Every finding on record at Mcgivney Health Care Center

Based on interview and record review, the facility failed to notify the Ombudsman of residents' transfer and discharges with the reason and destination of the transfer and to provide a guardian/responsible party with the notification of the bed hold policy for 10 of 10 residents reviewed for discharge process. (Resident B, C, D, E, F, G, H, J, K and L)Findings include: An email from the State Long Term Care Ombudsman, dated 8/19/26 at 10:43 a.m., indicated the facility had not reported any acute transfers or discharges since 10/13/25. 1. The clinical record for Resident B was reviewed on 8/18/26 at 10:02 a.m. The diagnoses included, but were not limited to, fracture of neck of right femur, Parkinson's disease, dementia, and hypertension. The clinical record indicated Resident B was transferred to the hospital on 5/6/26 and 7/25/26. The clinical record did not contain documentation to indicate the Office of the State Long-Term Care Ombudsman had been notified of the transfers. 2. The clinical record for Resident C was reviewed on 8/21/26 at 10:00 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, chronic respiratory failure, diabetes, stroke, tremor, epilepsy, dysphagia, aphasia, anxiety, depression, high blood pressure, and neuromuscular dysfunction of the bladder. The clinical record indicated Resident C was transferred to the hospital on 3/17/26, 5/31/26, 6/14/26, 6/28/26. The notice of transfer or discharge forms dated 3/17/26, 5/31/26, 6/14/26, 6/28/26, indicated the forms were provided to the resident upon discharge. The clinical record did not contain documentation to indicate that the Office of the State Long-Term Care Ombudsman had been notified of the transfers or Resident C's guardian was provided in writing, the reason for transfer or the bed hold policy for each transfer. During an interview, on 8/21/26 at 11:21 a.m., the Director of Operations indicated the transfer and discharge form and the bed hold policy were provided to Resident C, but the paperwork had not been mailed or provided to Resident C's guardian. 3. The clinical record for Resident D was reviewed on 8/21/26 at 11:13 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, upper respiratory infection and encephalopathy (disorder or disease which affects the structure or function of the brain). The clinical record indicated Resident D was transferred to the hospital on 1/16/26, 5/17/26 and 7/3/26. The clinical record did not contain documentation to indicate the Office of the State Long-Term Care Ombudsman had been notified of the transfers. 4. The clinical record for Resident E was reviewed on 8/21/26 at 11:24 a.m. The diagnoses included, but were not limited to, dementia, bradycardia (slow heartbeat), and pneumonitis (inflammation of the lung tissue) due to inhalation of food/vomit. The clinical record indicated Resident E was transferred to the hospital on 2/5/26, 2/10/26, 4/14/26, 6/10/26, and 7/5/26. The clinical record did not contain documentation to indicate the Office of the State Long-Term Care Ombudsman had been notified of the transfers. 5. The clinical record for Resident F was reviewed on 8/21/26 at 11:18 a.m. The diagnoses included, but were not limited to, dementia, chronic kidney disease, and type 2 diabetes. The clinical record indicated Resident F was transferred to the hospital on 1/31/26. The clinical record did not contain documentation to indicate the Office of the State Long-Term Care Ombudsman had been notified of the transfers. 6. The clinical record for Resident G was reviewed on 8/21/26 at 11:21 a.m. The diagnoses included, but were not limited to, right side hemiplegia (paralysis on one side) and dementia. The clinical record indicated Resident G was transferred to the hospital on 2/1/26. The clinical record did not contain documentation to indicate the Office of the State Long-Term Care Ombudsman had been notified of the transfers. 7. The clinical record for Resident H was reviewed on 8/21/26 at 11:29 a.m. The diagnoses included, but were not limited to, immunodeficiency virus disease, anemia, and acute embolism and thrombosis of deep vein in right lower extremity. The clinical record indicated Resident H was transferred to the hospital on 4/6/26. The clinical record did not contain documentation to indicate the Office of the State Long-Term Care Ombudsman had been notified of the transfers. 8. The clinical record for Resident J was reviewed on 8/21/26 at 11:37 a.m. The diagnoses included, but were not limited to, dementia, acute respiratory distress, and hypoxemia. The clinical record indicated Resident J was transferred to the hospital on 5/3/26. The clinical record did not contain documentation to indicate the Office of the State Long-Term Care Ombudsman had been notified of the transfers. 9. The clinical record for Resident K was reviewed on 8/21/26 at 11:39 a.m. The diagnoses included, but were not limited to, dementia, anxiety, and type 2 diabetes. The clinical record indicated Resident K was transferred to the hospital on 7/5/26. The clinical record did not contain documentation to indicate the Office of the State Long-Term Care Ombudsman had been notified of the transfers. 10. The clinical record for Resident L was reviewed on 8/21/26 at 11:42 a.m. The diagnoses included, but were not limited to, schizoaffective disorder bipolar type, hypertension, and generalized muscle weakness. The clinical record indicated Resident L was transferred to the hospital on 7/30/26. The clinical record did not contain documentation to indicate the Office of the State Long-Term Care Ombudsman had been notified of the transfers. During an interview, on 8/19/26 at 9:26 a.m., the Social Service Director indicated for the past 12 months notifications to the Ombudsman for transfers or discharges had not been completed. This week, the month of July 2026 was sent to the Ombudsman. During an interview, on 8/21/26 at 9:18 a.m., the Director of Operations indicated the facility had issues accessing the reporting system online. They did not contact anyone related to the issue. During an interview, on 8/21/26 at 10:16 a.m., the Ombudsman indicated the facility just emailed a list of transfers and discharges, for January 2026 to July 2026, on 8/18/26. The Ombudsman indicated the list was incomplete as the reason the residents were sent out and the location they had been transferred to had not been provided. An email, received on 8/20/26 at 10:58 a.m., the Executive Director indicated the facility did not have a specific policy to notify the Ombudsman and provided the transfer policy. A current facility policy, titled .Transfer Policy dated 2/15/17 and received from the Executive Director on 8/20/26 at 10:58 a.m., indicated .the facility must.notify the resident and the resident's representative of the transfer or discharge.in writing and in a language and manner they understand.send a copy of the notice (of transfer or discharge) to a representative of the Office of the Long-term Care Ombudsman.notice of bed-hold policy.before a nursing facility transfers a resident to a hospital.the facility must provide written information to the resident or resident representative that specifies.the duration of the state bed-hold policy.the reserve bed payment policy.the nursing facilities policies regarding bed-hold periods. This citation relates to Intake 3169072. 410 IAC (Indiana Administrative Code) 16.2-3.1-12(a)(6)(A)(iii) 410 IAC (Indiana Administrative Code) 16.2-3.1-12(a)(6)(A)(iv) 410 IAC (Indiana Administrative Code) 16.2-3.1-12(a)(25)(A)

Based on interview and record review, the facility failed to ensure a physician's order for advanced directive was accurate for 1 of 1 resident reviewed for advanced directives. (Resident 30)Findings include:The clinical record for Resident 30 was reviewed on [DATE] at 2:44 p.m. The diagnoses included, but were not limited to, vascular dementia with behavioral disturbance, bipolar disorder severe depressed without psychotic features, mood affective disorder, intermittent explosive disorder, alcohol abuse with intoxication, and chronic obstructive pulmonary disease.A physician's order, dated [DATE], indicated Resident 30 was a full code.A physician's order for scope of treatment (POST) form, dated [DATE], indicated Resident 30 did not want to be resuscitated with cardio-pulmonary resuscitation (CPR).A consent/declination to resuscitate form, signed [DATE], indicated Resident 30 did not want to be resuscitated if he had no pulse and was not breathing.A care plan, initiated [DATE] and dated as late reviewed [DATE], indicated Resident 30 was a full code, to honor the resident's code status, and to review it quarterly.The physician's order, dated [DATE], which indicated Resident 30 was a full code was not discontinued until [DATE].During an interview, on [DATE] at 11:30 a.m., the Social Services Designee (SSD) indicated Resident 30 should have had a do not resuscitate (DNR) code status since January. When the resident was admitted , the facility received the signed code status forms. A physician's order would be based off the signed forms, so staff knew how to proceed in an emergency.A current facility policy, titled Code Status, dated [DATE] and provided by the SSD on [DATE] at 10:00 a.m., indicated .the resident is full code until determined otherwise .The physician will see the resident in the first 30 days and will write order for code status.3.1-4(f)(4)(A)(ii)

Based on observation, interview and record review, the facility failed to ensure staff were aware of who was responsible to complete catheter care and to document catheter care was provided for 1 of 2 residents reviewed for urinary catheters. (Resident 12)Findings include: During an observation, on 8/19/25 at 10:53 a.m., Resident 12 had a urinary catheter.The clinical record for Resident 12 was reviewed on 8/20/25 at 10:31 a.m. The diagnoses included, but were not limited to, benign prostatic hyperplasia (prostate gland enlargement causing difficulty urinating) with lower urinary tract symptoms, prediabetes, and age-related physical debility.A physician's order, dated 8/6/25, indicated flush the urinary catheter daily with 40 milliliters (ml) of fluid.A physician's order to complete urinary catheter care on a routine basis was not located in the medical record.Cather care documentation was not located in the medical record.During an interview, on 8/20/25 at 3:03 p.m., Certified Nursing Assistant (CNA) 6 indicated the nurses completed the cleaning of the urinary catheters.During an interview, on 8/20/25 at 3:09 p.m., Licensed Practical Nurse (LPN) 4 indicated CNAs completed the cleaning of the urinary catheters.During an interview, on 8/21/25 at 11:10 a.m., the Director of Nursing (DON) indicated CNAs completed the cleaning of the urinary catheters.During an interview, on 8/21/25 at 1:36 p.m., LPN 3 indicated the nurses usually completed urinary catheter care.The staff members were unclear whose responsibility it was to complete catheter care.During an interview, on 8/21/25 at 1:42 p.m., the Minimum Data Set (MDS) Coordinator indicated catheter care should be charted in the progress notes under a health status note. She did not see where any catheter care was documented. Catheter care should be documented.A current facility policy, titled Suprapubic Catheter Care, undated and received from the Executive Director on 8/22/25 at 11:53 a.m., indicated .Review the resident's orders .Documentation: i. The following information should be recorded in the resident's medical record: a. The date and time the procedure was performed 3.1-41(a)(2)

Based on interview and record review, the facility failed to ensure psychotropic medications which were ordered as needed (prn) had a 14 day stop date and baseline Abnormal Involuntary Movement Scale (AIMS) assessments were completed for 2 of 5 residents reviewed for unnecessary medications. (Resident 6 and 30)Findings include:1. The clinical record for Resident 6 was reviewed on 8/20/25 at 11:23 a.m. The diagnoses included, but were not limited to, intracranial injury with loss of consciousness, chronic obstructive pulmonary disease, hemiplegia and hemiparesis affecting the left non-dominant side, dementia, traumatic brain injury, delusional disorders, and alcohol abuse. A physician's order, dated 2/14/25, indicated to give Xanax (an antianxiety medication) 0.25 milligrams (mg) every 8 hours as needed for anxiety. The order, dated 2/14/25, did not have a stop date. The physician's order for Xanax 0.25 mg every 8 hours as needed was not discontinued until 5/23/25. The as needed physician's order was current for over 90 days without review. During an interview, on 8/22/25 at 11:15 a.m., the Social Services Designee indicated the as needed Xanax required a 14-day stop date. 2. The clinical record for Resident 30 was reviewed on 8/19/25 at 2:44 p.m. The diagnoses included, but were not limited to, vascular dementia with other behavioral disturbance, bipolar disorder without psychotic features, mood affective disorder, intermittent explosive disorder, alcohol abuse with intoxication, and chronic obstructive pulmonary disease. The resident was admitted to the facility on [DATE]. A physician's order, dated 1/21/25, indicated to administer paliperidone (an atypical antipsychotic medication) 3 mg at bedtime. A physician's order, dated 1/22/25, indicated to administer Rexulti (an atypical antipsychotic medication) 0.5 mg once a day. An AIMS assessment was not completed until 3/24/25. During an interview, on 8/21/25 at 10:15 a.m., LPN 4 indicated an AIMS assessment must be completed at the start of an antipsychotic medication or on admission to the facility. The facility indicated they did not have a policy for psychoactive medications or prn medications. A current facility policy, titled Abnormal Involuntary Movement Scale (AIMS), dated 8/2017 and provided by the SSD on 8/21/25 at 10:00 a.m., indicated .The AIMS shall be completed within 14 days of initiation of psychotropic medication (baseline) 3.1-48(a)(2) 3.1-48(a)(3)

Based on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) was updated when new diagnoses and antipsychotic medications were added for 2 of 2 residents reviewed for PASARR. (Resident 30 and 3)Findings include:The clinical record for Resident 30 was reviewed on 8/19/25 at 2:44 p.m. The diagnoses included, but were not limited to, vascular dementia with other behavioral disturbance, bipolar disorder current episode severe depressed without psychotic features, mood affective disorder, intermittent explosive disorder, alcohol abuse with intoxication, and chronic obstructive pulmonary disease with acute exacerbation. A PASARR level II, dated 11/7/24, indicated Resident 30 had diagnoses of intermittent explosive disorder, intellectual disability, mood disorder, and schizophrenia. A psychosocial note, dated 4/23/25 at 11:28 a.m., indicated Resident 30 had diagnoses of dementia and bipolar. A PASARR level II, dated 11/7/24, did not include the diagnoses of dementia and bipolar. During an interview, on 8/21/25 at 11:35 a.m., the Social Services Designee (SSD) indicated she did not realize dementia and bipolar were not on the resident's PASARR and the facility should have submitted a new one for those diagnoses per the guidelines. 2. The clinical record for Resident 3 was reviewed on 8/20/25 at 9:21 a.m. The diagnoses included, but were not limited to, anxiety disorder, major depressive disorder, and affective mood disorder. A PASARR level II, dated 2/17/22, indicated there were no mental health medications listed, and if there was a significant change in physical or mental health, the nursing facility must submit an updated level I screening to see if a further PASARR evaluation was needed. A physician's order, dated 4/10/25, indicated to give Risperdal (an antipsychotic medication) 0.5 milligrams (mg). The PASARR was not updated after a new antipsychotic medication was added. During an interview, on 8/21/25 at 2:24 p.m., the SSD indicated after a new psychotropic was added, the facility should have resubmitted another PASARR. During an interview, on 8/22/25 at 10:56 a.m., the Executive Director (ED) indicated the facility did not have a PASARR policy. 3.1-16(d)(1)(A) 3.1-16(d)(1)(B)

Based on observation, interview and record review, the facility failed to ensure comprehensive care plans were developed to address the resident's medical needs for 2 of 14 residents reviewed for comprehensive care plans. (Resident 12 and 22) Findings include: 1. During an observation, on 8/19/25 at 10:53 a.m., Resident 12 had a urinary catheter and was receiving oxygen therapy.The clinical record for Resident 12 was reviewed on 8/20/25 at 10:31 a.m. The diagnoses included, but were not limited to, benign prostatic hyperplasia (prostate gland enlargement causing difficulty urinating) with lower urinary tract symptoms, prediabetes, age related physical debility, chronic obstructive pulmonary disease, and chronic respiratory failure.A physician's order, dated 8/6/25, indicated flush the urinary catheter daily with 40 milliliters (ml) of fluid.A physician's order, dated 8/14/25, indicated to check oxygen saturation every shift, and titrate the oxygen to 4L to maintain an oxygen saturation above 90%.A care plan for the use of a urinary catheter and oxygen therapy was not located in the resident's medical record.During an interview, on 8/20/25 at 2:38 p.m., the Minimum Data Set (MDS) Coordinator indicated she could not locate a care plan for a urinary catheter or oxygen therapy. Residents who have catheters and oxygen therapy should have care plans.2. The clinical record for Resident 22 was reviewed on 8/21/25 at 9:28 a.m. The diagnoses included, but were not limited to, schizoaffective disorder bipolar type, hypertension, and hyperlipidemia.Resident 22 received medications related to parkinsonism, drug induced subacute dyskinesia (a type of involuntary movement disorder which developed after taking certain medications), constipation, hypertension, and hyperlipidemia.There was no care plans located in Resident 22's medical record at the time of review related to the above listed medications.During an interview, on 8/21/25 at 1:52 p.m., the MDS Coordinator indicated nursing should have developed care plans for the medications.A current facility policy, titled Care Plans, dated as revised 6/11/21 and received from the Social Services Designee on 8/21/25 at 10:00 a.m., indicated .Collaboration of the care plan team is used to help analyze data obtained from the resident's diagnosis .and physician's orders to develop individualized care plans specific to each resident 3.1-35(a)3.1-35(b)(1)3.1-35(d)(1)

Based on interview and record review, the facility failed to ensure care plans were reviewed and updated after Minimum Data Set (MDS) assessments were completed for 2 of 14 residents reviewed for care planning. (Resident 4 and 6)Findings include: 1. The clinical record for Resident 4 was reviewed on 8/20/25 at 1:58 p.m. The diagnoses included, but were not limited to, encephalopathy, chronic obstructive pulmonary disease, epilepsy, schizophrenia, repeated falls, alcohol dependence, and congestive heart failure. A fall note, dated 1/26/25 at 11:30 a.m., indicated the resident was found on the floor with a swollen raised bump on his forehead. An incident note, dated 4/6/2025 at 11:30 a.m., indicated the resident was found walking on his knees. A Minimum Data Set (MDS) assessment was completed for Resident 4 on 6/2/25. A care plan, initiated on 7/28/24 and dated as last reviewed on 7/22/25, did not include Resident 4's falls on 1/26/25 or 4/6/25. A care plan, initiated on 3/20/24 and dated as last reviewed on 7/22/25, indicated Resident 4 was a high risk for falls related to gait and balance problems. No new interventions were noted in the resident's care plan after the multiple fall events. 2. The clinical record for Resident 6 was reviewed on 8/20/25 at 11:23 a.m. The diagnoses included, but were not limited to, intracranial injury with loss of consciousness, chronic obstructive pulmonary disease, hemiplegia and hemiparesis affecting the left non-dominant side, dementia, traumatic brain injury, delusional disorders, and alcohol abuse. A quarterly MDS assessment for Resident 6 was completed on 6/8/25. The comprehensive care plans for Resident 6 were reviewed on 3/31/25 and not again until 8/8/25. During an interview, on 8/21/25 at 11:25 a.m., the Social Services Designee (SSD) indicated she conducted the care plan meetings with the Interdisciplinary IDT team, but the MDS Coordinator was the one who reviewed the care plans. They were not reviewed with the care plan meetings. A current facility policy, titled Care Plans, dated 6/11/21 and received from the SSD on 8/21/25 at 10:00 a.m., indicated .Identify areas of concern triggered on the MDS .Evaluate the resident's .wishes, strengths, and needs .Care plans are a living document and as such may require updates following the mandated care plan completion date 3.1-35(c)(1) 3.1-35(c)(2)(A) 3.1-35(c)(2)(B) 3.1-35(c)(2)(C)

Based on interview and record review, the facility failed to ensure daily weights were obtained according to the physician's order and to assess and treat a resident for constipation for 2 of 2 residents reviewed for quality of care. (Resident 31 and 22)Findings include:1. The clinical record for Resident 31 was reviewed on 8/20/25 at 12:37 p.m. The diagnoses included, but were not limited to, type 2 diabetes, edema, and acute kidney failure.A physician's order, dated 7/18/25, indicated to weigh the resident daily related to edema.The Medication Administration Record (MAR) had the following:a. On 7/18/25, no weight was recorded.b. On 7/20/25, no weight was recorded.c. On 8/1/25, no weight was recorded.d. On 8/2/25, no weight was recorded.e. On 8/6/25, no weight was recorded.During an interview, on 8/21/25 at 9:40 a.m., Licensed Practical Nurse (LPN) 3 indicated he could not locate a daily weight for those days.During an interview, on 8/21/25 at 9:43 a.m., Qualified Medication Assistant (QMA) 5 indicated he could not locate those weights in the paper charting. The weights should have been completed.During an interview, on 8/21/25 at 9:47 a.m., LPN 3 indicated he could not locate the 8/2 or 8/6 daily weights, and they were missed.2. The clinical record for Resident 22 was reviewed on 8/21/25 at 9:28 a.m. The diagnoses included, but were not limited to, schizoaffective disorder bipolar type, hypertension, and hyperlipidemia.A physician's order, dated 2/24/23, indicated to administer Sennosides-Docusate Sodium 8.6-50 milligrams by mouth two times a day for constipation.A physician's order, dated 2/24/23, indicated to administer Polyethylene Glycol 3350 powder (Miralax)17 grams by mouth every 12 hours as needed for constipation.Resident 22 did not have a documented bowel movement from 7/16/25 to 7/22/25 (7 days) and from 8/17/25 to 8/20/25 (4 days).A physician's note, dated 7/21/25, indicated the resident had been assessed with no bowel related concerns. There were no other notes or assessments found to show Resident 22 had been assessed for bowel concerns prior to 7/21/25. There was no documentation or assessment found in the record to show the resident had been assessed for bowel concerns, 8/20/25, on day four of no bowel movement for Resident 22.The resident did not have a care plan which addressed constipation at the time of the record review.The Medication Administration Record (MAR), for July 2025, indicated Resident 22 received Sennosides Docusate Sodium 16 times between 7/16/25 to 7/22/25. There was no documentation to show Miralax had been administered for constipation per the physician's order.The MAR, for August 2025, indicated Resident 22 received Sennosides Docusate Sodium 40 times between 8/1/25 to 8/20/25. There was no documentation to show Miralax had been administered for constipation per the physician's order.During an interview, on 8/22/2025 at 9:59 a.m., LPN 4 indicated the CNAs were to inform a nurse if a resident had not had a bowel movement after three days. If a resident had not had a bowel movement after three days, the nurse should have completed a bowel assessment and provided as needed medication like Miralax. If the resident did not have a bowel protocol in place, the nurse would contact the physician for orders. The nurse would document the bowel assessment and notify the physician.A current facility policy, titled Weight and Measurement, dated as effective 2019 and received from the Activities Director on 8/22/25 at 11:30 a.m., indicated .The following information should be recorded in the resident's medical record. A. Time and date the procedure was performed. B. Weight and height of resident.Weights of each individual resident are to be obtained monthly and as recommended by Physician.A current facility policy, titled Bowel Elimination, dated as effective 6/17 and received from the Executive Director on 8/25/25 at 1:32 p.m., indicated .If there is no BM in 72 hours, the day shift nurse will initiate nursing protocol for Milk of Magnesia.If no BM in 48 hours following MOM protocol, a Dulcolax suppository will be given.If no BM in 24 hours following the suppository, the physician will be contacted for a Fleets enema 3.1-37(a)

Based on interview and record review, the facility failed to ensure a resident and the resident's representative was provided the written transfer and bed hold notices for 1 of 1 resident reviewed for hospitalization. (Resident 5)Findings include: The clinical record for Resident 5 was reviewed on 8/20/25 at 10:46 a.m. The diagnoses included, but were not limited to, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, disorder of the brain, type 2 diabetes mellitus, conversion disorder with seizures or convulsions, asthma, congestive heart failure, dementia, pseudobulbar affect (PBA), acute necrotizing hemorrhagic encephalopathy, and localized edema. A transfer to the hospital summary, dated 6/3/25 at 7:54 p.m., indicated the resident complained of shortness of breath and difficulty breathing. Despite interventions, the resident's oxygen saturation continued to decrease to 81%. The resident was transported to the hospital by ambulance, and the resident's mother was notified. During an interview, on 8/21/25 at 10:15 a.m., LPN 3 indicated that when the resident was sent to the hospital, the transfer paperwork was sent to the hospital with the resident, and the family was called. During an interview, on 8/21/25 at 10:30 a.m., the Social Services Designee (SSD) indicated the facility had not documented the written transfer notice and bed hold notice were given directly to the resident. The notices were often sent in the hospital paperwork packet with the residents. She did not realize the notices must be sent to the family member or representative when the resident was able to sign for himself. The facility gave verbal notice that the resident was being sent to the hospital. A current facility policy, titled Transfer, dated 2/15/17 and provided by the Executive Director on 8/22/25 at 10:15 a.m., indicated .Before a facility transfers or discharges a resident, the facility must.notify the resident and the resident representative of the transfer.in writing.At the time of transfer.a nursing facility must provide the resident and the resident representative with written notice.of the bed-hold policy. A current facility policy, titled Bedhold, dated 10/2014 and provided by the SSD on 8/20/25 at 10:45 a.m., indicated .facility personnel will provide written information to the residents and a family member or legal representative that specifies the facility bed hold policy. In case of emergency transfer, every effort will be made to notify the family or legal representative at the time of transfer.Should this not occur, effort will be made to provide written notice to the family .within 24 hours of transfer. Resident's copy of the notice will be sent with other documents accompanying residents to the hospital 3.1-12(a)(6)(A)(i) 3.1-12(a)(6)(A)(ii) 3.1-12(a)(6)(A)(iii)

Based on observation, interview and record review, the facility failed to ensure physician's orders were obtained for changing and dating oxygen tubing and to ensure humidified water was changed and dated for 2 of 2 residents reviewed for respiratory therapy. (Resident 1 and 12)Findings include:During an observation, on 8/19/25 at 10:45 a.m., Resident 1 was observed with a portable oxygen tank set to 2 liters per minute. The oxygen line did not have a date to show when it had last been changed. During an observation, on 8/20/25 at 11:38 a.m., LPN 4 indicated the oxygen line was supposed to be dated and it was not. During an observation, on 8/21/25 at 11:39 a.m., Resident 1's oxygen line did not have a date to show when it was last changed. During an observation, on 8/22/25 at 8:33 a.m., Resident 1's oxygen line did not have a date to show when it was last changed. The clinical record for Resident 1 was reviewed on 8/21/25 at 10:57 a.m. The diagnoses included, but were not limited to, dementia, hypertension, and a history of pneumonia. A physician's order indicated to check Resident 1's oxygen saturation every shift and to titrate the oxygen to 4 liters per minute to maintain an oxygen blood saturation above 90 percent. There was no physician's order located related to changing the oxygen line. 2. During an observation, on 8/19/25 at 10:53 a.m., Resident 12 was receiving humidified oxygen. The humidification bottle had approximately a centimeter of water left in the bottle and it was not bubbling. The oxygen tubing and the humidifier bottle did not have a date indicating when they were last changed. During an interview, on 8/19/25 at 1:52 p.m., Licensed Practical Nurse (LPN) 3 indicated Resident 12's water level in his humidifier bottle was low. There was not a date on the oxygen tubing or the humidifier bottle to show when they were last changed. The clinical record for Resident 12 was reviewed on 8/20/25 at 10:31 a.m. The diagnoses included, but were not limited to, chronic respiratory failure, chronic obstructive pulmonary disease, and dementia. A physician's order, dated 9/23/24, indicated to change and date the nebulizer tubing every Sunday night. During an interview, on 8/20/25 at 2:38 p.m., the Director of Nursing (DON) indicated if the humidification was working, the water would be bubbling. During an interview, on 8/22/25 at 10:03 a.m., LPN 4 indicated the oxygen tubing was supposed to be changed weekly and there should be a physician's order for it. Staff were supposed to date the tube to document when it was changed. The water for humidification was supposed to be changed when it was about 1/2 to 1/4 full. If the humidification was working, the water would be bubbling. During an interview, on 8/22/25 at 11:53 a.m., the Executive Director indicated there were a few oxygen policies, but none addressed changing, labeling, and dating the oxygen lines. 3.1-47(a)(6)

Based on observation, interview and record review, the facility failed to ensure a Registered Nurse (RN) was on duty for eight (8) consecutive hours, seven (7) days a week for 1 of 14 days reviewed for RN coverage. (8/22/25)Findings include:During an observation, on 8/22/25 between 8:00 a.m. and 4:00 p.m., the facility did not have a Registered Nurse on duty.The staffing records, from 8/16/25 through 8/26/25, listed two RNs as currently employed with the facility: the Director of Nursing and the Infection Preventionist. The facility staffing records did not indicate a RN was on duty 8/22/25.The facility was unable to provide documentation to show that an RN had been on duty for the night, day, or evening shift on 8/22/25.During an interview, on 8/26/25 at 9:47 a.m., the Executive Director indicated the facility followed the state regulations.A current facility policy, titled Nursing Staffing Hours, dated 2020 and received from the Executive Director on 8/26/25 at 9:35 a.m., indicated .The requirements for long-term care facilities require a skilled nursing facility provide twenty-four (24) hour licensed nursing services, an RN .for eight (8) consecutive hours a day 3.1-17(b)(3)

Based on observation, interview and record review, the facility failed to ensure spoiled food was discarded in 1 of 2 dry food storage areas reviewed for food storage. (the basement food storage area)Findings include:During an observation, on 8/19/25 at 11:12 a.m., bananas, with a received date of 8/6/25, were brown and black with a white growth substance on the stem. The bananas had spots which were oozing liquid and some bubbles forming.During an interview, on 8/21/25 at 11:40 a.m., the kitchen manager indicated the bananas needed to be thrown away as they were spoiled.A current facility policy, titled Expired Food, dated as last revised on 3/2/21 and received from the Activity Director on 8/22/25 at 11:30 a.m., indicated .DISPOSING OF SPOILED FOOD OR POSSIBLY CONTAMINATED: Place the food, i.e. expired, swollen metal cans or suspected glass jar in a heavy opaque or black garbage bag 3.1-21(i)(3)

Based on observation, interview and record review, the facility failed to ensure enhanced barrier precautions (EBP) were in place and followed for 2 of 2 residents reviewed for enhanced barrier precautions. (Resident 12 and 31)Findings include: 1. During an observation, on 8/19/25 at 10:53 a.m., Resident 12 had a urinary catheter.The clinical record for Resident 12 was reviewed on 8/20/25 at 10:31 a.m. The diagnoses included, but were not limited to, benign prostatic hyperplasia (prostate gland enlargement causing difficulty urinating) with lower urinary tract symptoms, prediabetes, and age-related physical debility.A physician's order, dated 8/6/25, indicated flush the urinary catheter daily with 40 milliliters (ml) of fluid.A physician's order for enhanced barrier precautions was not located in the medical record.There were no signs related to enhanced barrier precautions in the room or on Resident 12's door.During an observation, on 8/21/25 at 1:23 p.m., Licensed Practical Nurse (LPN) 3 completed catheter care for Resident 12. A gown was not worn during the procedure.During an interview, on 8/21/25 at 1:33 p.m., LPN 3 indicated he forgot to wear a gown during the procedure, and he was supposed to wear Personal Protective Equipment (PPE) during catheter care.2. During an observation, on 8/19/25 at 3:11 p.m., Resident 31 had a urinary catheter.The clinical record for Resident 31 was reviewed on 8/20/25 at 12:37 p.m. The diagnoses included, but were not limited to, acute kidney failure, neuromuscular dysfunction of the bladder, and hypertension.A physician's order for enhanced barrier precautions was not located in the medical record.There were no signs related to enhanced barrier precautions in the room or on Resident 31's door.During an interview, on 8/19/25 at 2:50 p.m., the Activity Director indicated she did not know what enhanced barrier precautions were.During an interview, on 8/19/25 at 2:55 p.m., the Director of Nursing (DON) indicated she did not know what enhanced barrier precautions were.During an interview, on 8/25/25 at 3:03 p.m., the DON indicated the facility never received any information about enhanced barrier precautions (EBP) and she did not know what it was until the survey. She understood now the staff were supposed to wear PPE during catheter care.The facility did not have a policy related to EBP.A current facility policy, titled Suprapubic Catheter Care, undated and received from the Executive Director on 8/22/25 at 11:53 a.m., indicated .Review the resident's orders .Personal Protective equipment (e.g., gowns, gloves, mask, ect., as needed) .3.1-18(b)(2)

Based on observation, interview and record review, the facility failed to provide at least 80 square feet (sq. ft.) per resident in 1 of 18 rooms. (room [ROOM NUMBER])Findings include:During an observation, on 8/19/25 at 3:04 p.m., room [ROOM NUMBER] was found to have two beds, two nightstands, two clothing wardrobes, and one dresser. Two residents were occupying the room.During an interview, on 8/19/25 at 3:04 p.m., Resident 21 indicated he liked his room and had no concerns with the size.During an interview, on 8/19/25 at 3:07 p.m., Resident 23 indicated he liked this room and had no concerns with the size of the room.During an interview, on 8/25/25 at 11:05 a.m., the Executive Director indicated there had been no physical changes to the room which had a previous room waiver since the last survey.A bed inventory form, dated 8/25/25, indicated room [ROOM NUMBER] contained two beds.A review of the facility measurements for room [ROOM NUMBER] indicated the bedroom did not provide 80 square feet per resident. room [ROOM NUMBER] was 153.83 square feet, and according to Life Safety Code the double occupancy in room [ROOM NUMBER] measured out to 76.9 square feet per resident. A Bed Inventory form indicated room [ROOM NUMBER] was a Title 19 NF (Medicaid) room and was certified for two resident beds. Facility documentation for the room size certification indicated the following: room [ROOM NUMBER], 2 beds/NF, 153.83 Sq.Ft/76.9 Sq.Ft for each resident.During an interview, on 8/26/25 at 9:47 a.m., the Executive Director indicated the facility followed the state regulations.3.1-19(l)(2)(A)

Based on interview and record review, the facility failed to develop a comprehensive care plan which addressed constipation, insomnia, hyperlipidemia, and pain for 2 of 2 residents reviewed for Based on interview and record review, the facility failed to develop a comprehensive care plan which addressed constipation, insomnia, hyperlipidemia, and pain for 2 of 2 residents reviewed for comprehensive care plans. (Resident 11 and 26) Findings include: 1. During an interview, on 9/25/24 at 10:59 a.m., Resident 11 indicated he was often constipated. The clinical record for Resident 11 was reviewed on 9/27/24 at 11:01 a.m. The diagnoses included, but were not limited to, muscle weakness, abnormal weight loss, and chronic idiopathic constipation. A physician's order, initiated on 2/20/23, indicated to give Linzess Oral Capsule (a medication for constipation) 145 micrograms (mcg) once a day related to chronic idiopathic constipation. A physician's order, initiated on 3/2/22, indicated to give Miralax Powder (a medication for constipation) 17 grams/scoop in the morning for constipation. There was no care plan found in the record to indicate the resident was prone to constipation and the use of Linzess or Miralax. During an interview, on 10/2/24 at 10:08 a.m., the Minimum Data Set (MDS) Nurse indicated she did not believe the facility had a policy addressing what needed to be care planned. During an interview, on 10/2/24 at 11:00 a.m., the MDS Nurse indicated the resident should have had a care plan addressing constipation. 2. The clinical record for Resident 26 was reviewed on 9/26/24 at 2:25 p.m. The diagnoses included, but were not limited to, hyperlipidemia, pain in an unspecified joint, and insomnia. A physician's order, initiated on 8/27/21, indicated to give Lipitor (a cholesterol medication) 10 milligrams daily at bedtime for mixed hyperlipidemia (elevated levels of fat in the blood). A physician's order, initiated on 4/22/22, indicated to give Melatonin (a supplement to help with sleep disorders) six (6) milligrams at bedtime for insomnia. A physician's order, initiated on 3/22/24, indicated to give tramadol (a pain reliever) 100 milligrams twice a day for joint pain. There were no care plans addressing the use of Lipitor for hyperlipidemia, Melatonin for insomnia or tramadol for pain found in the record. During an interview, on 10/2/24 at 10:07 a.m., the MDS Nurse indicated the resident should have had a care plan addressing mixed hyperlipidemia, difficulty sleeping, and pain. A current facility policy, titled Care Plans, dated as last reviewed in 2024 and received from the Executive Director on 10/2/24 at 10:32 a.m., indicated .Collaboration of the care plan team is used to help analyze data obtained from the resident's diagnosis, staff notation, MDS (Minimum Data Set) and physician's orders to develop individualized care plans specific to each resident 3.1-35(a) 3.1-35(b)(1)

Based on interview and record review, the facility failed to obtain laboratory results for the monitoring and effectiveness of a cholesterol medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 26) Finding includes: The clinical record for Resident 26 was reviewed on 9/26/24 at 2:25 p.m. The diagnoses included, but were not limited to, pain in an unspecified joint, insomnia, and mixed hyperlipidemia. A physician's order, initiated on 8/27/21, indicated to give Lipitor (a medication for high cholesterol) 10 milligrams daily at bedtime for mixed hyperlipidemia. A laboratory result, dated 2/11/22, indicated the resident had a high triglyceride level of 188. There were no other laboratory results in the record to indicate a lipid profile (a blood test to monitor the lipid levels in the blood) had been monitored after 2/11/22. There were no entries in the record to indicate laboratory orders had been received and/or were pending. During an interview, on 10/2/24 at 10:07 a.m., the Minimum Data Set (MDS) Nurse indicated the facility did not have a policy addressing monitoring laboratory results for medications and there were no current laboratory results to show monitoring of the cholesterol levels. During a telephone interview, on 10/2/24 at 10:48 a.m., Nurse Practitioner 2 indicated cholesterol labs should be checked at least annually. The facility was not able to provide a policy addressing the monitoring of the medication. 3.1-48(a)(3)

Based on interview and record review, the facility failed to monitor and document a resident's delusions related to the use of an antipsychotic medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 28) Finding includes: The clinical record for Resident 28 was reviewed on 10/1/24 at 9:21 a.m. The diagnoses included, but were not limited to, unspecified dementia, psychotic disorder with delusions, alcohol abuse, and hyperlipidemia. A physician's order, with a start date of 4/5/24, indicated to give Zyprexa (an antipsychotic medication) 7.5 milligrams (mg) by mouth at bedtime for a psychotic disorder with delusions. A care plan, with a revision date of 1/28/21, indicated the resident displayed at times delusions he believed he was incarcerated and he planned to discharge. A care plan, with a revision date of 4/12/24, indicated the resident used the psychotropic medication Zyprexa related to psychosis with delusions. During an interview, on 10/1/24 at 9:58 a.m., the Director of Nursing (DON) indicated Resident 28 did have delusions. Behaviors should be documented in the progress notes in a behavior note. During an interview, on 10/1/24 at 2:18 p.m., Licensed Practical Nurse (LPN) 3 indicated Resident 28 did have delusions. They document behaviors in the behavior notes. The resident thought someone was coming to pick him up from the facility when nobody was coming to pick him up. The resident would want to wear jeans and if staff would put anything else but jeans on him, he would say it was not the law. During an interview, on 10/1/24 at 2:40 p.m., the Minimum Data Set (MDS) Coordinator indicated Resident 28 did have delusions. She did not see anything in the notes about him having any delusions, During an interview, on 10/1/24 at 2:40 p.m., the DON indicated Resident 28 did have delusions. She did not see anything in the notes about him having any delusions. A Point of Care (POC) response history for the resident's behavior monitoring and interventions log indicated no delusions were marked from 5/30/24 to 10/2/24. A current facility policy, titled Use of Antipsychotic Medications/Gradual Dose Reductions, undated and received from the Executive Director on 10/2/24 at 10:30 a.m., indicated .Residents who have not used antipsychotic medications are not to be given these medications unless antipsychotic medication therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record A current facility policy, titled Behavior Tracking, with a revision date of 2024 and received from the Executive Director on 10/2/24 at 10:50 a.m., indicated .Behavior tracking is in the Point of Care (POC). Certified Nursing Assistants (CNAs) will track behavior interventions through POC. All staff observations regarding behaviors will be reported to Nursing and/or Social Services. Nursing and/or Social Services will put in a behavior progress note 3.1-48(a)(3) 3.1-48(a)(4) 3.1-48(a)(5) 3.1-48(b)(1)

Based on observation and interview, the facility failed to ensure food was properly stored in a kitchen refrigerator for 1 of 1 kitchen reviewed for food service safety. (the refrigerator) Finding includes: During an observation, on 9/27/24 at 11:02 a.m., there was thawing meat stored above a gallon of milk, next to yogurt and a grocery sack of green bell peppers which belonged to a resident and were unlabeled in a kitchen refrigerator. During an interview, on 9/27/24 at 11:09 a.m., the Kitchen Manager indicated the milk should be stored on the top rack and not under the thawing meat. They should not store residents' food in the kitchen refrigerator. They have a refrigerator for storing residents' food downstairs in storage. A current policy, titled [NAME] Health Care Center Food and Nutrition Policy, dated as last revised 3/1/17 and received from the Executive Director on 10/2/24 at 10:30 a.m., indicated .Uncooked and raw animal products and fish will be stored separately in drip-proof containers and below fruits, vegetables and other ready-to-eat foods .All foods belonging to residents must be labeled with the resident's name, the item and the use by date 3.1-21(i)(3)

Based on observation, interview and record review, the facility failed to provide at least 80 square feet per resident in 1 of 18 rooms reviewed for living space. (room [ROOM NUMBER]) Finding includes: During the entrance conference, on 9/25/24 at 10:12 a.m., the Director of Nursing indicated room [ROOM NUMBER] continued to have a room size waiver. During an observation of room [ROOM NUMBER] with Maintenance Staff 4, on 9/25/24 at 9:44 a.m., the room was found to contain two beds and two free standing wardrobes which were used for clothing and storage of personal items belonging to the two occupants of the room. A review of the facility measurement indicated room [ROOM NUMBER] was 153.83 square feet and according to Life Safety code the double occupancy of the room allowed 76.9 square feet of living space per resident. During an interview, on 9/30/24 at 2:34 p.m., Resident 29 indicated he liked his room and felt he had enough space for himself and his roommate. During an interview, on 9/30/24 at 2:49 p.m., Resident 21 indicated he had no concerns with his room and felt he had enough space for himself and his personal belongings. During an interview, on 10/2/24 at 11:34 a.m., the Executive Director indicated room [ROOM NUMBER] was occupied by two residents and should have 80 square feet of living space per resident. A Bed Inventory form, received on 10/2/24, indicated room [ROOM NUMBER] was a Title 18/19 SNF/NF (Medicare and Medicaid) room and was certified for two resident beds. 3.1-19(l)(2)(A)

Based on interview and record review, the facility failed to ensure a resident received the correct medication for 1 of 1 resident reviewed for a significant medication error. (Resident 20) Resident 20 required an intensive care stay in the hospital for 5 days. Finding includes: The record for Resident 20 was reviewed on 9/19/23 at 2:01 p.m. Diagnoses included, but were not limited to, dementia with other behavioral disturbance, bradycardia, abnormal weight loss, mood disorder, chronic pain syndrome, and hypertension. A progress note, dated 6/30/23 at 9:25 am, indicated the resident was noted to be lethargic. The skin was cool to touch, he had increased slurring speech, and his speech was garbled. The provider was notified and requested a transfer to the emergency department. An SBAR (situation, background, assessment, and recommendation form), dated 6/30/23 at 9:36 a.m., indicated the resident had a change in mental status and was given another resident's medications. A hospital patient summary report, dated 6/30/23 at 2:46 pm, indicated the admitting diagnosis was an overdose of antipsychotic accidental or unintentional accidental overdose of beta-adrenergic blocker. The resident was diagnosed with acute toxic encephalopathy (brain disfunction caused by toxic exposure) due to receiving the medications for another resident. Poison control recommended flumazenil (to help the resident wake up after an overdose) which was given in the emergency department. The resident also had a diagnosis of lactic acidosis (too little oxygen reaches body tissues) likely related to medications and poor intake. A diagnosis of sinus bradycardia (low heart rate) resulted from an inadvertent dose of metoprolol tartrate (for high blood pressure and heart rate)100 mg (milligrams). A progress note, from the attending physician in medical intensive care unit, dated 6/30/23 at 12:27 p.m., indicated the resident presented from his living facility sedated (sleepy). The resident was given medications which were not his own. These medications included 81 mg (milligrams) of aspirin, 0.5 mg of benztropine (for Parkinson's disease), 10 mg of buspirone (a medication for anxiety), 10 mg of Jardiance (a medication for diabetes), 1 mg lorazepam (a medication for anxiety), 100 mg pimavanserin (for Parkinson's disease), 1 gm (gram) metformin (used for diabetes) and 200 mg Seroquel (used for schizophrenia and bipolar). The resident's medication list included atorvastatin (a cholesterol medication) 40 mg, tamsulosin (for the prostate) 0.4 mg, aspirin 81 mg, Tylenol (for pain) 325 mg as needed, Imodium A-D (for loose stools) 2 mg as needed, and Zyprexa (for behavior disturbance/mood disorder) 5 mg. A progress note, dated 7/5/23 at 2:09 p.m., indicated the resident returned to the facility via stretcher, provider notified of medication changes at this time. Director of nursing notified of return. A medication variance report, dated 6/30/23 at 9:00 a.m., indicated the type of variance was the wrong resident and the reason was failure to identify the resident. Nurse 18 was placed back in orientation. During an interview, on 09/21/23 at 10:13 a.m., the Executive Director indicated he was aware of the significant medication error and the employee was terminated. A current policy, titled Medication Administration, no date, received from the Executive Director on 9/21/23 at 9:34 a.m., indicated .licensed or qualified personnel shall be responsible to follow accepted practices of medication administration as per physicians' order .picture or other method deemed comparable by the facility .if a picture is unavailable, verify resident identity with another staff member and with residents' prior administration 3.1-48(c)(2)