Every finding on record at Mason Health Care Center

Based on record review and interview, the facility failed to ensure that physician orders were completed per the parameters placed for administration of a medication for 1 of 3 residents reviewed for quality of care. (Resident D) Finding includes:A record review for Resident D was completed on 8/25/2026 at 9:42 A.M. Diagnoses included, but were not limited to: heart failure, diabetes mellitus type 2, malignant neoplasm of the renal pelvis and secondary malignant neoplasm of the lung. A Quarterly Minimum Data Set (MDS) assessment, dated 8/25/2026, indicated Resident D was cognitively intact.A Care Plan initiated, on 5/16/2025 and updated on 5/26/20026, indicated Resident D had essential hypertension of unknown origin and Resident D's blood pressure would be managed with her care plan interventions. Interventions included, but were not limited to: taking Resident D's blood pressure as ordered and observing for any pattern changes and taking the antihypertensive medications as ordered. A Physician's Order, dated 5/20/2026, indicated the medication, metoprolol tartrate (a medication used to treat high blood pressure, chest pain and improve survival after a heart attack) 25 milligrams (mg) 0.5 tablet was to be administered by mouth twice daily for hypertension and the medication was to be held if the resident's systolic blood pressure (upper number the blood pressure reading) was less than 130 mmHg (millimeters per mercury) or the resident's pulse rate was less than 60 beats per minute (BPM). A review, of the July 2026 Medication Administration Record (MAR), indicated metoprolol tartrate 25 mg by mouth with a half tab had been administered outside of the ordered parameters on the following dates:-7/16/2026 at 4:00 P.M., blood pressure 127/67 mmHg, pulse 78 BPM.-7/19/2026 at 4:00 P.M., blood pressure 129/64 mmHg, pulse 64 BPM.-7/23/2026 at 4:00 P.M., blood pressure 118/68 mmHg, pulse 66 BPM.7/25/2026 at 4:00 P.M., blood pressure 109/58 mmHg, pulse 69 BPM.-7/27/2026 at 830 A.M., blood pressure 129/62 mmHg, pulse 63 BPM.-7/27/2026 at 4:00 P.M., blood pressure 125/68 mmHg, pulse 65 BPM. A review, of the August 2026 Medication Administration Record (MAR), indicated the metoprolol tartrate 25 mg by mouth half tab had been administered outside the ordered parameters on the following dates:-8/8/2026 at 8:30 A.M., blood pressure 152/76 mmHg, pulse 77 BPM (was held).-8/10/2026 at 8:30 A.M., blood pressure 98/60 mmHg, pulse 75 BPM.-8/15/2026 at 8:30 A.M., blood pressure 119/58 mmHg, pulse 68 BPM.-8/16/2026 at 8:30 BP A.M., blood pressure 114/49 mmHg, pulse 76 BPM.-8/22/2026 at 8:30 A.M., blood pressure 114/66 mmHg, pulse 80 BPM. During an interview, on 8/25/2026 at 1:39 P.M., the Director of Nursing (DON) indicated the metoprolol tartrate should have been held according to the physician's orders and should not have been administered outside of the ordered vital sign parameters. A policy was provided by the Regional Director of Clinical Services, on 8/25/2026 at :44 P.M. The policy titled, Following Physician Orders/Parameters, indicated, .Purpose: To administer resident care in a safe and efficient manner and following physician orders and ordered parameters.Policy: All licensed healthcare providers shall consult the resident's medical orders for the appropriate physician/clinician order prior to administering or performing a resident procedure. 1) Check MAR/TAR for physician/clinician order.4) Check for vital signs, other tests to be done as prescribed by resident's physician/clinician. 410 Indiana Administrative Code (IAC) 3.1-37

Based on observation, record review and interview, the facility failed to provide privacy during incontinence care for 3 of 4 residents observed for activities of daily living. (Residents B, C & D)Finding includes:1.During an observation, on 3/9/2026 at 4:44 A.M., Resident B was assisted by CNA (Certified Nursing Assistant) 2 and 3 with incontinence care. CNA 2 and 3 did not pull Resident B's privacy curtain between Resident B and his roommate. A record review for Resident B was completed, on 3/9/2026 at 7:33 A.M. Diagnoses included, but were not limited to: nontraumatic intracerebral hemorrhage, dementia and altered mental status.An admission Minimum Data Set (MDS) assessment for Resident B was in progress and had not yet been fully completed.Resident B did not have a care plan that addressed incontinence care.2. During an observation, on 3/9/2026 at 5:22 A.M., Resident C was assisted by CNA 2 and 3 with the placement of an incontinence brief while lying in bed. CNA 2 pulled Resident C's lower garment to her ankles and placed the incontinence brief underneath Resident C. The privacy curtain had not been pulled between Resident C and her roommate, and the window blinds were not closed during the incontinence care.A record review for Resident C was completed on 3/9/2026 at 7:51 A.M. Diagnoses included, but were not limited to: Alzheimer's disease, dementia and overactive bladder.An Annual Minimum Data Set (MDS) assessment, dated 12/19/2025, indicated Resident C had severe cognitive impairment and required substantial assistance for toileting hygiene.A Care Plan, initiated on 8/1/2023 and revised on 3/6/2026, indicated Resident C was incontinent of bladder and bowel at times. Interventions included, but were not limited to: assist Resident C with clothing adjustment, cleansing, and transfers during toileting and assistance with incontinence care.3. During an observation, on 3/9/2026 at 5:40 A.M., Resident D was assisted by CNA 2 and 3. The privacy curtain by the window had been pulled, but not completely pulled to cover the exposed window at the end of the bed with the blinds open. The privacy curtain was not pulled between Resident D and her roommate.A record review for Resident D was completed, on 3/9/2026 at 8:15 A.M. Diagnoses included, but were not limited to: spastic hemiplegia, cerebral infarction and overactive bladder.A Quarterly MDS assessment, dated 12/22/205, indicated Resident D had severe cognitive impairment, was always incontinent of bladder and bowel and was dependent for toileting hygiene.A Care Plan, initiated on 3/28/2023 and revised on 2/16/2026, indicated Resident D was incontinent of bladder and bowel. Interventions included, but were not limited to: staff would check for incontinence frequently as needed and assist with incontinence care.During an interview, on 3/9/2026 at 5:48 A.M., CNA 2 indicated the privacy curtains and the window blinds should have been closed or pulled when incontinence care had been provided.A policy was provided by the Executive Director, on 3/9/2026 at 8:35 A.M. The policy titled, Resident Rights, indicated, .The resident has a right to be treated with respect and dignity.410 IAC 16-2-3.1-3(p)(4)

Based on observation, interview and record review, the facility failed to ensure staff changed gloves between soiled incontinence care and clean incontinence care for 3 of 4 residents observed for activities of daily living. (Residents B, C & D)Findings include:1.During an observation, on 3/9/2026 at 4:44 A.M., Resident B was observed being assisted with incontinence care after having been incontinent of urine in his disposable brief. CNA (Certified Nursing Assistant) 2 and 3 assisted Resident B, while he was in his bed, with incontinence care. CNA 2 and 3 removed the soiled brief and CNA 3 provided peri care using disposable wipes. CNA 3 then, without changing her gloves, assisted with applying a new, clean incontinence brief to Resident B.A record review for Resident B was completed, on 3/9/2026 at 7:33 A.M. Diagnoses included, but were not limited to: nontraumatic intracerebral hemorrhage, dementia and altered mental status.An admission Minimum Data Set (MDS) assessment indicated it had not yet been completed and was in progress.Resident B did not have a care plan that addressed incontinence care.2. During an observation, on 3/9/2026 at 5:22 A.M., Resident C was observed sitting on the edge of her bed wearing her daily clothing. Resident C did not have an incontinence brief on under her clothing. CNA 2 assisted Resident C with incontinent peri care by wiping her with disposable wipes. CNA 2 did not change her gloves after providing peri care before placing a clean incontinence brief on Resident C.A record review for Resident C was completed on 3/9/2026 at 7:51 A.M. Diagnoses included, but were not limited to: Alzheimer's disease, dementia and overactive bladder.An Annual Minimum Data Set (MDS) assessment, dated 12/19/2025, indicated Resident C had severe cognitive impairment and required substantial assistance for toileting hygiene.A Care Plan, initiated on 8/1/2023 and revised on 3/6/2026, indicated Resident C was incontinent of bladder and bowel at times. Interventions included, but were not limited to: assist Resident C with clothing adjustment, cleansing and transfers during toileting and assistance with incontinence care.3. During an observation, on 3/9/2026 at 5:40 A.M., Resident D was observed attempting to get out of bed. Resident D was noted to have a soiled incontinence brief in place. CNA 2 and 3 assisted Resident D with incontinence care. CNA 2 provided incontinent peri care, utilizing disposable wipes. After CNA 2 had provided peri care, she did not wash her hands or change her gloved before placing a clean incontinence brief on Resident D.A record review for Resident D was completed, on 3/9/2026 at 8:15 A.M. Diagnoses included, but were not limited to: spastic hemiplegia, cerebral infarction and overactive bladder.A Quarterly MDS assessment, dated 12/22/205, indicated Resident D had severe cognitive impairment, was always incontinent of bladder and bowel and was dependent for toileting hygiene.A Care Plan, initiated on 3/28/2023 and revised on 2/16/2026, indicated Resident D was incontinent of bladder and bowel. Interventions included, but were not limited to: staff would check for incontinence frequently as needed and asst with incontinence care.During an interview, on 3/9/2026 at 5:48 A.M., CNA 2 indicated gloves should have been changed after providing incontinence care and before placing a clean incontinence brief on the residents.A policy was provided by the Executive Director, on 3/9/2026 at 8:35 A.M. The policy titled, Incontinence, indicated, .Based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services.4. Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent Infections.410 IAC 16-2-3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to ensure foods were stored, prepared and served in a sanitary manner in 1 of 1 kitchens reviewed. This deficient practice had the potential to affect 75 of 75 residents who received meals from the kitchen.Findings include: 1. During an observation of the kitchen, with the Dietary Manager on 8/18/2025 at 9:53 A.M., the following was observed:In the Walk in cooler:-1 cream cheese box not sealed.-an opened container of apple juice with a use by date of 8/17/2025. During an interview on 8/18/2025 at 10:00 A.M., the dietary manager indicated the foods should have been sealed appropriately and the juice should have been removed from the cooler. 2. In the walk in freezer:-a box of egg patties not sealed in the box with some patties having ice build up on them. During an interview, on 8/18/2025 at 10:10 A.M., the dietary manager indicated the box of egg patties should have been sealed. 3. In the dry storage area:-an opened package of spaghetti not sealed tightly.-an opened box of corn starch not sealed tightly.-an opened package of macaroni not sealed tightly. During an interview, on 8/18/2025 at 10:20 A.M., the dietary manager indicated the foods should have been sealed. 4.During a follow-up visit of the kitchen, on 8/19/2025 at 11:00 A.M., the following was observed:-the front of the steam table was noted to have a greasy substance dripped down the steam table. -2 dirty and 2 wet soup bowls put away as clean. During an interview, on 8/19/2025 at 11:06 A.M., the Registered Dietician indicated, they get to the steam table cleaning periodically. 5. During a follow-up visit of the kitchen, on 8/26/2025 at 10:16 A.M., the following was observed: -small & large skillets had missing Teflon coating to the cooking surfaces.-cooking pans had a build up of black grease to the bottom surface and around the handle of the pans.-steamer pans put away under the food prep table were wet. During an interview, on 8/26/2025 at 11:10 A.M., the cook indicated she had not had time to clean the steam table. On 8/25/2025 at 9:03 A.M., the Administrator provided the policy titled, Food Safety Requirements, dated 4/9/2024, and indicated the policy was the one currently used by the facility. The policy indicated . 1. Food safety practices shall be followed throughout the facility's entire food handling process . Elements of the process include the following: . e. Equipment used in the handling of food, including dishes, utensils, mixers, grinders, and other equipment that comes in contact with food . c. iv. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by the use-by date, or frozen (where applicable)/discarded; and v. Keeping foods covered or in tight containers . 6. All equipment used in the handling of food shell be cleaned and sanitized, and handled in a manner to prevent contamination On 8/25/2025 at 9:03 A.M., the Administrator provided the policy titled, Steam Tables, dated 6/2021 and revised on 8/2025, and indicated the policy was the one currently used by the facility. The policy indicated . Steam tables will be maintained in a clean and sanitary condition. Steam tables should be cleaned after each use and thoroughly cleaned at least once per day . 3. Clean the inside and outside of each unit of the steam table 3.1-21(3)

Based on record review and interview, the facility failed to ensure there were appropriate medical symptoms to support the use of an antipsychotic for 1 of 5 residents reviewed for unnecessary medications. (Resident 51) Finding includes: The record for Resident 51 was reviewed on 8/25/2025 at 10:43 A.M. Diagnoses included, but were not limited to Alzheimer's disease, depression, bipolar, psychotic disorder and dementia. A Quarterly MDS (Minimum Data Set) assessment, dated 6/9/2025, indicated the resident was unable to complete a mini mental assessment, and received an antidepressant and anticonvulsant medication. A Physicians Order, dated 6/29/2025, indicated Seroquel (antipsychotic) 25 mg (milligram) 1 tablet one time only for anxiety (1 time dose). During an interview, on 8/25/2025 at 3:37 P.M., the Director of Nursing indicated the diagnoses was not appropriate for the use of Seroquel. On 8/26/2025 at 11:45 A.M., the Corporate Nurse provided the policy titled, Unnecessary Drugs Policy, dated 2/5/2025, and indicated the policy was the one currently used by the facility. The policy indicated . Each resident's drug regimen will be reviewed on an ongoing basis, taking into consideration the following elements: . c. Indications and clinical need for medication 3.1-3(w)

Based on record review and interview, the facility failed to ensure the care plan addressed the a diabetic resident's refusal of blood glucose monitoring for 1 of 1 residents reviewed for diabetic monitoring. (Resident 8)Findings include:The record for Resident 8 was reviewed on 8/22/2025 at 10:30 A.M. Diagnoses included, but were not limited to: Diabetes type 2, post-traumatic stress disorder, pulmonary hypertension with heart failure, restless leg syndrome and obesity. A Minimum Data Set (MDS) assessment, completed on 7/17/2025 indicated Resident 8 had no cognitive impairments, had a diabetes diagnosis and received insulin injections. The current Physician's orders for Resident 8 included the following diabetes management medications:Mounjaro Subcutaneous 10 milligrams (mg)/0.5 milliliter(ml) every Friday for diabetesJardiance 25 mg daily for diabetes Actos 15 mg daily for diabetesInsulin Glargine 100 units/ml 45 units subcutaneous twice a day for diabetesHumalog 100 u/ml, 10 units subcutaneous three times daily for diabetesDuring an interview, on 8/22/2025 at 10:20 A.M., RN 5 indicated resident 8's refusal of blood sugar checks started approximately a year ago. RN 5 indicated she was uncomfortable administering the numerous blood sugar medications to the resident without having assesed the resident's blood sugar level. RN 5 indicated Resident 8 had a physician's order to check blood sugars as needed if the resident exhibited signs or symptoms of hypo or hyperglycemia. During an interview, on 8/22/2025 at 1:20 P.M., Resident 8 indicated that she has been on the same medications for a long time and she did not feel she needed to check her blood sugar three times a day. She indicated she had tried a continuous glucose monitoring device but had not liked how painful it was to attach and detach from her arm. The current care plans related to diabetes for Resident 8 included a plan, initiated on 4/2/2024, with a problem that the resident may have fluctuating blood glucose levels. The care plan did not address the resident's refusal to have her blood glucose levels assessed. During an interview, on 8/26/25 at 11:09 A.M., the Director of Nursing indicated the resident's refusal for blood sugar checks should have been care planned. She indicated the facility did not have a specific policy regarding diabetic management. 3.1-35(b)(2)

Based on interview and record review, the facility failed to provide assistance with Activities of Daily Living (ADLs) related to showering for 1 of 2 residents reviewed for ADL care. (Resident 40) Finding includes:During an interview, on 8/19/2025 at 11:04 A.M., Resident 40 indicated the last shower she had was approximately eight days ago. A record review was completed for Resident 40 on 8/22/2025 at 9:18 A.M. Diagnoses included, but were not limited to: type 2 diabetes, depression and need for assistance with personal care. An admission MDS assessment, dated 3/11/25, indicated it was very important for the resident to choose between a bed bath, shower, or tub bath. A Quarterly Minimum Data Set (MDS) assessment, dated 6/11/2025, indicated Resident 40's cognition was moderately impaired and the resident required substantial/maximum assistance from staff with bathing and showering. A current Care Plan, initiated on 3/8/2025 indicated Resident 40 needed assistance with ADL's. Interventions included, but were not limited to: the resident required the assistance of one person with bathing. The Care Plan also indicated Resident 40 had specific choices related to her care. Interventions included, but were not limited to: the resident preferred showers and would receive them two times per week per facility shower schedule. A review of Resident 40's shower task indicated Resident 40 had received showers on the following dates: -6/9/2025-6/16/2025-6/24/2025-7/31/2025-8/7/2025-8/14/2025 A review of Resident 40's bed bath task indicated the resident had received a bed bath on the following dates: -7/13/2025-7/24/2025-7/28/2025-8/11/2025-8/21/2025 Thus, Resident 40 had only received 11 of 22 care planned bathing opportunities and 5 of the 11 received were not her preferred method of bathing, showers. During an interview, on 8/26/2025 at 9:36 A.M., the ED indicated Resident 40 should have been receiving two showers per week.On 8/26/2025 at 11:21 A.M., the ED provided the policy titled, Resident Showers, and indicated it was the policy currently being used by the facility. The policy indicated, Policy: It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice. 1. Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. 2. Partial baths may be given between regular shoer schedules as per facility policy 3.1-38(b)(2)

Based on record review and interview, the facility failed to notify the physician for significantly elevated blood glucose levels for 2 of 3 residents reviewed for blood glucose (Resident 32 & B).Findings include: 1. A record review was completed for Resident 32 on 8/20/2025 at 1:52 P.M. Diagnoses included, but were not limited to: type 2 diabetes. A Physician's Order, dated 8/6/2024 indicated a fasting blood glucose level was to be completed every morning one time per day and to notify the Nurse Practitioner if the resident's blood glucose level was below 70 mg/dl or above 400 mg/dl. A review of Resident 32's blood glucose levels indicated the resident's record lacked documentation the physician or Nurse Practitioner was notified of the resident's elevated blood glucose levels above 400 mg/dl for the following dates and times: -On 2/28/2025 at 7:37 A.M., Resident 32's blood glucose level was 443 mg/dl. -On 3/4/2025 at 10:11 A.M., Resident 32's blood glucose level was 546 mg/dl. -On 3/7/2025 at 9:19 A.M., Resident 32's blood glucose level was 436 mg/dl. During an interview, on 8/25/2025 at 10:43 A.M., RN 2 indicated if a resident's blood glucose level was outside the recommended parameters, they were supposed to notify the Nurse Practitioner and complete a progress note. During an interview, on 8/25/2025 at 11:03 A.M. the DON indicated the Nurse Practitioner should have been notified of Resident 32's elevated blood glucose levels. 2. The record for Resident B was reviewed on 8/22/2025 at 2:45 P.M. Diagnoses included, but were not limited to Cerebral infarct, dysphagia, severed protein calorie malnutrition, obstructive and reflux uropathy, diabetes type 2, acute kidney failure, adult failure to thrive and neuromuscular dysfunction of the bladder. An admission MDS (Minimum Data Set) assessment, dated 4/4/2025, indicated the resident was alert and oriented and was able to make his needs know, required extensive staff assist with transfers, bed mobility and showering and had an indwelling catheter. Physician's Orders, dated 4/2/2025, indicated the facility was to check the resident's blood sugar levels two times daily. The blood sugar documentation, dated 4/2/2025 through 4/18/2025 indicated the lowest blood sugar level result was 112 to the highest result of 313. The blood sugar documentation, dated 4/19/2025, indicated the following results: 329 at 4:38 A.M., 320 at 11:36 A.M., and 323 at 4:03 P.M. The blood sugar documentation, dated 4/20/2025, indicated the following results: blood glucose level was 319 at 7:13 A.M., the blood glucose level was 352 at 11:01 A.M., and the blood glucose level was 397 at 4:25 P.M. During an interview, on 8/26/25 at 9:12 A.M., LPN 11 indicated if a resident had a high blood glucose level, she would first call the NP (Nurse Practitioner) to get orders and go from there. If the resident had no insulin orders, she would call the NP and put this in the progress notes and let the Director of Nursing and Assistant Director of Nursing know. During an interview, in 8/26/2025 at 9:48 A.M., the Director of Nursing indicated the physician should have been notified of the elevated blood glucose levels and a progress note should have been completed at the time of the notification. Progress Notes, dated on 4/18 and 4/19/2025, lacked the documentation of the physician being notified of the abnormal levels. On 8/25/2025 at 11:29 A.M., the Administrator provided the policy titled, Following Physician Orders/Parameters, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: To administer resident care in a safe and effective manner and following physicians orders and ordered parameters. 2. Licensed healthcare personnel will consult and follow the physician/clinician order when performing any resident procedures This deficiency is related to intake 2594043. 3.1-37

Based on observation, record review and interview, the facility failed to ensure 1 of 3 residents reviewed for hearing and/or vision needs had their audiologist recommendation followed in a timely manner. (Resident 3)Finding includes: During an interview, on 8/18/2025 at 3:38 P.M., Resident 3 indicated she was hard of hearing. The record for Resident 3 was reviewed on 8/26/2025 at 7:16 A.M. Diagnoses included anemia, hypotension, hyperkalemia, unspecified hearing loss bilateral and atrial fibrillation. A Quarterly MDS (Minimum Data Set) assessment, dated 8/18/2025, indicated Resident 3 was alert and oriented and her ability to hear was highly impaired/absence of useful hearing. A Care Plan, initiated on 5/15/2024, indicated the resident had a communication deficit as evidenced by hearing loss. The plan indicated the following: I prefer that others communicate with me in writing. I often speak loudly related to my hearing loss. During an interview on, 8/21/2025 at 10:48 A.M., the Social Service Director indicated the resident had been seen by the audiologist in December 2024. An audiology Visit Summary form, dated 12/9/2024, indicated the following: Medical consult to obtain medical clearance for hearing aids - continue with current means of communication. Medical consult due to Eustachian tube dysfunction- left ear- if bilateral tinnitus persists- both ears. Hearing aid is recommended, Type BTE binaural impression taken: YES There was no evidence in the medical record that the resident had been referred to an audiologist for a hearing aid. During an interview, on 8/26/2025 at 11:13 A.M., the Social Service Director indicated the referral should have been scheduled. On 8/26/2025 at 11:23 A.M., the Corporate Nurse provided the policy titled, Hearing an Vision Services, dated 3/5/2024, and indicated the policy was the one currently used by the facility. The policy indicated .It is the policy of this facility to ensure that all residents have access to hearing and vision services and receive adaptive equipment as indicated . 3. The social worker/social service designee is responsible for assisting residents, and their families in locating and utilizing any available resources . provision of the vision and hearing services the resident needs. 3.1-39(a)

Based on record review and interview, the facility failed to ensure urine outputs were monitored for a resident with an indwelling catheter for 1 of 1 residents reviewed for catheters. (Resident B) Finding includes:The record for Resident B was reviewed on [DATE] at 2:45 P.M. Diagnoses included, but were not limited to Cerebral infarct, dysphagia, severed protein calorie malnutrition, obstructive and reflux uropathy, diabetes type 2, acute kidney failure, adult failure to thrive and neuromuscular dysfunction of the bladder. An admission MDS (Minimum Data Set) assessment, dated [DATE], indicated the resident was alert and oriented and was able to make his needs known, required extensive staff assist with transfers, bed mobility and showering and had an indwelling catheter.Physician orders related to the resident's indwelling catheter included the following: 4/42025---Change catheter as needed; Change Catheter drainage bag as needed, and Catheter care every shift.A Nursing Progress Note, dated [DATE] at 8:54 A.M., indicated there was no change in urinary output. The resident's urine was clear and the indwelling catheter was draining to gravity.A Physician's Order, dated [DATE], indicated to remove the Foley indwelling urinary catheter for a voiding trial.A Nursing Progress Note, dated [DATE] at 4:41 P.M., indicated there had been no urine output produced so far during the voiding trial and it had been 7 hours (since the indwelling urinary catheter had been removed). Resident B was straight cathed ( a procedure where a small thin hollow tube was inserted into the bladder to drain and collect urine from the bladder) which resulted with 250 cc of urine. The Nurse Practitioner ordered the resident to be straight cathead in 6 hours if no urine was produced and voided by the resident.A Nursing Progress Note, dated [DATE] at 11:23 P.M., indicated the resident had complained of urethra pain. A Nursing Progress Note, dated [DATE] at 11:46 P.M., indicated the Foley indwelling urinary catheter was reinserted because the resident was unable to void. There was a return of 600 cc's of clear yellow urine and the resident had complained of urethra pain when the catheter was reinserted. A Nursing Progress Note, dated [DATE] at 10:03 A.M., indicated no change in urine output, urine is clear. Has indwelling catheter draining to gravity. A Physician's Order, dated [DATE], indicated to obtain a UA-(urinalysis) lab test. A C&S (culture and sensitivity) laboratory test was ordered if indicated by the results of the urinalysis.A Nursing Progress Note, dated [DATE] at 5:02 P.M., indicated urine yellow in color, slight odor noted. UA C&S results pending at this time.A Nursing Progress Note, dated [DATE] at 3:45 A.M., indicated no change in urine output, urine is clear. Has indwelling catheter draining to gravity. A Nursing Progress Note, dated [DATE] at 8:00 P.M., as a late entry indicated 175 ml (milliliter) return with straight cath. Resident had voided less than 50 ml prior to cath. He had also urinated in his brief which was wet but not soaked. Urine clear yellow. No odor.A Physician Order, dated [DATE], indicated- straight Cath until resident voids independently then DC (discontinue).A Nursing Progress Note, dated [DATE] at 9:22 A.M., indicated no change in urine output. Urine is clear. Has indwelling catheter draining to gravity.A Nursing Progress Note, dated [DATE] at 9:54 A.M., resident urinated on his own. Will dc order for straight cath.A Nursing Progress Note, dated [DATE] at 6:25 P.M., indicated the urine results were: 10,000 to 50,000 organisms/candida glabrata (yeast that causes opportunistic life threatening infections). Nurse Practitioner aware. A Physician's Order, dated [DATE], included Ceftriaxone (a broad spectrum antibiotic) IM (intramuscular) x1 on [DATE].A Nursing Progress Note, dated [DATE] at 1:35 A.M., indicated no change in urine output. Urine is clear. Has indwelling catheter draining to gravity.A Physician Order, dated [DATE] at 11:02 A.M., included Pyridium (urinary tract analgesic) 200 mg 1 tablet every 6 hours as needed for urinary pain.A Nurses Progress Note, dated [DATE] at 2:21 P.M., indicated resident voided yellow urine with no issues. Incontinent of bowel/bladder.A Nursing Progress Note, dated [DATE] at 9:17 A.M., indicated no change in urine output. Urine is clear. Has indwelling catheter draining to gravity.A Nurses Progress Note, dated [DATE] at 12:22 P.M., indicated Resident B had urinary pain and had been medicated with the Pyridium medication.A Nurse Progress Note, dated [DATE] at 7:14 P.M., indicated Resident B had requested the Pyridium medication for urinary pain.A Nurse Progress Note, dated [DATE] at 10:25 P.M., indicated Resident B had requested the Pyridium medication for urinary pain.A Nurses Progress Note, dated [DATE] at 9:20 A.M., indicated the Foley catheter was discontinued due to soiled and dislodged.A Nursing Progress Note, dated [DATE] at 1:24 P. M., indicated no change in urine output. Urine is clear. Has indwelling catheter draining to gravity.A Nursing Progress Note, dated [DATE] at 10:23 A.M., indicated no change in urine output. Urine is clear. Has indwelling catheter draining to gravity.A Nurse Progress Note, dated [DATE] at 2:33 P.M., indicated Resident B had requested the Pyridium medication for urinary pain.A Nursing Progress Note, dated [DATE] at 9:59 A. M., indicated no change in urine output. Urine is yellow colored. Is continent of bladder.A Nurse Progress Note, dated [DATE] at 10:32 A.M., indicated Resident B had requested the Pyridium medication for urinary pain.A Nursing Progress Note, dated [DATE] at 5:13 A.M., indicated no change in urine output. Urine is yellowed color. Is continent of bladder.The clinical record lacked the documentation, from 4/18 to [DATE], to show the physician was notified of the continued urethral pain.During an interview, on [DATE] at 11:39 A.M, the Director of Nursing indicated the resident had an indwelling Foley catheter when he was transferred to the hospital on [DATE].Resident B was transferred to the the hospital emergency room on [DATE] because of a change in condition.The Emergency Department documentation, dated [DATE], indicated the following: chief complaint: sepsis (potentially life threatening infection) alert, recent stroke and apnic (loss of respiration) spells. Temperature was 100.2 degrees; blood pressure was 91/59; and his heart rate was 120 beats per minute. A urinalysis test (examination of the urine) obtained in the ER indicated the urine had a high number (41-99) of WBC (white blood cells), a high number (11-40) of RBC (red blood cells) and a high number (4+) of bacteria in the urine, which indicated a urinary infection. At 3:55 P.M., on [DATE], other Emergency documentation indicated the following: 1. Marked increase in the findings of active pneumonia in the lungs, and an element of pulmonary edema (liquid in the lungs) could also be present. 2. Findings of acute jejunitis (inflammation of the lining in the small intestine), and low grade colonic inflammation. 3. Bladder wall thickening could relate to cystitis or outlet obstruction. Residuals despite the presence of a Foley catheter, catheter dysfunction is suspected Emergency Department discharge instructions, dated [DATE] at 12:52.A.M indicated the resident had expired. A request for documentation of Resident B's urine outputs from [DATE] through [DATE] was made on [DATE] at 1:56 P.M.The facility indicated on [DATE] at 2:10 P.M., they could not provide Resident B's urine output amounts and indicated there should have been documentation of urine outputs for any resident with a Foley (urinary) catheter. During an interview, on [DATE] at 2:15 P.M., the Corporate Nurse indicated they did not have a policy regarding obtaining and documenting urine outputs for residents with urinary catheters.\This deficiency is related to intake 2594043.3.1-41(a)(2)

Based on record review and interview, the facility failed to ensure the narcotic (controlled substance) inventory book was completed thoroughly and accurately on 1 of 2 medication carts. (100 hall cart) Findings include:During an observation, on 8/22/2025 at 10:20 A.M., The narcotic card count sheet for the 100 Hallway medication cart lacked 8 signatures out of 72 opportunities. During an interview, on 8/22/2025 at 10:22 A.M., RN 5 indicated that the on coming and off going medical personnel who performed the narcotic inventory were responsible for signing the narcotic inventory book. RN 5 indicated staff should have signed the inventory book after the count was completed. On 8/25/2025 at 3:35 P.M., the Executive Director provided a policy titled Controlled Substance Administration and Accountability. The policy indicates, .two licensed nurses account for all controlled substances and access keys at the end of each shift. 3.1-25(e)(3)

Based on observation, interview and record review, the facility failed to ensure medications were administered according to physician's orders and professional standards for 5 of 30 opportunities, resulting in a medication administration error rate of 16.67%. (Resident 73 and 9) During an observation, on [DATE] at 9:02 A.M., RN 2 was administrating medications to Resident 73. RN 2 indicated he had 11 pills in the medication cup. The medication administered to Resident 73's were: Cymbalta 20 milligrams (mg), one tablet for depression Finasteride 5 mg, one tablet for benign prostatic hypertrophyFloranex probiotic one tabletPlavix 75 mg, one tablet for prophylaxis of blood clotsFerrous Sulfate 325 mg, one tablet for iron supplementationMetformin 500 mg, one tablet for diabetesMetoprolol Tartrate 25 mg, give 0.5 tablet for hypertensionTylenol 650 mg, one tablet for painVascepa 1 gram, give 2 tablets for hypertriglyceridemia Vitamin C 500 mg, one tablet for vitamin supplementation During a record review, on [DATE] at 9:20 A.M., Resident 73 had been prescribed Docusate 100 mg tablet daily on [DATE]. This medication was on a separate roll of pills in the medication cart. During an interview with RN 2, he indicated that he thought he had given the Docusate medication. However, during the initial medication pass observation only 11 pills were counted in the cup. The Docusate medication would have brought the count to twelve. During at observation, on [DATE] at 2:08 P.M.of the medication cart on the 400 hallway, a multi-use vial of insulin Lispro 100 units per milliliter had an opened date of [DATE]. RN 2 indicated he had ordered a refill for the insulin and it should arrive today. RN 2 indicated opened multi-dose insulin vials were to be discarded after 30 days. The record for Resident 9 reviewed on [DATE] at 3:11 P.M., indicated the resident had a diagnosis including diabetes. A current Physician's Order, dated [DATE], indicated Insulin Lispro sliding scale coverage subcutaneously before meals and at bedtime for blood glucose levels greater than 350. Review of the Medication Administration Record (MAR) for August indicated Resident 9 had received sliding scale coverage on [DATE] at 4:58 P.M., [DATE] at 8:36 P.M., [DATE] at 9:32 P.M. and [DATE] at 7:22 P.M. During an interview, on [DATE] at 9:15 A.M., RN 6 and QMA 7 indicated opened vials of insulin were to be discarded after 28 days per the facility's pharmacy recommendations. Thus, the resident received 4 doses of Lispro insulin from an expired multi-use pen that had been opened on [DATE] and had expired on [DATE]. On [DATE] at 3:25 P.M., the Executive Director provided a policy titled, Insulin Administration dated 12/2021 and indicated this was the policy the facility uses. The policy indicated, Opened vials can be kept in the medication cart until used or expires (28 days after opening). 3.1-48(c)(2)

Based on observation, interview and record review, the facility failed to secure and destroy discontinued controlled medications and properly dispose of expired medications on 1 of 2 medication carts and in 1 of 1 medication storage room observed. (Medication cart 100 hallway and Medication storage room [ROOM NUMBER]-400 hallway)Findings include:During an observation, on 8/22/2025 at 10:20 A.M., in the top drawer of the 100 hall medication cart, two Lorazepam 0.5 mg tablets medication cards for Resident 66 that had been discontinued on 8/4/2025 were found. One card contained 10 Lorazepam 0.5 mg tablets and one card contained 60 Lorazepam 0.5 mg tablets. During an interview, on 8/22/25 at 10:20 A.M., RN 5 indicated she had discovered the discontinued medication during the morning narcotic count and had removed the cards from the narcotic drawer of the medication cart. RN 5 indicated she intended to have the medications destroyed but was interrupted before she could take them to the appropriate area for disposal. RN 5 indicated the medication should have been destroyed on 8/4/2025 and she should have returned the medication to the locked narcotic box until it could properly be destroyed. During an observation, on 8/25/25 at 2:00 P.M., an unopened insulin lispro pen for Resident 9 was found in the medication storage room refrigerator on the 300/400 hall. The insulin pen had an expiration date of 5/20/2024. During an interview, on 8/25/2025 at 2:00 P.M., RN 5 indicated the insulin pen should have been discarded on the expiration date. On 8/25/25 at 3:25 P.M., the Executive Director (ED) provided a policy titled Controlled Substance Administration and Accountability dated 11/01/2023 which stated, .the charge nurse or other designee conducts a daily visual audit of the required documentation of controlled substances Medications removed from a medication cart have a documented physician order. On 8/25/25 at 3:25 P.M., the ED provided a policy titled, Destruction of Unused Drugs dated 11/01/2023 which stated, .the sealed container must be maintained in a secure area of the pharmacy or in a locked cabinet in the medication room until transferred to the waste disposal service 3.1-25 (m)(n)(o)

Based on observation, record review and interview, the facility failed to ensure staff followed infection control practices during a skin treatment for 1 of 1 skin treatments observed. (LPN 4) Finding includes: During an observation, on 8/18/2025 at 11:36 A.M., LPN 4 completed a wound treatment. LPN 4 placed her treatment supplies, including a pair of bandage scissors, directly onto the residents' table without placing a barrier down between the table and the supplies. LPN 4 then removed the residents' sock, the elastic bandage and then the gauze from the resident's right lower leg and removed the dressing to the heel and placed them in the trash can. LPN 4 then removed her gloves and applied hand sanitizer on both hands. She then, with opened hands, used a fanning motion to dry her hands and then applied new gloves. During an interview, on 8/18/2025 at 11:53 A.M., LPN 4 indicated she should have not fanned her hands and should have placed a barrier on the table. On 8/25/2025 at 4:30 P.M., the Corporate Nurse provided the policy titled, Hand Hygiene, dated 5/29/2024, and indicated the policy was the one currently used by the facility. The policy indicated . 4. Hand hygiene technique when using an alcohol-based hand rub: . b. Rub hands together, covering all surfaces of hands and fingers until hands feel dry. c. This should take about 20 seconds 3.1-18(a)

Based on record review and interview, the facility failed to ensure appropriate feeding tube care was provided regarding water flushes before and after medication administration and insertion site care for 1 of 3 residents reviewed for tube feeding. (Resident F) Finding includes: A complaint to the Indiana Department of Health (IDOH) was received on 6/11/2025 at 9:48 A.M. The complaint included, but was not limited to: .cleaning had not been performed around the feeding tube and only a gauze pad had been placed A closed record review for Resident F was completed on 6/16/2025 at 10:48 A.M. Diagnoses included, but were not limited to: cerebral infarction (stroke), dysphagia (difficulty swallowing), severe protein-calorie malnutrition and adult failure to thrive. An admission Minimum Data Set (MDS) assessment, dated 4/7/2025, indicated Resident F was cognitively intact and received artificial nutrition and hydration via a feeding tube. A Care Plan, initiated on 4/24/2025, indicated Resident F had a gastronomy tube (a tube surgically inserted through the abdominal wall directly into the stomach) related to dysphagia and cerebral vascular infarction. Interventions included, but were not limited to: gastronomy site care was to have been followed and Resident F was to have received water flushes as ordered. A review of Physician Orders, for April 2025, indicated Resident F had no orders for water flushes for medication administration through the feeding tube and had no orders for the feeding tube insertion site care. There was no documentation regarding any medication water flushes before and/or after medication administration and no insertion site dressing changes for Reisdent F. During an interview, on 6/17/2025 at 10:27 A.M., RN 2 indicated residents should have orders for flushes for medication administration and insertion site care of the feeding tube. A policy was provided by the Executive Director, on 6/17/2025 at 11:36 A.M. The policy titled, Flushing a Feeding Tube, indicated, .It is the policy of this facility to ensure that staff providing care and services to the resident via a feeding tube are aware of, competent in and utilize facility protocols regarding feeding nutrition and care. Feeding tube care and services will be provided in accordance with resident needs and professional standards of practice .Policy Explanation and Compliance Guidelines: 10 .flush the tube utilizing 60 mL [milliliters] catheter tip syringe using the prescribed amount of water every four [4] hours, before and after feedings and medications or as directed by the physician A policy was provided by the Executive Director, on 6/17/2025 at 11:36 A.M. The policy titled, Gastronomy Site Care, indicated, .It is the policy of this facility to perform gastronomy site care daily, prn [as needed], or per physician order and per current standards of practice .Policy Explanation and Compliance Guidelines: 1. Verify there is a physician order for gastronomy site care This citation relates to Complaint IN00461321. 3.1-44(a)(2)

Based on interview, record review and interview, the facility failed to provide scheduled pain medication in a timely manner for 1 of 3 residents reviewed for pharmaceutical services. (Resident B) Finding includes: During an interview, on 3/5/2025 at 9:28 A.M., Resident B indicated RN 2 was not allowed to provide medical services for her, including medication administration. This decision was made due to a prior incident of RN 2 scaring her during a night shift medication administration. She indicated RN 2 had been informed the other evening and night shift nurses were to administer her pain medications when needed at 4:00 P.M., 8:00P.M., 12:00 A.M. and 4:00 A.M. when RN 2 was scheduled to work A record review for Resident B was completed on 3/5/2025 at 10:32 A.M. Diagnoses included, but were not limited to: leukemia, anemia and anxiety disorder. A Quarterly Minimum Data Set assessment, completed 2/13/2025, indicated Resident B was cognitively intact and received opioid pain medication. She had medically complex conditions including a diagnosis of cancer. A Physician's Order, dated 12/2024, indicated Norco (hydrocodone-acetaminophen) 7.5 milligrams-325 milligrams every four hours for pain management. The medication administration times included: 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M. and 8:00 P.M. A document titled, Grievance Form, was completed by the facility Executive Director on behalf of Resident B on 1/27/2025. The grievance indicated Resident B had concerns related to the administration of her Norco (pain medication) and Zofran (antiemetic medication) medications. The investigation indicated the Zofran and Norco were scheduled as needed and routine. These medications had been changed to routine times for medication administration. A Medication Administration Audit Report, dated 2/1/2025 through 3/5/2025, for second shift (2:00 P.M. through 10:00 P.M.), indicated the following administration times: for the Norco: -2/3/2025 scheduled at 8:00 P.M., administered at 9:42 P.M. -2/4/2025 scheduled at 4:00 P.M., administered at 5:30 P.M. -2/4/2025 scheduled at 8:00 P.M., administered at 9:58 P.M. -2/6/2025 scheduled at 4:00 P.M., administered at 6:45 P.M. -2/7/2025 scheduled at 4:00 P.M., administered at 6:15 P.M. -2/8/2025 scheduled at 8:00 P.M., administered at 6:52 P.M. -2/10/2025 scheduled at 4:00 P.M, administered at 5:10 P.M. -2/14/2025 scheduled at 8:00 P.M., administered at 9:23 P.M. -2/16/2025 scheduled at 4:00 P.M., administered at 6:37 P.M. -2/18/2025 scheduled at 4:00 P.M., administered at 7:56 P.M. -2/24/2025 scheduled at 4:00 P.M., administered at 6:17 P.M. -2/25/2025 scheduled at 4:00 P.M., administered at 5:15 P.M. -2/26/2025 scheduled at 4:00 P.M., administered at 5:34 P.M. -3/2/2025 scheduled at 4:00 P.M., administered at 5:16 P.M. -3/2/2025 scheduled at 8:00 P.M., administered at 9:53 P.M. A Medication Administration Audit Report, dated 2/1/2025 through 3/5/2025, for the night shift (10:00 P.M.-6:00 A.M.) indicated the following administration times: -2/8/2025 scheduled at 12:00 A.M., administered at 2:36 A.M. -2/13/2025 scheduled at 4:00 A.M., administered at 5:57 A.M. -2/15/2025 scheduled at 4:00 A.M., administered at 5:19 A.M. -2/18/2025 scheduled at 2:00 A.M., administered at 10:35 P.M. -2/18/2025 scheduled at 4:00 A.M., administered at 10:35 P.M. -2/19/2025 scheduled at 4:00 A.M., administered at 5:07 A.M. -2/24/2025 scheduled at 4:00 A.M., administered at 5:05 A.M. During an interview, on 3/5/2025 at 1:02 P.M., RN 3 indicated there had been a communication problem with RN 2 communicating with the other licensed nursing staff to administer Resident B's pain medication during his scheduled shifts. She indicated a scheduled medication should have been administered within an hour before or an hour after the scheduled medication administration time. During an interview, on 3/5/2025 at 1:24 P.M., Resident B indicated that her pain level increased if she waited more than 40 minutes from the administration time to receive her pain medication. She indicated she would have to make sure she woke up during the night to ensure she received her pain medication. She indicated she had called the facility many times to have her pain medication administered to her or remind the staff to administer the medication. Resident B indicated she had spoken with RN 2 about his responsibilities to remind the other licensed nursing staff of her need to have her pain medication administered timely, and RN 2 indicated he would not inform the other staff as Resident B was not his responsibility. During an interview, on 3/5/2025 at 1:37 P.M., Resident B's daughter indicated she had had a conversation with RN 2 about his responsibility to inform the other licensed nursing staff of the need to administer Resident B's medications when he was scheduled to work. Resident B's daughter indicated he did not respond verbally to her request. A policy was provided by the Regional Director of Clinical Services, on 3/5/2025 at 2:09 P.M. The policy titled, Medication Administration, indicated, .12. Compare medication source [bubble pack, vial, etc.] with MAR [Medication Administration Record] to verify resident name, medication name, form, dose, route, and time .b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by the physician This citation relates to Complaint IN00454167. 3.1-37(a)

Based on observation, interview and record review, the facility failed to store, prepare and serve food in a sanitary manner in 1 of 1 kitchens observed and 2 of 2 nutrition pantries observed. This deficient practice had the potential to affect 72 of 72 who consumed food from the kitchen and nutrition pantries. Findings include: 1. During an initial tour of the kitchen, on [DATE] at 11:59 A.M., with the Dietary Manager, the following was observed: - black specs of a substance on a shelf in the walk-in cooler. - an opened, undated bag of tater tots not sealed in the freezer. - an opened bag of diced pepperoni with a used by date of [DATE] in the freezer. During an interview, on [DATE] at 12:10 P.M., the Dietary manager indicated the shelf should have been cleaned, the tater tots should have been dated and sealed and the pepperoni should have been removed. 2. During a meal observation, on [DATE] from 12:40 P.M., to 12:46 P.M., the following was observed: -at 12:43 P.M. CNA 5 passed a lunch tray with her finger extending over the rim of the plate. -at 12:46 P.M. CNA 4 passed a lunch tray with her finger extending over the rim of the plate. 3. During a meal observation, on [DATE] from 12:18 P.M. to 12:25 P.M., the following was observed: -at 12:18 P.M., CNA 4 assisted a resident with her meal. CNA 4 opened a bag containing a dinner roll, reached in and removed the dinner roll from the bag and placed it on the resident's plate with her bare hand. During an interview, on [DATE] at 12:25 P.M., CNA 4 indicated she should have worn a glove to remove the roll from the bag. 4. During a follow up visit of the main kitchen, on [DATE] at 9:38 A.M., the following was observed: - an opened and undated bag of cookies pieces not sealed appropriately in the dry storage area. - an opened, undated bag of confectioners sugar, opened packet of lemonade drink mix and an opened gravy packet. - 2 containers of Basil spice and black pepper with the expiration date of ,d+[DATE], on a shelf in the kitchen. During an interview, on [DATE] at 9:40 A.M., the Dietary manager indicated the cookies should have been sealed. During an interview, on [DATE] at 9:55 A.M., the Dietary manager indicated the opened items should have been sealed and the expired items should have been thrown out. 5. On [DATE] at 9:06 A.M., an observation of the ,d+[DATE] hall pantry was completed with QMA 13. The following was observed: the microwave had a dried crusty substance on the glass dish and there was dried food debrison the top of the inside. During an interview, on [DATE] at 9:08 A.M., QMA 13 indicated the microwave should not be that way and needed to be cleaned. 6. During an observation, on [DATE] at 9:10 A.M., of the ,d+[DATE] hall pantry with CNA 7, the following was observed: there was dried food debris on the top of the inside of the microwave. During an interview, on [DATE] at 9:12 A.M., CNA 7 indicated the microwave should have been cleaned. On [DATE] at 11:09 A.M., the Corporate Nurse provided the policy titled, Serving a Meal, dated [DATE], and indicated the policy was the one currently used by the facility. The policy indicated .6 .Avoid handling actual unwrapped food items with bare hands On [DATE] at 11:10 A.M., the Corporate Nurse provided the policy titled, Date Marking for Food Safety, dated [DATE], and indicated the policy was the one currently used by the facility. The policy indicated .2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded . 4. The marking system shall consist of color-coded label, the day/date of opening, and the day/date the item must 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 On [DATE] at 11:10 A.M., the Corporate Nurse provided the policy titled, Food Safety Requirements, dated [DATE], and indicated the policy was the one currently used by the facility. The policy indicated .1. Food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with the delivery of the food to the resident . b. Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms .d. Distribution and service of food to the resident, including transportation, set up, and assistance . f. Employee hygienic practices . iv. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by-date, or frozen (where applicable)/discarded . e. Use of gloves when touching and assisting with ready-to-eat foods . b. Stall shall not touch food with bare hands, exhibiting appropriate use of gloves . h. Gloves will be worn when directly touching ready-to-eat foods 3XXX,d+[DATE](i)(3)

Based on record review and interview, the facility failed to ensure a care plan regarding activities was revised and updated for 1 of 21 residents reviewed for care plans (Resident 6). Finding includes: The record for Resident 6 was reviewed on 8/29/2024 at 9:45 A.M. Diagnoses, included but were not limited to: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia, gastrostomy status, liver disease, diabetes mellitus with neuropathy, bipolar disorder, contracture, depression, anxiety and chronic kidney disease. An annual Minimum Data Set (MDS) assessment,, dated 3/27/24, indicated it was very important for Resident 6 to listen to music, be around pets, do favorite activities, go outside, and participate in religious activities. Resident 6 indicated it is not very important to do things with groups, keep up with news, and have magazines to read. An activity care plan, dated 7/13/2023, indicated Resident 6 benefited from individualized programming, enjoyed music like the Beatles, and enjoyed visits from her Jehovah Witness church. Interventions included, but were not limited to: provide resident with activity supplies such as magazines, crosswords and writing instruments, talk to resident about her face cream, and having her hair and nails done. An activity assessment updated on 6/27/2024, indicated Resident 6 was to receive one to one visits to help with socialization, attended sensory club and accepted pet visits. Activities note indicated Resident 6 received friendly visits 23 times from the dates of 8/1/2024 through 8/25/2024 and a manicure on 8/20/2024. During an interview, on 8/29/2024 at 2:01 P.M., the Administrative Director indicated the Activities Director was responsible for updating the activity care plan when she completed the activity quarterly assessments. On 8/29/2024, at 11:17 A.M. the Corporate Nurse provided a policy titled, Care Plan Revisions Upon Status Change, dated 11/1/2023, and indicated the policy was the one currently used by the facility. The policy indicated .care plan will be reviewed, and revised as necessary, when a resident experiences a status change . 3.1-35(d)(2)(B)

Based on interview, observation, and record review, the facility failed to provide appropriate communication devices for a Spanish speaking resident for 1 of 1 resident reviewed for communication. (Resident 29) Finding includes: During an interview with Resident 29's son, on 8/26/2024 at 3:21 P.M., he indicated Resident 29 could not speak English, and Spanish was her normal launguage for communication. A record review for Resident 29 was completed, on 8/28/2024 at 10:01 A.M. Diagnoses included, but were not limited to: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, anxiety disorder, dysphagia, and major depressive disorder. A Quarterly Minimum Data Set (MDS) assessment, dated 7/19/2024, indicated Resident 29 had moderate cognitive deficit and could make herself understood, and understood others. A Care Plan, dated 4/26/2024, and revised on 6/27/2024, indicated Resident 29 had a cognitive deficit related to a diagnosis of altered mental status, and her primary language was Spanish, which may required a translator at times. Interventions included: - Call my family to translate. - I benefit from tasks that are broken down into simple one step instructions. - I have difficulty understanding full complex sentences and benefit from using simple one- or two-word instructions and questions. - Use LTC communicator to translate for me. -When talking to me allow me enough time to process the information. A Care Plan, dated 8/27/2024, indicated Resident 29's primary language was Spanish and she reqired a translator at times. The goal was for Resident 29 to effectively communicate her needs and understand others. The interventions included: - Call my family to interpret as necessary. - Utilize interpreter services via LTC Solutions as indicated. During an observation, on 8/29/2024 at 11:15 A.M. through 11:45 A.M., Resident 29 was observed to be yelling out in Spanish. On 8/29/2024 at 12:52 P.M. through 1:04 P.M., Resident 29 was yelling out. A staff member gave her cookie, and took her to her office. On 8/29/2024 at 1:27 P.M., Resident 29 was observed yelling out with staff pushing her in the wheelchair up and down hallway. On 8/29/2024 at 1:29 P.M., RN 14 indicated he offered Resident 29 pain medication and an anxiety pill earlier, but she refused. He indicated he knows what she is saying using Google translator, some of the staff can spoke Spanish, and she had dementia and yelled all the time. At 1:50 P.M., the staff continued to push Resident 29 in her wheelchair as she was yelling out repeatedly in Spanish. On 8/30/2024 at 11:08 A.M., Resident 29 was in bed repeating [NAME] ya ya ya! Housekeeper 16 responded, I don't speak Spanish honey. During an interview, Housekeeper 16 indicated she tried to do her best with communication with Resident 29. She indicated she knew a little bit of Spanish, but not much. She indicated Resident 29 did not have a communication board in her room. During an interview, on 8/30/24 at 11:28 A.M., QMA 13 indicated if one of the Spanish speaking girls was available, she would have them speak to the resident, and she was supposed to use the online translation application for Spanish translation. She indicated she did not know about a communication board for Resident 29 as she has never paid attention to the process needed for translation. During an interview, on 8/30/2024 at 11:45 A.M., the Executive Director indicated a Spanish communication board in-service was completed on 7/16/2024 due to findings during a mock survey. The communication board for Resident 29 was to be placed at the nursing station. She provided the in-service attendance, the agenda and a poster of Spanish communication. There was no housekeeping staff in attendance. During an interview, on 8/30/2024 at 11:47 A.M., Housekeeper 15 did not know about the communication board. During an interview, on 8/30/2024 at 11:48 A.M., RN 14 indicated the Spanish communication board was not available at the nursing station. During an interview, on 8/30/2024 at 11:51 A.M., RN 17 indicated she could not find a Spanish communication board at the nurse's station, but found it in another Spanish speaking resident's room. A policy was provided, on 8/30/2024 at 1:24 P.M. by the Director off Nursing. the policy titled, Communicating with Persons with Limited English Proficiency, indicated, .It is the policy of this facility to take reasonable steps to ensure that persons with Limited English Proficiency [LEP] have meaningful access and equal opportunity to participate in our services, activities, programs, and other benefits. The purpose of this policy is to ensure meaningful communication with LEP residents and their authorized representatives involving their medical conditions and treatments .1. Facility staff will identify the language and communication needs of the LEP person during the pre-screening and admission process .4. Notification of the availability of language assistance services will also be provided through one or more of the following: outreach documents, telephone voice mail menus, and/or the facility's website .5. Language assistance will be provided through use of competent bilingual staff, staff interpreters, contracts or formal arrangements with local organizations providing interpretation or translation services, or technology and telephonic interpretation services .9. All staff will be provided notice of this policy, and staff that may have direct contact with LEP individuals will be trained in ineffective communication techniques, including the effective use of an interpreter

Based on observation, record review and interview, the facility failed to ensure respiratory equipment was changed per Physician orders for 1 of 1 resident reviewed for oxygen use. (Resident 14) Finding includes: During an observation, on 8/26/2024 at 2:38 P.M., Resident 14's oxygen tubing was dated 8/18/2024. The humidification bottle, dated 8/18/2024, was empty. During an observation, on 8/28/2024 at 10:25 A.M., Resident 14's water bottle was dated 8/18/2024, and remained empty. The 02 tubing was dated 8/18/2024. During an observation, on 8/29/2024 at 8:40 A.M., Resident 14's oxygen humidification water bottle, dated 8/18/2024, was empty and the 02 tubing was dated 8/18/2024. The record for Resident 14 was reviewed on 8/28/2024 at 9:38 A.M. Diagnoses included, but were not limited to: paraplegia, malnutrition, depression, asthma. A Quarterly Minimum Data Set (MDS) assessment, dated 6/6/2024, indicated the resident used oxygen. Current Physician Orders, dated 10/18/2023, indicated Resident 14 received oxygen at 2 liters per minute via nasal cannula for chronic obstructive pulmonary disease (COPD). A Physician's Order, dated 5/28/2024, indicated to change the oxygen tubing and supplies weekly, every night shift on Sunday. A Care Plan, dated 9/21/2023, indicated the resident had COPD. Interventions included, but were not limited to: will receive oxygen as ordered and oxygen tubing will be changed weekly as indicated. A Treatment Administration Record (TAR), dated 8/1/2024, indicated the O2 tubing and the water bottle had not been changed since 8/18/2024. During an interview, on 8/30/2024 at 1:23 P.M., LPN 3 indicated the tubing had not been changed and the water humidification water bottle should not be empty. On 8/29/2024 at 10:49 A.M., the Corporate Nurse provided the policy titled, Oxygen Concentrator, dated 2023, and indicated the policy was the one currently used by the facility. The policy indicated .e. Fill the humidifier container to the correct level with distilled water and attach to concentrator; or use a disposable humidifier . 5 . c. i. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. ii. Change humidifier bottle when empty, weekly, or as recommended by the manufacturer 3.1-47(6)

Based on interview, record review and observation the facility failed to implement pressure relieving interventions to prevent an unstageable pressure wound from developing for 1 of 3 residents reviewed for pressure ulcers. ( Resident 33) Finding includes: During an interview, on 9/19/2022 at 10:35 A.M., Resident 33 indicated his right heel was not healing. A clinical record review was completed on 9/20/2022 at 2:37 P.M. Resident 33's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission Assessment, dated 7/13/2022, indicated he had a surgical wound to the Right hip. A Braden Scale, dated 7/13/2022, indicated Resident 33 had a slight limited sensory perception, was chair fast, made frequent slight body changes, had inadequate nutrition and had a potential problem with friction and shear. Resident 33's score of 16 indicated he was at risk for pressure ulcers. A Base Line Care Plan, dated 7/13/2022, indicated Resident 33 was at risk for developing pressure ulcers related to impaired mobility. Interventions included: cushion in wheelchair pressure re-distribution, surface turn and reposition frequently, and weekly skin observations. A Therapy Mobility Form dated 7/14/2022, indicated the resident required maximum assistance to roll from side to side, and was dependent on staff assistance to change positions. A Nurses Note, dated 7/15/22, at 8:10 P.M., indicated [CONDITION(S)] to bilateral lower extremities and he tolerated being up in chair. An Admission MDS (Minimum Data Set), dated 7/16/2022, indicated the resident required extensive assist of 2 staff for bed mobility, transfers, dressing and toilet use. Had a limited range of motion to the right leg, and was at risk for pressure ulcers but had none at this time. Resident 33's shower schedule indicated he was to receive showers on Tuesday and Friday. A shower was received on 7/15/2022 but not on 7/19/2022. An Initial Pressure Ulcer Report dated 7/21/2022, indicated the resident had a unstageable pressure ulcer to the right heel which was a blood filled blister. The treatment consisted of application of skin prep, abdominal pad covering, and kerlix twice a day. New care plan interventions included off loading boots while in bed, staff to assist with turning and repositioning frequently and treatment as ordered. The July Treatment sheet indicted no off loading, (elevating) of the resident's heels had been completed until after the area was observed on 7/21/2022. A Nurses Note, dated 7/24/22 at 2:22 A.M., indicated the resident had reported to the staff that the blister to his right heel had popped. Area was assessed, cleansed and covered. Right heel elevated. A Physician's Wound Care Note on 7/27/22 at 2:31 P.M., indicated the wound was unstageable. The devitalized tissue was removed with a sharp curette. New orders were obtained to apply a silver foam to the area and a dry dressing, apply heel protectors, and obtain an x-ray of right heel. A Initial Pressure Ulcer Report, dated 8/1/2022, indicated Resident 33, had a stage 2 to the Left heel with an intact fluid filled blister. Treatment was to apply skin prep, and apply a covering. A Skin and Wound Evaluation, dated 8/22/2022, indicated the stage 2 pressure ulcer to left heel was healed. A Braden scale, dated 8/31/2022, indicated Resident 33 walks occasionally,had adequate nutrition, required assistance with moving and had a score of 16 indicating he was at risk for pressure ulcers. A Skin and Wound Evaluation dated 9/19/2022 indicated an unstageable pressure ulcer with slough/eschar (dead tissue) to the right heel, that measured 6.8 cm (centimeters) x 2.4 cm x 3.4 cm. During an interview, on 9/22/2022 at 11:05 A.M., CNA 5 indicated when the resident was admitted he stayed in bed for awhile. During a wound care observation on 9/22/2022 at 11:20 A.M. LPN 6 indicated the wound is covered with 95% slough (cellar debris), the dressing is done once a day and is measured every Monday. On 9/26/2022 at 11:03 A.M. The Regional Director of Quality Assurance provided the policy, Skin Integrity and Pressure Injury. dated 4/20/2022, an indicated the policy was the one currently used by the facility. The policy indicated .Pressure prevention 1, Interventions will be initiated based on the resident's risk determined by the Braden Risk. 2. Interventions will be initiated based on other risk factors such as incontinence of bowel and /or bladder, immobility, nutritional status, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 6 Staff will assist and/or remind the resident to reposition and turn at lease every 2 hours or more frequent depending on the resident risk and skin health .10. Float heels when in bed on residents at high or very high risk of skin breakdown. 11. Observe for [CONDITION(S)] or swelling in the feet and ankles and observe the fit of their shoes 3.1-40

Based on observation, record review, and interviews, the facility failed to ensure the nutritional status of 2 of 3 residents reviewed for nutrition and weight loss was maintained by thorough and timely assessments and interventions. (Resident #43 and Resident #83) Findings include: 1. The clinical record for Resident #83 was conducted on 6/3/14 at 8:34 A.M. Resident #83 was admitted to the facility on [DATE], with diagnoses, including but not limited to, [MEDICAL CONDITION], difficulty walking, cardiac dysrrhythmias, muscle weakness, cognitive communication deficit, [MEDICAL CONDITION]'s, [MEDICAL CONDITION], hypopotassemia, anxiety state, dementia without behavioral disturbance, history of falls, hypertension, [MEDICAL CONDITION] and collapse, [MEDICAL CONDITION], and heart failure. The physician's orders [REDACTED]." The physician's orders [REDACTED]." The initial MDS (Minimum Data Set) assessment, completed on 11/22/13, indicated the resident required supervision and set up assistance for eating needs, weighed 117 pounds and it was not known if there had been any recent weight loss or gain. The care plan related to nutritional needs, initiated on 11/26/14, indicated the following: "(Resident's name) needs a General/Healthful diet (Resident's name) will consume 75-100% of diet; have nutrition related lab values within normal limits; have stable weight and intact skin." Interventions included: "Diet and supplements per MD (physician) order, Obtain and honor food preferences, Review lab values when indicated, Review skin assessments per protocol, and Review weight and food and fluid intakes per protocol." A Nutritional at Risk dietary note, dated 11/22/13, indicated the following: "resident previously on healthshakes - recommend restart." There was no order or notes about restarting healthshakes for the resident. A mini nutritional assessment, completed on 11/26/13, indicated the resident had experienced a decline in intake, had no weight loss, was bed or chair bound, had experienced acute disease in the past 3 months, had mild dementia, and had a body mass index between 19 and 20. The 12/17/13, 01/03/14 and 01/10/14 Nutrition at Risk notes did not recommend any interventions besides continuing to monitor weekly weights. The 01/17/14 late entry Nutrition at Risk note, indicated the resident's weight was down to 99 pounds. The note indicated Healthshakes were recommended but the resident refused to drink them. There was a recommendation by the dietician to consider an appetite stimulant. The note indicated supplements had been offered with minimal success. There were no orders to start and/or discontinue nutritional supplements for Resident #83 from her admission on 11/13/13 to 01/17/14 noted in the electronic charting physician orders [REDACTED]. There was no order for an appetite stimulant until 01/30/14 when [MEDICATION NAME] was ordered. The resident's weight was documented as 99 pounds on 02/19/14, an over 10 percent weight loss since the resident was admitted in November 2013 with a weight of initial 117 pounds. A quarterly MDS assessment, completed on 05/24/14, indicated the resident's weight had dropped to 97 pounds, her eating assistance needs had stayed the same, and again any weight loss or gain of 5 percent or more was "unknown." The 97 pound weight dropped the resident's Body Mass Index to 16.1. Interview with the Director of Nursing (DON), on 06/05/14 at 11:00 A.M., indicated the nurse practitioner was notified by 01/30/14 of the weight loss and the recommendation for an appetite stimulant made by the dietician. During the interview, the DON indicated the previous dietician had spoken with Resident #83 and utilized information from the resident's previous admission issues from August 2013 and did not order healthshakes or any other supplement during the current admission The DON indicated the resident had stated she did not like the healthshakes so no other attempt was made until 06/04/14 to address the resident's weight issues besides the [MEDICATION NAME]. physician's orders [REDACTED].#83, in September 2013, prior to her discharge indicated she was receiving a regular diet and healthshakes twice a day. It was unknown if she was drinking the healthshakes at the time. A Dietary Nutritional At Risk Assessment, located in the progress notes and dated 11/26/13, indicated the dietician had assessed the resident's initial nutritional status. The assessment noted Resident #83's poor meal intakes, noted her pertinent medications and disease processes, pertinent lab studies, indicated her skin was intact, and recommended to liberalize the diet to regular in light of the age of the resident versus the NAS (no added salt) restriction as well as the low BMI and recent treatment for [REDACTED]. The DON presented a Mini Nutritional Assessment, completed on 11/26/13, by the previous dietician which indicated the resident had experienced a moderate decrease in food intake over the past 3 months, had demonstrated no weight loss over the past 3 months, was bed or chair bound, had suffered psychological stress or acute disease issues in the past 3 months, had mild dementia, and had a Body Mass Index (BMI) between 19 -20. There was no specific assessment information related to caloric and fluid needs, disease processes, recent laboratory studies, skin conditions or any other aspect which could affect the resident's nutritional status assessed by the dietician. During the interview, the Director of Nursing confirmed until 06/04/14, when the current dietician reassessed Resident #83's nutritional needs and weight loss and recommended to add an ice cream to the evening meal to increase caloric intake, other than the appetite stimulant mediation, ordered on [DATE], there had been no reevaluation or intervention to prevent further weight loss and assist the resident to regain the weight she had lost. 2. On 6/5/14 at 9:50 A.M., a review of the clinical record for Resident #43 was conducted. The record indicated the resident was admitted to the facility on [DATE] and was discharged to another facility on 3/18/14. The resident's [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A mini nutritional assessment, dated 1/24/14, indicated the resident had mild dementia, the BMI (Body Mass Index) was between 21 and 22 and the resident was at risk for malnutrition. A dietary nutritional at risk assessment, dated 1/24/14, indicated the current weight was 144# (pounds), the BMI was 21.7, the estimated caloric needs was 1625-1950, meal intakes 50-75%, the resident was able to feed self, the skin status: mild braden indicated. The recommendation was: 4 oz (ounce) health shake BID (twice daily) b/t (between) meals to aid in meeting nutrient needs. A physician order, dated 1/30/14, indicated health shakes 4 oz two times daily. A dietary progress note, dated 1/31/14, indicated new supplement order: 4 oz health shake BID. A dietary nutrition at risk note, dated 2/19/14, indicated recommendation: continue current plan of care and weekly weights. A dietary nutrition at risk note, dated 3/3/14, indicated recommendation: continue to monitor weekly weights. A dietary nutrition at risk note, dated 3/10/14, indicated recommendation: continue to monitor weekly weights. A monthly weights and percentages for Resident #43 indicated the weight on 1/16/14 was 144#. On 1/29/14, 15 days after admission, the weight was 140# a 4 pound or 2.8% loss. On 2/12/14, 30 days after admission, the weight was 130# a 14 pound or 9.7% loss. On 3/12/14, 60 days after admission, the weight was 122# a 22 pound or 15.3% loss. Review of the clinical record indicated there were no additional dietary interventions initiated to prevent further weight loss. Review of the meal consumption intake report for Resident #43 indicated the following: for the breakfast meal - a meal refusal was recorded on 1/28/14. 0-25% was recorded for 1/17/14. 26-50% was recorded for 1/25/14 and 3/14/14. For the lunch meal- a meal refusal was recorded on 1/17/14 and 1/24/14. 26-50% consumed on 1/28/14, 2/15/14 and 3/14/14. For the dinner meal- a meal refusal on 2/5/14. 26-50% consumed on 1/18/14, 1/19/14, 1/26/14 and 3/14/14. Review of the nutritional supplement intake report for the resident indicated the following: for the afternoon snack 25% was consumed on 2/17/14 and 3/4/14. For the evening snack 25% was consumed on 2/7/14, 2/14/14, 2/19/14, 3/1/14, 3/2/14, 3/7/14 and 3/17/14. On 6/5/14 at 1:15 P.M., review of a care plan, initiated 1/29/14 with no revision date, indicated the focus: General/healthful diet. Interventions included but were not limited to, monitor lab values when available, monitor skin assessments, monitor weight and food and fluid intakes, obtain and honor food preferences, and regular diet with thin liquids. There was no indication that the care plan was revised when the health shake was ordered on [DATE]. On 6/5/14 at 1:30 P.M., review of the current policy titled "Resident Nutrition Risk" received from the Assistant Director of Nursing indicated "...Residents are considered to be at potential risk if they have any of the following conditions:...b. Significant weight loss...f. abnormal lab values (ex: dehydration)...5. A Licensed Nurse, Dietary Manager, or Registered Dietician will be responsible for:..b. Notifying the physician when a significant weight change occurs or a nutritional problem is validated...d. Documenting weights, variances and notification of significant changes in the medical record...6. The consulting Registered Dietician is responsible for:...b. Recommending appropriate, accepted nutritional interventions that will improve the resident's nutritional status...." On 6/5/14 at 2:15 P.M., review of the current policy titled "Care Plans Protocol" received from the corporate nurse indicated "...Establishing and updating care plan...The care plan should be revised on an on-going basis to reflect changes in the resident and the care the resident is receiving...Acute changes and order changes should be addressed on the care plan and are the responsibility of staff nurses to establish, revise, or discontinue care plan goal or interventions...." On 6/5/14 at 2:30 P.M., an interview with the Director of Nursing indicated, the nutrition at risk committee meets weekly and consists of the Dietician, the Dietary Manager, the Director of Nursing and the Unit Managers. During the meeting they discuss resident's with significant weight loss. The Dietician makes recommendations regarding supplements, reweighs etc. The recommendations are then placed in the physician folders at the nursing stations for the physician or the nurse practitioner to review and sign. The licensed nurses or unit managers should notify the physician of a significant weight loss. The DON further indicated that the resident's care plan should have been updated and revised when the health shake was ordered on [DATE]. 3.1-46(a)(1)