Every finding on record at Mill Pond Health Campus

Based on observation, interview, and record review, the facility failed to ensure proper food handling for 2 of 2 hall tray meal service observations. This had the potential to affect residents receiving hall trays during the lunch meal service. Findings include:During a lunch meal service observation (healthcare lunch trays), on 5/7/26 at 12:40 p.m., Dietary Services Assistant 18 was preparing the hall trays at her hot cart (cart used to transport food and keep it warm) and removed ice from the ice bucket with the use of an ice scoop, she placed the ice in a cup and placed the ice scoop back into the ice bucket with the ice. She placed the drink cup on a tray to be served. At 12:44 p.m. she prepared another drink for a hall tray and placed the ice scoop back into the ice bucket after she prepared the drink. At 12:45 p.m. she prepared another drink for a hall tray and placed the ice scoop back into the ice bucket after she prepared the drink. At 12:46 p.m. and 12:47 p.m., the dietary services assistant prepared more drinks for the hall trays and returned the ice scoop back into the ice bucket. At 12:48 p.m., the dietary services assistant left the common area and proceeded down the 300 hallway with the ice bucket uncovered down the hallway and the ice scoop still in the bucket. During a breakfast meal service observation (healthcare breakfast trays), on 5/8/26 at 9:09 a.m., Dietary Services Assistant 18 was standing at the hot cart and the ice scoop was noted to be inside the ice bucket with the ice. She left the common area with the cart and proceeded down the 300 hallway with ice bucket uncovered. During an interview, on 5/11/26 at 9:00 a.m., Dietary Services Assistant 6 indicated the ice bucket should be covered with plastic when being transported down the hallway, she further indicated they had always kept the ice scoop in the ice bucket when not in use. During an interview, on 5/11/26 at 12:51 p.m., Dietary Services Assistant 9 indicated she was educated today (5/11/26) by the dietary manager to make sure to place the ice scoop in a separate container when not in use. She further indicated in the past they would just place the ice scoop in the ice bucket when not in use. On 5/11/26 at 11:03 a.m., the Regional Nurse Consultant provided an undated document, titled, In-Use Utensils; Between Use Storage, and indicated it was the current policy being used by the facility. The policy indicated, . (2) In food that is not potentially hazardous with their handles above the top of the food within containers or equipment that can be closed, such as bins of ice.(5) In a clean, protected location if the utensils, such as ice scoops. 410 IAC (Indiana Administrative Code) 16.2-3.1-21(i)(3)

Based on record review and interview, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for 2 of 29 MDS assessments reviewed for accuracy (Residents 26 and 15). Findings include: 1. Resident 26's closed record was reviewed on [DATE] at 10:08 a.m. A significant change MDS, dated [DATE], indicated the resident had severe cognitive deficit, had a documented terminal illness, and received hospice (end of life) services. The census indicated the resident expired on [DATE]. The record lacked documentation of a death in facility MDS. The last documented MDS was the significant change MDS on [DATE]. During an interview, on [DATE] at 10:15 a.m., the MDS Coordinator indicated the death in facility MDS had been overlooked and had not been completed. The CMS (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 Manual, dated [DATE], indicated, .A0301: Type of Assessment.F.12. Death in Facility.Coding Tips and Special Populations.A0310E=0 for: Entry of Death in Facility. 2. On [DATE] the medical record of Resident 15 was reviewed. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, unspecified cirrhosis of liver (severe, permanent scarring of the liver caused by long-term liver damage or disease), encounter for palliative care (end of life comfort care), and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). A physician order, dated [DATE], indicated resident admitted under hospice services related to terminal diagnosis of unspecified cirrhosis of liver disease, if disease runs normal course life expectancy of 6 months or less. A Minimum Data Set (MDS) assessment, dated [DATE], indicated hospice services were provided during the assessment period, and the resident was severely cognitively impaired requiring maximum assistance for all care needs. An MDS, dated [DATE], indicated hospice services had not been provided during the assessment period. A care plan dated [DATE] indicated Resident 15 had elected for comfort care and had chosen hospice services. Interventions included, but were not limited to, provide basic comfort measures. On [DATE] at 10:14 p.m., during an interview the MDS nurse indicated she did not catch the entry when completing the MDS. She acknowledged the resident was on hospice services during the look back period. On [DATE] at 1:36 p.m., the Regional Nurse Consultant indicated the facility follows the RAI assessment manual. The Resident Assessment Instrument (RA)I manual indicated, . section O0110K1, Hospice care. Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions.

Based on observation interview and record review, the facility failed to ensure the privacy of the residents was maintained for 2 of 8 observations for privacy (Residents 29 and 32). Findings include: 1. On 5/8/26 at 10:47 a.m., during an interview Resident 29 indicated the staff had come into the bathroom while she was sitting on the toilet and checked her blood pressure. She indicated she had asked them to wait, but they came in anyway and checked her blood pressure. She indicated this was embarrassing and she should have time alone to use the bathroom facilities. She indicated there were times she was getting dressed and the staff walked in without asking permission to come in and failed to knock on the door. During the resident interview, three staff members came in without knocking on the door or waiting for permission to enter. Activities Assistant 4 came in and asked about activities, Certified Nursing Aide (CNA) 3 came in and delivered water, and a third unidentified employee came in and walked to the other side of the room and then left. On 5/11/26 at 10:00 a.m., reviewed the medical record of Resident 29. The resident was admitted to the facility on [DATE]. Diagnoses included but were not limited to Unspecified dementia (the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high), hemiplegia (a loss of strength in the arm, leg, and sometimes face on one side of the body), and hemiparesis (a relatively mild loss of strength) following cerebral infarction affecting right dominant side). A Minimum Data Set (MDS) assessment, dated 4/20/26, indicated the resident was cognitively intact and required assistance from the staff for daily care needs. A care plan, dated 4/24/25, indicated the resident had impaired cognition with associated short term memory impairment and risk for confusion, disorientation, altered mood, impaired or reduced safety awareness related to dementia. Interventions included, but were not limited to, greet with verbal and non-verbal gestures, using resident's preferred name. On 5/11/26 at 11:32 a.m., during an interview, Licensed Practical Nurse (LPN) 7 indicated the expectation was all employees should knock and wait for permission to enter a resident's room. On 5/11/26 at 11:38 a.m., during an interview, Housekeeper 8 indicated when entering a resident's room, she would knock on the door and wait for permission prior to entering the resident's room. 2. During the lunch meal service observation (healthcare hall trays), on 5/11/26 at 12:38 p.m., Resident 32 was sitting in his Broda chair (specialized highly adjustable medical wheelchair or reclining chair designed for long term care) in the common area across from the nurse's station. There was also a female resident sitting in her wheelchair in front of the television. A few minutes later a CNA pushed another female resident in her wheelchair into the common area from the dining room to watch the television. A contracted Hospice Nurse entered the common area and sat next to Resident 32. The nurse did not address the resident when she sat down next to him. The contracted Hospice Nurse 12 obtained vital signs on Resident 32. The nurse obtained his blood pressure using a wrist cuff, temporal (forehead) temperature, pulse oximeter reading, heart rate, and palpated his abdomen with her bare hands. There were several other residents and staff in the hallway at that time along with dietary staff preparing and serving the lunch hall trays. The Hospice Nurse also took a phone call while charting and completing her assessment on Resident 32. The Hospice Nurse never addressed or communicated with Resident 32 during the assessment. Resident 32's record was reviewed on 5/11/26 at 2:36 p.m. The profile indicated the resident diagnoses included, but were not limited to, unspecified dementia (group of conditions characterized by impairment of at least two brain functions such as memory and judgment), and dysphagia (difficulty swallowing food, liquids, or salvia). A quarterly Minimum Data Set (MDS) assessment, dated 3/26/26, indicated the resident was rarely understood and was on hospice services. During an interview, on 5/11/26 at 2:18 9.m., the Registered Nurse (RN) 10 indicated that staff should not be performing assessments and/or vital signs in a common area on any resident. The assessment should be completed behind closed doors for privacy. On 5/11/26 at 11:00 a.m., the Regional Nurse Consultant provided a document, with a revised date of 5/11/17, titled, Resident Rights Guidelines, and indicated it was the policy currently being used by the facility. The policy indicated, .2. Our residents have a right to: a. Be treated with dignity and respect .d. Privacy 410 IAC (Indiana Administrative Code) 16.2-3.1-3(o)(5)

Based on interview and record review, the facility failed to ensure a resident's preferences were met, for 1 of 2 residents reviewed for choices (Resident 18). Findings include:During an interview, on 5/7/26 at 10:47 a.m., Resident 18 indicated she used to receive 3 showers a week until she developed the need to use a shower chair. Now she was lucky if she got 2 per week. Resident 18's record was reviewed on 5/8/26 at 2:25 p.m. The profile indicated the resident's diagnoses included, but were not limited to, multiple sclerosis unspecified (a chronic neurological disorder in which the body's immune system attacks the protective covering of the nerve cells in the brain) and diabetes mellitus with hyperglycemia (too much sugar in the blood). An annual Minimum Data Set (MDS) assessment, dated 1/27/26, indicated the resident had no cognitive deficit, had no documented behaviors of refusal of care, and was dependent with her personal hygiene and bathing. An annual Life Enrichment assessment, dated 1/29/26, indicated the resident preferred showers. The assessment lacked documentation as to how many showers per week the resident preferred. A profile care guide care plan, dated 3/15/22, indicated the resident preferred showers. Interventions included, but were not limited to, shower per schedule. The resident's care plans lacked documentation of refusals with assistance of her ADL (activities of daily living- the basic skills necessary for individuals to independently care for themselves, such as eating and bathing). Review of the April 2026 Point of Care (POC) document (the recording and documenting of patient information directly at the bedside or point of care) indicated the resident had received showers on 4/8/26, 4/19/26, 4/22/26, and 4/25/26. The POC lacked documentation of any resident refusal of care. Review of the May 2026 POC document indicated the resident had received showers on 5/3/26 and 5/10/26. The POC lacked documentation of any resident refusal of care. During an interview, on 5/11/26 at 12:20 p.m., the Assistant Director of Nursing Services (ADNS) indicated the facility staff did not complete shower sheets. The POC was where the staff would document showers and baths given along with any refusal of care by a resident. During an interview, on 5/11/26 at 12:44 p.m., the Life Enrichment Director indicated she completed the preferences for the residents but only asked the preference of shower versus bath. She had just started to ask the residents about their preference of the day for the bath or shower but had never asked the numbers they preferred. It was her understanding that the facility expectation was that each resident would get 2 per week. She did not believe this was a policy, but just the expectation. During an interview, on 5/11/26 at 2:35 p.m., the Regional Clinical Support indicated there was not a specific policy for the number of showers residents would receive, but the staff would attempt to make sure every resident received 2 showers a week. She was unable to find any documentation of the Resident 18's refusals for her showers. On 5/11/26 at 2:51 p.m., the Regional Clinical Support provided a document, with a revised date of 5/11/16, titled, Guidelines for Bathing Preference, and indicated it was the policy currently in use by the facility. The policy indicated, .Procedure.2, The resident shall determine their preference for bathing upon admission.c. Type of bathing-tub bath, bed bath or shower.4. Bathing shall occur at least twice a week unless resident's preference states otherwise. 410 IAC (Indiana Administrative Code) 16.2-3.1-3(u)(1)

Based on observation and interview, the facility failed to ensure medication was labeled with a date opened during 1 of 3 medication cart observations.Findings include:On 5/11/26 at 2:40 p.m., during observation of medication cart with Licensed Practical Nurse (LPN) 7 observed an insulin pen containing Lantus insulin, identified as being prescribed to Resident 18 with no date opened recorded on the label.On 5/11/26 at 2:42 p.m., during an interview LPN 7 acknowledged insulin pens must have a date opened on the pen.On 5/11/26 at 2:49 p.m., the medical record of Resident 18 was reviewed. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, diabetes mellitus type 2 (a disease that occurs when your blood glucose, also called blood sugar, is too high), hypertension (high blood pressure), and major depressive disorder (an illness characterized by persistent sadness and a loss of interest in activities that you normally enjoy, accompanied by an inability to carry out daily activities, for at least two weeks).A physician order, dated 8/8/25, indicated to administer 60 units subcutaneous (under the skin) Lantus Solostar U-100 Insulin (insulin glargine) insulin 100 unit/mL (3 mL) twice a day.On 5/11/26 at 2:52 p.m., the Regional Nurse Consultant provided a document, titled, Medication Storage In The Facility, dated 11/18, and indicated it was the policy currently being used by the facility. The policy indicated, .D. When the original seal of a manufacturers container or vial is initially broken, the container or vial will be dated.1. A date opened sticker shall be placed on the medication (NOTE: the best stickers to affix contain both a date opened and expiration notation line) .410 Indiana Administrative Code (IAC) 3.1-25(j)410 Indiana Administrative Code (IAC) 3.1-25 (m)410 Indiana Administrative Code (IAC) 3.1-25 (n)

Based on record review and interview, the facility failed to ensure accurate documentation of medication administration for 1 of 3 residents reviewed for medication administration (Residents 3), and the facility failed to ensure a written physician order was obtained to send resident to the hospital for 1 of 4 residents reviewed for hospitalizations (Resident 2).Findings include:1. During an interview, on 5/7/26 at 1:24 p.m., Resident 3 indicated the nursing staff were late administering her insulin a lot of the time and there were some days that she didn't get her insulin injections at all. During an interview, on 5/12/26 at 10:44 a.m., Resident 3 indicated it was usually the same nurse on nightshift that was late administering her medications (pills and insulin) and sometimes she didn't get her medications at all. Resident 3's record was reviewed on 5/11/26 at 11:31 a.m. The profile indicated the resident's diagnoses included, but were not limited to, type II diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), end stage renal disease (the final, permanent stage of chronic kidney disease), and encephalopathy (any disease, damage, or malfunction that alters brain function or structure). A quarterly Minimum Data Set (MDS) assessment, dated 3/15/26, indicated the resident was cognitively intact and was on insulin injections and received anti-depressant, anti-coagulant (blood thinner), and diuretic (water pill) medications. A care plan, dated 12/23/22, indicated the resident had potential for cardiovascular distress related to diagnosis of HTN (hypertension -elevated blood pressure) and CHF (congestive heart failure-the heart muscles become weakened or stiff, meaning it cannot pump blood efficiently to meet the body's needs). Interventions included, but were not limited to, medications as ordered, observe for and report side effects as needed. A care plan, dated 12/23/22, indicated the resident was at risk for hypo/hyperglycemia (low or elevated blood sugar) related to diabetes mellitus. Interventions included, but were not limited to, medication per order and monitor blood sugars per md (medical doctor) order. A physician order, dated 3/11/26, indicated to administer amlodipine (treats high blood pressure) 5 mg (milligrams) by mouth once daily from 6 to (-) 10:00 p.m. Review of April 2026 MAR (Medication Administration Record) indicated the following administration times for the 6 - 10:00 p.m. dose of amlodipine medication: a. On 4/1/26 the medication was documented as late administration: Charted late due to patient care at 11:07 p.m. by Licensed Practical Nurse (LPN) 17. b. On 4/3/26 the medication was documented as late administration: Charted late due to patient care at 10:27 p.m. by LPN 17. c. On 4/8/26 the medication was documented as late administration: Charted late due to patient care at 11:51 p.m. by LPN 17. d. On 4/9/26 the medication was documented as late administration: Charted late due to patient care at 11:59 p.m. by LPN 17. e. On 4/15/26 the medication was documented as late administration: Charted late due to patient care at 10:43 p.m. by LPN 17. f. On 4/16/26 the medication was documented as late administration: Charted late due to patient care at 10:27 p.m. by LPN 17. g. On 4/17/26 the medication was documented as late administration: Charted late due to patient care at 11:13 p.m. by LPN 17. h. On 4/23/26 the medication was documented as late administration: Charted late due to patient care at 11:40 p.m. by LPN 17. i. On 4/28/26 the medication was documented as late administration: Charted late due to patient care at 11:11 p.m. by LPN 17. j. On 4/30/26 the medication was documented as late administration: Charted late due to patient care at 11:10 p.m. by LPN 17. Review of May 2026 MAR indicated the following administration times for the 6 - 10:00 p.m. dose of amlodipine medication: a. On 5/5/26 the medication was documented as late administration: Charted late due to patient care at 11:36 p.m. by LPN 17. b. On 5/6/26 the medication was documented as late administration: Charted late due to patient care at 10:43 p.m. by LPN 17. c. On 5/7/26 the medication was documented as late administration: Charted late administered on time 11:43 p.m. by LPN 17. A physician order, dated 2/10/26, indicated to administer Eliquis (blood thinner) 5 mg by mouth twice daily at 6 - 10:00 a.m. and 6 - 10:00 p.m. Review of April 2026 indicated the following administration times for the 6 - 10:00 p.m. dose of Eliquis mediation: a. On 4/1/26 the medication was documented as late administration: Charted late due to patient care at 11:07 p.m. by LPN 17. b. On 4/15/26 the medication was documented as late administration: Charted late due to patient care at 10:43 p.m. by LPN 17. c. On 4/21/26 the medication was documented as late administration: Charted late due to patient care at 11:18 p.m. by LPN 17. d. On 4/28/26 the medication was documented as late administration: Charted late due to patient care at 11:11 p.m. by LPN 17. Review of May 2026 indicated the following administration times for the 6 - 10:00 p.m. dose of Eliquis mediation: a. On 5/5/26 the medication was documented as late administration: Charted late due to patient care at 11:36 p.m. by LPN 17. b. On 5/6/26 the medication was documented as late administration: Charted late due to patient care at 10:43 p.m. by LPN 17. c. On 5/7/26 the medication was documented as late administration: Charted late administered on time 11:43 p.m. by LPN 17. A physician order, dated 2/10/26, indicated to administer isosorbide dinitrate (treat chest pain and manage heart failure) 20 mg by mouth twice a day on Mon, Wed, and Fri. at 6-10:00 a.m. and 6 - 10:00 p.m. Review of April 2026 indicated the following administration times for the 6 - 10:00 p.m. dose of isosorbide dinitrate mediation: a. On 4/1/26 the medication was documented as late administration: Charted late due to patient care at 11:07 p.m. by LPN 17. b. On 4/3/26 the medication was documented as late administration: Charted late due to patient care at 10:27 p.m. by LPN 17. c. On 4/8/26 the medication was documented as late administration: Charted late due to patient care at 11:51 p.m. by LPN 17. d. On 4/15/26 the medication was documented as late administration: Charted late due to patient care at 10:43 p.m. by LPN 17. e. On 4/17/26 the medication was documented as late administration: Charted late due to patient care at 11:13 p.m. by LPN 17. Review of May 2026 indicated the following administration times for the 6 - 10:00 p.m. dose of isosorbide dinitrate mediation: a. On 5/6/26 the medication was documented on 5/7/26 as late administration: Charted late due to patient care at 1:02 a.m. by LPN 17. b. On 5/11/26 the medication was documented on 5/12/26 as late administration: Charted late due to patient care at 12:03 a.m. by LPN 17. A physician order, dated 2/10/26, indicated to administer isosorbide dinitrate (treat chest pain and manage heart failure) 20 mg by mouth three times a day on Sun, Tuesday, Thursday, and Saturday. at 6 - 10:00 a.m. 11:00 a.m. - 1:30 p.m., and 6 - 10:00 p.m. Review of April 2026 MAR indicated the following administration times for the 6 - 10:00 p.m. dose of isosorbide dinitrate mediation: a. On 4/9/26 the medication was documented as late administration: Charted late due to patient care at 11:59 p.m. by LPN 17. b. On 4/14/26 the medication was documented as late administration: Charted late administered on time at 11:11 p.m. by LPN 17. c. On 4/16/26 the medication was documented as late administration: Charted late due to patient care at 10:27 p.m. by LPN 17. d. On 4/21/26 the medication was documented on 4/22/26 as late administration: Charted late due to patient care at 12:28 a.m. by LPN 17. e. On 4/23/26 the medication was documented as late administration: Charted late due to patient care at 11:40 p.m. by LPN 17. f. On 4/28/26 the medication was documented as late administration: Charted late due to patient care at 11:11 p.m. by LPN 17. g. On 4/30/26 the medication was documented as late administration: Charted late due to patient care at 11:10 p.m. by LPN 17. Review of May 2026 indicated the following administration times for the 6 - 10:00 p.m. dose of isosorbide dinitrate mediation: a. On 5/5/26 the mediation was documented on 5/6/26 as late administration: Charted late due to patient care at 1:03 am. by LPN 17. A physician order, dated 3/18/26, indicated to administer Basaglar Kwik-Pen (insulin medication) 100 unit/ml (milliliters), give 5 units subcutaneously (under the skin) at bedtime from 7 - 11:30 p.m. Review of April 2026 MAR indicated the following administration times for the 7 - 11:30 p.m. dose of Basaglar mediation: a. On 4/10/26 the record lacked documentation of the insulin being administered. Review of May 2026 MAR indicated the following administration times for the 7-11:30 p.m. dose of Basaglar mediation: a. On 5/5/26 the medication was documented as late administration: Charted late due to patient care at 11:36 p.m. by LPN 17. b. On 5/7/26 the medication was documented as late administration: Charted late administered on time 11:43 p.m. by LPN 17. During an interview, on 5/12/26 at 9:16 a.m., LPN 16 indicated she would administer the resident's medication to them and immediately return to the computer to document them as given. During an interview, on 5/12/26 at 11:51 a.m., LPN 11 indicated she would document she gave the residents' their medications as soon as she left their room and returned to the computer. During an interview, on 5/13/26 at 10:19 a.m., the Regional Nurse Consultant indicated she was not aware of why a nurse would document patient care on the medication administration record. It was the expectation that nursing staff would document as soon as the medication was administered. During a phone interview, on 5/13/26 at 10:29 a.m., LPN 17 indicated she was busy on the nightshift and had to assist other staff with their duties and therefore she was late documenting her medication administration pass. She indicated Resident 3 would often get her medication on time, but the documentation did not reflect that. She could not recall why some of the medications that were a part of the bedtime medication pass had different times of administration on the MAR. She indicated she gave all the bedtime medications to Resident 3 at the same time, but the documentation did not reflect that at times. During an interview, on 5/13/26 at 11:54 a.m., the Regional Nurse Consultant indicated medication administration should be documented as soon as administered by nursing. On 5/13/26 at 11:52 a.m., the Regional Nurse Consultant provided a document with a revised date of 11/18, titled, Preparation and General Guidelines, and indicated it was the current policy being used by the facility. The policy indicated, .1) The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. 2. On 5/12/26 at 2:30 p.m., the medical record of Resident 2 was reviewed. The resident was admitted to the facility on [DATE]. Diagnoses included but were not limited to encephalopathy (any disease, damage, or malfunction of the brain), hypertension (high blood pressure), and type 2 diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high). The medical record indicated on 4/26/26 the resident experienced a sudden change and decline in condition. The record indicated the resident was assessed and the on call physician was notified and a telephone order was obtained to send the resident to the hospital. The record lacked documentation of a physician order to transfer the resident to the hospital. On 5/13/26 at 10:25 a.m., during an interview Registered Nurse (RN) 2 indicated if she were sending a resident to the hospital she would call the physician and obtain an order to send the resident to the hospital and she would document the information in the medical record. On 5/13/26 at 11:00 a.m., the Regional Clinical Nurse provided a document, titled, Guidelines for Transfer and Discharge, dated5/3/17, and indicated it was the policy currently being used by the facility. The policy indicated, .2. Emergency Transfers/Discharges.a. Nursing should obtain physician's orders for emergency transfer or discharge and may include stating the reason the transfer or discharge is necessary on an emergency basis. 410 Indiana Administrative Code (IAC) 3.1-50(f)

Based on record review and interview, the facility failed to ensure discharge reporting information was communicated to the receiving healthcare facility for 1 of 4 residents reviewed for hospitalization (Resident 2). Findings include:On 5/12/26 at 2:30 p.m., the medical record of Resident 2 was reviewed. The resident was admitted to the facility on [DATE]. Diagnoses included, but was not limited to, encephalopathy (any disease, damage, or malfunction of the brain), hypertension (high blood pressure), and type 2 diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high). An admission Minimum Data (MDS) assessment, dated 4/7/26, indicated the resident had severe cognitive impairment and required maximum assistance from the staff for all care needs. The medical record indicated on 4/26/26 the resident experienced a sudden change and decline in condition. The resident was assessed and physician notified. The resident was sent to the hospital and admitted to Intensive Care Unit (ICU). The record lacked documentation of resident condition report being called to the hospital emergency room (ER) or the Emergency Response Service (EMS) at the time of the discharge. The record lacked documentation of written condition report including most recent vital signs, list of medications and allergies or a physician order to transfer the resident to the hospital. On 5/13/26 at 10:25 a.m., during an interview Registered Nurse (RN) 2 indicated if she were sending a resident to the hospital she would call the physician and obtain an order to send the resident to the hospital. She would then call the family then call report to the hospital emergency room nurse, if she knew where the resident was being sent. She indicated she would give her number to EMS and ask them to call her and notify her of where they sent the resident. She acknowledged she could give report to the attending EMS and ask them to report the information to the ER nurse. She indicated she would document how the report was communicated in the medical record. On 5/13/26 at 11:25 a.m., during an interview the regional Nurse Consultant acknowledged the record lacked evidence of a physician order to send the resident to the hospital and the record lacked evidence of written report being given to the hospital. On 5/13/26 at 11:00 a.m., the Regional Clinical Nurse provided a document, titled, Guidelines for Transfer and Discharge, dated 5/3/17, and indicated it was the policy currently being used by the facility. The policy indicated, .2. Emergency Transfers/Discharges.a. Nursing should obtain physician's orders for emergency transfer or discharge and may include stating the reason the transfer or discharge is necessary on an emergency basis .c. Nursing should print and send the resident's CCD (continuum of care document) which includes current diagnosis, most recent vital signs, allergies, attending physician, current medications, treatments, and advanced directives. 410 IAC (Indiana Administrative Code) 16.2-3.1-12(a)(6)(B)

Based on record review and interview, the facility failed to develop a care plan for the resident's respiratory durable medical equipment, a cough assist device and a suctioning device, for 1 of 3 residents reviewed for quality of care. (Resident B)Findings include:A clinical record review for Resident B was completed on 8/19/25 at 10:26 a.m. Diagnoses included amyotrophic lateral sclerosis (ALS) (a progressive neurodegenerative disease), dysphagia (difficulty swallowing), rheumatoid arthritis, depression, and anxiety. The resident was admitted to the facility from her home on 7/15/25 and was receiving hospice services. An admission Minimum Data Set (MDS) assessment, dated 7/21/25, indicated the resident was cognitively intact, was unable to speak, understood others and was able to be understood. The resident required substantial to maximal assistance for dressing, bed mobility, and personal hygiene. She was dependent on staff for assistance with transfer, wheelchair mobility, showering, toileting, A nursing progress note, dated 7/15/25 at 9:17 p.m., included the resident was alert and oriented and communicated by using a whiteboard. She utilized a ventilator machine at night and had an airway clearance device at bedside.The resident's care plan lacked a problem, goal, or approach regarding the resident's ventilator machine, airway clearance device (suctioning), and cough assist device.During an interview on 8/19/25 at 2:18 p.m., the Director of Nursing (DON) indicated the resident had been using the respiratory equipment at home and had used them in the facility on her own. The staff had not been in-serviced regarding the cough assist device or the ventilator machine that she used at night. There was a staff member that worked most days on her hall that was familiar with the ventilator machine. The resident's care plan lacked an entry regarding her respiratory devices. During an interview on 8/19/25 at 5:05 p.m., the Corporate Nurse Consultant indicated the equipment was her preference to use. She had brought them from home and used them as needed. The hospice care plan indicated that hospice was responsible for medical supplies. The facility had not entered a care plan for the cough assist device or the suctioning device.A current facility policy, revised 8/21/24, titled, 48 Hour Baseline Care Plan Guidelines, provided by the Corporate Nurse Consultant on 8/19/25 at 5:11 p.m., included the following: Procedure .5. Any changes to the residents care will be care planned accordingly until the comprehensive care plan is developed and then will be included on the comprehensive care plan.This citation relates to Intake 2584408.3.1-35(a)

Based on record review and interview, the facility failed to obtain physician's orders or the assessment for the use of a cough assist device and an airway clearance device (suctioning) for 1 of 4 residents reviewed for quality of care. (Resident B)Findings include:A clinical record review for Resident B was completed on 8/19/25 at 10:26 a.m. Diagnoses included amyotrophic lateral sclerosis (ALS) (a progressive neurodegenerative disease), dysphagia (difficulty swallowing), rheumatoid arthritis, depression, and anxiety. The resident was admitted to the facility from her home on 7/15/25 and was receiving hospice services. An admission minimum data set (MDS) assessment, dated 7/21/25, indicated the resident was cognitively intact, was unable to speak, understood others and was able to be understood. The resident required substantial to maximal assistance for dressing, bed mobility, and personal hygiene. She was dependent on staff for assistance with transfer, wheelchair mobility, showering, and toileting. A nursing progress note, dated 7/15/25 at 3:23 p.m. included the resident was alert and oriented and used a whiteboard for communication. The resident had a gastric tube and received supplement five times a day. Resident orders had been entered.A nursing progress note, dated 7/15/25 at 9:17 p.m., included the resident was alert and oriented and communicated by using a whiteboard. She utilized a ventilator machine at night and had an airway clearance device at bedside.The physician's orders lacked an order for an airway clearance device or a cough assist device. During an interview on 8/19/25 at 2:18 p.m., the Director of Nursing (DON) indicated there should have been physician orders regarding the resident's cough assist device and airway clearance device (suctioning). The resident had used the devices as needed. The resident had been using the respiratory equipment at home and had used them in the facility on her own. The resident's care plan lacked an entry regarding her respiratory devices. During an interview on 8/19/25 at 5:05 p.m., the Corporate Nurse Consultant indicated the equipment was her preference to use. She had brought them from home and used them as needed. The hospice care plan indicated that hospice was responsible for medical supplies. The facility had not entered a care plan or physician orders for the cough assist device or the suctioning device.No policy was provided prior to the exit conference. The Corporate Nurse Consultant indicated there was no specific policy regarding physician orders. This citation relates to Intake 2584408.3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure a physician order was obtained for a Tubigrip (a tubular bandage that provides support for sprains, strains, swelling, and more) for 1 of 1 resident reviewed for limited range of motion (Resident 32). Findings include: During the initial pool observation, on 2/28/25 at 10:46 a.m., Resident 32 was sitting up in bed eating breakfast and a dressing was noted on the resident's left arm from her hand to up past her elbow. The resident indicated the wrap had been on her left arm for a while because she banged it on the side rail of her bed, and she was unable to use her left arm normally. Resident 32's record was reviewed on 3/3/25 at 10:18 a.m. The profile indicated the resident's diagnosis included, but were not limited to, brain mass (a cancerous or noncancerous mass or growth of abnormal cells in the brain), Alzheimer's disease with early onset (when Alzheimer's is diagnosed before the age of [AGE] years old), and edema, unspecified (swelling caused by excess fluid in tissues or body cavities). A quarterly Minimum Data Set (MDS) assessment, dated 1/12/25, indicated the resident had moderate cognitive impairment and had functional impairment on one side. A care plan, dated 7/8/24, indicated the resident was at risk for skin breakdown; requires assistance with bed mobility, transfers, and toileting. Interventions included, but were not limited to, left arm geri sleeve (long sleeve to help prevent skin shear) and avoid shearing skin during positioning, transferring, and turning. The care plan lacked an intervention indicating the resident had a Tubigrip on left arm. During an interview with a family member, on 3/3/25 at 1:30 p.m., the family member indicated the dressing had been on the resident's left arm for awhile and she thought it was because of the swelling in her left arm and skin tears. A late entry progress note, dated 12/26/24, indicated Resident 32 had a new skin tear to her left arm and had increased swelling in her arm. Steri strips (thin adhesive bandages that help close wounds) applied to the skin tear. A progress note, dated 1/26/35, indicated Resident 32 had received another skin tear to left forearm during care while turning in bed. Left arm was very edematous and the resident had little movement in the arm. A progress note, dated 2/1/25, indicated Resident 32 had a skin tear to her left upper posterior arm. Resident's arm noted to be very edematous, skin was very frail, and thin due to swelling. Hospice notified and would assess the resident tomorrow. A hospice progress note, dated 2/2/25, indicated Resident 32 had a skin tear to the back of left arm. The resident's record lacked documentation of a physician order for any kind of wrap or dressing/sleeve to resident's left arm. During an interview, on 3/3/25 at 2:21 p.m., the Certified Resident Medication Aide (CRMA) 5 indicated the resident had on a dressing/sleeve due to the skin tears on her left arm. During an interview, on 3/3/25 at 2:22 p.m., Registered Nurse (RN) 6 indicated Resident 32 had skin tears to her left arm and it was swollen, so the dressing/sleeve was used as a preventive measure. During an interview, on 3/4/25 at 9:04 a.m., the Clinical Support Nurse indicated Resident 32 had a Tubigrip on her left arm but was unable to find a physician order for its use. On 3/4/25 at 1:55 p.m., the Clinical Support Nurse provided a document with a revised date of 9/21/17, titled, Physician - Provider Notification Guidelines, and indicated it was the policy currently being used by the facility. The policy indicated, .To ensure the resident's physician or practitioner is aware of all diagnostic testing results or change in condition in a timely manner to evaluate condition for need of provisions of appropriate interventions for care .1. Resident assessments for change in condition suspected injury, event of unknown origin or ordered lab and or other diagnostic tests should be completed in a timely manner 3.1-37

Based on observation, record review, and interview, the facility failed to ensure that a nebulizer (a small machine that turns liquid medicine into a mist that can be inhaled into the lungs) mask was bagged when not in use for 1 of 2 residents reviewed for respiratory care (Resident 19). Findings include: During the initial observation of Resident 19, on 2/28/25 at 9:41 a.m., the resident's nebulizer mask was observed un-bagged and sitting on her bed side table. During a random observation, on 3/4/25 at 9:41 a.m., the resident's nebulizer mask was observed un-bagged and sitting on her bed side table. During a random observation, on 3/5/25 at 9:18 a.m., the resident's nebulizer mask was observed un-bagged and sitting on her bed side table. At the same time the Clinical Support observed the un-bagged mask. Resident 19's record was reviewed on 3/4/25 at 9:47 a.m. The profile indicated the resident's diagnoses included, but were not limited to, atherosclerotic heart disease of native coronary artery (a buildup of fats, cholesterol and other substances in and on the walls of the heart arteries that reduces blood flow) and stage 4 chronic kidney disease (a condition where the kidneys are severely damaged and are not filtering waste well). A quarterly Minimum Data Set (MDS) assessment, dated 12/6/24, indicated the resident had no cognitive deficit. The assessment lacked documentation of any shortness of breath (SOB). Review of the resident's care plans lacked documentation of any respiratory concerns, or the use of medications related to respiratory concerns. A physician's order, dated 2/19/25, indicated to administer one 0.5 milligram (mg)-3 mg (2.5 mg base)/3 milliliter (ml) vial of ipratropium-albuterol solution (a medication which works by opening the airways and reducing inflammation in the lungs to help the patient breathe) for nebulization every 4 hours as needed. Review of the February 2025 medication administration record (MAR) indicated the resident had been administered one nebulizer treatment on, 2/20/25 at 2:36 p.m., for congestion. A Nurse Practitioner (a registered nurse with advanced training to diagnose and treat patients) note, dated 2/19/25 at 10:15 a.m., indicated the resident had been seen for increased weakness and fatigue. She had the flu the other week. No SOB was documented, but she had a productive cough (a cough that brings up mucous or phlegm [thick substance secreted by the mucous membranes of the respiratory passages]). Interventions included, but were not limited to, Duonebs (medication that combines ipratropium and albuterol to treat chronic obstructive pulmonary disease) every 4 hours as needed. During an interview, on 3/5/25 at 9:18 a.m., the Clinical Support indicated the resident's nebulizer mask should have been bagged and dated for storage when not in use. On 3/5/25 at 9:40 a.m., the Clinical Support provided a document, with a review date of 12/16/24, titled, Respiratory Equipment, and indicated it was the policy currently being used by the facility. The policy indicated, .SOP Details .3. Medication Nebulizers .f. Store .in plastic bag, marked with date and resident's name, between uses 3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure a recommendation made by the Pharmacists was addressed in a timely manner for 1 of 5 residents reviewed for unnecessary medications (Resident 22). Findings include: Resident 22's record was reviewed on 2/28/25 at 2:10 p.m. The profile indicated the resident's diagnoses included, but were not limited to, hypertensive heart and chronic kidney disease with heart failure (conditions that can lead to heart failure that linked to high blood pressure) and stage 5 chronic kidney disease (a condition when the kidneys are severely damaged and have stopped doing their job of filtering waste from the blood). The profile lacked documentation of a diagnosis of hypotension (low blood pressure). A quarterly Minimum Data Set (MDS) assessment, dated 1/26/25, indicated the resident had no cognitive deficit and received dialysis (a treatment that removes waste products and excess fluid from the blood when the kidneys are not functioning properly). A care plan, dated 4/17/24, indicated the resident was non-compliant with physician orders, which included, but were not limited to, not taking medications. The care plan lacked documentation of the resident having hypotension. A pharmacy recommendation, dated 4/29/24, indicated to consider adjusting the dose times and hold parameters for the resident's Midodrine (anti-hypotensive medication) 5 milligrams (mg) three times a day (TID). The statement, Leave alone, had been written on the bottom of the document with the date of 5/2/24. The recommendation lacked any physician documentation to justify the statement. During an interview, on 3/3/25 at 1:58 p.m., the Clinical Support indicated she could not find documentation for a rationale for the statement leave alone. A pharmacy recommendation, dated 6/24/24, indicated to avoid giving the evening dose of Midodrine 5 mg TID after evening meal or within 4 hours of bedtime to prevent supine hypertension (HTN-high blood pressure when lying down). The document indicated the task had been completed. Review of the June 24 medication administration record (MAR) indicated the medication had been given between 6:00 p.m., and 10:00 p.m. The MAR lacked documentation of the specific time the medication had been administered. A pharmacy recommendation, dated 7/22/24, indicated to avoid giving evening dose of Midodrine 5 mg TID after evening meal or within 4 hours of bedtime to prevent supine HTN. The document indicated the task had been completed. Review of the July 2024 MAR indicated the evening dosage times had been changed to 4:00 p.m., to 6:00 p.m. During an interview, on 3/3/25 at 2:26 p.m., the Executive Director (ED) indicated the expectation was that pharmacy recommendations would be addressed within the time prior to the next pharmacy medication regimen review date. During an interview, on 3/3/25 at 2:28 p.m., the Clinical Support indicated she was not able to locate a specific policy related to the physician addressing the pharmacy recommendations. The facility would follow the State and Federal regulations. It was expected that all pharmacy recommendations would be addressed timely by the physician and the facility. 3.1-48(a)(4) 3.1-48(a)(6)

Based on observation, interview, and record review, the facility failed to ensure proper labeling of prepared food, and the facility failed to dispose of expired food for 1 of 2 kitchen observations. This had the potential to affect 50 of 50 residents who received food from the kitchen. Findings include: 1. During an initial kitchen tour with the Business Office Manager (the Dietary Manager was unavailable), on [DATE] at 10:27 a.m., a plastic container of prepared chicken salad was observed on a shelf in the walk-in refrigerator. There was no label or use by date on the container of chicken salad. The business office manager was not aware of when the chicken salad was prepared and how long it had been in the walk-in refrigerator. She indicated the chicken salad would have to be discarded since it did not contain a label with a use by date on it. During an interview, on [DATE] at 10:30 a.m., Dietary Services Assistant 8 indicated prepared food was good for 4 days and then should be discarded. 2. In the refrigerator, on [DATE] at 10:32 a.m., there was a plastic container of prepared poppy seed dressing with a use by date of [DATE], container of prepared lemonade with a use by date of [DATE], container of prepared apple raspberry juice with a use by date of [DATE], container of prepared blue Gatorade with a use by date of [DATE], and an opened container of thickened liquid with a use by date of [DATE]. The business office manager indicated the juices and salad dressing should have been discarded. During an interview, on [DATE] at 9:26 a.m., the Dietary Manager indicated prepared food items were good for 3 days and then should be discarded. The food items should contain a label with a use by date and then should be discarded after that date. On [DATE] at 12:30 p.m., the Clinical Support Nurse, provided a document with a review date of [DATE], titled, Leftover Food Storage, and indicated it was the policy currently being used by the facility. The policy indicated, .To enforce proper storage and usage of leftover food and ultimately avoid microbial foodborne illness .2. Date all food and use or discard within three days 3XXX,d+[DATE](i)(3)

Based on record review and interviews, the facility failed to ensure that a staff member followed the facility abuse policy and cell phone use policy for 1 of 3 residents reviewed for abuse (Resident B). The deficient practice was corrected on 7/5/24, prior to the start of the survey, and was therefore past noncompliance. Finding includes: On 7/24/24 at 9:45 a.m., a review of an Indiana Department of Health (IDOH) Reportable Incident document, dated 6/29/24 at 9:30 p.m., indicated Certified Resident Care Assistant (CRCA) 9 posted a video on a social media platform with an unidentifiable resident in the restroom. The video contained a caption indicating, this woman will be the death of me, and the employee was making a grimacing face while holding up her middle finger. The CRCA was immediately suspended upon the report of the social media video and an investigation began. Review of investigation summary, dated 6/29/24 at 11:00 p.m., indicated that a staff member reported to the ED that a social media video was posted of a resident in the background and CRCA 9 was making hand gestures in the background. The CRCA was suspended on 6/29/24 pending an investigation. On 6/30/24 abuse education was initiated with active staff. On 7/1/24 the resident was identified through an interview with the suspended employee. Resident B was identified as the one in the video. Once an identification of the resident had been made the responsible party and medical doctor was informed. The facility interviewed CRCA 9, and she admitted to violating the facility's abuse policy. The CRCA was terminated from her position at the facility. All residents had a head-to-toe skin assessment completed and residents with a BIMS above 8 were interviewed. Education was provided to all staff. Resident B's record was reviewed on 7/24/24 at 1:23 p.m. The profile indicated the resident's diagnosis included, but were not limited to, depression (a mental state that can affect person's thoughts, feelings, behaviors, and sense of well-being), generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities), and Alzheimer's (a progressive disease that destroys memory and other important mental functions). A Brief Interview for Mental Status (BIMS) assessment completed on 5/28/24, indicated the resident had severe cognitive impairment. During an interview, on 7/24/24 at 11:10 a.m., the Dementia Care Director indicated she was aware of the incident that occurred on 6/29/24 on the evening shift, but she was not working that evening. The Dementia Care Director indicated she did not see the social media post that CRCA 9 sent to other co-workers and was surprised to hear that it had occurred. The Dementia Care Director was not aware of the employee having any other disciplinary issues. The Dementia Care Director indicated all staff were educated when hired on cell phone usage and posting on social media. During an interview, on 7/24/24 at 11:15 a.m., the Certified Residential Medication Aide (CRMA) 4 indicated she was made aware of the social media video after the fact. CRCA 9 had not sent her the video and so therefore she had not seen it personally. CRMA 4 indicated she was shocked to hear that it had occurred and was not aware of the staff member ever doing anything like that before. Staff were educated during their onboarding training about cell phone use and what not to post on social media. During an interview, on 7/24/24 at 11:31 a.m., the Regional Nurse Consultant indicated CRCA 9 sent a video on a social media platform to her coworkers which was reported to the Executive Director (ED) on 6/29/24. The resident who was in the video was not identifiable. The CRCA made a poor choice and was terminated for her actions. During an interview, on 7/24/24 at 11:57 a.m., the Social Worker with hospice, indicated Resident B was pleasantly confused and was not usually aware of her surroundings. During an interview, on 7/24/24 at 12:05 p.m., the Director of Health Services (DHS) indicated she was made aware of the social media post from the ED on the same evening it had occurred. CRCA 9 was immediately suspended, pending investigation. The DHS indicated that had not had any other instances with this staff member prior to the post. The social media video was sent to fell ow co workers and reported to the ED. During an interview, on 7/24/24 at 1:47 p.m., Social Service Director (SSD) indicated she was aware of the social media video but did not see it personally. Resident B was watched for a few days after the instance, and she had not noticed any psychological changes. SSD indicated the resident was not cognitively intact. Review of an Episodic Event form, dated 7/1/24 indicated CRCA 9 was having a bad day and made a poor choice making a video and posting it on a social media platform. Immediate education was initiated with current staff members and will continue ongoing. The facility will audit compliance by interviewing a total of 3 staff members weekly until they are 100% compliant, then weekly times 4 weeks. Then monthly times 5 months by asking related questioned to the facility abuse policy. Review of the in-service sign-up sheet, dated 6/30/24 and 7/1/24, indicated staff were educated on abuse and cell phone usage. The sign-up sheet contained 92 staff signatures. During an interview, on 7/24/24 at 2:15 p.m., the DHS indicated CRCA 9 was terminated from her position on 7/5/24. On 7/24/24 at 11:35 a.m., the Regional Nurse Consultant provided a document, dated June 2023, titled, Cell Phones, Cameras, and Electronic Devices, and indicated it was the policy currently being used by the facility. The policy indicated, .b. Use of personal cell phones and other electronic devices are strictly prohibited in work areas .c. The unauthorized use of a cell phone, camera or other electronic device to photograph or record any resident and/or his/her personal space, including accommodations and personal care, without the resident's or designated representative's written consent is prohibited On 7/24/24 at 11:35 a.m., the Regional Nurse Consultant provided a document, with a revised date of 8/29/29, titled, Abuse and Neglect Procedural Guidelines, and indicated it was the policy currently being used by the facility. The policy indicated, .l. Social Media - This would include keeping and/or distributing demeaning or humiliating photographs and recordings through social media or multimedia messaging The deficient practice was corrected by 7/5/24 after the facility implemented a systemic plan that included the following actions: head to toe skin assessment of all residents, interviews were conducted on all residents with a BIMS over 8, in-servicing education to staff related to abuse and cell phone usage, and ongoing monitoring by Quality Assurance and Performance Improvement (QAPI). This Federal finding relates to Complaint IN00437687. 3.1-27(a) 3.1-27(b)

Based on observation, interview, and record review, the facility failed to ensure an opened multi-dose vial of tuberculin (TB) protein derivative solution (a sterile solution containing the growth products or specific substances extracted from the tubercle bacillus and used in the diagnosis of tuberculosis) had documentation of the date the vial was opened for use for 1 of 1 medication storage room reviewed. Finding includes: During an observation tour of the medication storage room, on 1/22/24 at 10:50 a.m., no open date was observed on an opened multi-dose vial of TB protein derivative solution. During an interview, on 1/22/24 at 10:55 a.m., the Assistant Director of Health Services (ADHS) indicated the TB vial would have been used for both residents and staff. The nurse who had opened the TB vial must have just forgotten to put the date opened on the vial. All the nurses should know that any multi-dose vial of medication should have an open date documented on the vial and discarded after 30 days. On 1/22/24 at 11:40 a.m., the Regional Director of Clinical Operations (RDCO) indicated the opened vial of the TB protein derivative solution should have been dated when opened and discarded after 30 days. The RDCO provided and identified a document as a current facility policy titled, Medication Storage in the Facility, revised dated January 2018. The policy indicated, .D. When the original seal of a manufacturer's container or vial is initially broken, the container will be dated .1) A date opened sticker shall be placed on the medication. (OTE: the best stickers to affix contain both a date opened and expiration notation line). The expiration date of the vial or container will be [30] days unless the manufacturer recommends another date or regulations/guidelines require different dating 3.1-25(j) 3.1-25(k)(6)

Based on observation, interview, and record review, the facility failed to ensure a resident's bed was fully assembled which resulted in the resident having a fall from the bed and sustaining a hip fracture for 1 of 3 residents reviewed for accidents. (Resident B) The isolated actual harm deficient practice began on January 10, 2023 when the facility failed to ensure a resident's bed was fully assembled. The deficient practice was corrected on January 12, 2023, prior to the start of the survey, and was therefore Past Noncompliance. Findings include: Resident B's clinical records were reviewed on January 19, 2023 at 9:55 a.m. Diagnoses included, but were not limited to cancer, coronary artery disease, heart failure, hypertension, diabetes mellitus, thyroid disorder, and seizure disorder. The admission Minimum Data Set (MDS) assessment, dated January 04, 2023, indicated Resident B was cognitively intact. When communicating she was able to understand others with clear comprehension. She could independently walk, with a walker, in her room with staff's supervision. She had fallen at home prior to her admission. A Fall Risk Review (non-dated, identified by the Director of Nursing as completed upon admission) indicated identified fall risks that included, but were not limited to a history of falls prior to admission within the past month, falls within the past two to six months and had an unsteady gait (unsteady when walking). The review indicated the resident was a moderate risk for falls. A Care plan, with start date January 09, 2023, indicated Resident B was at risk for falling related to history of falls prior to admission. The care plan goal, dated through April 09, 2023, indicated Resident B would remain free of falls with major injury. Care approaches staff would implement to achieve the established goal indicated: January 09, 2023 start date: -Therapy would evaluate and treat as needed. -Staff to assist with transfers as needed. -Provide non-skid footwear. -Keep personal items and frequently used items within reach. -Keep call light within reach. -Ensure the floor was free of liquids and foreign objects. -Encourage resident to assume standing position slowly. January 10, 2023 start date: -Bed frame changed. Resident B's progress notes indicated: January 02, 2023 at 5:33 p.m., Resident was able to walk with a walker and stand by assistance. Resident would use a wheelchair for long distance. January 03, 2023 at 9:45 a.m., Physician Admit Note. Patient admitted for rehab following seizure and subdural hematoma [brain injury with bleeding]. Patient unsteady . January 06, 2023 at 2:51 a.m., Resident ambulated with a walker and unsteady gait. January 10, 2023 at 8:45 a.m., Writer called to room and notified that resident had a fall. Resident had complaints of left hip pain. N.O. [new order] received for left hip/pelvis x-ray January 11, 2023 at 5:27 p.m., IDT Review [review committee] - Resident noted with fall in her room. Resident stated she was standing up with walker and went to sit down on the end of the bed and slid off on to the floor Resident B's left hip X-ray, dated January 10, 2023, indicated an intertrochanteric left femoral fracture (type of hip fracture). Resident B's discharge hospital notes, dated January 15, 2023, indicated, .she sustained a fall in her room at [nursing home] Her fall appeared to be mechanical in nature [attribute fall to extrinsic factors in the environment]. She was found to have a left hip fracture and was admitted to Orthopedic surgery service for management During the interview, on January 19, 2023 at 10:45 a.m., Employee 13 indicated on the morning of January 10, 2023 she entered Resident B's room and observed her to be on the floor at the foot end of her bed. The mattress had slid off the bed and was hanging off the foot end of the bed. No foot board was on the bed and the two bottom corner mattress guards, that would secure the mattress in place, were gone. Employee 13 then alerted Employee 7 of the fall. During the interview, on January 19, 2023 at 10:25 a.m., Employee 7 indicated on the morning of January 10, 2023 Employee 13 reported Resident B had fallen in her room. Employee 7 went to Resident B's room and observed the resident to be on the floor at the foot end of the bed. No foot board was on the bed and the two bottom corner mattress guards, that would secure the mattress in place, were gone. The mattress was observed to have slid down from the top of the bed and hung over the foot end of the bed drooping towards the floor. Resident B had reported she went to sit down and the bed moved on me. Employee 7 checked the bed frame wheels and the wheels had been in the locked position and the bed had not moved, only the mattress had. On January 19, 2023 at 1:10 p.m., Resident B's roommate (identified from resident room census dated January 10, 2023) was interviewed. During the interview, the roommate indicated Resident B's bed foot board had been removed prior to her being admitted . The roommate pointed out two resident closets and a chest of drawers on the right side of the room when walking into the room. The roommate had not been able to freely maneuver her wheelchair between the chest and closets and previous roommates (prior to Resident B) bed on the left side of the room. Staff had come to the room and removed the foot board to allow her independent mobility. The roommate's clinical records were reviewed on January 19, 2023 at 1:00 p.m. The quarterly Minimum Data Set Assessment indicated the roommate was cognitively intact. On January 19, 2023 at 9:35 a.m., Resident B's family was interviewed. During the interview, the family indicated since Resident B's first day of admission through January 10, 2023, the foot board of her bed had been missing. The mattress had slide down and would need to be pulled up to be correctly positioned on the bed frame. Staff were aware of this issue, as staff had been observed to slide the mattress up from the bottom of the bed to correctly center it on the frame. During the interview, on January 19, 2023 at 11:15 a.m., the Administrator indicated Resident B's bed from January 10, 2023 had been removed and was no longer in use. A bed similar to the Resident B's bed was observed. During the observation, the Administrator pointed at the foot board of the bed and indicated the foot board had not been on the bed at the time of the fall. On the bed frame, at the corner foot ends were plastic cups that fit around the bottom corners of the mattress. The cups may have been missing, and not on the bed, at the time of the fall. On January 19, 2023 at 1:25 p.m. the Administrator provided a copy of Trilogy Service Standards (non-dated). The Administrator indicated the standards are utilized as a check list to ensure room readiness for each new resident. A review of the check list indicated a .Plant Operations . Furniture in good repair; Bed functions properly. The Past Noncompliance isolated actual harm deficient practice began on January 10, 2023. The deficient practice was removed corrected by January 12, 2023 after the facility implemented a systemic plan that included the following actions: -Resident B's bed was removed from service. -A facility wide bed audit was completed. -Staff were in-serviced on correct implementation of Trilogy Service Standards that included ensuring all furniture was in good repair and beds function properly. -Staff were in-serviced on correct implementation of immediately reporting and to whom of resident equipment in need of repair. -Administrative staff auditing resident beds weekly and monitoring of systemic plan. This Federal tag relates to Complaint IN00399133. 3.1-45(a)(1)

Based on interview, observation, and record review, the facility failed to ensure catheters (a tube inserted into the bladder to drain urine) were not inserted without a clinical justification resulting in actual harm when a resident had multiple urinary tract infections ([CONDITION(S)]) and 2 hospital transfers for [CONDITION(S)]'s (Resident 22) and catheter tubing and bags were not in direct contact with the floor (Residents 22 and 19) for 2 of 3 residents reviewed for catheters and [CONDITION(S)]'s. Findings include: 1. During an interview, on 9/27/22 at 10:51 a.m., Resident 22 indicated she was not sure why she had a catheter, and wished she did not have it. She had severe bladder pain, and was not sure if she had been checked for a [CONDITION(S)]. At the same time, the resident was observed up in her wheelchair in the lounge area, with the catheter bag partially inside a dignity bag (bag to cover up the urine drainage system to provide privacy). The dignity bag was dragging the floor. On 9/27/22 at 12:46 p.m., Resident 22 was observed up in her wheelchair, on the patio, with the Foley (a flexible tube inserted through the urethra into the bladder to drain urine) catheter bag dragging the floor. On 9/27/22 at 3:14 p.m., Resident 22 was observed up in her wheelchair, propelling herself down the hallway, and the Foley catheter tubing was touching the floor. The Foley catheter bag was partially inside the dignity bag, and the dignity bag was dragging the floor. Resident 22's record was reviewed on 9/28/22 at 11:37 a.m. An annual Minimum Data Set (MDS) assessment, dated 8/16/22, indicated the resident had a moderate cognitive impairment, an indwelling catheter, and required extensive assistance of 1 staff member for toilet use. Census information indicated the resident was admitted to the facility on [DATE]. An admission assessment, dated 10/8/19, indicated was continent of the bladder and did not have an indwelling catheter. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note, dated 1/20/21, indicated the resident's hospice (specialized care for the terminally ill) nurse placed a Foley catheter the day before, 16 F and 5 ml balloon. The note lacked documentation of a clinical indication for the catheter or any indication the resident had urinary retention. A progress note, dated 1/21/21, indicated an Interdisciplinary Team (IDT) review of the Foley catheter placement for urinary retention. The note lacked documentation of the urinary retention or any other clinical indication for the catheter. A diagnosis, dated 1/21/21, indicated neuromuscular dysfunction of the bladder (lacking bladder control due to brain,, spinal cord, or nerve problems). The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note, dated 10/24/22, indicated the resident no longer received hospice services. A physician's progress note, dated 12/21/21, indicated the resident urinated too much and wanted a catheter. The physician's assessment indicated incontinence and the plan was to discontinue [MEDICATION(S)] (a diuretic) to see if it helped with urination and to possibly increase the [MEDICATION(S)] at the next visit if no improvement. A re-admission nursing assessment, dated 3/5/22, indicated the resident did not have an indwelling catheter. A physician's progress note, dated 4/7/22, indicated the resident complained frequently of urination and leaking, and wanted to try something. The resident was on [MEDICATION(S)] for chronic swelling of legs, still some [CONDITION(S)] (swelling), planned to try [MEDICATION(S)] 10 mg every day. A physician's progress note, dated 5/5/22, indicated the resident was seen related to sore right upper quadrant of abdomen, complained of bloating, and gas. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note, dated 5/16/22, indicated the resident had a non-healing wound to the right inner groin, history of urinary incontinence, usual inability to know when incontinent, and increased moisture when up in wheelchair due to sweating and briefs (adult diaper). Physician ordered a Foley catheter be inserted through 5/30/22, and removed on 5/31/22, if improvements were noted. If none noted, the physician was to be updated for further direction. The note lacked documentation the resident had urinary retention or another diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note, dated 5/16/22, indicated an 18 F, 30 ml balloon Foley catheter was inserted with sterile technique. The notes lacked documentation the resident had urinary retention or another diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note, dated 5/16/22, indicated IDT review of Foley catheter, placement was to promote healing to inner groin from urine excoriation. The note lacked documentation the resident had urinary retention. A care plan, date initiated 5/19/22, indicated the resident had a Foley catheter for [CONDITION(S)] bladder. Interventions included, but were not limited to, observe for signs or symptoms of [CONDITION(S)]. A progress note, dated 5/21/22, indicated the Foley catheter, 18 F, 30 ml, was replaced using sterile technique due to occlusion. Cloudy urine with sediment was immediately returned. The note lacked documentation the resident had urinary retention or another diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Progress notes lacked documentation the Foley catheter was followed up on 5/30/22, as ordered by the physician. A progress note, dated 6/13/22, indicated the nurse attempted to flush the Foley catheter but was unsuccessful. The Foley catheter was repositioned, and flush attempted again, but was unsuccessful. The catheter was removed, and re-anchored with an 18 F and 30 ml balloon. Cloudy yellow urine was immediately returned. The note lacked documentation the resident had urinary retention or another diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note, dated 6/18/22, indicated the resident had a yeast like odor to the vaginal area, and white discharge was noted. The physician was notified. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note, dated 6/19/22, indicated the resident remained with a yeast like odor to the peri (groin) area. A [MEDICATION(S)] was administered that morning. A progress note, dated 7/6/22, indicated the physician was notified a urine chemical strip (detects changes in a person's urine such as potential infections) was performed with positive results. The resident complained of burning and discomfort. The resident's urine was noted with a strong, foul odor, and visible sediment. A sample was sent to the lab. A progress note, dated 7/7/22, indicated the resident was tearful the last evening and complained of urinary and back pain related to [CONDITION(S)]. As needed pain medications were administered as ordered and a new order for [MEDICATION(S)] (a urinary pain relief medication) was obtained. A progress note, dated 7/8/22, indicated the lab was unable to do a culture on the urine sample sent related to multiple organisms were present A recollection was indicated. The physician ordered the urine to be re-collected and sent to the lab for further work up. A progress note, dated 7/8/22, indicated a new urine sample was collected for lab pick up. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note, dated 7/10/22, indicated the resident had a fever earlier in the shift and had positive urinalysis results after recollection due to contamination. The physician was notified of the results and ordered [MEDICATION(S)] (an antibiotic) 500 mg by mouth twice daily for 7 days. A physician's progress note, dated 7/11/22, indicated the resident was seen for multiple problems including, but not limited to, upset stomach and back pain. The resident was previously on hospice services, but was discharged when she had a fecal impaction. The assessment indicated the resident had a [CONDITION(S)], and the plan was to change the [MEDICATION(S)] to [MEDICATION(S)] (an antibiotic) 500 mg by mouth for 10 days. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note, dated 7/25/22, indicated the resident complained of bladder pain, and the catheter had a moderate amount of cloudy yellow urine. Water intake was encouraged and the resident was given an as needed Azo tablet. A progress note, dated 7/27/22, indicated the resident complained of generalized pain throughout the abdomen. The resident was not able to say exactly where the pain was, but responded when the area near the bladder was palpated. The resident had a functional Foley catheter. The physician was notified. A physician's progress note, dated 7/27/22, indicated the resident was seen related to complaints of right upper quadrant and epigastric (upper abdomen) pain and cried during the exam. The resident was not sure if she wanted to go to the emergency room , but eventually agreed to go. The resident had a Foley catheter for urinary retention. The note lacked documentation of when or how the urinary retention was diagnosed . A diagnosis, dated 7/27/22, indicated acute [MEDICATION(S)] (infection of the bladder or lower urinary tract) without hematuria (blood in urine). Hospital records, dated 7/27/22, indicated the resident was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was prescribed [MEDICATION(S)] (an antibiotic) 100 mg by mouth every 12 hours for 7 days. The resident present to the hospital with a Foley catheter, which was changed while she was there. A computed tomography (CT) scan (medical imaging technique used to obtain detailed internal images of the body) of the abdomen and pelvis was performed at the hospital and indicated the left ureter (thin tube between kidney and bladder) was dilated and no urethral calculus (stone) was noted. The dilation was possibly due to a recently passed stone. A progress note, dated 7/27/22, indicated the resident returned from the hospital, and [MEDICATION(S)] 100 mg twice daily for 7 days was ordered. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's progress note, dated 8/31/22, indicated the resident was seen related to complaints of bladder spasms, and had chronic Foley for [CONDITION(S)] bladder and urine retention. The progress note lacked documentation the Foley catheter was actually inserted related to urine excoriation and any support for how the [CONDITION(S)] bladder or urinary retention were diagnosed . The physician ordered [MEDICATION(S)] 5 mg twice daily. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's progress note, dated 9/13/22, indicated the resident was seen related to complaints of bladder spasms and pain. The resident had a standard Foley catheter in place and increased swelling to the left leg. The physician ordered to increase the [MEDICATION(S)] to 10 mg twice daily and increase [MEDICATION(S)] to 40 mg twice daily. A progress note, dated 9/18/22, indicated the resident complained of abdominal pain at a 10 out of 10 on the pain scale despite medication being administered. The resident had watery stool, nausea and vomiting, and abdominal distention with a history of bowel obstructions. The resident was sent to the emergency room for evaluation and treatment. Hospital records, dated 9/18/22, indicated the resident was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident complained of abdominal pain and was not sure when it started. The resident was prescribed [MEDICATION(S)] 100 mg by mouth every 12 hours for 7 days. A CT scan of the abdomen and pelvis was performed at the hospital and indicated the bladder was decompressed with a Foley catheter in place, and there were nonobstructing stones in the left kidney. Impressions of the CT scan included, but were not limited to, inflamed appearing urinary bladder with Foley catheter in place with possible [MEDICATION(S)], correlate with urinalysis (urine test to check for infection). A progress note, dated 9/19/22, indicated an IDT review of the hospitalization . The resident was sent to the hospital for abdominal pain and the resident returned from the emergency room with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record lacked documentation the resident was referred to a urologist (a physician who specializes in the urinary system) or any supporting documentation the resident had urinary retention. During an interview, on 9/29/22 at 9:39 a.m., the Director of Health Services (DHS) indicated the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She was not sure why the catheter was inserted in May or what testing or clinical justification was found for the diagnosis. During an interview, on 9/29/22 at 10:48 a.m., the DHS indicated the Foley catheter was inserted in May 2022 for moisture associated skin breakdown, and this was not a normal reason a catheter would have been placed. She was not able to find any follow up was done for the catheter as per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She reviewed the documentation from when the resident had a Foley catheter from January to October 2021, and was unable to find any supportive documentation for the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was on hospice services at the time, but was not any longer. Foley catheter tubing and bags should not have been in contact with the floor. The resident was not referred to a urologist. On 9/29/22 at 11:31 a.m., the DHS provided a document titled, Guidelines for the Use of Indwelling Catheter, and indicated it was the policy currently being used by the facility. The policy indicated, .OVERVIEW: The purpose of urinary catheterization is to provide urinary drainage when medically necessary and to evaluate its continued use. A resident who enters the campus with an indwelling urinary catheter, or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary .An indwelling catheter is not used unless there is a valid medical justification; An indwelling catheter for which continuing use is not medically justified is discontinued as soon as clinically warranted by the attending physician and/or urologist .A resident with or without a catheter, receives the appropriate care and services to prevent infections to the extent possible .SOP DETAILS: 1. Urinary catheters are deemed medically necessary for the following reasons and must have supporting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident has acute urinary retention or bladder outlet obstruction .f. Other conditions as deemed valid by the attending physician and/or urologists with supporting documentation. Examples of Inappropriate Uses of Indwelling Catheters: g. As a substitute for nursing care of the resident with incontinence 2. On 9/28/22 at 9:36 a.m., Resident 19 was observed sitting in a wheelchair by the nurses' station. Resident 19's catheter (a tube inserted into the bladder to drain urine) tubing was observed touching the floor underneath his wheelchair. On 9/28/22 at 2:34 p.m., Resident 19 was observed lying in bed with his eyes closed, the catheter bag was observed hanging from bed frame with the catheter tubing on the floor. On 9/29/22 at 10:51 a.m., the Director of Health Services (DHS) indicated catheter tubing should not be on the floor. On 9/30/22 at 12:19 p.m., Resident 19 was observed sitting in a wheelchair in the main dining room eating lunch with the catheter tubing touching the floor. On 9/30/22 at 12:28 p.m., Resident 19 was observed sitting in a wheelchair propelling himself from the dining room with the catheter tubing dragging onto the floor. At that time, the Clinical Support observed the resident propelling himself with the catheter tubing touching the floor and indicated Resident 19's catheter tubing should not be touching the floor. The Clinical Support indicated she would go and assist Resident 19 with his catheter tubing to get the tubing off the floor. On 10/5/22 at 12:42 p.m., Resident 19 was observing sitting in a wheelchair propelling himself from the dining room with the catheter tubing dragging the floor. Resident 19's record was reviewed on 9/29/22 at 10:26 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (MDS) assessment, dated 9/22/22, indicated the resident was cognitively intact, had an indwelling catheter, required extensive assistance of one person for toilet use, required extensive assistance of two persons for dressing and personal hygiene, and had impairments of the lower extremities (hip, knee, ankle, foot) on both sides. A bowel and bladder care plan, initiated on 12/6/19, indicated Resident 19 required a suprapubic (S/P) (a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary flow) catheter. Interventions included but were not limited to leg strap in place to prevent resident's catheter from being pulling out, provide assistance with catheter care and change catheter per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/29/22 at 11:31 a.m., the DHS provided a document titled, Urinary Catheter Care, and indicated it was the policy currently being used by the facility. The policy indicated, .OVERVIEW: To prevent infection of the resident's urinary tract. SOP DETAILS: .11. Be sure the catheter tubing and drainage bag are kept off the floor 3.1-41(a)(1) 3.1-41(a)(2)

Based on observation, record review, and interview, the facility failed to ensure a call light was kept within the resident's reach for 1 of 16 residents reviewed for call lights (Resident 25). Findings include: On 9/27/22 at 10:26 a.m., An unidentified staff member was observed leaving Resident 25's room. Resident 25 was observed up in the chair, in her room. The call light was lying on the resident's bed, not within the resident's reach. On 9/28/22 at 2:57 p.m., Resident 25 was observed sitting in the chair, in her room. The call light was lying across the bed, out of the resident's reach. On 9/29/22 at 1:11 p.m., Resident 25 was observed sitting in the chair, in her room, eating lunch. The call light was observed lying on the floor at the foot of the bed. At the same time, the resident indicated she was supposed to press the call button in order to get staff assistance, and the call light was, over there, and pointed towards the foot of the bed. The resident indicated she was not able to reach the call light. On 9/29/22 at 1:24 p.m., Resident 25 was observed sitting in the chair, in her room. She yelled out, Come here, come here, I need help! Registered Nurse (RN) 14 entered the resident's room. On 9/29/22 at 1:34 p.m., Resident 25 was observed sitting in the chair, in her room, and her call light was within reach. At the same time, RN 14 indicated she was the nurse who entered the resident's room when she yelled out. She noticed the resident's call light was not within reach, and was on the floor. Call lights should have been kept within residents' reach. Resident 25 was able to use the call light if she could reach it. Resident 25's record was reviewed on 9/29/22 at 1:17 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (MDS) assessment, dated 8/25/22, indicated the resident had a moderate cognitive impairment and required extensive assistance from staff for activities of daily living (ADL) (daily tasks related to resident care and hygiene). A care plan, goal target dated, 12/1/22, indicated the resident was at risk for falls. Interventions included, but were not limited to, keep call light within reach. On 10/4/22 at 10:46 a.m., the Executive Director (ED) provided a document titled, Guidelines for Answering Call Lights, and indicated it was the policy currently being used by the facility. The policy indicated, .POLICY: Guidelines for Answering Call Lights. PURPOSE: To respond to the resident's request and needs. PROCEDURES: .2. Ensure the call light is plugged in securely to the outlet and in reach of the resident 3.1-3(v)(1)

Based on observation, record review, and interview, the facility failed to ensure privacy was provided during a catheter (a tube inserted into the bladder to drain urine) care observation (Resident 22) and a resident was not dressed in pants with holes in them (Resident 36) for 2 of 2 residents reviewed for dignity. Findings include: 1. On 9/29/22 at 1:25 p.m., Resident 22's catheter care was observed. Upon entrance to the resident's room, Resident 22 was observed lying in bed, pants off, in a brief (adult diaper), uncovered. Qualified Medication Aide (QMA) 15 and Certified Nursing Assistant (CNA)13 were in the resident's bathroom, washing their hands. QMA 15 and CNA 13 completed catheter care, and left the resident's bedside to wash their hands and retrieve a clean brief. During the time they were away from the bedside, the resident was left nude from the waist down, and uncovered. After QMA 15 and CNA 13 washed their hands and retrieved a clean brief, they returned to the resident's bedside, put the clean brief on the resident, and covered the resident up with a sheet. Resident 22's record was reviewed on 9/28/22 at 11:37 a.m. An annual Minimum Data Set (MDS) assessment, dated 8/16/22, indicated the resident had a moderate cognitive impairment, an indwelling catheter, and required extensive assistance of 1 staff member for toileting and personal hygiene. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, initiated 5/19/22, indicated the resident had a Foley catheter. Interventions included, but were not limited to, provide assistance with catheter care. During an interview, on 9/29/22 at 2:07 p.m., Registered Nurse (RN) 14 indicated the resident should have been provided privacy during catheter care. On 9/29/22 at 11:31 a.m., the Director of Health Services (DHS) provided a document titled, Urinary Catheter Care, and indicated it was the policy currently being used by the facility. The policy indicated, .OVERVIEW: To prevent infection of the resident's urinary tract. SOP DETAILS: .20. To perform the procedure: .i. Provide privacy. Cover the resident with a sheet, exposing on the perineal area 2. During an observation, on 9/27/22 at 12:04 p.m., Resident 36 was observed in the restorative dining room with other residents and staff. A large hole in the right hip area of his sweat pants was observed, and his leg was clearly visible through the hole. Resident 36's record was reviewed on 10/3/22 at 10:07 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (MDS) assessment, dated 8/25/22, indicated the resident had a severe cognitive impairment and required extensive assistance of 2 staff members for dressing. A care plan, goal target dated 12/1/22, indicated the resident had potential for decline in current functional and cognitive status related to [CONDITION(S)]. Interventions included, but were not limited to, provide required level of assistance for activities of daily living (ADL) (daily tasks related to resident care and hygiene) care including, but not limited to, dressing. During an interview, on 9/30/22 at 11:44 a.m., Licensed Practical Nurse (LPN) 12 indicated staff should not have dressed Resident 36 in clothes with holes in them. During an interview, on 9/30/22 at 11:47 a.m., Certified Nursing Assistant (CNA) 13 indicated she was aware Resident 36 had a hole in his pants on 9/27/22, and she assisted him with getting dressed that day. The resident's pants had holes in them from staff pulling them up. Sometimes they would put the pants with holes in them on the resident if he did not have anything else to wear. He needed new clothes, and she had told the nurse. During an interview, on 9/30/22 at 12:48 p.m., the Social Services Director (SSD) indicated she was not notified the resident needed clothes. The facility staff would have assisted in purchasing the resident's clothes because he did not have family to help him. The staff should not have dressed the resident in clothes with holes in them. On 10/3/22 at 12:00 p.m., the Director of Health Services (DHS) provided a document titled, Resident Rights Guidelines, and indicated it was the policy currently being used by the facility. The policy indicated, .POLICY: Resident Rights Guidelines. PURPOSE: To ensure resident rights are respected and protected and provide an environment in which they can be exercised. PROCEDURES: Procedure: .2. Our residents shave a right to .a. Be treated with dignity and respect 3.1-3(t)

Based on interview and record review, the facility failed to ensure residents were provided showers as preferred for 1 of 2 residents reviewed for choices (Resident 27). Findings include: During an interview, on 9/27/22 at 11:02 a.m., Resident 27 indicated she was scheduled for a shower twice a week but had only been getting a shower occasionally. Resident 27's record was reviewed on 9/29/22 at 2:10 p.m. A quarterly Minimum Data Set (MDS) assessment, dated 8/17/22, indicated the resident was cognitively intact, required supervision-oversight for dressing, toilet use and personal hygiene, and required one-person physical help in part of bathing activity with impairments on both lower extremities. A profile care guide care plan, dated 4/5/22, indicated to shower resident per schedule. The medical record lacked documentation of refusal of showers. On 9/29/22 at 3:43 p.m., the Director of Health Services (DHS) indicated Resident 27 was scheduled for showers twice a week, on Mondays and Thursdays, with a staff setup for the showers, but the resident had not received two showers weekly, according to the shower sheets documentation. The DHS provided Resident 27's shower sheets documents for August and September 2022. The shower sheets documentation titled, Point of Care ADL Report (MDS 3.0), indicated the resident had received showers on 8/1/22, 8/5/22, 8/15/22, 8/18/22, 8/22/22, 8/25/22, 8/29/22, 9/1/22, 9/5/22, 9/8/22, 9/12/22, 9/19/22, 9/22/22, and 9/29/22. On 9/29/22 at 4:28 p.m., Clinical Support provided and identified a document as a current facility policy, titled Guidelines for Bathing Preference, dated 5/11/16. The policy indicated, .Purpose .To establish a personal preference bathing routine .Procedures .1. The resident will be advised of Trilogy's guidelines for residents to self determine their plan of care and schedule during their stay in the campus .2. The resident shall determine their preference for bathing upon admission .a. Day of the week .b. Time of day - morning or evening .c. Type of bathing - tub bath, bed bath or shower .4. Bathing shall occur at least twice a week unless resident preference states otherwise 3.1-3(u)(3)

Based on interview, observation, and record review, the facility failed to evaluate alternate pressure reducing options and failed to ensure a timely repair/replacement of a broken recliner for a resident whose preference was to sleep in a recliner. This deficient practice resulted in stage II pressure ulcers developing on the buttocks of a resident not identified at risk for pressure ulcers for 1 of 3 residents reviewed for pressure ulcers (Resident A). Finding includes: During interview of Resident A on 1/12/15 at 10:35 a.m., the resident indicated her "bottom" was sore. The resident indicated she slept in her recliner because her back hurt and indicated the recliner had been broken since before Christmas. She indicated she was unable to recline the chair and her son told her he would call the company where the chair had been purchased. During the interview the resident was sitting in a wheelchair without a pressure relieving cushion. She patted the seat of the recliner and indicated her bottom was sore from sitting in the recliner all night without being able to recline. During interview of LPN #9, on 1/12/15 at 10:35 a.m., the nurse indicated she thought the resident's son was going to get a new chair for her. The nurse indicated the resident had a concern with her "bottom" and indicated the resident refused the waffle seat cushion that was offered. During interview of LPN #8, on 1/12/15 at 12:05 p.m., the LPN indicated "some time before Christmas" the resident's son indicated the chair's foot rest would not come up when he tried to recline the chair. The LPN indicated the son told him he was going to get the chair fixed and indicated he had not told any other staff about the broken chair. During interview of the wound nurse on 1/12/15 at 11:25 a.m., the nurse indicated the resident's chair was broken and she thought the resident's son was going to take care of fixing it. The wound nurse stated "I gave her a waffle cushion to sit on while in the wheelchair and in the recliner but she refused to use it. She also refused the offer of a bed." During observation on 1/12/15 at 11:25 a.m., the wound nurse assessed the resident's buttocks, the resident was observed with an open area on the upper, right, inner gluteal fold and another open area on the left buttock. The wound nurse indicated the areas were stage 2 pressure ulcers (Stage II - Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister.) Prior to the observation, the resident was sitting in a wheelchair without a cushion. The resident stood to allow the observation. Resident A's clinical record was reviewed on 1/12/15 at 2 p.m. A [DIAGNOSES REDACTED]. A quarterly assessment dated , 8/20/14, indicated the resident was cognitively intact, required limited assist of one person for toileting and not at risk for developing a pressure ulcer. A form titled "Pressure/Stasis/Arterial/Diabetic Ulcer Assessment" was noted, dated 12/29/14, indicating a stage 1 (Stage I - An observable, pressure-related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: - Skin temperature (warmth or coolness); - Tissue consistency (firm or boggy); - Sensation (pain, itching); and/or - A defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues.) pressure area on the sacrum measuring 4 cm (centimeter) length by 11 cm width by 0 cm depth. A nurse's note, dated 12/30/14 at 10:00 a.m., indicated the resident was noted with a red area on the coccyx. The note indicated the wound nurse assessed the area and suggested the resident sleep in a bed instead of a recliner to relieve pressure from the coccyx area. The documentation indicated the resident refused and stated she couldn't sleep in a bed because it hurt her back. The record indicated the resident was given a waffle cushion to sit on while in recliner and/or wheelchair to relieve pressure. Documentation on 1/6/15 indicated a stage 1 pressure area on the resident's left buttocks measuring 2.0 cm by 2.0 cm by 0 cm and a stage 1 area on right buttocks measuring 2.0 cm by 2.0 cm by 0 depth. Documentation on 1/12/15 indicated a stage 2 pressure area on the right inside gluteal fold measuring 1 cm length by 0.2 cm width by 0.1 cm depth., a stage 2 pressure area on the left buttock measuring 1 cm length by 1 cm width by less than 0.1 cm depth. and a stage 1 pressure area to the right buttock measuring 1 cm length by 1 cm width by 0 depth. During interview of the wound nurse on 1/13/15 at 10 a.m., the wound nurse indicated she had called the company where the resident purchased her recliner, and indicated the company planned to deliver a recliner for the resident on that date. The wound nurse indicated the only pressure reducing interventions offered since the stage one pressure area was identified on 12/30/14, were a waffle cushion and a bed. During review of a facility policy and procedure titled "WOUND STAGING AND IDENTIFICATION EDUCATIONAL INFORMATION" received on, 1/13/15 at 3 p.m., from the wound nurse, documentation indicated possible causes for non-healing wounds as "Continued pressure". This Federal tag relates to complaint IN 418. 3.1-40(a)(2)

Based on interview, observation, and record review, the facility failed to evaluate alternate pressure reducing options and failed to ensure a timely repair/replacement of a broken recliner for a resident whose preference was to sleep in a recliner. This deficient practice resulted in stage II pressure ulcers developing on the buttocks of a resident not identified at risk for pressure ulcers for 1 of 3 residents reviewed for pressure ulcers (Resident A). Finding includes: During interview of Resident A on 1/12/15 at 10:35 a.m., the resident indicated her "bottom" was sore. The resident indicated she slept in her recliner because her back hurt and indicated the recliner had been broken since before Christmas. She indicated she was unable to recline the chair and her son told her he would call the company where the chair had been purchased. During the interview the resident was sitting in a wheelchair without a pressure relieving cushion. She patted the seat of the recliner and indicated her bottom was sore from sitting in the recliner all night without being able to recline. During interview of LPN #9, on 1/12/15 at 10:35 a.m., the nurse indicated she thought the resident's son was going to get a new chair for her. The nurse indicated the resident had a concern with her "bottom" and indicated the resident refused the waffle seat cushion that was offered. During interview of LPN #8, on 1/12/15 at 12:05 p.m., the LPN indicated "some time before Christmas" the resident's son indicated the chair's foot rest would not come up when he tried to recline the chair. The LPN indicated the son told him he was going to get the chair fixed and indicated he had not told any other staff about the broken chair. During interview of the wound nurse on 1/12/15 at 11:25 a.m., the nurse indicated the resident's chair was broken and she thought the resident's son was going to take care of fixing it. The wound nurse stated "I gave her a waffle cushion to sit on while in the wheelchair and in the recliner but she refused to use it. She also refused the offer of a bed." During observation on 1/12/15 at 11:25 a.m., the wound nurse assessed the resident's buttocks, the resident was observed with an open area on the upper, right, inner gluteal fold and another open area on the left buttock. The wound nurse indicated the areas were stage 2 pressure ulcers (Stage II - Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister.) Prior to the observation, the resident was sitting in a wheelchair without a cushion. The resident stood to allow the observation. Resident A's clinical record was reviewed on 1/12/15 at 2 p.m. A [DIAGNOSES REDACTED]. A quarterly assessment dated , 8/20/14, indicated the resident was cognitively intact, required limited assist of one person for toileting and not at risk for developing a pressure ulcer. A form titled "Pressure/Stasis/Arterial/Diabetic Ulcer Assessment" was noted, dated 12/29/14, indicating a stage 1 (Stage I - An observable, pressure-related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: - Skin temperature (warmth or coolness); - Tissue consistency (firm or boggy); - Sensation (pain, itching); and/or - A defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues.) pressure area on the sacrum measuring 4 cm (centimeter) length by 11 cm width by 0 cm depth. A nurse's note, dated 12/30/14 at 10:00 a.m., indicated the resident was noted with a red area on the coccyx. The note indicated the wound nurse assessed the area and suggested the resident sleep in a bed instead of a recliner to relieve pressure from the coccyx area. The documentation indicated the resident refused and stated she couldn't sleep in a bed because it hurt her back. The record indicated the resident was given a waffle cushion to sit on while in recliner and/or wheelchair to relieve pressure. Documentation on 1/6/15 indicated a stage 1 pressure area on the resident's left buttocks measuring 2.0 cm by 2.0 cm by 0 cm and a stage 1 area on right buttocks measuring 2.0 cm by 2.0 cm by 0 depth. Documentation on 1/12/15 indicated a stage 2 pressure area on the right inside gluteal fold measuring 1 cm length by 0.2 cm width by 0.1 cm depth., a stage 2 pressure area on the left buttock measuring 1 cm length by 1 cm width by less than 0.1 cm depth. and a stage 1 pressure area to the right buttock measuring 1 cm length by 1 cm width by 0 depth. During interview of the wound nurse on 1/13/15 at 10 a.m., the wound nurse indicated she had called the company where the resident purchased her recliner, and indicated the company planned to deliver a recliner for the resident on that date. The wound nurse indicated the only pressure reducing interventions offered since the stage one pressure area was identified on 12/30/14, were a waffle cushion and a bed. During review of a facility policy and procedure titled "WOUND STAGING AND IDENTIFICATION EDUCATIONAL INFORMATION" received on, 1/13/15 at 3 p.m., from the wound nurse, documentation indicated possible causes for non-healing wounds as "Continued pressure". This Federal tag relates to complaint IN 418. 3.1-40(a)(2)