Every finding on record at Miller's Merry Manor

Based on record review and interview, the facility failed to provide appropriate assistance to prevent an avoidable accident for 1 of 3 residents reviewed for accidents hazards. This deficient practice resulted in the resident acquiring a left clavicle (collarbone) fracture, left rib fracture, and sub-capital fracture (the femoral neck breaks near the head of the femur, inside the joint capsule) of the right hip. (Resident D) Findings include:The clinical record for Resident D was reviewed on 05/19/2026 at 10:36 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 04/09/2026, indicated the resident was severely cognitively impaired and required extensive assistance of staff for mobility. The resident had and impairment on one side of upper and lower extremities. The resident's diagnoses included, but were not limited to, stroke (a medical emergency that occurs when blood flow to an area of the brain is cut off or a blood vessel in the brain bursts), aphasia (a language disorder that affects a person's ability to communicate), and anxiety (feeling of uneasiness). A Facility Incident Report, dated 05/14/2026, indicated Resident D sustained fractures related to a fall from his bed. A Hospital Document, dated 05/14/2026 at 10:22 A.M., indicated the resident had a left clavicle (collarbone) fracture, left rib fracture, and sub-capital fracture of the right hip. The resident also had a superficial hematoma (collection of blood that has pooled outside of a blood vessel, typically due to injury) over the parietal region (located at the upper back and crown of the skull) of the scalp. A Progress Note, dated 05/14/2026 at 3:22 A.M., indicated Resident D was turned on his right side while being changed by a Certified Nursing Assistant (CNA). Licensed Practical Nurse (LPN) 2 left the room to gather supplies. Upon return the CNA was observed outside of Resident D's room. Upon returning to Resident D's room the resident was found lying on his back on the floor. The resident was observed to have a 7-centimeter (cm) x (by) 6 cm hematoma on the back left of his head. Resident D was sent to the emergency room. During an interview, on 05/19/2026 at 10:05 A.M., Resident D indicated that he fell out of bed and hurt his side. There were no staff in the room when he fell. During an interview, on 05/19/2026 at 1:47 P.M., LPN 2 indicated she was informed by CNA 3 that Resident D's dressing needed changed. LPN 2 and CNA 3 went into Resident D's room and began to provide hygiene care. The bed was waist high to provide care. LPN 2 needed more supplies and left the room. When she left the room CNA 3 was still in the room. Resident D was on his right side on the edge of the bed with CNA 3 holding onto him. When LPN 2 came out of the supply room CNA 3 was standing outside of the resident's room in the hallway. They both went back into Resident D's room together and found the resident lying on his back on the floor. Resident D did not have any mobility in his right arm and had very limited mobility in his right leg. A Witness Statement, provided by the Administrator on 05/19/2026 at 3:42 P.M., indicated CNA 3 indicated she was providing care for Resident D on 05/14/2026 when the nurse went to get a larger dressing for the resident, she stayed in the room with the resident when the nurse left the room. After waiting a few minutes, she left the room to find the nurse. She left the resident turned on his side in the bed. When both staff returned to room, Resident D was on the floor next to his bed. During an interview, on 05/19/2026 at 2:45 P.M., CNA 4 indicated Resident D had very limited mobility of his right leg and no mobility of his right arm. The resident required two physical staff members for mobility while in bed. The resident required a full body mechanical lift for transfers. During an interview, on 05/19/2026 at 3:04 P.M., Clinical Support Nurse 6 indicated they did not have a facility policy for accidents. The current facility policy, titled Nursing Assistant - Certified Job Title, with a revision date of 11/03/2019, was provided by the Administrator on 05/19/2026 at 3:09 P.M. The policy indicated, .To assist the professional nursing staff in continually rendering resident care while affording dignity, comfort, and safety to those residents . This deficiency was corrected on 05/18/2026, after the facility assessed all residents care plans for falls; provided education to all staff related to fall management, to include dependent resident with bed mobility; and ongoing audits to monitor for fall prevention and was therefore Past Noncompliance. This citation relates to Intake 3014884. 410 IAC (Indiana Administrative Code) 3.1-45(a)(1)

Based on record review and interview, the facility failed to have medications available to administer as prescribed to 1 of 3 residents reviewed for pharmacy services. (Resident E) Findings include: The clinical record for Resident E was reviewed on 05/19/2026 at 1:12 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 03/18/2026, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, diabetes mellitus (a chronic metabolic disease characterized by high blood sugar resulting from defects in insulin), non-Alzheimer's dementia (cognitive disorders caused by diseases other than Alzheimer's), and Parkinson's Disease (a progressive neurological disorder that affects the nervous system and parts of the body controlling movement). A Physician's Order, dated 05/04/2026 and discontinued date of 05/18/2026, indicated Resident E was to receive Trulicity Subcutaneous (under the skin) solution Autoinjector 4.5 milligram (mg)/0.5 milliliter (ml) one time a day every Monday for Diabetes. The May 2026 Electronic Medication Administration Record (EMAR) indicated Resident E was not administered Trulicity 4.5mg/0.5ml on Monday May 11th, or Monday May 18th. An EMAR Medication Note, dated 05/11/2026 at 10:17 A.M., indicated Resident E's Trulicity medication was not available. An EMAR Medication Note, dated 05/18/2026 at 08:00 A.M., indicated Resident E's Trulicity medication was not available but on order. During an interview, on 05/19/2026 at 3:14 P.M., Licensed Practical Nurse (LPN) 5 indicated she was Resident E's nurse on 05/11/2026 and she knew the resident was out of Trulicity but forgot to notify the pharmacy or physician about being unable to administer the medication. During an interview, on 05/19/2026 at 2:36 P.M., LPN 7 indicated whenever a medication was unavailable, she would contact the pharmacy to have the medication delivered as soon as possible. The pharmacy could deliver within two hours, or they were at the facility every day in the evenings for routine deliveries. All medications should have been administered as ordered, and if they were not available from the pharmacy the physician should be notified. During an interview, on 05/19/2026 at 3:04 P.M., Clinical Support Nurse 6 indicated if a medication that was ordered was not available the nurse should contact the pharmacy to have the medication delivered the same day. If not available, they should contact the physician for additional orders. The nursing staff did not follow protocol for the resident's medication. The current undated facility policy titled, Unavailable Medications, was provided by the Administrator on 05/19/2026 at 2:49 P.M. The policy indicated, .The facility must make every effort to ensure that medications are available to meet the needs of each resident . 410 IAC (Indiana Administrative Code) 3.1-25(b)

Based on record review and interview, the facility failed to prevent a burn from coffee for 1 of 3 residents reviewed for accidents. (Resident C)Findings include:A Facility Reported Incident, dated 09/21/2025, indicated on 09/20/2025 while Resident C was eating lunch in her room, she had accidently spilled her coffee onto her right shin. The resident had a light pink area and a blister that measured 2.0 centimeters (cm) X (by) 1.5 cm X 0.5 cm on the right shin. A cold compress was applied immediately and then a new order was obtained for Aquaphor (an ointment) to the right shin and cover with a sterile dressing. Upon the facility investigation the resident had asked a staff member to heat up her coffee from lunch because she did not feel like it was hot enough. The staff member warmed up the coffee per the resident's request, and the resident had later bumped the table the coffee was sitting on and that caused the coffee to accidently spill onto her leg.During an interview, on 11/24/2025 at 11:01 A.M., CNA 3 indicated Resident C didn't like to come out of her room much. She needed limited assistance with care and fed herself. She was alert and oriented. She wasn't here when the resident spilled the hot liquid. She had been in-serviced (educated) on not warming residents' coffee in the microwave and to just get the resident a fresh cup. During an interview, on 11/24/2025 at 11:05 A.M., the Administrator indicated the incident with Resident C happened on a weekend. She got notification from staff that the resident had spilled coffee on her right leg during lunch. Throughout the investigation it was determined that Agency CNA 4 had warmed up the resident's coffee per her request and then the resident bumped the table the coffee was sitting on. The coffee spilled onto herself. The resident had a pink blister to her leg. The staff should never warm coffee up in the microwave and should just get them a fresh cup. All staff were in-serviced on proper policy and procedure for hot beverages.During an interview, on 11/24/2025 at 12:01 P.M., the Director of Nursing (DON) indicated the Agency CNA was in-serviced on the hot beverage policy at the time of the incident and all the other staff members were in-serviced at a later date. The CNA assignment sheets would list the resident's new interventions and that was how agency staff were made aware of changes. During an interview, on 11/25/2025 at 10:06 A.M., Resident C indicated the hot coffee hurt her leg when it was spilled on her. She had asked someone to warm up her coffee, and they warmed it up in the microwave. After they brought it back to her, she bumped the table, and it spilled on her right leg. The area to her leg was healed at this time. The area was observed without concerns. The clinical record review for Resident C was reviewed on 11/24/2025 at 10:23 A.M. An admission Minimum Data Set (MDS) assessment, dated 08/11/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, cardiorespiratory conditions, cancer, hypertension, thyroid disorder, Alzheimer's disease, and anxiety. The resident had no impairments, used a walker and wheelchair, and required staff assistance to set up her meals for eating. An Initial Nursing Occurrence Assessment, dated 09/20/2025, indicated the resident had spilled her coffee on her right shin leaving a burned pink area with a blister that measured 2.0 cm X 1.5 cm X 0.5 cm. A Non-Pressure Wound Assessment, dated 09/23/2025, indicated the resident had a second degree burn to the right outer leg. The blister had ruptured and measured 4.0 cm X 5.0 cm X 0.1 cm.A Non-Pressure Wound Assessment, dated 10/21/2025, indicated the resident had a second degree burn to the right outer leg. The area measured 2.5 cm X 1.0 cm X less than 0.1 cm. A Non-Pressure Wound Assessment, dated 11/04/2025, indicated the resident second degree burn to the right outer leg had healed.There was no documentation the agency CNA staff members were in-serviced on the facility hot beverage policy. The current facility policy tilted, Hot Beverage Service, with a start date of 04/30/2019 was provided by the Administrator on 11/24/2025 at 11:31 A.M. The policy indicated, .The facility recognizes that the service of hot beverages at palatable drinking temperatures can pose a risk for burns. The facility will provide hot beverages to residents, family and visitors in a way that minimizes risks to the extent possible.This citation relates to Intake 2603444.3.1-45(a)(1)3.1-45(a)(2)

Based on observation and interview, the facility failed to store foods in a sanitary manner related to unlabeled and outdated foods and employee personal items in the main kitchen refrigerators for 1 of 3 kitchen observations. Findings include: During the initial tour of the facility kitchen with Dietary Aide (DA) 4 on 05/20/25 at 9:21 A.M., the following items were observed in the refrigerators: - An uncovered bowl of yellow gelatin dessert with whipped topping and a slice of berry pie were on a tray on the top shelf of the refrigerator. The items nor the tray were dated, - A large, lidded container with two cheese sandwiches labeled as prepared on 05/11/25, and - An employee's unopened energy drink and bottle of diet soda. During an interview, on 05/20/25 at 9:25 A.M., DA 4 indicated the desserts on the tray were not labeled and should be thrown out. The label on the cheese sandwiches indicated they were prepared on 05/11/25. The sandwiches were good for one week after they were prepared. The energy drink and soda belonged to her and should have been placed in the employee refrigerator. During an interview, on 05/27/25 at 10:14 A.M., the Dietary Manager indicated employee items were not supposed to be stored in the kitchen refrigerator. There was not a policy related to employee items in the kitchen refrigerator. During an interview, on 05/27/25 at 2:37 P.M., the Dietary Manager indicated items like the pie and the gelatin should be covered and the tray should be labeled with prepared on and use by dates. The cheese sandwiches were good for seven days after they were prepared. The current facility policy, titled Dietary Manuals, with a print date of 05/27/25, was provided by the Dietary Manager on 05/27/25 at 11:44 A.M. The policy indicated, .all foods should be stored and protected under safe and sanitary conditions .Food not in original containers are clearly labeled for contents, dated, and stored in food rated containers with tight fitting lids . 31-21(i)(2) 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure a resident that self-administered medications was appropriately assessed for self-administration for 1 of 12 residents reviewed for medications. (Resident 28) Findings include: Resident 28 was observed on 05/20/25 at 2:31 P.M. The resident was in her room sitting on the side of her bed with an overbed table in front of her. The resident was holding a mask connected to a nebulizer machine up to her face and a breathing treatment was being administered. The door was closed, and no nursing staff were present. During an interview, on 05/27/25 at 10:21 A.M., the resident indicated she received breathing treatments twice a day. The nurse would bring the medication and put it in the nebulizer. They checked her oxygen levels before the treatment and then she would hold the mask and administer the treatment herself. One certain nurse would stay in the room while the treatment was being administered. All the other nurses did not stay in the room and let the resident do it by herself. During an interview, on 05/27/25 at 10:28 A.M., the Director of Nursing (DON) indicated there were no residents in the facility that self-administered medication. If a resident did self-administer, there would be an assessment to ensure they were capable of administering the medication and there would be a physician's order to self-administer. When administering a breathing treatment, nurses should first listen to the resident's lung sounds, respirations, and cough. They would then begin the treatment and stay in the room with the resident for the entire time it took for the medication to be administered, about fifteen minutes. When the treatment was complete, the nurse should reassess the resident. The resident's clinical record was reviewed on 05/22/25 at 2:35 P.M. A Significant Change Minimum Data Set assessment, dated 05/02/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, heart failure, hypertension, and COPD (Chronic Obstructive Pulmonary Disease). The resident's current physician's orders included, but were not limited to, an open-ended order with a start date of 03/25/25, for staff to administer the resident's Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) milligrams (mg) two times a day for shortness of breath. The resident's record lacked a physician's order to self-administer medications and a medication self-administration assessment. The current facility policy, titled Subject: Self Administration of Meds Procedure & Assessments, with a print date of 05/27/25, was provided by the DON on 05/27/25 at 11:05 A.M. The policy indicated, .For each medication to be self-adm [sic], the resident's ability must be assessed .a physician's order must be obtained . The current facility policy, titled Subject: High Mist Nebulizer or Oxygen Tank Procedure, with a print date of 05/27/25, was provided by the DON on 05/27/25 at 11:31 A.M. The policy indicated, .Nurse must remain with resident during treatment, unless the resident has been assessed to be safe to self-administer the treatment and has a current physician's order to do so . 3.1-11(a)

Based on record review and interview, the facility failed to follow the physician's orders related to cardiac medication administration parameters for 2 of 12 residents reviewed for quality of care. (Residents 28 and 21) Findings include: 1. Resident 28's clinical record was reviewed on 05/22/25 at 2:35 P.M. A Significant Change Minimum Data Set (MDS) assessment, dated 05/02/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, heart failure, hypertension, and COPD (Chronic Obstructive Pulmonary Disease). The resident's current physician's order included, but was not limited to, an order with a start date of 04/29/25 and a discontinued-on date of 05/21/25, for staff to administer the resident's clonidine hydrochloride 0.3 milligram (mg) tablet at bedtime for hypertension. The medication was to be held if the resident's systolic blood pressure (top number) was less than 180. The May 2025 Electronic Medication Administration Record (EMAR) indicated the medication was administered when the systolic blood pressure was less than 180 on the following dates: - On 05/09/25 the resident's blood pressure was 166/72, - On 05/12/25 the resident's blood pressure was 156/74, and - On 05/16/25 the resident's blood pressure was 145/82. 38769 2. The clinical record for Resident 21 was reviewed on 05/21/25 at 3:17 P.M. A Significant Change MDS assessment, dated 03/08/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, Parkinson's disease, anemia, atrial fibrillation, coronary artery disease, heart failure, hypertension, and neurogenic bladder. A physician's note, dated 03/06/25, indicated the staff were to hold the resident's metoprolol (a cardiovascular medication) if the resident's heart rate was less than 60 or the systolic blood pressure was less than 110. A physician's order, dated 03/01/2025 through 04/23/25, indicated the staff were to administer the resident's metoprolol 50 mg, three times a day for hypertension. The staff were to hold the medication if the resident's heart rate was less than 60/systolic blood pressure was less than 110. The physician reviewed the order and decreased the frequency of the medication. A new physician's order, dated 04/23/25 through 05/01/25, indicated the staff were to administer the resident's metoprolol 50 mg, twice a day for hypertension. The staff were to hold the medication if the resident's heart rate was less than 60/systolic blood pressure was less than 110. The physician reviewed the order and decreased the dosage of the medication. An open-ended physician's order, with a start date of 05/01/25, indicated the staff were to administer the resident's metoprolol 25 mg, twice a day for hypertension. The staff were to hold the medication if the resident's heart rate was less than 60 or the systolic blood pressure was less than 110. The March, April, and May 2025 EMAR indicated the medication was administered when the resident's heart rate was not obtained or the resident's heart rate was less than 60 or the systolic blood pressure was less than 110 on the following dates and times: - On 03/07/25 the resident's heart rate was not obtained for the morning or the evening dose, - On 03/08/25 the resident's heart rate was not obtained for the morning dose, - On 03/25/25 the resident's blood pressure was 102/64 for the evening dose, - On 04/06/25 the resident's heart rate was 43 for the midday dose, - On 04/11/25 the resident's heart rate was 56 and the blood pressure was 104/76 for the evening dose, - On 04/12/25 the resident's heart rate was 50 for the morning dose, - On 04/15/25 the resident's blood pressure was 93/64 for the morning dose, - On 04/24/25 the resident's heart rate and blood pressure were not obtained for the evening dose, - On 04/25/25 the resident's heart rate was 56 for the morning dose and the heart rate was not obtained for evening dose, - On 04/26/25 the resident's heart rate and blood pressure were not obtained for the morning dose, - On 04/27/25 the resident's heart rate and blood pressure were not obtained for the morning dose, - On 04/28/25 the resident's heart rate and blood pressure were not obtained for the morning dose, - On 04/29/25 the resident's heart rate was 43 for the morning dose, - On 04/30/25 the resident's heart rate was 55 for the morning dose, - On 05/01/25 the resident's blood pressure was 99/54 for the morning dose, - On 05/03/25 the resident's heart rate was 51 and the blood pressure was 105/65 for the morning dose, - On 05/11/25 the resident's heart rate was 58 for the morning dose, - On 05/13/25 the resident's heart rate was 55 for the morning dose, and - On 05/17/25 the resident's heart rate was 56 for the morning and evening dose. During an interview, on 05/23/25 at 1:25 P.M., RN 2 indicated if a resident had hold parameters on a medication, she would obtain the vital signs before she administered the medication. If the medication was outside the parameters, then she would not administer the medication and would document in the EMAR why the medication was not given. During an interview, on 05/27/25 at 2:18 P.M., the Inservice Director indicated when she obtained the order for the metoprolol in March for Resident 21's hold parameters it was to hold the medication for a systolic blood pressure of less than 110 or a heart rate less than 60. The current facility policy titled, Medication Administration was provided by the Director of Nursing on 05/23/25 at 2:05 P.M. The policy indicated, .Keep medications that require special nursing assessments in a separate cup .Complete necessary assessments before administering medications . 3.1-37(a)

Based on observation and interview, the facility failed to store medications appropriately for 1 of 2 medication carts observed (North Hall Medication Cart) Findings include: The North Hall Medication Cart was observed with Licensed Practical Nurse 3 On 05/27/25 at 9:56 A.M., and contained the following: - a vial of insulin glargine with no open date for Resident 43. The bottle was 3/4 full and had a pharmacy date of 10/20/24 and - an albuterol inhaler for Resident 35 with no open date. The package had a pharmacy date of 12/20/24. During an interview, on 05/27/25 at 10:07 A.M., the Director of Nursing indicated insulin vials and inhalers should have open dates on them once they were opened. The insulin was good for 28 days after it was opened. The current facility policy titled, Storage of Medications dated 12/26/2024, was provided by the Director of Nursing on 05/27/25 at 11:10 A.M. The policy indicated, .Medications and biological are stored safely, securely, and properly, following manufacturer's recommendations .Certain medications or package types, such as IV solutions, multiple dose injectable vials, ophthalmic, nitroglycerin tablets, blood sugar solutions and strips, once opened, require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency .When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated . 3.1-25(o)

Based on interview, observation, and record review, the facility failed to provide scheduled ADL (Activities of Daily Living) care related to bathing for 3 of 12 residents reviewed. (Residents 4, 15, and 37) Findings include: 1. During an interview on 07/08/24 at 10:22 A.M., Resident 4 indicated she went two weeks without a bath a couple of months ago because things just kept happening. There were phone calls and emergencies. During an interview on 07/11/24 at 10:11 A.M., the resident indicated her bath days were twice a week on day shift. When she didn't get a bath, it made her feel dirty! The resident's clinical record was reviewed on 07/09/24 at 9:43 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 06/19/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease, heart failure, and post-polio syndrome. The current Care Plan for the resident's preferences, with an initiated date of 06/07/22, was provided by the Regional Administrator on 07/12/24 at 12:47 P.M., and indicated it was important to the resident to receive a bed bath two times a week. The SHOWER LIST was provided by the Administrator on 07/12/24 at 10:53 A.M., and indicated the resident was to get a bath/shower during day shift on Mondays and Thursdays. The CNA Shower Sheet paper records and the Tasks record for baths/showers from the EHR (Electronic Health Record) were provided by the DON (Director of Nursing) on 07/10/24 at 11:39 A.M., and indicated the resident received a full body bath on the following dates: - 04/22/24, - 05/02/24, the resident went nine days without a full body bath, and - 05/09/24, the resident went six days without a full body bath, - 05/13/24, - 05/16/24, - 05/24/24, - 05/27/24, - 05/30/24, - 06/03/24, - 06/10/24, the resident went six days without a full body bath, - 06/17/24, the resident went six days without a full body bath, - 06/20/24, - 06/27/24, the resident went six days without a full body bath, - 07/01/24, and - 07/08/24, the resident went six days without a full body bath. The resident was to receive a bath or shower on Mondays and Thursdays. From 04/22/24 to 07/08/24, the resident should have received 23 baths. The resident had received 15 baths. No refusals were documented on the CNA Shower Sheet records or in the EHR. During an interview on 07/09/24 at 2:35 P.M., the Social Services Director indicated the resident was very pleasant and usually did not refuse care. During an interview and observation on 07/10/24 at 10:25 A.M., Corporate Nurse 6 indicated if a resident had a shower, it should be documented in the EHR. The Shower Sheets were kept for 90 days then they were shredded. The Shower Sheets were observed in a large clear plastic tub in piles. During an interview on 07/11/24 at 10:37 A.M., CNA (Certified Nurse Aide) 3 indicated residents were scheduled for a bath or shower twice a week, Monday through Saturday. The staff filled out a Shower Sheet with the resident's name, room number, date, and skin inspections. She signs the sheet, the resident signs it if they were coherent, and the nurse signed the sheet. They also did daily charting on the computer, and it asked about the showers. They had the opportunity to document whether the resident had a full shower, full bath, or any refusals. They had the option, on the computer system, to chart refusals. If a resident refused a shower/bath the first time, she notified the nurse and would approach the resident later. If they refused a second time, she notified the nurse. Sometimes if the nurse talked to them, they would take a shower. The Shower Sheets and the computer had the option to document refusals. 33613 2. Resident 15's clinical record was reviewed on 07/10/24 at 3:15 P.M. An Admission MDS assessment, dated 03/27/24, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but was not limited to, a stroke, hypertension, and seizure disorder. The resident was dependent on staff for all ADLs. The CNA Shower Sheet paper records and the Tasks record for Baths/showers from the EHR were provided by the DON on 07/10/24 3:15 P.M., and indicated the resident received a full body bath on the following dates: - Friday, 06/07/24, full body bath, - Tuesday, 06/11/24, full body bath, - Friday, 06/21/24, full body bath and, - Tuesday, 07/09/24, full body bath. The resident was to receive a bath or shower on Tuesdays and Fridays. From 06/01/24 to 07/10/24, the resident should have received 11 baths. The resident only received 4. There were only two days marked as a refusal on the bathing records. During an interview on 07/12/24 at 12:21 P.M., CNA 3 indicated the resident liked to stick to a routine and receive a bed bath or shower in the morning prior to breakfast. She was dependent of all ADLs. She was to receive her showers two times a week on Tuesday and Friday. 38239 3. On 07/11/24 at 9:24 A.M., Resident 37 indicated he didn't get his scheduled showers. Yesterday, he was in the therapy room and staff came and told him they would shower him after lunch, but they never came back to do it. Now he had to go out for an appointment without having been showered. He was supposed to get a shower twice a week. It had been a while since he'd had a shower. The resident's clinical record was reviewed on 07/09/24 at 12:14 P.M. An Annual MDS assessment, dated 06/26/24, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, CKD (Chronic Kidney Disease), obstructive uropathy, and diabetes. The resident had an indwelling urinary catheter and currently received an antibiotic for a urinary tract infection. The resident's Preferences Care Plan, with an initiation date of 06/25/24, indicated the resident preferred to take a shower twice a week. The facility Shower List was provided by the Administrator on 07/12/24 at 10:53 A.M. The list indicated the resident was to receive a shower on Wednesdays and Saturdays on day shift. The CNA Shower Sheet paper record and the Tasks record for baths/showers from the EHR for June and July 2024 were provided by the DON on 07/10/24 11:39 AM., and indicated the following: - the resident declined a shower on Saturday, June 22, 2024, - the resident declined a shower on Wednesday, June 26, 2024, and - the resident received a shower on Thursday, June 27, 2024. A Progress Note, dated Saturday, July 6, 2024, at 9:21 P.M., indicated the resident refused to be showered per staff. A Progress Note, dated Wednesday, July 10, 2024, at 11:50 A.M., indicated the resident declined a shower that morning and would be offered a partial bath after lunch along with a change of clothes. During an interview on 07/11/24 at 1:05 P.M., QMA 2 indicated if a resident refused a shower, she would let the nurse know and come back and try again. It would be documented in the resident's record. The resident's clinical record indicated they were admitted to the facility on Monday, June 17, 2024, and had received one shower since admission. The facility admission packet was reviewed and included, under Resident Rights, regarding planning and implementing care, the resident had the right to receive the services included in the plan of care. The current Charting Procedure policy, dated 10/23/23, was provided by the DON on 07/12/24 at 10:10 A.M., and indicated, .PURPOSE .To accurately document in an organized manner all pertinent information related to the resident in the medical record . 3.1-38(b)(2)

Based on interview, record review, and observation, the facility failed to monitor a wound for a resident who was at risk for skin breakdown for 1 of 12 residents reviewed for Quality of Care. (Resident 4) Findings include: During an interview on 07/08/24 on 10:25 A.M., Resident 4 indicated they had a wound in between their legs where the mechanical lift grabbed their leg and bites it. During an observation and interview on 07/10/24 at 11:08 A.M., the resident was in bed and indicated the area was on their inner thigh. It was painful. The staff gave them Tylenol and it had helped. It had looked like hamburger at one point if it didn't have a top on it. The resident clarified that the wound was from the mechanical lift. During an interview on 07/12/24 at 10:28 A.M., the resident indicated they had the wound probably for years, ever since the facility started using the mechanical lift. It healed then opened back up. The clinical record was reviewed on 07/09/24 at 9:43 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 06/19/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease, heart failure, and post-polio syndrome. The resident was at risk for pressure ulcers. The Nursing-New Skin Alteration assessment dated [DATE] was provided by the Regional Administrator on 07/12/24 at 11:53 A.M. The Assessment indicated, .Treatment Record (TAR) must be updated w/ (with) new skin problems. Even if no treatment is ordered it must be monitored at least daily until healed . The resident had a new wound on the right posterior upper thigh that was open and measured 5.6 cm (centimeters) x (by) 4.0 cm. The wound was red in color, non-blanchable, had uneven edges, was cool to the touch, and had no odor or drainage. Triad cream (a zinc oxide paste) was applied to the wound. The Nursing-Weekly Assessment records dated 05/14/24 through 07/09/24, were provided by the DON (Director of Nursing) on 07/12/24 at 11:36 A.M. The records lacked documentation the resident had any new skin alterations, including, but not limited to, wounds, rashes, excoriation, skin tears, or abrasions. A current Care Plan for the resident's Right posterior upper thigh skin alteration, with an initiated date of 05/13/24, was provided by the DON on 07/12/24 at 1:08 P.M. The Care Plan indicated the resident had a history of skin alterations and risk factors that included, but were not limited to, morbid obesity and immobility. The Care Plan did not indicate the skin concern had been resolved. The EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) for May 2024, was provided by the DON on 07/12/24 at 11:36 A.M. The record lacked documentation the resident's wound, identified on 05/12/24, was being monitored daily. The Progress Notes from 05/06/24 to 07/08/24 were provided by the Regional Administrator on 07/12/24 at 12:47 P.M. The record lacked documentation regarding the resident's wound identified on 05/12/24. During an interview on 07/12/24 at 10:30 A.M., the DON indicated regarding skin assessments, when they found a new skin condition, they opened an initial occurrence or a new skin alteration assessment. Then the residents were followed by the Wound Nurse until the wounds were healed. They would assess the wound weekly. The weekly assessments would be under the Assessment tab on the EHR (Electronic Health Record). Even if it was a non-pressure wound it would be monitored weekly. Based on whether it was improving or declining, the Wound Nurse would consult with the providers. The DON reviewed Resident 4's New Skin Alteration assessment dated [DATE], and indicated when there was a skin alteration, the staff would monitor them in the EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) daily. The new skin alteration should have been documented on the Nursing-Weekly assessment dated [DATE]. If the wound still existed, it would be documented on the Weekly assessments. On 07/10/24 at 11:47 A.M., incontinence care was observed for the resident with QMA (Qualified Medication Aide) 2 and CNA (Certified Nurse Aide) 3. While cleaning the resident's backside, a light pink area with irregular edges approximately the size of a half dollar was observed. The area had traces of white ointment on it with no measurable depth. As the staff cleaned the resident, a couple of small areas around the edge of the wound started to bleed slightly. The current nursing Charting Procedure policy, dated 10/23/23, was provided by the DON on 07/12/24 at 10:10 A.M. The policy indicated, .PURPOSE .To accurately document in an organized manner all pertinent information related to the resident in the medical record .Nursing progress notes and assessments will be completed in the EMR (Electronic Medical Record) .PERTINENT CHARTING .Documentation will be completed for all pertinent issues either in nurses progress notes or in the assessment module of the EMR .Any new physical .complaint will be documented in the EMR under the coordination assessment and/or progress note .Pertinent charting will be completed daily or more often until resolved or stable . 3.1-37(a)

Based on record review and interview, the facility failed to provide COVID-19 booster immunizations in a timely manner for 3 of 8 residents reviewed for immunizations. (Residents E, F, and H) Findings include: 1. The clinical record for Resident E was reviewed on 11/29/23 at 1:42 P.M. The resident was admitted on [DATE]. An Admission MDS assessment, dated 09/18/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, diabetes, heart disease, and rib fractures. The COVID-19 Vaccination Status, Consent & Information record, dated 09/11/23, was provided by the Administrator on 11/29/23 at 3:39 P.M. The record indicated the resident had been educated and requested the COVID-19 vaccine be administered. The record was signed by the resident's representative on 09/12/23. The resident had received the following COVID-19 immunizations: - dated 02/10/21, - dated 03/05/21, - dated 10/19/21, - dated 05/31/22, and - dated 10/28/22, prior to admission. The clinical record lacked documentation the resident had received a COVID-19 booster since 10/28/22 or following admission on 09/11/23. The booster was not administered until 11/15/23. The Infection Surveillance Data Collection Form log was provided by the DON on 11/29/23 at 11:07 A.M. The record indicated the resident tested positive for COVID-19 ON 11/16/23. The Progress Notes, from 09/01/23 to present, lacked documentation the resident had been offered a COVID-19 booster prior to 11/15/23. The current, completed, and discontinued physician's orders, from 09/01/23 to present, lacked orders for a COVID-19 booster vaccine prior to 11/15/23. 2. The clinical record for Resident F was reviewed on 11/29/23 at 1:48 P.M. The resident was admitted on [DATE]. A Quarterly MDS assessment, dated 11/08/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, Parkinson's disease and respiratory failure. The COVID-19 Vaccination Status, Consent & Information record, dated 08/01/23, was provided by the Administrator on 11/29/23 at 3:39 P.M. The record indicated the resident had been educated and requested the COVID-19 vaccine be administered. The record was signed by the resident's representative on 08/01/23. The resident had received the following COVID-19 immunizations: - dated 01/20/21, - dated 02/17/21, - dated 01/20/22, and - dated 07/06/22, prior to admission. The clinical record lacked documentation the resident had received a COVID-19 booster since 07/06/22 or following admission on 08/01/23. The Infection Surveillance Data Collection Form log was provided by the DON on 11/29/23 at 11:07 A.M. The record indicated the resident tested positive for COVID-19 ON 11/20/23. The Progress Notes, from 09/01/23 to present, lacked documentation the resident had been offered a COVID-19 booster. The current, completed, and discontinued physician's orders, from 09/01/23 to present, lacked orders for a COVID-19 booster shot. 3. The clinical record for Resident H was reviewed on 11/29/23 at 3:28 P.M. The resident was admitted on [DATE]. An Admission MDS assessment, dated 10/06/23, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, coronary artery disease and chronic obstructive pulmonary disease. The COVID-19 Vaccination Status, Consent & Information record, dated 09/29/23, was provided by the Administrator on 11/30/23 at 12:25 P.M. The record indicated the resident had been educated and requested the COVID-19 vaccine be administered. The record was signed by the resident on 09/29/23. The resident had received the following COVID-19 immunizations: - dated 01/26/21, - dated 02/24/21, and - dated 01/13/23, prior to admission. The clinical record lacked documentation the resident had received a COVID-19 booster since 01/13/23 or following admission on 09/29/23. The booster was not administered until 11/15/23. The Progress Notes, from 09/01/23 to present, lacked documentation the resident had been offered a COVID-19 booster prior to 11/15/23. The current, completed, and discontinued physician's orders, from 09/01/23 to present, lacked orders for a COVID-19 booster shot prior to 11/15/23. During an interview on 11/29/23 at 11:30 A.M., the DON indicated residents' consents for vaccines were in their admission agreements and on their paper hard charts. During an interview on 11/29/23 at 11:11 A.M., the Administrator indicated no residents had been sent out to the hospital for COVID-19 during this recent outbreak. During an interview on 11/29/23 at 3:35 P.M., the DON indicated when a resident was admitted and desired to have immunizations the facility would review their CHIRP (Children & Hoosiers Immunization Registry Program) and see what immunizations they had and discuss with the resident or family what immunizations were currently available and needed at that time. The staff contacted the MD and would get the order for whatever vaccines that specific resident needed, contact the pharmacy, and order them. It usually took about 24 hours if the pharmacy had the vaccines in stock. They had not had any trouble getting vaccines. Once the vaccines were received in house, usually the next day, they were administered as ordered. During an interview on 11/29/23 at 3:58 P.M., the DON indicated she had been in her current position since August 2023. She had ordered a house stock of the new COVID-19 vaccines on 11/13/23 and provided a copy of the order receipt. She indicated she had not ordered any COVID-19 vaccines prior to 11/13/23. She did not think their pharmacy had the boosters available until 11/01/23. During an interview on 11/29/23 at 4:20 P.M., the Consultant Pharmacist indicated the pharmacy did not have the vaccines available until November 1, 2023, and they had sent correspondence to the facilities letting them know they were available. On November 6,2023, the pharmacy received the order for the vaccines. There was a delay because the vaccines were routed to the wrong queue. The facility brought it to their attention on 11/13/23 and the vaccines were sent out that night. When the pharmacy received an order, it was usually sent out in 24 to 48 hours. During an interview on 11/30/23 at 11:25 A.M., the Nurse Consultant indicated if a medicine or vaccine was not available from their pharmacy, they would have a backup plan with their pharmacy or use a local retail pharmacy. If it was something their pharmacy was not able to get, they would go through a local retail pharmacy. A CDC (Centers for Disease Control) press release, dated 09/12/23, indicated, . Updated COVID-19 vaccines from Pfizer-BioNTech and Moderna will be available later this week. Vaccination remains the best protection against COVID-19-related hospitalization and death. Vaccination also reduces your chance of suffering the effects of Long COVID, which can develop during or following acute infection and last for an extended duration. If you have not received a COVID-19 vaccine in the past 2 months, get an updated COVID-19 vaccine to protect yourself this fall and winter . The current Prevention and Containment of Coronavirus (COVID-19) policy dated 09/08/23, was provided by the Administrator on 11/30/23 at 1:27 P.M. The policy indicated, .Policy .To follow the guidelines and recommendations set forth by the Indiana State Department of Health, CDC, .and other experts in the field of infection control and prevention and epidemiology in prevent the transmission and containment of COVID-19 .The corporate COVID-19 committee .will review all resource updates, guidance and recommendations and will revise or create policies and procedures dealing with COVID-19 as deemed necessary .COVID vaccination is encouraged and promoted for staff, residents and visitors. Vaccination is offered to all staff and residents .COVID vaccine .Must have a physician order and consent .Encourage staff and residents to stay up-to-date on COVID-19 vaccine . This citation relates to Complaint IN00422517. 3.1-18(b)(1)

Based on record review and interview, the facility failed to provided RN coverage for 20 of 25 days reviewed. Findings included: The as worked nurse staffing schedules were provided by the Administrator on 05/24/23 at 3:06 P.M. The schedules lacked RN coverage for the following dates: - 10/01/22, no RN coverage - 10/02/22, only four hours RN coverage, - 10/08/22, only four hours RN coverage, - 10/09/22, only four hours RN coverage, - 10/15/22, no RN coverage, - 10/16/22, only four hours RN coverage, - 10/22/22, no RN coverage, - 10/23/22, only four hours RN coverage, - 11/12/22, no RN coverage, - 11/23/22, only four hours RN coverage, - 11/26/22, only four hours RN coverage, - 11/27/22, only four hours RN coverage, - 12/10/22, only four hours RN coverage, - 12/11/22, no RN coverage, - 12/24/22, no RN coverage, - 12/31/22, only four hours RN coverage, - 01/01/23, only four hours RN coverage, - 04/09/23, only four hours RN coverage, - 05/13/23, no RN coverage,and - 05/14/23, no RN coverage. During an interview on 05/24/23 at 3:39 P.M., LPN (Licensed Practical Nurse) 3 indicated there was supposed to be an RN in the building for 8 hours a day. The RN coverage was a little spotty at the moment. She didn't have any RN's to work the weekend shifts. During an interview on 05/25/23 at 11:06 A.M., the Administrator indicated the facility did not have a policy for RN coverage. They would follow the State and Federal regulation. 3.1-17(b)(3)

Based on record review and interview, the facility failed to monitor vitals signs and follow a physician's order related to blood sugar monitoring for 2 of 13 residents reviewed for quality of care. (Residents 231 and 1) Findings include: 1.A. The record for Resident 231 was reviewed on 05/23/23 at 2:27 P.M. The diagnoses included, but were not limited to, heart failure, hypertension, diabetes, and kidney disease. A physician's order, dated 04/26/23 through 05/04/23, indicated the resident was to be administered Digoxin (a heart medication), one tablet, once a day. The staff were to hold the medication if the heart rate was less than 60. The April and May 2023 EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) were reviewed and indicated the resident had received the medication on 04/26/23 through 05/04/23 with no documented heart rates. During an interview on 05/25/23 at 1:24 P.M., the MDS (Minimum Data Set) Coordinator indicated if a resident required the heart rate to be monitored prior to administration of the medication it would be documented in the EMAR/ETAR. If the medication was to be held due to the heart rate parameters then it would also be documented in the EMAR/ETAR. 1.B. An open-ended physician's order, with a start date of 05/05/23, indicated the residents blood sugar was to be checked once a day at 5:30 A.M., with no insulin coverage. The MD was to be notified if the blood sugar was less than 70 or greater than 400. The record, including the May 2023 EMAR/ETAR, lacked the resident's blood sugar level was documented on the following dates: - 05/06/23 through 05/09/23, - 05/11/23 through 05/12/23, - 05/14/23 through 05/15/23, and - 05/17/23 through 05/20/23. 38239 2. During an interview on 05/23/23 at 11:08 A.M., Resident 1 indicated she was diabetic and received insulin before meals. Sometimes her blood sugar was high. The resident's record was reviewed on 05/25/23 at 10:24 A.M. A Quarterly MDS assessment, dated 03/22/23, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, diabetes, anemia, stroke, non-Alzheimer's dementia, and malnutrition. The resident received insulin everyday of the assessment review period. The resident's current medication orders included a physician's order, with a start date of 11/14/22 that was discontinued on 05/26/23, for Humalog insulin solution. Nursing staff were to assess the resident's blood sugar before meals and administer insulin based on a sliding scale. Nursing staff were to notify the MD if the resident's blood sugar was less than 60 or greater than 350. During an interview on 05/25/23 at 1:20 P.M., RN 2 indicated the nurses documented blood sugar assessments in the EMAR. They should follow physician's orders and notify the MD of a blood sugar reading that was higher or lower than the parameters set in the order. They should document the notification and the MD's response in the computer. The April and May 2023 EMARs were reviewed on 05/26/23 at 12:07 P.M. The EMARs indicated the resident's blood sugar was greater than 350 on the following dates and times: - On 04/07/23 at 8:00 A.M., the resident's blood sugar was 400, - On 04/20/23 at 5:00 P.M., the resident's blood sugar was 359, - On 04/21/23 at 11:30 A.M., the resident's blood sugar was 366, - On 04/22/23 at 11:30 A.M., the resident's blood sugar was 385, - On 05/07/23 at 5:00 P.M., the resident's blood sugar was 376, - On 05/09/23 at 11:30 A.M., the resident's blood sugar was 390, - On 05/13/23 at 11:30 A.M., the resident's blood sugar was 377, - On 05/14/23 at 5:00 P.M., the resident's blood sugar was 387, - On 05/16/23 at 11:30 A.M., the resident's blood sugar was 396, - On 05/19/23 at 5:00 P.M., the resident's blood sugar was 393, - On 05/20/23 at 5:00 P.M., the resident's blood sugar was 387, and - On 05/23/23 at 11:30 A.M., the resident's blood sugar was 367. The resident's record lacked documentation the MD was notified of the blood sugars that were higher than 350. A Care Plan for hypo/hyperglycemia was provided by the Administrator on 05/26/23 at 11:49 A.M. The interventions included, but were not limited to, an intervention that was initiated on 11/04/22 to notify the MD of blood sugar readings outside the ordered parameters. The current facility policy, titled Medication Administration Procedure, with a start date of 08/29/2016, was provided by the Administrator on 05/26/23 at 10:42 A.M. The policy indicated, .Complete necessary assessments before administering medications . The current facility policy, titled Physician and Family Notification of Condition Changes, with a start date of 11/30/2016, was provided by the Administrator on 05/26/23 at 10:42 A.M. The policy indicated, .keep the physician, resident, and family appraised of all condition changes .Notify the physician of any change in condition that may or may not warrant a change in the treatment plan .document the information reported .document the response from the physician . 3.1-37(a)

Based on record review and interview, the facility failed to ensure a resident's physician was notified of low heart rate values for 1 of 1 resident reviewed for notification of change. (Resident 28) Findings include: The clinical record for Resident 28 was reviewed on 04/25/22 at 2:34 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 03/24/22, indicated the resident was severely cognitively impaired. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The complete care plan was provided by the Administrator on 04/25/22 at 12:40 P.M. A care plan indicated the resident had chronic cardiovascular disease, [CONDITION(S)] (low heart rate), and the presence of a pacemaker. Interventions included, but were not limited to, observe for signs and symptoms of decreased cardiac output. The EMAR/ETARs (Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. The October record included the following orders: - Pacemaker: Check apical pulse rate and rhythm daily for one full minute. Notify the physician if below 60 (beats per minute), every day shift. The start date was 06/04/21. The discontinued date was 10/26/21. - Pacemaker: Check apical pulse rate and rhythm daily for one full minute. Notify the physician if above or below, every day shift. The start date was 10/28/21. The discontinued date was 03/08/22. The order, with a start date of 10/28/21, lacked the call parameter of notifying the physician when the heart rate was below 60. During an interview on 04/21/22 at 1:47 P.M., RN 3 indicated all orders were on the computer on the EMAR/ETAR. If an order had call parameters that the physician was to be notified, she would go under the progress notes and document that she had notified the physician. The notification would show up under EMAR Progress Notes that the physician had been notified. The pacemaker order was not complete. The order in October should have been carried over with the parameters in place. The physician should have been notified according to the parameters. The EMAR/ETAR indicated the resident had low heart rate values below 60 on the following dates: - 11/09/21, heart rate 58, - 01/04/22, heart rate 52, - 01/19/22, heart rate 51, - 01/20/22, heart rate 58, - 01/21/22, heart rate 56, - 01/22/22, heart rate 55, - 01/23/22, heart rate 58, - 01/24/22, heart rate 50, - 01/25/22, heart rate 52, - 01/28/22, heart rate 58, - 02/01/22, heart rate 51, - 02/02/22, heart rate 56, - 02/16/22, heart rate 50, - 02/18/22, heart rate 52, - 02/20/22, heart rate 54, - 02/22/22, heart rate 58, - 02/26/22, heart rate 58, - 02/27/22, heart rate 52, and - 02/28/22, heart rate 54. The progress notes from October 2021 through April 2022 were provided by the DON on 04/22/22 at 9:12 A.M. A note, dated 10/27/21 at 11:49 P.M., indicated the resident had been readmitted to the facility after a short hospital stay. The notes lacked documentation as to when the resident was discharged to the hospital and that the physician had been notified of the above listed low heart rate values. During an interview on 04/25/22 at 2:24 P.M., the DON indicated the resident received his pacemaker in March of 2021 while a resident in the facility. The staff monitored the site and his apical pulse. They watched for high and low heart rates on the pacemaker. The current new admission and return to facility procedure, dated 01/16/20, was provided by the Administrator on 04/25/22 at 12:40 P.M. The policy indicated, .PHYSICIAN ORDERS [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse(s) should be looking for any new orders, and /or changes in previous orders .admitting nurse must call physician and verify all transfer orders upon admission . The current pacemaker care procedure policy, with a start date of 08/02/10, was provided by the Administrator on 04/25/22 at 12:40 P.M. The policy indicated, .ensure residents with pacemakers have proper care and maintenance .Obtain physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .What parameters (high & low) of apical pulse to notify the physician . The current physician and family notification of condition changes policy, with a start date of 11/30/16, was provided by the Administrator on 04/25/22 at 12:40 P.M. The policy indicated, .Notify the physician of any change in condition that may or may not warrant a change in the treatment plan .Document the information reported to the physician in the nurses notes including the time and date of notification. Be thorough and explicit . 3.1-5(a)(2)

Based on record review and interview, the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident 33) Findings include: The clinical record for Resident 33 was reviewed on 04/22/22 at 9:54 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 03/17/22, indicated the resident was cognitively intact. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required extensive staff assistance with bed mobility, transfers, toilet use, and personal hygiene. The resident had 2 unhealed Stage 3 (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle was not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) pressure ulcers. a. A Non-Pressure wound assessment, dated 01/03/22, indicated the resident had a moisture lesion to the inner right buttocks. The treatment was to cleanse with normal saline, paint with a barrier cream and cover with a foam border. A Wound Center Note, dated 01/06/22, indicated the resident had a Stage 2 (partial thickness loss with exposed dermis. The wound bed was viable, pink or red, moist and may also present as an intact or ruptured serum-filled blister) pressure ulcer to the right buttock. The treatment was to clean with normal saline and cover with antimicrobial and foam dressing. A Wound Center Note, dated 01/20/22, indicated the resident had a Stage 3 pressure ulcer on the right buttock. The wound treatment was changed. The new order was to clean with normal saline and cover with collagen and a foam dressing. The January 2022 ETAR (Electronic Treatment Administration Record) lacked documentation the treatment had been changed. b. A Non-Pressure wound assessment, dated 01/03/22, indicated the resident had a moisture lesion to the inner left buttocks. The treatment was to cleanse with normal saline, paint with a barrier cream and cover with a foam border. A Wound Center Note, dated 01/06/22, indicated the resident had a Stage 2 pressure ulcer to the left buttock. The treatment was to clean with normal saline and cover with antimicrobial and foam dressing. A Wound Center Note, dated 01/20/22, indicated the resident had a Stage 3 pressure ulcer on the left buttock. The wound treatment was changed. The new order was to clean with normal saline and cover with collagen and a foam dressing. The January 2022 ETAR (Electronic Treatment Administration Record) lacked the treatment had been changed. During an interview on 04/25/22 at 10:25 A.M., RN 3 indicated when a resident went out to appointments and returned with new orders, the physician or Nurse Practitioner was in he building and had new orders, any agreed on pharmacy recommendations that were approved, the nurse working that hallway would input any new orders before the end of their shift. During an interview on 04/25/22 at 2:28 P.M., The Wound Nurse indicated when the resident had returned from the wound clinic the nurse should have entered the new orders into the computer per the wound clinic. The current facility policy, tilted Pressure Injury Treatment, start date of 01/16/2020, was provided by the DON (Director of Nursing) on 04/25/22 at 2:17 P.M. The policy indicated, .to provide all residents with pressure injuries treatments that are recommended by the NPIAP [National Pressure Injury Advisory Panel] in accordance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to follow appropriate infection control guidelines to prevent UTIs (Urinary Tract Infections) for residents with indwelling urinary catheters for 1 of 4 residents reviewed for UTIs. (Resident 13) Findings include: During an observation and interview on 04/19/22 at 12:26 P.M., Resident 13 was in his room in a wheelchair. His urinary catheter bag was covered. The tubing to the catheter was on the floor under the resident's left foot. The resident indicated he had the urinary catheter to relieve his kidneys and he had been on an antibiotic recently for a [CONDITION(S)]. Facility staff came into the resident's room to deliver his lunch tray, leaving the urinary catheter tubing on the floor. During an observation on 04/20/22 at 12:50 P.M., the resident was sitting in his room in his wheelchair. Over an inch of his urinary catheter tubing was laying against the floor. The tubing contained yellow urine with sediment. During an observation and interview on 04/21/22 at 2:36 P.M., the resident was in a wheelchair in his room. Over an inch of his urinary catheter tubing was laying against the floor. The resident indicated he was not feeling well and would like to lay down. The clinical record was reviewed on 04/20/22 at 1:06 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 03/03/22, indicated the resident was moderately cognitively impaired. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required the extensive assistance of one staff member for bed mobility, transfers, toilet use, and personal hygiene. The resident had an indwelling urinary catheter. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. The order indicated the resident received [MEDICATION(S)], an antibiotic, 500 milligrams, two times a day for a [CONDITION(S)], with a start date of 03/24/22 and a discontinued date of 03/31/22. During an interview on 04/22/22 at 10:37 A.M., TNA (Temporary Nurse Aide) 5 indicated the resident had worked with therapy for a while. His transfers were not safe. She provided stand by assistance for transfers from the bed to the wheelchair. He sometimes transferred himself from the wheelchair to the bed, but always received assistance with transfers from the bed to the wheelchair. During an interview on 04/25/22 at 1:30 P.M., CNA (Certified Nurse Aide) 4 indicated for a resident with an indwelling urinary catheter, the tubing should not touch the floor. The current Foley Catheter Care & Maintenance policy, with a start date of 08/30/07, was provided by the Administrator on 04/25/22 at 3:50 P.M. The policy indicated, .Purpose .To reduce the likelihood of infection .Placement of Catheter Tubing Procedure .Ensure bag or tubing is not touching floor . 3.1-41(a)(2)

Based on record review and interview, the facility failed to implement pharmacy recommendations in a timely manner related to GDRs (Gradual Dose Reductions) to [CONDITION(S)] medications for 3 of 7 residents reviewed for drug regimen review. (Residents 29, 26, and 21) Findings include: 1. The clinical record for Resident 29 was reviewed on 04/25/22 at 2:05 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 03/24/22, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, stroke, dementia, and depression. The EMAR/ETAR (Electronic Medication Administration Record / Electronic Treatment Administration Record) for December 2021 through February 2022, were provided by the DON (Director of Nursing) on 04/22/22 at 2:20 P.M. The record included the following order: - [MEDICATION(S)] (an antidepressant) 10 milligrams, by mouth, once a day, with a start date of 07/23/21, and a discontinued date of 02/25/22. A Consultant Pharmacy Communication to Physician report, dated 12/17/21, indicated a GDR Recommendation, to stop the current [MEDICATION(S)] order and start 10 mg, one by mouth every day on 6 days of the week, holding on day of choice. The form indicated the MD agreed with the recommendation and was signed and dated 12/23/21. The December 2021, and January 2022, EMAR indicated the medication had not been changed. The February 2022 EMAR included the following orders: - [MEDICATION(S)] 10 milligrams, by mouth, once a day, with a start date of 07/23/21, and a discontinued date of 02/25/22. - [MEDICATION(S)] 10 milligrams, by mouth, once a day, for 6 days, with a start date of 02/26/22, and a discontinued date of 02/28/22. The March 2022 EMAR included the following orders: - an open ended order for [MEDICATION(S)] 10 milligrams, by mouth, once a day, every Monday, Tuesday, Wednesday, Thursday, Friday, and Saturday, with a start date of 03/01/22. - an open ended order for [MEDICATION(S)] 5 milligrams, by mouth, every Sunday, with a start date of 03/06/22. 2. The clinical record for Resident 26 was reviewed on 04/21/22 at 1:43 P.M. A Quarterly MDS assessment, dated 03/24/22, indicated the resident was moderately cognitively impaired. The Diagnoses included, but were not limited to, dementia with behavioral disturbances, heart failure, hypertension, depression, and [CONDITION(S)]. A physician's order, dated 07/19/21 through 12/28/21, indicated the resident received [MEDICATION(S)] 0.5 mg once a day for dementia with delusions. A Consultant Pharmacy Communication to Physician form, dated 12/17/21, indicated a GDR Recommendation to stop the current [MEDICATION(S)] order and start 0.5 mg, one by mouth every day at 2:00 P.M., 6 days a week, holding on day of choice, and [MEDICATION(S)] 0.25 mg once by mouth once a week at 2:00 P.M. on day of choice. The form indicated the MD agreed with the recommendation and was signed and dated 12/23/21. The December 2021 EMAR indicated the medication had not been changed until 12/28/21 (five days after the physician signed the form). During an interview on 04/25/22 at 10:25 A.M., RN 3 indicated when a resident went out to appointments and returned with new orders, the physician or Nurse Practitioner was in the building and had new orders or any agreed on pharmacy recommendations that were approved, the nurse working that hallway would input any new orders before the end of their shift. 3. The clinical record for Resident 21 was reviewed on 04/22/22 at 9:48 A.M. A Quarterly MDS assessment, dated 03/10/22, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, [CONDITION(S)], hypertension, [CONDITION(S)], and depression. He received an antidepressant for seven out of seven days during the assessment period. A physician's order, dated 05/01/21 through 12/28/21, indicated [MEDICATION(S)] 20 mg once a day for depression. A Consultant Pharmacy Communication to Physician form, dated 12/17/21, indicated a GDR Recommendation to stop the current [MEDICATION(S)] order and start 20 mg, once a day, 6 days a week, holding on day of choice, and [MEDICATION(S)] 10 mg, once weekly on day of choice. The form indicated the MD agreed with the recommendation and was signed and dated 12/23/21. The December 2021 EMAR indicated the medication had not been changed until 12/29/22 (6 days after the physician signed the form). During an interview on 04/22/22 at 10:03 A.M., the Social Service Designee indicated when pharmacy recommendations are made they are sent to the Medical Director for approval and signature then put into place on the resident's clinical record. During an interview on 04/22/22 at 02:26 P.M., RN 2 indicated the signed physician orders should be placed in the EMAR as soon possible. The current Response to Pharmacist Recommendations policy, with a start date of 04/11/17, was provided by the Quality Assurance Nurse on 04/22/22 at 3:07 P.M. The policy indicated, .The facility will communicate all consultant pharmacist's recommendations to the attending physician in a timely manner for review and for any action to be taken regarding the recommendation . 3.1-48(a)(5)

Based on record review and interview, the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Residents 22 and 28) Findings include: 1. The clinical record for Resident 22 was reviewed on 04/20/22 at 2:26 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 03/17/22, indicated the resident was moderately cognitively impaired. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Communication of New or Changed Plan of Care/Orders, dated 02/10/22 at 5:42 P.M., indicated the resident was prescribed Midorine (a blood pressure medication), 10 mg, by mouth, three times a day.Blood pressure MUST be monitored and recorded ., for a-fib ([CONDITION(S)]). The resident's clinical record lacked documented blood pressure monitoring for the medication from 02/25/22 to current. There was no indication the physician discontinued the order to monitor the resident's blood pressure related to the medication. During an interview on 04/24/22 at 11:01 A.M., the DON (Director of Nursing) indicated the resident's blood pressure should have been monitored. The current facility policy titled, New Orders - Verbal/Telephone, with a start date of 03/23/2018, was provided by the Administrator on 04/25/22 at 12:40 P.M. The policy indicated, .To ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. The clinical record for Resident 28 was reviewed on 04/25/22 at 2:34 P.M. A Quarterly MDS assessment, dated 03/24/22, indicated the resident was severely cognitively impaired. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident received an anticoagulant (blood thinner) for seven of the seven days during the review period. The EMAR/ETAR (Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. The record included the following order: - An open ended order for [MEDICATION(S)], inject 1 milliliter subcutaneously every 12 hours for coronary artery disease, with a start date of 03/11/22. The records lacked documentation the resident was being monitored for ASE (Adverse Side Effects), such as bleeding, related to the use of the anticoagulant. During an interview on 04/21/22 at 1:47 P.M. RN 3, indicated all physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was on [MEDICATION(S)], an anticoagulant, and should have been monitored for bleeding and black tarry stools. The resident had not been sent out for any bleeding concerns. The resident had been tested to monitor for blood clotting disorders and that was why he was placed on [MEDICATION(S)]. The current facility policy, titled Medication Administration Procedure, with a start date of 08/29/2016, was provided by the Administrator on 04/25/22 at 3:50 P.M. The policy indicated, .Know the action, purpose of med, safe dose ranges, and adverse effects of medications . 3.1-48(a)(1) 3.1-48(a)(3)

Based on record review and interview, the facility failed to transcribe new admission orders and monitor for adverse side effects of [CONDITION(S)] medications for 2 of 7 residents reviewed for unnecessary medications. (Residents 38 and 28) Findings include: 1. The clinical record for Resident 38 was reviewed on 04/21/22 at 9:52 A.M. The diagnoses included, but were not limited to, fracture to the right femur, diabetes, heart failure, dementia, depression, and anxiety. A Hospital Discharge record, dated 04/18/22, indicated the physician ordered for the resident to be prescribed [MEDICATION(S)] (an antidepressant) 40 mg (milligrams) daily. The clinical record for Resident 38 indicated there were duplicate orders for [MEDICATION(S)] 40 mg, daily. The April 2022 EMAR (Electronic Medication Administration Record) indicated the resident had received [MEDICATION(S)] 80 mg on April 19 and 20, 2022. During an interview on 04/25/22 at 10:25 P.M., RN 3 indicated when a resident was admitted to the facility within 4 hours of admission the nurse would complete an admission assessment and have all medications entered into the clinical record. The medication list would be faxed to the pharmacy. The nurses were the ones that entered the medications. The medications were then verified by a second nurse and then again in a morning meeting. If a resident had a duplicate order then she would look at the resident's chart to verify the order. If she had any questions then she would call the provider. During an interview on 04/25/22 at 2:01 P.M., RN 3 indicated a check mark and initials on the EMAR would mean the resident had received the medication. During an interview on 04/25/22 at 11:05 A.M., the DON (Director of Nursing) indicated it appeared the resident had received a double dose of the [MEDICATION(S)] for 2 days. The current facility policy titled, New Orders - Verbal/Telephone, with a start date of 03/23/2018, was provided by the Administrator on 04/25/22 at 12:40 P.M. The policy indicate, .To ensure physician orders are transcribed correctly and carried out per plan by a licensed nurse . 2. The clinical record for Resident 28 was reviewed on 04/25/22 at 2:34 P.M. A Quarterly MDS assessment, dated 03/24/22, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, dementia, cancer, heart failure, depression, and [CONDITION(S)]. The resident received an antipsychotic medication for seven of the seven days during the review period. The EMAR/ETAR for March and April 2022, was provided by the DON on 04/22/22 at 9:12 A.M. The record included the following order: - An open ended order for [MEDICATION(S)], an antipsychotic medication, 10 milligrams, at bedtime for dementia with delusions, with a start date of 03/11/22. The records lacked documentation the resident was being monitored for ASE to the antipsychotic medication from 03/11/22 to 04/22/22. During an interview on 04/21/22 at 1:47 P.M., RN 3 indicated all orders, treatments, and monitoring for ASE were documented on the computer on the EMAR/ETAR. Monitoring for ASE to [CONDITION(S)] medications should also be on the EMAR/ ETAR. The current [CONDITION(S)] drug use policy, with a start date of 02/18/19, was provided by the Administrator on 04/25/22 at 12:40 P.M. The policy indicated, .Side Effect Monitoring: Monitor daily on Med Admin Record (MAR) . 3.1-48(a)(1) 3.1-48(a)(3)

Based on observation, interview, and record review, the facility failed to ensure interventions were in place for a resident at risk for falls for 1 of 3 residents reviewed for accident hazards. (Resident C) Findings include: The clinical record for Resident C was reviewed on 4/19/21 at 11:15 a.m. The resident's diagnoses included, but were not limited to, dementia, unsteady on feet, abnormal gait and mobility, weakness, and a pathological fracture of the left ankle. A Quarterly Minimum Data Set (MDS) assessment, dated 3/9/21, indicated the resident's cognition was moderately impaired. The resident wore glasses and had hearing aids. She required extensive assistance of two physicial staff members for transfer and mobility. A Care Plan, dated 2/20/20, indicated the resident was a Fall Risk. The fall interventions for the resident were for safety strips to be placed on the floor beside the bed, in front of the recliner, under the recliner, and in front of the toilet. A Care Plan, dated 10/8/20, indicated the resident was to have bright colored tape on the call light to alert the resident to call for assistance. During an observation on 4/19/21 at 11:24 a.m., the resident was in her recliner in her room, her legs were elevated, and she had a brace on her left lower extremity. There was no bright colored tape on her call light and no safety strips on the floor next to the bed, under the chair, or in front of the toilet. During an interview on 4/19/21 at 1:36 p.m., the DON indicated Resident C's roommate reported the resident had transferred herself from the wheelchair to the recliner. The resident had hollered out but did not fall. There was swelling observed on the morning of 3/6/21 by a QMA and a Therapist. During an observation on 4/19/21 at 1:40 p.m., the resident was lying in bed. There was no bright colored tape on the call light and no safety strips on the floor next to the bed, under the chair, or in front of the toilet. During an interview and observation on 4/20/21 at 9:16 a.m., LPN 2 retrieved a CNA hall sheet from her right hand pocket and reviewed it at that time. She indicated Resident C should have had florescent tape on her call light and no-slip (safety) stripes on the floor. She picked the call light up off the floor between the bed and chair. The LPN indicated there was no florescent tape on the call light and there were no safety stripes on the floor. The current facility policy titled Fall Management Procedure and dated 1/10/2019, was provided by the Administrator on 4/19/21 at 10:50 a.m. The policy indicated, .Purpose A. To assess all residents for risk factors that may contribute to a fall and to provide planned interventions .for resident use in maintaining or returning to the highest level of physical .functioning as possible . This Federal Tag relates to Complaint IN 923. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure infection control practices for COVID-19 were followed during the pandemic, related to identify symptoms of COVID-19 and isolating the resident to help mitigate the spread of COVID-19 for 1 of 3 residents reviewed for infection control. (Resident B) Findings include: The clinical record for Resident B was reviewed on 01/26/21 at 11:30 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 12/30/20, indicated the resident was severely cognitively impaired. [DIAGNOSES REDACTED]. A Progress Note, dated 01/23/21 at 6:27 P.M., indicated the nurse was given, in shift change report for that day, that the resident began coughing overnight after being laid down flat. The resident was not coughing at shift change. The resident began coughing after breakfast. The resident coughed any time he was fed. The resident did not have an increased temperature. His lung sounds were clear. The resident was in his normal state of alertness. The nurse would continue to monitor. A Progress Note, dated 01/24/21 at 1:10 P.M., indicated the resident had a nonproductive cough and his lung sounds had a wheeze/rub (a high pitch [MEDICATION NAME] sound while breathing, often associated with difficulty breathing) anteriorly on exhale in both lungs. The resident had no signs or symptoms of respiratory distress. His vital signs were stable and his level of consciousness was normal. The nurse would continue to monitor. The clinical record lacked documentation that the resident had been placed in Transmission Based Precautions after showing signs of cough and respiratory wheeze. A Progress Note, dated 01/25/21 at 5:46 A.M., indicated the resident presented at the end of the shift with a fever 101. A wet cough was noted. Oxygen saturation of 92% (percent) on room air. (95% - 100% is acceptable in the elderly) Tylenol was given for the fever at 5:30 A.M. The nurse would pass on in report to monitor the resident. A Progress Note, dated 01/25/21 at 6:37 A.M., indicated the resident had a reddened face and his skin was warm to the touch. His lung sounds were congested and a wet cough was noted. The resident was repositioned and a drink of water was given. The nurse would make the NP (Nurse Practitioner) aware. A Progress Note, dated 01/25/21 at 8:00 A.M., indicated the resident was placed in Transmission Based Precautions. During an interview on 01/26/21 at 1:48 P.M., RN 2, indicated in order to place a resident in Transmission based Precautions they would need to have two signs or symptoms of Covid. If they only have one sign or symptom they are monitored and the information would be passed on to the next shift. During an interview on 01/26/21 at 3:30 P.M., the Infection Preventionist Nurse, indicated all residents are monitored at least daily for signs and symptoms of Covid, temperature, and oxygen saturation. Residents are placed in Transmission Based Precautions if they have an temperature of 100 or greater, if they have any two symptoms of Covid, or if an order is given by the Doctor or NP. Resident B having had a cough and a change in lung sounds, would have been concidered as having two symptoms. The CDC guidance - Preparing for COVID-19: Long-term Care Facilities, Nursing Homes, dated as updated 11/20/20, indicated the following: Evaluate and Manage Residents with Symptoms of COVID-19. Ask residents to report if they feel feverish or have symptoms consistent with COVID-19. Actively monitor all residents upon admission and at least daily for fever (T greater than or equal to 100.0 F) and symptoms consistent with COVID-19. Ideally, include an assessment of oxygen saturation via pulse oximetry. If residents have fever or symptoms consistent with COVID-19, implement Transmission-Based Precautions. Older adults with COVID-19 may not show common symptoms such as fever or respiratory symptoms. Less common symptoms can include new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell. Additionally, more than two temperatures >99.0oF might also be a sign of fever in this population. Identification of these symptoms should prompt isolation and further evaluation for COVID-19 3.1-18(b)

Based on interview and record review, the facility failed to adequately investigate an allegation of abuse and ensure the immediate reporting of an allegation of abuse to the Indiana State Department of Health, when a staff member used a phone to take a video/picture of resident care (Resident #B) and shared it with other employees via social media, for 1 of 11 residents reviewed for abuse. The Immediate Jeopardy began on the evening of 02/26/2016, when a staff member videotaped/took a picture of Resident #B's personal care and shared the video/picture on social media. The Administrator and the Quality Assurance Corporate Nurse were notified of the Immediate Jeopardy at 2:15 P.M., on 03/14/2016. The Immediate Jeopardy was removed on 3/16/2016, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: During a confidential interview on 03/13/2016, Staff #1 indicated he/she had received a Snap (Snapchat name of video program) of Resident #B's brief and stool. The staff member indicated, after receiving the Snap, he/she did not inform management, but instead told Staff #3 there was a video of him/her providing resident care and was told by Staff #3 he/she would go to the Administrator. Staff #1 indicated Staff #2 had sent the video and that he/she was able to identify the resident by the amount and type of stool in the video and the staff member by the voice in the video. During a confidential interview on 03/13/2016, Staff #3 indicated Staff #2 was holding up his/her phone while Staff #3 was providing resident care to Resident #B. The staff member indicated he/she had not been aware the care being provided was being recorded at the time. Staff #3 reported to Staff #4 on 02/26/2016 that Staff #2 was video taping direct resident care. Staff #4 assured Staff #3 that it would be reported to the DON and Administrator. Staff #3 was aware Staff #4 called the DON right away. Staff #3 indicated the Administrator called the facility and spoke with Staff #2 and informed the staff to delete any pictures off their phones. Staff #3 indicated the next day (02/27/2016) when they came in to work, they again reported the allegation of a video/and or pictures being taken of resident care again to the Administrator. During a confidential interview on 03/13/2016, Staff #4 indicated on Friday, 02/26/2016, Staff #3 brought a concern to him/her about Staff #2 video taping during resident care. Staff #4 indicated they called the DON immediately and informed them of the allegation, including the fact that it was a resident being filmed during care. Staff #4 indicated the Administrator called the facility that night (02/26/2016) and told the staff they were not to be taking pictures and to delete any pictures they had on their phones. Staff #4 indicated when they returned to the facility on Monday (02/29/2016), they were concerned about the situation and took the concern directly to the Administrator. The Administrator claimed to not know that the pictures had involved resident care, Staff #4 informed her of the allegations made by Staff #3 that pictures and/or video had been taken during direct resident care of Resident #B. During a confidential interview on 03/14/2016, Staff #5 indicated he/she had heard rumors from several CNA's on 03/03/2016 that there was a video taken by staff of Resident #B being toileted. Staff #5 indicated he/she informed the ADON (Assistant Director of Nursing) of the concern on 03/03/2016 and was told by the ADON that she would address the issue. During a confidential interview on 03/14/2016, Staff #6 indicated he/she was aware a staff member had reported a video being taken of resident care to the DON and the Administrator the night the allegation occurred (02/26/2016). Staff #6 indicated the Administrator had called the facility the night of the allegation, 02/26/2016, and had told staff all pictures needed to be deleted off their phones. During a confidential interview on 03/14/2016, Staff #7 indicated he/she was told on 02/27/2016 by another staff member that a video had been taken of a resident during resident care. Staff #7 indicated he/she notified the Administrator the next morning (02/28/2016), as it was very late. During an interview on 03/13/2016 at 8:05 P.M., the Administrator indicated Staff #3 had reported Staff #2 taking pictures of them (Staff #3) despite being asked to stop on 02/26/2016. The Administrator indicated when she was informed, she had called the facility on 02/26/2016 immediately and spoken to Staff #2 and told him/her they were not to be taking pictures or using their phone in the facility. The Administrator further indicated she and the AIT (Administrator in Training) talked to Staff #2 the following Monday, 02/29/2016, and asked the staff member if she had taken any pictures of residents, to which he/she replied, no. The Administrator indicated Staff #2 had assured her that no pictures of residents had been taken, only pictures of staff. She indicated the staff had been inserviced about HIPAA (Health Insurance Portability and Accountability Act), privacy, and abuse on 02/29/2016, 03/01/2016, and 03/07/2016. The Administrator indicated she had never been told by any staff there was a video and/or picture of a resident or resident care. The Administrator further indicated the procedure for an allegation of abuse, such as pictures of residents being taken, included reporting the allegation and investigating by interviewing staff and residents. During an interview on 03/14/2016 at 1:20 P.M., the DON indicated a staff member had called her on Friday (02/26/2016) night and told her pictures were being taken in the facility. She indicated she was told by staff that the pictures were being taken of Staff #3 when he/she did not want to be photographed and there was a possibility of a picture being taken in the shower room, but the staff member was not sure. The DON indicated she did not ask further to confirm if any residents were in the pictures. The DON indicated she informed the Administrator via text message on 02/26/2016 and when she called to make sure the information had been received, the Administrator told her it had already been handled. The DON indicated the concern was not investigated as if residents were involved. She indicated the Administrator had handled the situation by calling the facility and informing staff that pictures were not to be taken in the facility, talking to second shift about not taking pictures, and telling second shift to inform the other shifts about not taking pictures. During an interview on 03/14/2016 at 3:33 P.M., the ADON indicated Staff #3 had brought the concern to her and to the Administrator at a different time that a video had been taken during resident care, but that she assumed it was just of the staff member and did not include the resident. The ADON indicated she did not ask if the video included the resident. The ADON further indicated residents were not interviewed regarding the allegations until this week (03/13/2016). The Concern Record, dated 02/26/2016, indicated an aide (Staff #3) said a coworker (Staff #2) was taking their picture and sending it to others. The Administrator immediately called the building and spoke with Staff #2 and reminded the staff that no cellphones were to be used in the building and photos could not be taken in the building at any time. The plan of action, starting 02/26/2016, included the Administrator and the AIT speaking with Staff #2 on 02/29/2016 regarding taking pictures of staff and/or residents, reviewing the policy regarding cellphones and pictures with Staff #2, and inservicing nursing staff on the cell phone/picture policy and procedure. There was no plan included to interview residents or other staff, or to suspend the accused staff member. The Abuse Prohibition, Reporting, and Investigation policy indicated, All reports of alleged abuse/abuse and all unusual occurrences, must be reported to the Administrator immediately, and to the resident's representative .as soon as feasibly possible, but no later than within 24 hours of the reporting or discovery of the incident . and .Violations .will be reported to the Long Term Care Division of the Indiana State Department of Health and other officials in accordance with state law . The Immediate Jeopardy began on 02/26/2016, was removed on 3/16/2016 when the facility completed interviews with resident and staff, educated staff regarding the abuse and immediate reporting of abuse. The Immediate Jeopardy was removed on 3/16/2016, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy because not all staff had been educated on abuse and immediate reporting of abuse. This Federal tag relates to complaint IN 395. 3.1-28(c) 3.1-28(d)

Based on interview and record review, the facility failed to ensure policy and procedures were followed in reporting an allegation of abuse by an employee towards a resident to the Indiana State Department of Health when a staff member video taped/took a picture of a resident without their consent for 1 of 11 residents reviewed for abuse in a sample of 11. (Resident #B) The Immediate Jeopardy began on the evening of 02/26/2016, when a staff member videotaped/took a picture of Resident #B's personal care and shared the video/picture on social media. The Administrator and the Quality Assurance Corporate Nurse were notified of the Immediate Jeopardy at 2:15 P.M., on 03/14/2016. The Immediate Jeopardy was removed on 3/16/2016, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: Starting on 02/26/2016, allegations of videos and/or photographs being taken during resident care were reported by staff to the Administrator, the DON, and the ADON. The investigation of these allegations only included interviewing the one identified staff member (Staff #2), who was not suspended at that time. Inservices were held for nursing staff following the incident. The allegations were not reported to the Indiana State Department of Health. The timeline, as reported by staff and administration, was as follows: On 02/26/2016, Staff #2 recorded Staff #3 providing personal care to Resident #B and shared it on social media with other employees, including Staff #1. After receiving the video/picture, Staff #1 reported to Staff #3 that he/she was videoed/photographed providing resident care. Staff #3 then brought the concern to Staff #4 that evening on 02/26/2016. Staff #4 immediately call the DON (Director of Nursing) on 02/26/2016 and the DON texted the Administrator the same night (02/26/2016). Following this text, the Administrator called the facility and informed Staff #2 he/she could not take pictures and/or videos and needed to delete any pictures/videos he/she had taken and that all staff needed to delete any pictures/videos that had been taken. The DON followed up with the Administrator on 02/26/2016 and was informed the concern had been handled. On 02/27/2016, Staff #3 brought the concern of being filmed/photographed during resident care to the Administrator. Also on 02/27/2016, Staff #7 was notified of a video and/or picture being taken during resident care and brought the concern to the Administrator the next morning on 02/28/2016. The Administrator and the AIT (Administrator in Training) spoke with Staff #2 on 02/29/2016 and questioned the staff member regarding taking pictures in the facility of staff and/or residents. On 02/29/2016, Staff #4 again informed the Administrator of the allegations of a video/picture being taken during personal care for Resident #B. Staff were inserviced regarding HIPAA (Health Insurance Portability and Accountability Act), privacy, and cellphones on 02/29/2016, 03/01/2016, and 03/07/2016. On 03/03/2016, Staff #5 heard concerns of a video/picture being taken of Resident #B being toileted and brought the concern to the ADON (Assistant Director of Nursing). During an interview on 03/13/2016 at 8:05 P.M., the Administrator indicated she had been informed of staff taking pictures of other staff in the facility on 02/26/2016, but was not aware staff had taken pictures and/or videos of residents except for a resident's hands. The Administrator indicated she had interviewed Staff #2 on 02/29/2016 regarding taking pictures in the facility and had inservices done for nursing staff regarding HIPAA (Health Insurance Portability and Accountability Act), privacy, and abuse on 02/29/2016, 03/01/2016, and 03/07/2016. During an interview on 03/14/2016 at 1:20 P.M., the DON indicated, after being informed pictures were being taken in the facility on 02/26/2016, she had not asked further to confirm if any residents had been included in the pictures. The DON indicated the concern had been investigated as if no residents had been involved. During an interview on 03/14/2016 at 3:33 P.M., the ADON indicated when the allegation of a video being taken during resident care had been brought to her, she had assumed the video had just been of the staff member and did not include a resident. The ADON further indicated residents had not been interviewed regarding the allegations until this week (03/13/2016). The current facility policy, titled Abuse Prohibition, Reporting, and Investigation and dated 07/15/2015, was provided by the Administrator on 03/14/2016 at 9:01 A.M. and was reviewed at that time. The policy indicated, .Miller's Health Systems has policies and procedures in place that ensures that all alleged violations involving mistreatment, neglect or abuse .are reported immediately to the Administrator of the facility and to other officials in accordance with State law through established procedures . and .has policies and procedures in place that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in process . The policy indicated the definition of sexual abuse included photographing a resident's Rectal (sic), genital or breast areas and the definition of mental abuse included humiliation. The policy further indicated mistreatment of [REDACTED]. The Abuse Prohibition, Reporting, and Investigation policy indicated, All reports of alleged abuse/abuse and all unusual occurrences, must be reported to the Administrator immediately, and to the resident's representative .as soon as feasibly possible, but no later than within 24 hours of the reporting or discovery of the incident . and .Violations .will be reported to the Long Term Care Division of the Indiana State Department of Health and other officials in accordance with state law . The current Investigation and Reporting to Correct Authority policy dated 07/15/ 2015, was provided by the administrator on 03/14/2016 at 9:01 A.M. and reviewed at that time. The policy indicated, .The Administrator, or designee, shall initiate and direct the investigation immediately, and within 5 days a report of this investigation must be forwarded to the Long Term Care Division of the Indiana State Department of Health .Any staff member implicated in the alleged abuse will be removed from the facility at once and will remain suspended until the investigation is completed. A thorough investigation will be initiated and employee conduct policies implemented as appropriate .Residents will be questioned (if alert and competent) about the nature of the incident, and their statements will be put in writing .An investigation will be completed to assure other residents have not been affected .This may involve interviewing staff members when appropriate . The current facility policy, titled Social Networking and dated 02/12/2010, was provided by the Quality Assurance Corporate Nurse on 03/14/2016 at 4:49 P.M. and was reviewed at that time. The policy indicated, .All posts should be respectful to .residents .Avoiding defamatory statements such as those containing images, photographs .that are offensive or sexually explicit .Social media activities are not authorized during working times or in working areas . The Immediate Jeopardy began on 02/26/2016, was removed on 03/16/2016 when the facility completed interviews with resident and staff, educated staff regarding the abuse and immediate reporting of abuse. The Immediate Jeopardy was removed on 3/16/2016, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy because not all staff had been educated on abuse and immediate reporting of abuse. This Federal tag relates to complaint IN 395. 3.1-28(a)

Based on observation, interview and record review, the facility failed to ensure psychosocial well-being of the resident was maintained related to inappropriate video/pictures of resident brief/toileting care, and pictures of residents without proper consent, by a staff member. This deficient practice affected 2 of 19 residents reviewed for abuse. (Resident #B and #C) Findings include: 1. During a confidential interview on 03/13/2016, Staff #1 indicated he/she had received a Snap (Snapchat name of video/picture program) of Resident #B's brief and stool. During a confidential interview on 03/13/2016, Staff #3 indicated Staff #2 was holding up his/her phone while Staff #3 was providing care to Resident #B. The staff member indicated he/she had not been aware that the care being provided was recorded at the time. Staff #3 reported to Staff #4 on 02/26/2016 that Staff #2 was video taping direct resident care. During a confidential interview on 03/13/2016, Staff #4 indicated on Friday, 02/26/2016, Staff #3 brought a concern to him/her about Staff #2 video taping during resident care. Staff #4 indicated they called the DON immediately and the DON was informed of the allegation, including the fact that a resident was filmed during care. During an interview on 03/13/2016 at 8:05 P.M., the Administrator indicated she had been informed of staff taking pictures of other staff in the facility on 02/26/2016, but was not aware staff had taken pictures and/or videos of residents except for a resident's hands. During a confidential interview on 03/14/2016, Staff #5 indicated he/she had heard rumors from several CNA's on 03/03/2016 that there was a video taken by staff of Resident #B being toileted. During a confidential interview on 03/14/2016, Staff #6 indicated he/she was present when a staff member had reported a video being taken of resident care to the DON and the Administrator the night the allegation occurred (02/26/2016). During an interview on 03/14/2016 at 1:20 P.M., the DON indicated, after being informed pictures were taken in the facility on 02/26/2016, she had not further confirmed if residents had been included in the pictures. The DON indicated the concern had been investigated as if no residents had been involved. During an interview on 03/14/2016 at 3:00 P.M., CNA #30 indicated he/she heard that staff were taking video/pictures of residents. CNA #30 further indicated he/she was shocked and would feel humiliated and angry if someone took her/his picture like the one taken of Resident #B. During an interview on 03/14/2016 at 3:30 P.M., CNA #33 indicated he/she would have been sad and upset if pictures/video had been taken his/her family members like that had been of Resident #B. He/She further indicated no one knows who could end up seeing the pictures. During an interview on 03/14/2016 at 3:33 P.M., the ADON indicated when the allegation of a video being taken during resident care had been brought to her, she had assumed the video had just been of the staff member and did not include a resident. Resident #B's clinical record was reviewed on 03/13/16 at 5:00 P.M. [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment, dated 02/05/16, indicated Resident #B was cognitively impaired, with a BIMS (Brief Interview for Mental Status) score of 04 out of a possible 15. Resident #B, required extensive assistance of two staff members for toilet use and total dependence for personal hygiene. Resident #B was noted to be frequently incontinent of bladder and occasionally incontinent of bowel. 2. Paperwork for the investigation conducted by the facility, including interviews and incident reports, was provided by the Regional Vice President on 03/17/2016 at 9:07 A.M. and was reviewed at that time. The investigation summary indicated CNA #26, CNA #27, and CNA #28 had their picture taken with a resident they were fond of. (Resident #C) The allegations of video/pictures were indicated to occur a few weeks prior to 03/15/2016 and on 02/26/2016 were reported by the facility to the Indiana State Department of Health on 03/15/2016. During an interview conducted by the facility on 03/15/2016 at 11:15 A.M., CNA #26 indicated there was a photo taken with herself, CNA #27, CNA #28 and Resident #C at least a month ago. The CNA further indicated Resident #C's family had not given her permission to take the photo. During an interview conducted by the facility on 03/15/2016 at 1:55 P.M., CNA #27 indicated CNA #26, CNA #28 and herself took a photo with Resident #C in the resident's room while Resident #C was fully clothed and awake. During an interview on 03/17/2016, the QA (Quality Assurance) Nurse #25 indicated two CNA's (CNA #26 and CNA #27) admitted to taking a picture with Resident #C. The QA Nurse indicated both CNA's reported Resident #C agreed to having the picture taken and the resident was sitting up in bed, fully clothed during the picture. QA Nurse #25 indicated Resident #C did not remember the incident involving having his picture taken. During an interview on 03/17/2016 at 10:40 A.M., the Regional Vice President indicated Resident #C was involved in a group selfie with a few of the staff. He further indicated taking a picture with Resident #C was considered unacceptable because the resident was mentally incapable of giving proper consent and did not remember the picture with staff occurring. Resident #C's most recent admission MDS (Minimum Data Set) assessment, dated 02/11/2016, indicated the resident had a BIMS (Brief Interview for Mental Status) of 13 and was cognitively intact. Resident #C's [DIAGNOSES REDACTED]. The current facility policy, titled Abuse Prohibition, Reporting, and Investigation and dated 07/15/2015, was provided by the Administrator on 03/14/2016 at 9:01 A.M. and was reviewed at that time. The policy indicated the definition of sexual abuse included photographing a resident's Rectal (sic), genital or breast areas and the definition of mental abuse included humiliation. The policy further indicated mistreatment of [REDACTED]. The current facility policy, titled Social Networking and dated 02/12/2010, was provided by the Quality Assurance Corporate Nurse on 03/14/2016 at 4:49 P.M. and was reviewed at that time. The policy indicated, .All posts should be respectful to .residents .Avoiding defamatory statements such as those containing images, photographs .that are offensive or sexually explicit .Social media activities are not authorized during working times or in working areas . This Federal tag relates to complaint IN 395. 3.1-27(a)(1)

Based on observation, interview, and record review, the facility failed to thoroughly assess, monitor, treat, and seek new treatment orders for a skin rash, which led to the resident yelling out in pain when incontinence care was provided and led to rash area worsening for 1 of 2 residents reviewed for wounds in a sample of 3. (Resident A) Findings Include: During initial observation tour on 10/17/11 at 11:40 a.m., with LPN (Unit Manager) #1 present, Resident A was identified by LPN #1 as being confused, not reliable for interview, required 1 staff for assistance, was propelled in a wheelchair by staff, had [MEDICAL CONDITION] on her legs and a rash on her bottom which was being treated with Dermafungal ointment. On 10/17/11 at 1:00 p.m., Resident A was observed seated in her recliner. The resident's family was present in the room and indicated the resident had just been transferred from her wheelchair to her recliner. The resident's wheelchair was observed to not have any type of cushion in the seat of the chair. On 10/17/11 at 3:45 p.m., CNA #1 and CNA#2 were observed to transfer the resident from the resident's wheelchair to a bathroom commode. The resident was observed to not have any type of cushion in her wheelchair. The CNA's were observed to remove a wet brief. The brief appeared to be heavy with urine and had a dark yellow/tan discoloration in the groin area of the brief. While the CNA's performed incontinence care, the resident yelled out, "OW that hurts." The resident's entire groin area appeared to be dark purple in color. Her inner buttocks was reddened with a rash and two pinpoint open dark red areas. CNA #2 indicated "You (Resident A) are really red down there." The CNA's indicated they didn't normally work on the hall Resident A resided on. CNA #1 indicated she remembered the resident had a "little bit" of redness when she returned from the hospital, but that it had been awhile since she had taken care of Resident A. CNA #2 indicated she was going to look for some creme. The CNA returned with a tube of "Sensicare Creme" (barrier creme) and applied the creme to the resident's bottom and groin area. The resident yelled out in pain when this creme was applied. There was no "Dermafungal Creme" in the resident's drawer. Interview of CNA #1 on 10/17/11 at 4:52 p.m., indicated she was told that Resident A had diarrhea "a few days ago." CNA #1 indicated when Resident A was incontinent "We wash her and put the Sensicare on her." We don't necessarily tell the nurse every time she's (Resident A) incontinent but we tell the nurse when the area is worse . We told the nurse about the pin point areas. Interview of RN #1 on 10/17/11 at 5:00 p.m., indicated she had just done a treatment on Resident A's bottom. RN #1 indicated she had applied a [MEDICATION NAME] dressing to the new open area on the resident's bottom. RN #1 indicated she did not look at the resident's groin area. RN#1 indicated Resident A received a treatment just once a shift for her bottom and anytime anybody puts something on the resident's bottom after she is incontinent was fine. RN #1 indicated the Sensicare was a good barrier creme and it was fine for the CNA's to use this creme on the resident's bottom. RN #1 was observed to transfer Resident A from her recliner to her wheelchair. No cushion was observed in the resident's wheelchair. During daily exit conference with the Administrator and the DON (Director of Nursing) on 10/17/11 at 5:30 p.m., the DON indicated she thought Resident A had a cushion for her wheelchair. Documentation of skin area descriptions was requested from the DON at this time. Interview of RN #2 (Charge Nurse on hall Resident A resided on) on 10/18/11 at 9:00 a.m., indicated she had not checked the resident's skin yet, but the CNA's did. RN #2 indicated she did not look at the resident's inner groin area yesterday. Interview of LPN #2 (MDS nurse) on 10/18/11 at 9:07 a.m., indicated the facility did not have a wound nurse, but each resident was given a head to toe assessment weekly, which was done by the charge nurse. LPN #2 indicated after the red galled area was reported yesterday, she and LPN #1 (Unit Manager) "went in & assessed (Resident A's) skin and wrote up assessment and received new order." LPN #2 indicated when the resident was admitted from the hospital she had a rash with "closed satellite pustules." LPN #2 indicated the resident had received a lot of antibiotics in the hospital. LPN #2 indicated she had not looked at the resident's inner thigh yet. On 10/18/11 at 9:35 a.m., with the DON, RN #2 and LPN #2 present, Resident A was transferred from her bedside chair to her bed for observation of her skin. The resident's inner buttocks was observed to be reddened with dark red area around the edges. The resident's labia and groin area were observed to be reddened. The resident yelled out in pain when Dermafungal (an anti-fungal ointment for wound treatment) was applied. Interview of LPN #2 on 10/18/11 at 11:45 a.m., indicated staff were using both the [MEDICATION NAME] (anitfungal powder) and the Dermafungal. LPN #2 indicated treatment was being done daily and staff were monitoring, but do not document unless something is new or there is a change or if a treatment was not working. LPN #2 indicated she thought CNA's were calling the whole area "buttocks." LPN #2 indicated the resident's MDS and care plan were due to be updated "today." Interview of LPN #1 (Unit Manager) on 10/18/11 at 12:10 p.m., indicated Resident A's doctor was not notified of the resident's reddened labia and inner thighs because it was not a change. LPN #1 indicated CNA's monitor residents skin during showers and mark on the shower sheets if there is a change in the residents skin. Copies of Resident A's shower sheets were provided by LPN #1 on 10/17/11. A shower sheet, dated 10/06/11, indicated Resident A had a "rash" on her buttocks. A shower sheet, dated 10/08/11, indicated Resident A's buttocks were "a little red." A shower sheet, dated 10/10/11, indicated Resident A had a "rash" on her buttocks. A shower sheet, dated 10/13/11, indicated Resident A had a "rash" on her buttocks. A shower sheet, dated 10/15/11, indicated Resident A had no skin issues, breakdown, or redness. This shower sheet was signed by LPN #1. Interview of RN #2 (Charge Nurse on floor Resident A resided ) on 10/18/11 at 12:30 p.m., indicated she was not aware the resident had a reddened inner peri area and inner thighs until this morning. RN #2 indicated she would have had the CNA's put the Dermafungal on after the resident was incontinent had she known when the resident was incontinent. RN #2 indicated the Dermafungal was in kept in stock at the facility. Review of Resident A's clinical record on 10/17/11 at 12:00 p.m., indicated the resident had [DIAGNOSES REDACTED]. A "...Nursing -Transfer to hospital" form, dated 10/01/11 at 12:47 a.m., indicated, "...Resident yelled out for help to get up and walk to bathroom. This nurse assisted. Resident having increased difficulty with gait....complaints voiced of difficulty breathing and this nurse noted increase in respiratory rate....O2 (oxygen) sats (saturation) 66% room air...O2 (Oxygen) applied at 3 LPN (liters per nasal cannula) then O2 sats 76%...increased O2 to 4 LPN then O2 sats 88-90%....Lung sounds coarse throughout....complaints of feeling hot. Notified MD on call and new order received to send to ER (emergency room )." A weekly assessment form, dated 10/5/11, (day the resident returned from the hospital to the facility) indicated a section titled "New skin Alteration Findings." This section had areas to check mark for any "new wound noted" and "New rash/Excoriation." These areas were not check marked. This section also had areas for nursing to document descriptions/locations of any wounds. These areas were left blank. An "Admission Information, sheet, dated 10/05/11, included, but was not limited to, a section for skin issues. This sections was check marked in a box beside the words "rash/excoriation." This section also included "List Type of alteration(s); location(s); Measurement-length, width, depth; Description: Documented in this area was, "bottom has incontinence [MEDICAL CONDITION], resident arrived and was incontinent of bowel and bladder upon arrival." No measurements or other description was documented. The information sheet lacked documentation indicating any other reddened or rash areas other than the resident's bottom. A physician's orders [REDACTED]." A physician's telephone order, dated 10/05/11, indicated, "....Apply Dermafungal Q (every) shift &...(after) ea (each) incont (incontinent) episode." A physician's orders [REDACTED]." A "...Daily Nursing-assess (assessment).....,"dated 10/11/11, indicated Resident A had no "New Skin Alteration Findings." Check mark areas for these sections were blank. This assessment lacked documented description and measurements of the rash areas. A Medicare MDS (Minimum Data Set) assessment, dated 10/12/11, indicated Resident A had cognitive impairment; required extensive assistance of staff for transfers, hygiene, and bathing; was frequently incontinent of bowel and bladder. The assessment indicated Resident A was at risk for skin break down and was receiving application of ointments other than to her feet. A "ViewProgress (sic) Note," dated 10/16/11 at 20:40 (8:40 p.m.)., was provided by the DON on 10/18/11 at 9:30 am. This note indicated, "Resident (Resident A) has been crying and yelling out for help and then has difficulty remembering what she was yelling for....Groin and buttock red from frequent incontinence. Changed frequently; [MEDICATION NAME] powder applied." A care plan (not dated) indicated, "At risk for skin breakdown D/T (due to) incontinence & Alzheimer dementia. Approaches for the care plan were Monitor skin Q (every) shift for S/SX (signs/symptoms) of potential skin breakdown (E.G. redness/discoloration or open areas. Alert charge nurse if observed for notification of physician as needed to obtain TX (treatment) orders...." A care plan, (not dated), indicated, "Resident is incontinent of urine frequently & uses incont (incontinent) briefs, is at risk for UTI (urinary tract infection)." The short term goal for this care plan was "resident will remain free of UTI." Interventions for this care plan were, "Medicate as ordered with....Monitor for S/Sx (signs/symptoms) of UTI (c/o (complaints) of pain/burning...Assist to toilet upon rising, before and after meals at bedtime on command." A Medication Record for October, 2011 indicated Resident A received the Dermafungal treatment daily - once a shift on 10/06/11 through 10/17/11. The Medication Record lacked documentation supporting Resident A receiving the Dermafungal treatment after incontinent episodes. The Medication Record indicated Resident A received the [MEDICATION NAME] Powder 4 times daily from 10/06/11 - 10/17/11. A physician's orders [REDACTED]." A copy of a wound assessment was provided by LPN #1 on 10/18/11 at 10:40 a.m. The wound assessment, indicated, " Type of wound: Incontinence associated [MEDICAL CONDITION] of wound: area is on anterior side of right buttocks." The assessment indicated the area measured 0.1 centimeters by 0.1 centimeters in length and width and the area was 0.1 centimeters in depth. The date and time of this assessment was 10/17/11 at 4:46 p.m. The assessment lacked documentation supporting whether or not the resident's groin area and perineum reddened/rash areas were assessed by nursing. An updated care plan was found in the front of Resident A's clinical record on 10/18/11 at 10:00 a.m. The care plan indicated, "Focus - 10/5/11 Location - bilateral buttocks with [DIAGNOSES REDACTED] (diffused redness over the skin) and closed satellite pustules scattered throughout due to incontinence while at acute hospital - 10/17/11 actual skin breakdown due to incontinence on bilateral buttocks. This care plan indicated, "Date initiated: 10/5/2011...Revision on: 10/18/11." Interventions on this care plan included, "Nurse to measure/assess weekly & notify family & physician as needed....administer topical treatment to bilateral buttocks as per MD order...Administer treatment - clean with normal saline - apply [MEDICATION NAME] and change every 3 days and PRN as ordered - Provide with pressure reducing device to chair." The "Goals" for this care plan were to show reduction in size of open area and show no signs of infection. Interview of the DON (Director of Nursing) on 10/18/11 at 12:00 p.m., indicated the Nurse Practitioner was in with Resident A to look at the rash areas. The DON indicated nursing staff toileted Resident A every 2 hours. A physician's telephone order, dated 10/18/11 (no time documented), indicated, "cleanse area on (R) buttocks c NS (normal saline). Apply [MEDICATION NAME], change q 3 days and PRN. Continue current treatment to peri-area, groin and rash/excoriated area q shift and PRN. Difflucan (oral anti-fungal medication) 100 mg (milligrams) ii (2) tabs po (by mouth) today then i (1) po qd (every day) x (time) 4 days. This order was written by the Nurse Practitioner. A policy titled "Wound & Non-Would Assessment & Documentation" was provided by LPN #1 on 10/17/11 at 4:00 p.m. The policy was dated 11/02/10. The policy indicated, "...Non-Wound Skin Alterations...All non-wound skin alterations, as defined below, will be managed by the licensed staff nurses. Initial assessment and documentation will be completed on the 'Nursing-New skin alteration assessment' or if on a new admit on the 'Nursing-admission/return assessment' or if due to an occurrence on the 'nursing occurrence initial assessment' or on the 'nursing daily assessment...The non-wound area will be placed on the TAR (Treatment Administration Record) with instructions to monitor at least daily until it is healed....Definition of non-wounds: .....Rash - skin eruption caused by allergy or irritation. Dermis (skin) is rough or bumpy and reddened. Pain or itching may be present....." This Federal/State Finding relates to Complaint IN 083. 3.1-37(a)