referred to as bladder and bowel dysfunction), [DATE], hematuria (blood in the urine) added on [DATE], and urinary tract infection (infection of the bladder) added on [DATE]. An annual Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident B was cognitively intact and had an indwelling urinary catheter. Physician orders, dated [DATE], ordered Flomax 0.4 milligrams (mg) 1 capsule daily for urinary retention. Physician orders, dated [DATE], ordered anticoagulant medication staff to observe discolored urine and black tarry stools. Foley catheters care every shift and may change foley catheter PRN (as needed) for dislodgement/occlusion as needed for foley catheter. May irrigate Foley Catheter with 10 ml sterile H20 (water) or normal saline as needed. Physician orders, dated [DATE], ordered aspirin low dose 81 milligrams (mg) tablet chewable 1 tablet daily for anticoagulant (blood thinner). Physician orders, dated [DATE], ordered Eliquis oral tablet 2.5 mg 1 tablet two times per day for A-Fib (irregular heart rate) and history of CVA, (Cerebral vascular accident, stroke). Physician orders, dated [DATE], change foley catheter once monthly with 30 ml (milliliters)/20 Fr (French) (indicates the size of the catheter) Foley urinary catheter (a thin, flexible catheter used especially to drain urine from the bladder), every night shift every 30 day(s) for urinary retention, A care plan, dated [DATE], indicated the resident was at risk for complications related to indwelling catheter, intervention included but was not limited to notifying Medical Doctor (MD) of abnormal findings. A care plan, dated [DATE], indicated the resident was at risk for abnormal bleeding secondary to anticoagulant therapy. Interventions included but were not limited to, observing for signs of abnormal bleeding, coffee ground emesis, blood tinged or frank blood in urine. The care plan interventions were revised on [DATE] to include document abnormal findings and notify MD (Medical Doctor). A care plan, dated [DATE], indicated the resident had a urinary tract infection, resolved [DATE]. A care plan, dated [DATE], indicated the resident had a urinary tract infection and was in isolation for Klebsiella Oxytoca which was resolved [DATE]. A care plan, dated [DATE], indicated the resident had a urinary tract infection that was resolved on [DATE]. On [DATE] at 9:15 a.m., the DNS provided a copy of the urinary output record for February ,d+[DATE], 2024, for Resident B. The record indicated the total daily 24 hr. output for Resident B was the following: ,d+[DATE] - 1100 milliliters (ml) ,d+[DATE] - 750 ml. No output was recorded for the night shift. ,d+[DATE] - 650 ml. No output was recorded for the night shift. ,d+[DATE] - 970 ml ,d+[DATE] - 700 ml. No output was recorded for the night shift. ,d+[DATE] - 650 ml ,d+[DATE] - 1290 ml ,d+[DATE] - 1150 ml ,d+[DATE] - 1150 ml ,d+[DATE] - 1000 ml ,d+[DATE] - 750 ml. No output was recorded for the night shift. ,d+[DATE] - 750 ml. No output was recorded for the night shift. ,d+[DATE] - 840 ml ,d+[DATE] - 250 ml. No output was recorded for the night shift. ,d+[DATE] - 2300 ml ,d+[DATE] - 500 ml. No output was recorded for the night shift. ,d+[DATE] - 800 ml. No output was recorded for the night shift. ,d+[DATE] - 1400 ml. No output was recorded for the night shift. ,d+[DATE] - 850 ml ,d+[DATE] - 200 ml. No output was recorded for the night shift. ,d+[DATE] - 1360 ml ,d+[DATE] - 500 ml. No output was recorded for the night shift. ,d+[DATE] - 1800 ml ,d+[DATE] - 940 ml ,d+[DATE] - 250 ml. No output was recorded for the night shift. ,d+[DATE] - 1650 ml ,d+[DATE] - 950 ml. No output was recorded for the night shift. ,d+[DATE] - 240 ml On [DATE] at 10:19 p.m., the Nurse Progress Note indicated Resident B's abdomen was distended over the bladder. Resident B complained of some pain when touched, very little output in foley drain bag (the urine that drains through the catheter is connected to a bag). The nurse attempted to adjust the catheter and attempted to irrigate the catheter with no success. Documentation indicated the nurse removed the catheter and inserted and anchored a new catheter. The new catheter returned 650 ml of bloody urine. Resident B stated he felt better. Documentation lacked a complete assessment of the resident's condition including vital signs, abdominal assessment, or pain assessment. The physician was not notified of the difficulty with catheter irrigation, and increased blood in the urine. On [DATE] at 10:43 p.m., a Nurse Progress note lacked any follow up note regarding blood in urine or notification of the physician. The note indicated Resident B was resting in bed with no complaints, call light within reach. Documentation lacked follow-up assessments of the resident's condition including vital signs assessment, abdominal distention, or pain assessments. On [DATE] at 4:30 a.m., a Nurses' Note Summary Report was initiated. Resident B's vital signs included blood pressure of ,d+[DATE], pulse of 107 regular, respirations 16 breaths per minute, temperature 96.9, pulse oximetry 92% (indicates the oxygen levels in the blood). Blood was in the resident's urine and blood clots were coming from around penis and in the catheter tubing. The resident was vomiting dark brown, black emesis. The primary care provider was notified (the nurse practitioner), and an order received for the resident to be sent to ER (emergency room ) for evaluation. On [DATE] at 6:22 a.m., a Nurse Progress Note indicated the Foley urinary catheter had been draining bloody urine. A large amount of blood clots noted in catheter tubing. The resident was vomiting brown, black emesis. Blood pressure was ,d+[DATE], faint pulse was 107 beats per minute, respirations 16 breaths per minute, and oxygen saturation 92%. Resident was pale and drowsy, and somewhat lethargic. Ambulance service was called, and the nurse was instructed to call 911 for transportation. The resident was transferred to the hospital at 5:10 a.m. The documentation indicated the resident had an acute change of condition at 10:19 p.m., on [DATE]. The physician was not notified until 4:30 a.m., on [DATE], 5 hours 11 minutes after the change in condition was identified. After the order to send to the ER was obtained, the resident was not sent to the ER for 40 minutes. Review of Resident B's medical record the record lacked documentation of communication between the facility and the urologist or the urology office, regarding the increased blood in the urine or a request to have the urologist change the catheter. The record lacked documentation of Resident B being followed by a Urologist for the blood in his urine. The nurse's progress note record lacked documentation of the NP visit and examination of the resident on [DATE]. A hospital consultation report, dated [DATE], indicated a computed tomography (CT) scan of the abdomen showed urinary bladder hemorrhage with inflammation of the bladder and bilateral pneumonia likely from aspiration. A hospital discharge note, dated [DATE], indicated Resident B presented to the ER with hypotension and hypoxia. The urinary analysis (UA) suggested a UTI. Resident B had dark brown, or coffee ground emesis and hematuria Resident B was put on oxygen per nasal cannula but had massive amount of projectile vomiting and required intubation to protect his airway and was put on a ventilator in the ER and moved to the intensive care unit. He was placed on intravenous vasopressin to increase blood pressure. The POA was informed of poor prognosis and Resident B was moved to comfort care. Resident B expired on [DATE] at 1:15 a.m. During an interview on [DATE] at 11:47 a.m., LPN 10 indicated Resident B had an indwelling foley catheter and was recently admitted to the hospital due to sepsis infection and respiratory issue. Resident B was sent to the hospital on [DATE]. She indicated the resident had been seeing a urologist due to blood in his urine. If a resident had blood in urine, she would notify the physician. She would assess the resident and obtain vital signs and if there was a Registered Nurse (RN) available she would ask the RN to assess the resident as well. During an interview on [DATE] at 12:50 p.m., the DNS indicated the nurse called her late on the night of [DATE]. She did not get the call because she was asleep. She did not find out about the condition of Resident B until the next morning. The resident was sent to the hospital due to excess bleeding around the catheter and vomiting black emesis. She indicated it was not unusual for him to have blood in his urine. She did not know why the nurse did not call the doctor the evening before. She indicated the NP had seen the resident on [DATE] and had noted he had blood in the urine. If the issue was the same, it would not be a change of condition and they would not necessarily call the doctor. On [DATE] at 1:00 p.m., the DNS provided a copy of the NP notes with a service date of [DATE]. Documentation on the note indicated it was electronically signed by the NP on [DATE] and uploaded into the medical record on [DATE]. The NP indicated she saw the resident due to hematuria (blood in urine) and dysuria (painful urination). She indicated the resident had been seen by a urologist and the catheter is normally changed by him monthly. She indicated the catheter was irrigating fine, but the resident was having penile pain and passing lots of clots through the catheter as well as around the catheter and out the urethra (the tube through which urine leaves the body). The NP Progress Note indicated Resident B had been sent to theER on [DATE] for catheter complications and per the ER notes the nursing home facility was unable to remove the Foley catheter, was bleeding from the catheter site and having severe pain. Resident B was diagnosed with sepsis and released from the hospital on [DATE]. On [DATE] the NP saw Resident B and sent him to the hospital to see Urologist 18 to change his catheter. On [DATE] the patient was seen by the NP and the note indicated Resident B was going to be seen by Urologist 18 for a catheter change on [DATE]. She indicated the staff were trying to reach the urology office to see if Urologist 18 would like to see the resident to change the catheter. Resident B's medical record lacked documentation Urologist 18's office was contacted and lacked a response from the urologist's office. Documentation from Resident B's urologist appointments was requested from the DNS on [DATE] at 1:45 p.m. During a phone interview on [DATE] at 3:23 p.m., LPN 13 indicated she provided care to Resident B on [DATE] through the morning of [DATE]. She indicated she had assessed the resident and obtained vital signs. She did not notify the physician because this was nothing new. She indicated she assessed the resident through the night. The resident was alert and talking until she sent him to the hospital. On [DATE] at 11:06 a.m., LPN 13's a written statement, dated [DATE] at 2:45 p.m., was provided and indicated LPN 13 called the nursing manager on-call to alert of event, then she called NP 17 who told LPN 13 that due to Resident B's Do Not Resuscitate (DNR) status to ask if the family wanted to send Resident B to the hospital, and if they family requested it LPN 13 could send him to the hospital. LPN 13 was unable to reach family after a few attempts, so she called the nursing manager back. LPN 13, the nurse manager, and Resident B, who was alert and coherent, determined the resident would like to go to (Name of Hospital) for evaluation. LPN 13 then attempted to set transportation through the non-emergent transportation, but they were not available. So, LPN 13 sent Resident B via 911 to the hospital. Transfer paperwork including the out hospital DNR. During an interview on [DATE] at 11:50 a.m., Certified Nurse Aide (CNA) 11 explained how she emptied and measured the catheter output. CNA 11 indicated she dried the end of the drain tube which the urine was emptied from the drain bag the tip with a paper towel. She did not clean off the tube with anything else and did not clean with alcohol swab. She completed catheter care if the resident had a bowel movement. And she would provide catheter care for the resident before she leaves for the day. During an interview on [DATE] at 12:05 p.m., Resident A indicated the staff did not provide catheter care routinely. On [DATE] at 10:12 a.m., during an interview with Certified Nurse Aide (CNA) 12, the CNA indicated she provided catheter care every two hours for a resident when she changed the resident's incontinent brief or after personal care as needed. She indicated she emptied the Foley drain bag as needed. She unclipped the drain tube, which was attached to the drain bag, emptied the urine from the bag and wiped the drain tubing with a paper towel. She indicated she did not clean the tube with anything else. She clipped the tube closed and inserted it into the bag holder. During an interview on [DATE] at 11:06 a.m., the Regional Nurse for the facility indicated Resident B had hematuria since December. She indicated the facility had called the urologist several times. The resident was sent out to the hospital for the Urologist to change Resident B's catheter in the past. During an interview on [DATE] at 11:06 a.m., the NP indicated Urologist 18 changed Resident B's catheter if there were issues with the facility staff changing it. The NP indicated when she saw Resident B on [DATE] she had reached out to Urologist 18's office to see if the urologist wanted to change Resident B's catheter. She was unsure if there was a response from the urologist's office. The NP indicated she also contacted Resident B's physicians at the local veteran's hospital regarding the anticoagulant while having hematuria but did not receive a response. During a phone interview on [DATE] at 1:38 p.m., Urologist 18 indicated Resident B was not his patient. He only had his catheter changed by them 2 times. Once when the resident was at another local hospital his catheter was stuck and could not be removed. The other hospital transferred Resident B to the local hospital Urologist 18 worked. Urologist 18 saw Resident B in the ER and changed his catheter. Resident B came to the office to have catheter changed on [DATE] after the nursing facility and Resident B asked the office to change the catheter for them. Resident B was never his patient. Urologist 18 was not his physician, he was not familiar with Resident B's care, did not oversee Resident B's conditions, and had only seen him twice to have the catheter changed. On [DATE] at 9:35 a.m., during an interview, the DNS indicated Resident B was admitted to the facility with an indwelling foley catheter for neurogenic bladder. The primary care physician was following the resident for management of the catheter. When he was admitted from another nursing facility his discharge records indicated he was to be followed by Urologist 20. When she called the number for Urologist 20, she was told the resident was to see Urologist 18. She assumed Urologist 18 had taken over the practice for Urologist 20. She indicated the resident was a patient of Urologist 18. She acknowledged he had been seen by Urologist 18 at the hospital when he had been in the ER. There were no urologist notes for Resident B besides the hospital ER notes. On [DATE] at 1:00 p.m., the DNS provided a document, titled, Change of condition, dated [DATE], and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: to ensure timely interventions for a change in a resident's condition .2. Acute change in condition .a. Any sudden or serious change in a resident's condition will be communicated to the physician .3. Non-urgent change in condition .a all symptoms and unusual signs will be documented in the medical chart and communicated to the attending physician/NP. Non-urgent changes are a minor change in physical and mental behavior, abnormal laboratory and x-ray results that are not life threatening .b. The charge nurse is responsible for notification of physician .prior to the end of the shift On [DATE] at 1:00 p.m., the DNS provided an undated document, titled, Catheter Care, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy .It is the policy if this facility to ensure that residents with indwelling catheters receive appropriate catheter care .1. Catheter care will be performed every shift and as needed by nursing personnel On [DATE] at 9:58 a.m., the DNS provided a document, titled, Emptying a urinary drainage bag, dated [DATE], and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose .The purpose of this procedure are to prevent drainage bag from becoming full and allowing urine to flow back into the bladder, to measure output, and to obtain a sterile specimen .Steps in the procedure .6. Remove the drain tube from its holder .7. Open the drainage bag and let the urine flow into the measuring container .8. After the drainage bag has emptied, close the drain .9. Wipe the drain with an alcohol sponge or swab .replace the drain tube back into its holder The immediate jeopardy that began on [DATE] was removed on [DATE] when the facility assessed all residents with urinary catheters for signs and symptoms of infection, nursing staff were in-serviced on catheter care and urinary tract infections, staff were educated on assessment and change of condition with urinary catheters. The noncompliance remained at the lower scope and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need for continued monitoring. This citation relates to Complaint IN00429806. 3XXX,d+[DATE](a)(1) 3XXX,d+[DATE](a)(2)

Based on observation, interview, and record review, the facility failed to ensure appropriate interventions for pressure ulcers were implemented resulting in harm when a resident's skin tear worsened to an unstageable (full-thickness tissue loss in which the base of the ulcer is covered by slough or eschar) with signs of infection and then a stage 3 (full thickness skin loss involving damage or necrosis of subcutaneous that may extend down to, but not through, underlying fascia) pressure ulcer to the right buttocks for 1 of 2 residents reviewed for pressure ulcers (Resident 47). Findings include: During a wound treatment observation, on 12/12/19 at 8:56 a.m., with the Wound Nurse, the right buttocks wound area was irrigated with acetic acid solution, which returned as clear. The wound area was patted dry. The wound had round attached edges and75 % granulation tissue (new vascular tissue in granular form on an ulcer or the healing surface of a wound) was observed. The peri wound area was pink and blanchable with no exudate observed. Alginate rope (rope and ribbon dressings used to pack cavity wounds) was packed around the edges of the wound area. A foam dressing was applied to cover the wound. The resident was observed to tolerate the treatment well. During an interview, on 12/12/19 at 9:00 a.m., the Wound Nurse indicated the resident had developed an unstageable pressure ulcer to her right buttock at the facility. The wound cap had come off in early (MONTH) and the wound was then classified as a stage 3 (full thickness skin loss involving damage or necrosis of subcutaneous tissue (the tissue below the skin) that may extend down to, but not through, underlying fascia). The wound area had initially been a skin tear and developed into a pressure ulcer. Treatment and interventions were put into place immediately after she had been notified of the wound development. Since the initiation of the treatments, the area was now looking very good, and was showing great signs of healing. She noted that the resident had been given pain medication prior to the treatment procedure. Resident 47's record was reviewed on 12/12/19 at 1:11 p.m. The profile indicated the resident's [DIAGNOSES REDACTED]. A Braden Scale (an assessment for scoring the risk for development of pressure ulcers) assessment, dated 8/12/17, indicated the resident was high risk for pressure ulcers with a score of 11. An annual Minimum Data Set (MDS) assessment, dated 5/3/19, indicated the resident was at risk for the development of pressure ulcers. A quarterly MDS assessment, dated 8/2/19, indicated the resident was at risk for the development of pressure ulcers. A handwritten timeline of the resident's wound on her right buttocks, was provided by the Wound Nurse, on 12/12/19 at 10:51 a.m., indicated an unidentified Certified Nurse Aides (CNA) notified the Wound Nurse, on 10/28/19, that the resident had sustained a skin tear while being taken off of the toilet. The Wound Nurse notified the physician of the skin tear on 10/29/19. On 11/4/19, staff reported to the Wound Nurse the area to the resident's right buttock had an ill- defined irregular shape arc form, with medium clear fluid exudate and a foul odor. The Wound Nurse assessed the area and describe it as 90% granulation tissue with adherent yellow slough with red blanchable peri wound area. The wound was classified as unstageable. The resident reported pain when the area was touched. The Wound Nurse notified the physician and received orders for wound culture and Keflex (antibiotic medication) to be initiated. Treatment orders for [MEDICATION NAME] (advanced wound care dressing demonstrating its clinical ability to promote the removal of necrotic tissue and advance a wound toward healing), and cover with foam dressing. Immediate interventions included, but were not limited to, placement of a low air loss (LAL) mattress (a pressure-relieving mattress with alternating air flow, used to prevent and treat pressure ulcers), bedrest, wedge cushion (a cushion used to assist with positioning), and turn every 2 hours. A care plan, dated 11/4/19, indicated the resident had developed a pressure ulcer to her right buttocks. Interventions included, but were not limited to, LAL mattress. No care plan for the resident being at risk for skin integrity or for the development of pressure ulcers, had been developed, until the resident's pressure ulcer was discovered on 11/4/19. A physician's orders [REDACTED]. Apply [MEDICATION NAME] and cover with bordered foam dressing every-other-day for unstageable to right buttocks. Change as needed for soilage or dislodgement. The order had been discontinued 11/7/19. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A significant change MDS assessment, dated 11/15/19, indicated the resident was at risk for pressure ulcers, and had 1+ unhealed pressure ulcers. Treatment included, but were not limited to, pressure reduction device for chair and bed, turn and reposition, and nutrition/hydration care. A Wound Assessment Progress Report, dated 12/2/19, indicated the wound had been classified as a stage 3. New orders had been obtained for alginate rope and cover with foam. During an interview, on 12/13/19 at 11:01 a.m., the Wound Nurse indicated a skin risk care plan had never been developed for the resident. All of her Braden assessment scored her at a low risk for pressure ulcers. She was not aware the resident's MDS had documented her as at risk for developing pressure ulcers. She had never been trained of the importance of the Care Area Assessment (CAA) (process provides guidance on how to focus on key issues identified during a comprehensive MDS assessment and directs facility staff and health professionals to evaluate triggered care areas). During an interview, on 12/13/19 at 12:55 p.m., the Administrator indicated no one had ever spoken with the Wound Nurse about the importance of the CAA's and about how she was responsible for the CAA's for the skin section of the MDS assessment, in the time she had been in the position. During an interview, on 12/13/19 at 1:38 p.m., the Director of Nursing (DON) indicated a skin risk care plan should have been developed on the resident, if the MDS assessment indicated she was at risk for pressure ulcer development. During an interview, on 12/13/19 at 1:45 p.m., Registered Nurse (RN) 5 indicated was not aware of any interventions that had been in place for the resident, prior to the development of her current pressure ulcer, other than the standard mattress they had for all beds, which were designed to assist in the prevention and healing of wounds up to stage 3. Any preventative orders that may have been in place, would have been discontinued when new orders were written when the new issue developed on 11/4/19. On 12/13/19 at 2:07 p.m , the DON provided a document, dated 10/17/18, titled, Pressure Ulcer/Injury Risk, and indicated it was the policy currently being used by the facility. The policy indicated, .Steps in the Procedure .5. Develop the resident-centered care plan and interventions based on the risk factors identified in the assessments, the condition of the skin, the resident' overall clinical condition On 12/13/19 at 2:07 p.m., the DON provided a document, dated 4/11/8, titled, Care Plans, Goals and Objectives, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy Interpretation and Implementation .3. Care plan goals and objectives are derived from information contained in the resident's comprehensive assessment 3.1-40(a)(1)

Based on observation, record review and interview, the facility failed to identify symptoms of change in condition for a resident with heart failure and [MEDICAL CONDITION] and notify the doctor for treatment for 1 of 5 residents reviewed for unnecessary medications. Resident 44 had significant changes in daily weight gains and losses prior to the resident's heart stopping, and the resident needing cardiopulmonary resuscitation (CPR) (a lifesaving procedure performed when the heart stops beating) before being transferred and admitted to the hospital (Resident 44). Findings include: During an observation, on [DATE] at 8:13 a.m., Resident 44 was observed in bed. The resident had a [MEDICATION NAME] (used for pain) patch cut in half and applied to each side of the upper chest. At this time, the resident indicated it was applied for pain that was caused from chest compressions during cardiopulmonary resuscitation (CPR) (a lifesaving procedure performed when the heart stops beating). Resident 44's record was reviewed on [DATE] at 1:30 p.m. [DIAGNOSES REDACTED]. A care plan, initiated [DATE] and reviewed [DATE], indicated the resident elected to be a full code. A care plan, initiated [DATE] and reviewed [DATE], indicated the resident received a diuretic and was at risk for weight changes. Interventions included, but were not limited to, notify physician of any significant weight changes. A physician's orders [REDACTED]. A Medication Administration Record [REDACTED] [DATE]: 199 lbs. [DATE]: 181 lbs. [DATE]: 166.4 lbs. [DATE]: 199 lbs. [DATE]: 199 lbs. [DATE]: 165.4 lbs. [DATE]: 167.4 lbs. [DATE]: 170 lbs. [DATE]: 168.2 lbs. [DATE]: 178 lbs. [DATE]: 167.2 lbs. [DATE]: 167.8 lbs. [DATE]: 167.6 lbs. [DATE]: 178 lbs. [DATE]: 179 lbs. [DATE]: no weight documented. [DATE]: 166.2 lbs. [DATE]: 178 lbs. [DATE]: 178 lbs. [DATE]: 162.8 lbs. [DATE]: 174.8 lbs. The MAR indicated [REDACTED]. A review of progress notes, dated (MONTH) 2019, lacked documentation the physician had been notified of the daily weight changes. A progress note, dated [DATE] at 4:06 p.m., indicated it was a late entry for 10:30 a.m. The nurse called 911 to alert emergency medical transport that resident was a full code and unresponsive. It was reported to 911 the resident was not breathing and CPR was started. At 10:40 a.m. emergency responders arrived to the facility to transport the resident and at 10:45 a.m. transported to the resident out of the facility. A hospital consultation, dated [DATE], indicated impression: .the most likely cause of [MEDICAL CONDITION] would have been orthostatic [MEDICAL CONDITION] given the resident's cardiac history and medications, although [MEDICAL CONDITION] due to [DIAGNOSES REDACTED] or other arrhythmias cannot be completely excluded with the known history of coronary disease and also [DIAGNOSES REDACTED] A hospital discharge summary, dated [DATE], indicated discharge [DIAGNOSES REDACTED]. During an interview, on [DATE] at 9:54 a.m., Registered Nurse (RN) 5 indicated she could not find where the physician had been notified of the resident's daily weight losses and gains during the month of November. During an interview, on [DATE] at 10:29 a.m., Licensed Practical Nurse (LPN) 14 indicated there should be parameters in place when a resident was a daily weight. The physician should be notified if there was a 3 to 4 lb weight change in 24 hours. During an interview, on [DATE] at 10:38 a.m., the Director of Nursing (DON) indicated a resident should have parameters in place when they have a physician's orders [REDACTED]. The physician should be notified if there was 2 lb. weight loss or gain in 24 hours and 5 lb. weight loss or gain in a week. Prior to today, Resident 44 did not have an order for [REDACTED]. On [DATE] at 9:46 a.m., the Assistant Director of Nursing (ADON) provided a document, revised [DATE], and titled, Heart Failure Assessment and Recognition, and indicated it was the policy currently being used by the facility. The policy indicated, .Treatment/Management: 1. The physician will review and make recommendations for relevant aspects of the nursing care plan: for example, what symptoms to expect, how often and what (weights, renal function .) to monitor, when to report findings to the physician, etc. 2. The physician will address related medical issues; for example, adjust or stop medications that may be precipitating heart failure, modify doses of diuretics, determine whether oxygen is needed, etc .Monitoring and Follow-Up: 1. The physician will help monitor the progress of individuals with heart failure, including ongoing evaluation and documentation of signs, symptoms, and condition changes 3XXX,[DATE](a)

Based on observation, interview, and record review, the facility failed to ensure safety measures were in place related to assisted transfers for 1 of 1 resident who utilized a slideboard and 2 of 2 residents observed transferred with a stand up mechanical lift. This deficient practice resulted in Resident B sustaining fractures. (Residents B, C, and E.) Findings include: 1. On 2/7/19 at 9:00 a.m., Licensed Practical Nurse (LPN) 3 indicated, on 1/23/19, he had been called to Resident B's room. Two Certified Nursing Aide (CNAs) were with the resident. He found the resident sitting on the floor. He asked what had happened and CNAs 16 and 17 had indicated they had been transferring the resident from the bed to a wheelchair with a slideboard. The resident had slipped off of the board and landed on the floor. The board at that time was not in place. An assessment was completed for the resident and no signs of injury or complaints of pain were noted. The resident was assisted back to bed with a mechanical lift. The physician was notified. Later the resident started showing signs of discomfort, the physician was notified, and a mobile x-ray was ordered. Results of the x-ray indicated there had been left tibia and fibula fractures. On 2/11/19 at 2:31 p.m., CNA 17 indicated CNA 16 had asked her to assist with transferring the resident from the bed to wheelchair. She had been positioned behind the resident's chair and CNA 16 had been in front of the resident. The resident had leaned to the side and the slideboard was positioned under her. The resident then scooted herself across the board. The resident leaned forward towards CNA 17 and started sliding off of the board and went down to her knees. On 2/11/19 at 2:37 p.m., CNA 16 indicated she had been positioned in front of the resident and CNA 17 was behind the resident. The resident had been scooting herself across the board by grabbing the outside arm of the wheelchair. About half way across the board on the last scoot, the resident just slid off of the board and landed with legs underneath her. None of the CNAs had been comfortable with the use of the board and no training had been done prior to use of the device. The physical therapist (PT) had indicated they should use the board instead of a mechanical lift, per the resident's request, even though staff were not comfortable with the lift. The nurse had commented that this was an accident waiting to happen. The resident had grabbed the board and gestured how to use it. Physical Therapist 18 was interviewed on 2/11/19 at 11:52 a.m. He indicated the resident had been admitted with a slideboard utilized at home. Initially he had told staff if they needed any assistance with it to come to him for training. He had done several impromptu staff educations but did not keep a record and could not recall who they had been. On 2/11/19 at 3:50 p.m., CNA 12 indicated she had asked the Physical Therapist for training on the board. Another CNA was with her, but she could not remember who. On 2/11/19 at 3:55 p.m., CNA 19 was interviewed. She indicated training for use of the slideboard had not been done before the incident. On 2/11/19 at 4:20 p.m., the (Director of Nursing) DON indicated training for use of the slideboard had not been done prior to the fall. Documentation of the fall investigation was provided by Risk Management Staff on 2/11/19 at 11:40 a.m. The investigation included, but was not limited to, a written statement by CNA 16. The statement indicated .she (the resident) was half way on the bed and the wheelchair when I noticed that she was on the edge of the board, and not far enough back on the board. That's when I started to reach around (resident's name) and walked around the back of the wheelchair to try to pull (resident's name) back towards the back of the wheelchair. By that time (resident name) was already sliding down slowly off of the board and down the side of the bed . A post fall investigation, completed by Risk Management staff on 1/23/19, provided by the DON on 2/11/19 at 4:20 p.m., included, but was not limited to, pressure reducing boots on. The DON indicated the boots were not non-slip footwear. Documentation on the form indicated education would be done of proper use of the slideboard and proper footwear during transfers. Resident B's clinical record was reviewed on 2/11/19 at 2:11 p.m. An admission date of [DATE], was noted. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A plan of care for Resident B, dated 1/5/19, addressed the problem of fall risk due to generalized weakness, with weakness of left side due to [MEDICAL CONDITION] and cast on right and left lower extremities. An approach included, but was not limited to, I am an (sit to stand) .lift for transfers with assist of 3 . The PT Therapist Progress note, dated 1/19/19, included, but was not limited to, Pt (patient) continues to require the expertise, knowledge, clinical judgement, decision-making and abilities of a therapist that other staff, caretakers or the patient cannot provide independently. Skilled analysis of patient progress suggests pt is improving her transfer ability with use of a slide board. Will continue to progress as tolerated by pt . 2. On 2/11/19 9:20 a.m., Resident E was observed to be transferred from the bed to wheelchair with a sit to stand lift by CNAs 14 and 15. The resident was assisted to sit up on the side of the bed, she had on non-slip shoes, and staff positioned the white, fuzzy, strap utilized for the lift around the resident's back and under her arms. A black strap was attached to the white lift belt with a clasp on it. Staff attempted to secure the black strap with the clasp and it would not latch. The black strap was left attached to the white lift belt unfastened. Staff indicated the facility had two or three other stand up lifts. The resident's feet were positioned on the base of the lift, and the resident was raised to a semi-standing position with the white belt under her arms. The lift was pulled away from the bed, pivoted, the base opened around wheelchair (locked), and lowered the resident into the chair. The resident's clinical record was reviewed on 2/11/19 at 2:00 p.m. An annual Minimum Data Set (MDS) assessment, dated 1/10/18, coded the resident with severe cognitive impairment. The assessment indicated the resident required extensive assistance of two for transfers and was non-ambulatory. A plan of care, dated 1/10/18, indicated the resident was a fall risk related to confusion and generalized weakness. An approach included, but was not limited to, resident will be transferred with a sit to stand lift. 3. On 2/11/19 at 9:30 a.m., CNAs 12 and 13 were observed to transfer Resident C from the wheelchair to bed with a sit to stand lift. Staff positioned the white, fuzzy, sling around the resident's back. The black waist belt was positioned around the resident, the clasp would not latch, CNA 12 tied the it in a knot and placed a gait belt around the resident. The base of lift was opened around the wheelchair. The resident was lifted to a standing position with the white sling under his axilla, (arm pits), the lift was pulled away from the chair and pivoted to the bed. The base of the lift was positioned under the resident's bed and the resident was lowered onto the bed. Resident C's clinical record was reviewed on 2/11/19 at 3:00 p.m. An annual MDS dated [DATE] coded the resident with a severe cognitive impairment. The resident required extensive assistance of two for transfers. A plan of care, dated 11/2/16, indicated the resident's most recent goal/target, dated 3/21/19, included, but was not limited to, the resident will transfer with a sit to stand lift. On 2/11/19 at 10:20 a.m., LPN 5 indicated the lifts were located in the hallways of both nursing units. Sit to stand lifts 4 and 5 were observed with the white, fuzzy, slings and the openings for the waist belt (to be inserted), and no belts were in place. On 2/11/19 at 10:25 a.m., the Central Supply staff person was interviewed. She provided three different gait belts in the supply room, she indicated there were no belts specifically for the sit to stand lifts. On 2/11/19 at 11:31 a.m., the Assistant Director of Nursing (ADON) was interviewed and indicated the (sit to stand lift) company representative had been contacted and advised that (brand name of lift) belts had to be used with the lifts. The ADON indicated the belts would have to be ordered. On 2/11/19 at 1:00 p.m., the DON indicated they had been able to get a (brand name of lift) belt from their sister facility so one of the lifts could be in use. The others would be pulled and marked as out of order until belts had been received. Documentation posted on each of the Sara lifts was noted of .LIFT INSTRUCTIONS .6. PLACE THE SLING AROUND THE RESIDENT. A. FASTENS (sic) THE SAFETY STRAP AROUND THE RESIDENTS (sic) WAIST SECURELY . A lift performance check list, provided by the Staff Development Coordinator (SDC) on 2/11/19 at 12:10 p.m., included, but was not limited to, 7. Fastens (sic) the safety straps. The SDC indicated the safety straps was the waist belts that attached to the white slings. She indicated the checks were done upon hire and the last inservice for the lift was in October, (YEAR). Manufacturer's directions for the (brand name of lift) lift, no date, provided by the DON on 2/11/19 at 2:00 p.m., included, but was not limited to, 1. Bring the (lift) .carefully up to the patient placing the patient's feet on the footrest and continuing forward, if possible, until the knee pad is just in contact with the patient's knee or upper shin. Put on the brakes 2. Lower the support arms and place the sling round the patient's back so that it lies approximately .(2) (inches) or so horizontally above the waist line Note! If the sling is fitted with a strap, ensure the strap is brought loosely around the body and not twisted or trapped behind the patient's back.5. Fasten the straps (if fitted) by pushing the buckle together, ensure the straps are loose and not twisted when they are fastened. Finally, adjust the strap until firm but comfortable by pulling the outer strap through the buckle. The strap will assist in supporting the patient in the sling during the lifting procedure. When you wish to remove the sling, first release the strap by depressing the locking tab, then separate the buckle. WARNING: DO NOT ATTEMPT TO RELEASE THE STRAP WHILE THE PATIENT IS SUPPORTED BY THE SLING.IF THE BUCKLE STRAP IS NOT USED THE BELT BUCKLE COULD GET CAUGHT IN THE CHAIR OR OTHER OBJECT WHICH THE PATIENT IS SITTING IN, LIFTING IT UP OFF THE FLOOR. THIS COULD RESULT IN INJURY TO THE PATIENT OR OPERATOR A document titled Reporting of Broken/Defective Equipment, (no date) provided by the DON on 2/11/19 at 1:15 p.m., included any equipment noted to be defective/broken should be reported using the following steps: 1. Report to immediate supervisor, 2. Fill out a maintenance report form and place on the maintenance clip board for maintenance to pick up on their rounds .4. If appropriate, remove the equipment from service with a note that states either out of service, do not use, broken etc . The DON indicated the lifts had not been reported. This Federal tag relates to Complaint IN 224. 3.1-45(a)

Based on observation, interview, and record review, the facility failed to ensure worsening pressure ulcers and development of new pressure area was monitored and reported to the physician for a need for treatment resulting in the resident being transferred to the emergency room and admitted to the Intensive Care Unit for 1 of 3 residents reviewed with pressure ulcers in a total sample of 7 residents who had pressure areas (Resident C). The Immediate Jeopardy began on 7/19/17 when a nursing communication form, dated 7/19/17, indicated Resident C's foot ulcer developed a foul odor, and Looked terrible! and no physician notification or follow up was done. The Administrator and Contracted Consultant were notified of the immediate jeopardy on 8/4/17 at 1:40 p.m. The immediate jeopardy was removed, and the deficient practice corrected on August 5, 2017 Findings include: Resident C was observed on 8/3/17 at 9:30 a.m. Licensed Practical Nurse (LPN) 8 was performing a dressing change on the resident's right foot. The foot had been soaked in Dakons solution (antiseptic), was dried and calcium alginate was applied. The area was covered with 4 by 4 gauze pads, then abdominal pads, and wrapped with kerlix (gauze bandage). The wound had a very foul odor. Resident C was observed on 8/4/17 at 8:45 a.m., with LPN/Unit Manager, 3 and Certified Nurse Aide (CNA) 5. The gauze dressing on the foot was observed with reddish brown drainage coming through the bandage with a very foul odor. The resident was repositioned and skin was checked. A Stage II pressure (partial-thickness skin loss) area was observed on the right hip, no dressing was in place. The CNA indicated it was the same area she had noted on a computerized Bathing Roster for dates 7/1/17 through 8/31/17, where she had documented on 7/21/17 at 10:04 a.m., Skin Check, New Skin Concern - Nurse notified. Resident C's clinical record was reviewed on 8/3/17 at 11:15 a.m. An admission date of [DATE] was noted. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set ((MDS) dated [DATE], coded the resident with no cognitive impairment. Required assistance of one for bed mobility and transfers. The assessment indicated the resident was not at risk for pressure sores, and had no history of pressure sores. A physician's orders [REDACTED]. The treatments were documented as done daily. A form titled Wound/Skin Healing Record, had documentation of a pressure ulcer, date of onset 7/17/17 between right 4th and 5th toes. (no measurements) the next documentation on the form was dated 7/21/17. An unstageable 7.0 by 2.0 centimeter area with serosanguineous exudate, moderate odor, moderate amount of exudate, black/brown wound bed, surrounding skin color black/brown, with hardness/induration surrounding tissue wound edges. The assessment indicated the resident was having no pain. Documentation on a 24 hour nursing communication form, dated 7/19/17, provided by the Administrator on 8/4/17 at 10:05 a.m., 4th 5th toes on r (right) foot look horrible! Foul odor. Documentation was noted on a progress note, dated 7/20/17 at 1:34 p.m., of changed dressing to right toes, cleansed and ointment applied area black/dark areas and oozing, the smell is that strong decaying odor cont (continue) to monitor reported to unit manager by .(name) LPN. A plan of care addressed the problem of At risk for skin breakdown due to occasional urinary incontinence, with onset date of 7/11/16. Interventions included, but were not limited to, Observe skin for any changes daily during care. Notify MD (medical doctor) of any changes in skin condition. The hospital records were reviewed on 8/3/17 at 10:00 a.m., provided by the Administrator. Documentation in the report included, but was not limited to, 7/25/17 at 9:04 p.m., ER (emergency room )[MEDICAL CONDITION], gangrenous toes . Pt (patient) presented to the ED (emergency department) for complaints of lethargy and weakness. Pt currently has an infection of the right foot. Pt denies any pain to the lower extremity today. Pt seen at bedside in the ICU (intensive care unit). Pt presented to the ED with [MEDICAL CONDITION] and lethargic. Pt denies any n/f/c (no further complaints) today. Pt doesn't have any family at bedside this am. Documentation on an ED Visit Flowsheet for 7/26/17 included Pressure Ulcer right Lateral Plantar Foot, present on admission, brown oozing drainage, gangrene right toe. Documentation of the area on 7/27/17 included maggots noted in wound. Additional documentation, dated 7/26/17 at midnight, included there was a Stage II pressure Ulcer to the right hip. Measurements were 3 cm (centimeters) by 1.5 cm with [DIAGNOSES REDACTED] surrounding tissue. Documentation on 7/26/17 at 4:00 p.m. indicated the area was a Stage III (full thickness loss). A hospital nursing note, dated 7/28/17, was noted of dressing change done on r (right) foot, when old dressing removed about 30 live maggots fell off. redressed (sic) with 4 X (by) and Kerlix. inseptected (sic) and removed and disposed of all maggots seen. Treatment orders were changed the day of the resident's return to the facility, 7/28/17 and then again on 8/1/17 to New order: cleanse wound to 4th and 5th toes on right foot with 30 cc Dakins Solution mixed with 30 cc (millimeters) normal saline. Apply calcium alginate to open wound area. Allow to dry. Cover with gauze and wrap with Kerlix daily and prn (as needed) if soiled. [MEDICATION NAME] 200 (mg) milligrams for 10 days for wound infection and [MEDICATION NAME] 100 mg by mouth two times a day for 14 days for wound infection. On 8/4/17 at 8:45 a.m., LPN #3 was interviewed. She indicated she did not remember being made aware of the area on the resident's hip. She indicated she had not been able to find any information of the physician being made aware of the area, or the worsening condition of the areas on the resident's toes until the physician visited on 7/25/17, and ordered the resident be sent to the hospital. On 8/4/17 at 10:30 a.m., the Administrator provided measurements of the hip area. The documentation was noted of a Stage II 1 cm X 1.5 cm X less than 0.1. The physician was notified and treatment orders obtained. The Administrator and LPN #9 were interviewed on 8/4/17 at 4:22 p.m. They indicated a written policy outlining the facility's wound management program had not completely been developed. The indicated the nurse that first is made aware of a new area, should measure and observe, notify the physician and family. Obtain treatment orders, let resident and family know of new orders. Document the area on the 24 hour sheet to be reviewed in morning meetings. Areas will then be measured weekly by the Unit Managers, who are responsible for notifying the physicians if a need to alter treatments. The immediate jeopardy that began on 8/4/17 was removed on 8/5/17 when the facility assessed all residents' skin, developed and inserviced nursing staff on the new policy and procedures for Resident Skin Assessments, notified physician's of new findings and received and implemented new orders. Documentation in the new policy titled Resident Skin Assessment, indicated the Charge Nurses will be responsible for following up to ensure orders are completed in a timely manner, and communicated to the attending physician, responsible family member, Unit Managers, and the Administrator. The noncompliance remained at the lower scope and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility need for continued monitoring. This federal tag is related to complaint IN 623. 3.1-40()(1) 3.1-40(a)(2) 3.1-40(a)(3)

Based on observation, interview, and record review, the facility failed to ensure worsening pressure ulcers and development of new pressure area was reported to the physician for a need for change of treatment resulting in the resident being transferred to the emergency room and admitted to the Intensive Care Unit for 1 of 3 residents reviewed with pressure ulcers in a total sample of 7 residents who had pressure areas (Resident C). The Immediate Jeopardy began on 7/19/17 when a nursing communication form, dated 7/19/17, indicated Resident C's foot ulcer developed a foul odor, and Looked terrible! and no physician notification or follow up was done. The Administrator and Contracted Consultant were notified of the immediate jeopardy on 8/4/17 at 1:40 p.m. The immediate jeopardy was removed, and the deficient practice corrected on August 5, 2017. Findings include: Resident C was observed on 8/3/17 at 9:30 a.m. Licensed Practical Nurse (LPN) 8 was performing a dressing change on the resident's right foot. The foot had been soaked in Dakins solution (antiseptic), was dried and calcium alginate was applied. The area was covered with 4 by 4 gauze pads, then abdominal pads, and wrapped with kerlix (gauze bandage). The wound had a very foul odor. Resident C was observed on 8/4/17 at 8:45 a.m., with LPN/Unit Manager, 3 and Certified Nurse Aide (CNA) 5. The gauze dressing on the foot was observed with reddish brown drainage coming through the bandage with a very foul odor. The resident was repositioned and skin was checked. A Stage II pressure (partial-thickness skin loss) area was observed on the right hip, no dressing was in place. The CNA indicated it was the same area she had noted on a computerized Bathing Roster for dates 7/1/17 through 8/31/17, where she had documented on 7/21/17 at 10:04 a.m., Skin Check, New Skin Concern - Nurse notified. Resident C's clinical record was reviewed on 8/3/17 at 11:15 a.m. An admission date of [DATE] was noted. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set ((MDS) dated [DATE], coded the resident with no cognitive impairment. Required assistance of one for bed mobility and transfers. The assessment indicated the resident was not at risk for pressure sores, and had no history of pressure sores. A physician's orders [REDACTED]. The treatments were documented as done daily. A form titled Wound/Skin Healing Record, had documentation of a pressure ulcer, date of onset 7/17/17 between right 4th and 5th toes. (no measurements) the next documentation on the form was dated 7/21/17. An unstageable 7.0 by 2.0 centimeter area with serosanguineous exudate, moderate odor, moderate amount of exudate, black/brown wound bed, surrounding skin color black/brown, with hardness/induration surrounding tissue wound edges. The assessment indicated the resident was having no pain. Documentation on a 24 hour nursing communication form, dated 7/19/17, provided by the Administrator on 8/4/17 at 10:05 a.m., 4th 5th toes on r (right) foot look horrible! Foul odor. Documentation was noted on a progress note, dated 7/20/17 at 1:34 p.m., of changed dressing to right toes, cleansed and ointment applied area black/dark areas and oozing, the smell is that strong decaying odor cont (continue) to monitor reported to unit manager by .(name) LPN. A plan of care addressed the problem of At risk for skin breakdown due to occasional urinary incontinence, with onset date of 7/11/16. Interventions included, but were not limited to, Observe skin for any changes daily during care. Notify MD (medical doctor) of any changes in skin condition. The hospital records were reviewed on 8/3/17 at 10:00 a.m., provided by the Administrator. Documentation in the report included, but was not limited to, 7/25/17 at 9:04 p.m., ER (emergency room )[MEDICAL CONDITION], gangrenous toes . Pt (patient) presented to the ED (emergency department) for complaints of lethargy and weakness. Pt currently has an infection of the right foot. Pt denies any pain to the lower extremity today. Pt seen at bedside in the ICU (intensive care unit). Pt presented to the ED with [MEDICAL CONDITION] and lethargic. Pt denies any n/f/c (no further complaints) today. Pt doesn't have any family at bedside this am. Documentation on an ED Visit Flowsheet for 7/26/17 included Pressure Ulcer right Lateral Plantar Foot, present on admission, brown oozing drainage, gangrene right toe. Documentation of the area on 7/27/17 included maggots noted in wound. Additional documentation, dated 7/26/17 at midnight, included there was a Stage II pressure Ulcer to the right hip. Measurements were 3 cm (centimeters) by 1.5 cm with [DIAGNOSES REDACTED] surrounding tissue. Documentation on 7/26/17 at 4:00 p.m. indicated the area was a Stage III (full thickness loss). A hospital nursing note, dated 7/28/17, was noted of dressing change done on r (right) foot, when old dressing removed about 30 live maggots fell off. redressed (sic) with 4 X (by) and Kerlix. inseptected (sic) and removed and disposed of all maggots seen. Treatment orders were changed the day of the resident's return to the facility, 7/28/17 and then again on 8/1/17 to New order: cleanse wound to 4th and 5th toes on right foot with 30 cc Dakins Solution mixed with 30 cc (millimeters) normal saline. Apply calcium alginate to open wound area. Allow to dry. Cover with gauze and wrap with Kerlix daily and prn (as needed) if soiled. [MEDICATION NAME] 200 (mg) milligrams for 10 days for wound infection and [MEDICATION NAME] 100 mg by mouth two times a day for 14 days for wound infection. On 8/4/17 at 8:45 a.m., LPN #3 was interviewed. She indicated she did not remember being made aware of the area on the resident's hip. She indicated she had not been able to find any information of the physician being made aware of the area, or the worsening condition of the areas on the resident's toes until the physician visited on 7/25/17, and ordered the resident be sent to the hospital. On 8/4/17 at 10:30 a.m., the Administrator provided measurements of the hip area. The documentation was noted of a Stage II 1 cm X 1.5 cm X less than 0.1. The physician was notified and treatment orders obtained. A facility policy titled Change in a Resident's Condition or Status, provided by the Administrator on 8/7/17 at 2:48 p.m., with revision date of 8/7/17, included, but was not limited to, Policy Statement Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights. Policy Interpretation and Implementation 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a (an): d. Significant change in the resident's physical/emotional/mental condition; e. Need to alter the resident's medical treatment significantly; 2. A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions; b. Impacts more than one area of the resident's health status; c. Requires interdisciplinary review and/or revision to the care plan The immediate jeopardy that began on 8/4/17 was removed on 8/5/17 when the facility assessed all residents' skin, developed and inserviced nursing staff on the new policy and procedures for Resident Skin Assessments, notified physician's of new findings and received and implemented new orders. Documentation in the new policy titled Resident Skin Assessment, indicated the Charge Nurses will be responsible for following up to ensure orders are completed in a timely manner, and communicated to the attending physician, responsible family member, Unit Managers, and the Administrator. The noncompliance remained at the lower scope and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility need for continued monitoring. This federal tag is related to complaint IN 623. 3.1-5(a)(2) 3.1-5(a)(3)