Every finding on record at Munster Med-Inn

Based on record review and interview the facility failed to implement measures to prevent resident-to-resident verbal and physical abuse to a cognitively impaired dependent resident (Resident C) by his roommate (Resident B), who had a history of behaviors and recent verbal abuse toward Resident C, resulting in a physical altercation where Resident B struck Resident C in the face causing observed bruising, a bloody nose and swelling to his left jaw and cheek as well as facial fractures for 2 of 8 residents reviewed for abuse. The immediate jeopardy began on 12/11/25 when a resident with a history of known physical and verbal behaviors was involved in a resident-to-resident verbal altercation with his roommate, which later escalated on a different day into a resident-to-resident physical altercation causing harm and a fractured facial bone. The Administrator, Director of Nursing, [NAME] President of Operations, and Nurse Consultant were notified of the immediate jeopardy at 5:20 p.m. on 1/27/26. The immediate jeopardy was removed, and the deficient practice corrected on 12/29/25, prior to the start of the survey, and was therefore Past Noncompliance.Finding includes: a. The record for Resident B was reviewed on 1/22/26 at 9:40 a.m. Diagnoses included, but were not limited to, vascular dementia with behaviors, chronic kidney disease stage 4, traumatic subdural hemorrhage (brain bleed), hemiplegia (weakness) on the right side, delusional disorder, intellectual disabilities, psychotic disorder with delusions, and anxiety.The 9/2/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident had no behaviors and was moderately impaired for daily decision making. A Behavior Note, dated 10/9/25 at 10:46 a.m., indicated the resident was observed ambulating around his room without assistance. The staff responded to the resident and tried to assist him to the wheelchair, as he became verbally aggressive with staff, yelling and threatening them. A Behavior Note, dated 10/15/25 at 3:37 a.m., indicated the resident got out of bed again. While attempting to assist him back to bed, he grabbed the staff's wrist and squeezed it hard. A Behavior Note, dated 10/16/25 at 1:57 p.m., indicated the resident was sitting in the dining room and started yelling aggressive words across the room. A Behavior Note, dated 11/3/25 at 9:18 a.m., indicated the resident was being pulled up in bed by 2 CNAs and spit on both. The Annual MDS assessment, dated 11/12/25, indicated the resident was moderately impaired for decision making. The resident had little interest in doing things, felt down and tired, and had trouble concentrating. The resident had not displayed any hallucinations or delusions, but had physical, verbal and other behaviors that occurred in the last 1 to 3 days during the assessment reference period. The resident's behaviors significantly interfered with care and activities and had an impact on others of significant risk of physical injury, disruption of care and the living environment. The resident's behaviors had worsened since last assessment, and he needed substantial to max assist with transfers. The resident received antipsychotic, antianxiety, antidepressant, and anticonvulsant medications. A Care Plan, revised on 11/20/25, indicated the resident displayed verbal behavioral symptoms not directed toward others as evidenced by yelling and using profanity towards self. The approaches were to separate the resident from others as needed. A Care Plan, revised on 11/20/25, indicated the resident was at risk for complications related to receiving antipsychotic medications due to behavior management. The approaches were to monitor/record occurrence of for target behavior symptoms (Specify: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. etc.) and document per facility protocol. A contracted Behavioral Nurse Practitioner (NP) note, dated 11/5/26 at 11:00 p.m., indicated they received a call from social service regarding the resident and he continued to exhibit more agitated behaviors and fluctuation in mood. The medication of Depakote (an anticonvulsant used for mood disorders) would be restarted as it was previously discontinued as part of a gradual dose reduction. A Behavior Note, dated 11/6/25 at 11:21 a.m., indicated the resident was observed spitting on staff during care. A Behavior Note, dated 11/28/25 at 3:45 p.m., indicated the resident was observed in activities. At that time, he started to yell an outburst about killing. The resident was moved to a different seat but the outbursts and yelling continued. He was moved to the hallway. There was no other documentation or interventions done after the resident had the outburst about killing. A Medication Administration note, dated 12/3/25 at 11:12 p.m., indicated the resident was yelling at roommate while roommate was sleeping, prn (as needed) Lorazepam (an antianxiety medication) 0.5 milligrams (mg) given for agitation and anxiety. A Medication Administration note, dated 12/5/25 at 1:28 a.m., indicated the resident was yelling at roommate, prn Lorazepam 0.5 milligrams given for agitation and anxiety. A Behavior Note, dated 12/11/25 at 2:38 a.m., indicated, Writer heard resident yelling, went in to check on resident. Resident was standing up hovering over roommate yelling. CNAs and writer assisted resident back into bed, PRN lorazepam given. Resident in bed relaxing, safety measures in place. There were no additional interventions put into place and Resident B was not moved to another room after he was observed yelling and hovering over Resident C on 12/11/25. An Incident Note, dated 12/28/25 at 11:10 p.m., indicated Resident was involved in a physical altercation with his roommate. Residents were separated and body assessment completed. [Resident B] has no injuries. Resident was placed on 1:1 supervision. Resident sister and MD were notified and orders received to transfer resident to emergency room for psych evaluation. Report called in to ER nurse. (sic) A Nurses' Note, dated 12/29/25 at 2:42 p.m., indicated Resident B would be transferred to a neuro psych hospital by ambulance in 30 minutes. The facility IDOH (Indiana Department of Health) incident report, dated 12/28/25, indicated Resident B and Resident C were in a physical altercation, both were immediately separated. The nurse assessed Resident C and he was noted with facial bruising/discoloration and some bleeding from his nose. Resident B had no injuries; however, both residents were sent to the emergency room. The police, physician, and family were all notified. The follow up investigation indicated both residents resided in the memory care unit and were roommates. The incident was not witnessed, however upon entering the room the CNA observed Resident B to have blood on his clothing and Resident C had blood around his nose with redness and discoloration to the side of his face. Resident C could not initially articulate what had happened, however, upon re-questioning, admitted something had occurred but indicated his roommate did not want to speak about it. Review of the facility's investigation indicated all staff on shift at the approximate time of the incident were interviewed. It was determined that staff provided care to both residents at approximately 9:45 p.m., and both residents were resting quietly in bed. At approximately 11:10 p.m., the CNA was doing initial rounds after shift change and found the residents in the above-mentioned condition. Both residents were sent to the hospital, and Resident C sustained a depressed fracture involving the anterior wall of the left maxilla (upper jawbone) and associated maxillary hemorrhage (bleeding). He returned to the facility that day, and Resident B was transferred to an inpatient neuro psych facility. A facility documented interview from CNA 1 indicated changed both of them on 8 am and 8:30 pm, had a family emergency and had to leave around 10:30 pm, heard loud yelling from a male voice stating something like turn off the light I did not know who it was and I was in the lounge area did not think anything of it due to residents yelling all the time. (sic)A facility documented interview from LPN 1 indicated I started working that side about 8 pm when other nurse left. Did not see much of them during the shift. Right at shift change Resident B yelled out something but I could not make out what happened, it was like jibberish [sic]. He was in his room. I am not sure if the aide went to his room, but I did not. I never saw him display any aggressive behavior toward staff for residents. The other nurse gave his meds. I was in the hallway around 10 pm. There were still residents up in the dining room, so we were getting them together to go to bed. Resident B is known to yell out. The police report, dated 12/28/25 at 11:19 p.m., indicated responded to call from the facility in reference to assault that just occurred. They called stated that one of the residents attacked his roommate. The victim was observed laying [sic] in bed with a bloody face and multiple bruises and swelling to the face and mouth area. He was unaware of what happened due to reported dementia . The incident occurred between 10 p.m. and 11 p.m.A CAT scan (diagnostic imaging test using X-rays and a computer to create detailed 3D pictures of bones, organs, and tissues) of the facial bones was completed at the hospital for Resident C on 12/29/25. The impression was 6 mm (millimeter) depressed fracture involving the anterior wall of the left maxilla (upper jawbone/cheek) with associated maxillary hemorrhage (bleeding). b. The record for Resident C was reviewed on 1/27/26 at 12:05 p.m. Diagnoses included, but were not limited to, dementia, anxiety, and Alzheimer's Disease. The 11/14/25 Quarterly MDS assessment indicated the resident was not cognitively intact for daily decision making and needed substantial to max assist with ADLs. During an interview on 1/27/26 at 2:00 p.m., the Director of Nursing indicated she was not aware of the incident that happened on 12/11/25. She indicated staff were to report to her or the Administrator of any new or worsening behaviors. During an interview on 1/27/26 at 2:00 p.m., the Nurse Consultant indicated she was unaware of the incident that happened on 12/11/25 as well and staff were to report any new behaviors a resident exhibited. The behavior policy had not changed, and it was the same one in place when both incidents happened. Staff were inserviced regarding behavior reporting during all staff meetings and were also assigned some computer training. There was no 5th Floor Unit Manager during both incidents and the unit managers on floors one through four were all overseeing some aspect of resident care for the fifth floor. The Memory Care Director was also to oversee behaviors. During an interview on 1/27/26 at 2:20 p.m., the Memory Care Director indicated she was not aware of the incident on 12/11/25 when Resident B was observed yelling and hovering over Resident C in their room. She indicated staff were to let her know of any type of behavior any of the residents displayed. During an interview on 1/28/26 at 3:30 p.m., CNA 1 indicated she was taking care of Resident B and Resident C on 12/28/25. She told the nurse she received many phone calls from home and had to leave early at 10:30 p.m., due to a family emergency. It was her first time working on the memory care unit, so she was not familiar with any of the residents. She was told by other staff that Resident B yells out all the time. She checked on all her residents before she left and that was before 10:00 p.m. She was in the lounge (located right across from Residents B and C's room) on the phone with her family and she heard Resident B yelling, however, the nurses were in the hallway, so she did not feel she had to get up and check on him, because they were standing right there, so she remained on the phone with her family dealing with the emergency. The current 12/31/24 Behavior Management policy, provided by the Assistant Administrator on 1/27/26 at 9:00 a.m., indicated when a resident exhibited behaviors, it was the responsibility of the staff member that witnessed the behavior to report it to the resident's care staff and document the behavior accordingly. If the behavior was disruptive to others, the resident should be temporally separated from others.The current 9/1/24 Abuse Prevention and Reporting policy, provided by the Assistant Administrator on 1/27/26 at 9:00 a.m., indicated the resident had the right to be free from abuse and neglect. Any incident or allegation involving abuse or neglect will result in an investigation and should be documented. All alleged violations involving abuse or neglect were reported to the Administrator immediately but not later than two hours after the allegation was made. The past noncompliance immediate jeopardy began on 12/11/25. The immediate jeopardy was removed and the deficient practice corrected by 12/29/25 after the facility implemented a systemic plan that included the following actions: The facility immediately put a plan of correction into place and had a quality assurance meeting with the department heads. All staff were then inserviced on the different types of abuse and reporting abuse. Staff were also inserviced on the behavior management program for any resident with new or worsening behaviors and when and who to report those behaviors. The residents were separated and Resident B returned to a private room on a different floor. This citation relates to Intakes 2698383, 2704995, 2705043, and 2710478.3.1-27(a)(1)

Based on record review and interview, the facility staff failed to report resident-to-resident verbal abuse from a resident with known behaviors (Resident B) towards his roommate (Resident C) to administration, which resulted in a lack of interventions to prevent later physical abuse for 2 of 8 residents reviewed for abuse. (Residents B and C) The immediate jeopardy began on 12/11/25 when a resident with a history of known physical and verbal behaviors was involved in a resident-to-resident verbal altercation with his roommate, which later escalated on a different day into a resident-to-resident physical altercation causing harm and a fractured jawbone. The Administrator, Director of Nursing, [NAME] President of Operations, and Nurse Consultant were notified of the immediate jeopardy at 5:20 p.m., on 1/27/26. The immediate jeopardy was removed, and the deficient practice corrected, on 12/29/25, prior to the start of the survey and was therefore Past Noncompliance. Finding includes:The record for Resident B was reviewed on 1/22/26 at 9:40 a.m. at 9:40 a.m. Diagnoses included, but were not limited to, vascular dementia with behaviors, chronic kidney disease stage 4, traumatic subdural hemorrhage (brain bleed), hemiplegia (weakness) on the right side, delusional disorder, intellectual disabilities, psychotic disorder with delusions, and anxiety.The 9/2/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident had no behaviors and was moderately impaired for daily decision making. The Annual MDS assessment, dated 11/12/25, indicated the resident was moderately impaired for decision making. The resident had little interest in doing things, felt down and tired, and had trouble concentrating. The resident had not displayed any hallucinations or delusions, but had physical, verbal and other behaviors that occurred in the last 1 to 3 days during the assessment reference period. The residents' behaviors significantly interfered with care and activities and had an impact on others of significant risk of physical injury, disruption of care and the living environment. The resident's behavior had worsened since last assessment, and he needed substantial to max assist with transfers. The resident received antipsychotic, antianxiety, antidepressant, and anticonvulsant medications. A Care Plan, revised on 11/20/25, indicated the resident displayed verbal behavioral symptoms not directed toward others as evidenced by yelling and using profanity towards self. The approaches were to separate the resident from others as needed. A Care Plan, revised on 11/20/25, indicated the resident was at risk for complications related to receiving antipsychotic medications due to behavior management. The approaches were to monitor/record occurrence of for target behavior symptoms (Specify: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. etc.) and document per facility protocol. A Medication Administration note, dated 12/3/25 at 11:12 p.m., indicated the resident was yelling at roommate while roommate was sleeping, prn Lorazepam (an anti-anxiety medication) 0.5 milligrams (mg) given for agitation and anxiety. A Medication Administration note, dated 12/5/25 at 1:28 a.m., indicated the resident was yelling at roommate, prn Lorazepam 0.5 milligrams (mg) given for agitation and anxiety. A Behavior Note, dated 12/11/25 at 2:38 a.m., indicated Writer heard resident yelling, went in to check on resident. Resident was standing up hovering over roommate yelling. CNAs and writer assisted resident back into bed, PRN lorazepam given. Resident in bed relaxing, safety measures in place. There were no new interventions, and Resident B was not moved to another room after he was observed yelling and hovering over Resident C. There were no documented notifications to the Director of Nursing, Administrator or charge nurse or interventions implemented after all the above incidents. Both residents remained in the same room. An Incident Note, dated 12/28/25 at 11:10 p.m., indicated Resident was involved in a physical altercation with his roommate. Residents were separated and body assessment completed. [Resident B] has no injuries Resident was placed on 1:1 supervision. Resident sister and MD were notified and orders received to transfer resident to emergency room for psych evaluation. Report called in to ER nurse. (sic) Per the facility investigation, Resident C was sent to the hospital and diagnosed with a depressed fracture involving the anterior wall of the left maxilla (upper jawbone) and associated maxillary hemorrhage (bleeding).Cross reference F600. During an interview on 1/27/26 at 2:00 p.m., the Nurse Consultant indicated she was unaware of the incident that happened on 12/11/25 as well and staff were to report any new behaviors a resident has. The behavior policy had not changed, and it was the same one in place when both incidents happened. Staff were inserviced regarding behavior reporting during all staff meetings and had additional computer training. There was no 5th Floor Unit Manager during both incidents and the unit managers on floors one through four were all overseeing some aspect of resident care for the fifth floor. The Memory Care Director was also to oversee behaviors. During an interview on 1/27/26 at 2:20 p.m., the Memory Care Director indicated she was not aware of the incident on 12/11/25 when Resident B was observed yelling and hovering over Resident C in their room. She indicated staff were to let her know of any type of behavior any of the residents displayed. During an interview on 1/28/26 at 6:13 a.m., LPN 2 indicated she was the nurse on duty 12/11/25 and was taking care of both residents. The resident yelled all the time, so that was nothing new, however, she did not report that Resident B was observed hovering over Resident C's bed and yelling at him to anyone. At that time, there was no 5th floor unit manager. During an interview on 1/28/26 at 7:18 a.m., RN 1 indicated she was primarily the full time day shift nurse on the fifth floor (memory care unit). She was unaware of the incident that took place on 12/11/25 between Resident B and Resident C. There was supposed to be an end of shift report given to the oncoming nurse so if there were any new or worsening behaviors a resident had exhibited, it should have been passed down to the next shift so they would be able to monitor them. During an interview on 1/28/26 at 11:30 a.m., Nurse Consultant 1 indicated a behavior management meeting was held monthly with the NP from the contracted behavioral center, the pharmacist, the Memory Care Director, some of the nurse managers and the Director of Nursing. They primarily discuss GDR (gradual dose reduction) actions for residents and would review behaviors. She was unsure if the resident was reviewed after the 12/2025 incidents. The current 12/31/24 Behavior Management policy, provided by the Assistant Administrator on 1/27/26 at 9:00 a.m., indicated when a resident exhibited behaviors, it was the responsibility of the staff member that witnessed the behavior to report it to the resident's care staff and document the behavior accordingly. If the behavior was disruptive to others, the resident should be temporally separated from others.The past noncompliance immediate jeopardy began on 12/11/25. The immediate jeopardy was removed and the deficient practice corrected by 12/29/25 after the facility implemented a systemic plan that included the following actions: The facility immediately put a plan of correction into place and had a quality assurance meeting with the department heads. All staff were then inserviced on the different types of abuse and reporting abuse. Staff were also inserviced on the behavior management program for any resident with new or worsening behaviors and when and who to report those behaviors. This citation relates to Intakes 2698383, 2704995, 2705043, 2710478.3.1-28(c)

Based on observation, record review, and interview, the facility failed to ensure a resident assessed without limited range of motion upon therapy discharge received recommended restorative services resulting in the development of a contracture to the right hand for 1 of 4 residents reviewed for range of motion. (Resident M)Finding includes:During random observations on 1/20/26 at 12:41 p.m., on 1/21/26 at 9:12 a.m.,1/22/26 at 9:24 a.m. and 1:18 p.m., and on 1/23/26 at 8:00 a.m. and 8:17 a.m., Resident M was observed in bed. At those times, the resident's right hand was closed in the shape of a fist. The resident indicated he could not move that hand or open it. There was no anticontracture device observed in his hand. The record for Resident M was reviewed on 1/23/26 at 11:05 a.m Diagnoses included, but were not limited to, stroke, monoplegia of upper limb affecting right side and dementia. The 12/2/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and had a functional limited range of motion to his upper extremity on one side. A Care Plan, dated 12/12/25, indicated the resident was at risk for complications related to the diagnosis of a stroke. The approaches were monitor any changes, weakness, or paralysis of an extremity. An Occupational Therapy (OT) evaluation and plan of treatment for the certification period of 4/3/25 through 6/26/25 indicated the resident's right upper extremities range of motion and strength, shoulder, elbow and wrist were impaired, however there was no contracture.An Occupational Therapy Discharge summary, dated [DATE], indicated the discharge recommendations were for 24 hour care with restorative program. Restorative program for active range of motion exercises on left upper extremity and passive range of motion to right upper extremity.During an interview on 1/23/26 at 11:19 a.m., the Restorative Nurse indicated she was unaware of the recommendation for restorative therapy. When she received a paper for a restorative referral, she would then evaluate the resident to see if they were a candidate, sometimes she would pick them up and sometimes she wouldn't. During an interview on 1/23/26 at 12:06 p.m., Occupational Therapist (OT) 1 indicated Resident M did not have a contracture back in June 2025, he was seen by OT and at that time there was a referral to restorative nursing, however, he was unsure if he was picked up by restorative when released by OT. He indicated he would evaluate him today and will pick him for active therapy to see what he can do about the right hand. During an interview on 1/23/26 at 1:53 p.m. OT 1 indicated he had just evaluated the resident and picked him for a right hand contracture. During an interview on 1/27/26 at 2:00 p.m., the Director of Nursing had no additional information to provide. 3.1-42(a)(1)

Based on record review and interview, the facility failed to ensure the mandatory submission of staffing information, based on payroll data, was electronically submitted to iQIES. This had the potential to affect the 164 residents who resided in the facility. The deficient practice was corrected on 12/18/25, prior to the start of the survey, and was therefore past noncompliance. The facility identified the concern and immediately reviewed all PBJ data for the affected submission period. All previous submissions were audited and all prior submissions had been submitted and received timely. Administrative staff responsible for PBJ submission were re-educated immediately on CMS PBJ requirements and submission timelines. A standardized PBJ submission process was implemented, including monthly internal deadlines ahead of CMS due dates. All PBJ submission information will be reviewed by [NAME] President (VP) of Operations, VP of Quality Measures, and Senior HR director 15 days prior to CMS submission due date. A second audit will be completed by Senior HR director 5 days prior to CMS submission due date to ensure that all submissions are transmitted and received timely. Finding includes:Nurse Staffing information was reviewed on 1/27/26 at 10:00 a.m. The CMS Payroll Based Journal (PBJ) Staffing Data report for FY Quarter 4 2025 indicated the facility failed to submit data.During an interview on 1/27/26 at 4:20 p.m., the [NAME] President (VP) of Operations indicated he was able to pull up the submission log of PBJ for the 4th quarter for the facility. The information from iQIES indicated there was a connection error and files failed to send. He indicated Nurse Consultant 2, the Human Resource (HR) Director Consultant, and himself all sit down quarterly and go over all the schedules before submitting to iQIES. During an interview on 1/27/26 at 4:20 p.m., Nurse Consultant 2 indicated she had called iQIES on 12/17/25 and they informed her it was the facility's responsibility to make sure the PBJ was transmitted and submitted. She indicated the HR Director, the VP of Operations and herself met on 11/11/25 to finalize the 4th quarter PBJ as it was due on 11/14/25. She did not check to ensure submission had gone through.

Based on observation, record review and interview, the facility failed to ensure infection control practices were in place and implemented related to wearing gloves in the hallway, not changing gloves after providing incontinence care and bathing, not wearing personal protective equipment (PPE) in enhanced barrier precaution rooms, and failing to disinfect multi-use equipment during random infection control observations. (Resident 128 and Second and Third Floor)Findings include:1. During a random observation on 1/22/26 at 1:57 p.m., Housekeeper 1 was observed on the Second Floor wearing gloves in the hallway. She proceeded to the soiled utility room to dispose of some garbage. She continued to wear the gloves after exiting the soiled utility room. She then proceeded to the nurse's station carrying a broom and was wearing the same pair of gloves. At 2:08 p.m., the Housekeeper was pushing her cart down the odd hall and was wearing gloves. At 2:14 p.m., the Housekeeper continued to walk up and down the odd hall while wearing gloves. During an interview on 1/27/26 at 2:00 p.m., the Nurse Consultant indicated the Housekeeper should not have been wearing gloves in the hallway. 2. During a partial bed bath observation on 1/22/26 9:58 a.m., CNA 3 entered Resident 128's room and donned a pair of clean gloves to both hands. The resident was observed lying in bed and had a peg tube (a tube inserted directly into the stomach for nutrition). The enteral feeding was turned off at that time. The CNA did not don an isolation gown prior to the start of the bed bath. The CNA filled the yellow wash basin with water and soap and then removed her covers and the hospital gown. She washed her face, under her arms, and her abdomen. The CNA then unfastened the strap on her brief and rolled her over to the left side. She removed it and there was a large amount of fresh bowel movement inside the brief. CNA 3 proceeded to clean the resident's buttocks and peri area with the same water and gloved hands. After providing incontinence care and with the same gloved hands, she put deodorant under the resident's arms and put another a shirt over her head and through her arms. With the same gloved hands, she provided oral care, put ointment on her lips, brushed the resident's hair by smoothing it with her gloved hands, and then applied lotion to the resident's face and legs. At 10:24 a.m., LPN 3 entered the room and donned clean gloves to both hands. She lifted up the resident's shirt and touched the peg tube, opened the clasp, and flushed the peg tube with water. After flushing the peg tube she connected the enteral tube feeding and started the pump. LPN 3 did not don an isolation gown prior to flushing the peg tube. There was a sign located on the outside of the resident's door that indicated Enhanced Barrier Precautions. If coming in contact with the resident staff should don gloves and an isolation gown. During an interview on 1/27/26 at 10:22 a.m. CNA 3 indicated she did not wear an isolation gown and thought she only needed to wear gloves when coming in contact with a resident with a peg tube. During an interview on 1/27/26 at 10:24 a.m., LPN 3 indicated she was aware she needed to wear gown while working around or with the resident's peg tube. During an interview on 1/27/26 at 2:00 p.m., Nurse Consultant 1 had no additional information to provide. A policy titled, Infection Prevention and Control Program, received as current from the Administrator as current on 1/20/26 at 10:15a.m. indicated the facility's standard precautions were to wear gloves when coming in contact with blood or body fluid. Gloves were to be changed and hand hygiene performed before moving from a contaminated body site to a clean body site during resident care. 3. During observation of a medication pass on the 3rd floor on 1/22/26 at 9:37 a.m., LPN 6 checked Resident X's blood pressure, pulse oximetry, and temperature. LPN 6 then checked the vital signs of 5 other residents on using the same equipment, without cleaning it between residents. During an interview on 1/22/26 at 10:00 a.m., LPN 6 indicated reusable equipment should be cleaned in between each resident use, but she did not clean it. During an interview on 1/22/26 at 10:50 a.m., the Infection Preventionist indicated equipment should be cleaned after each resident use. There should be disinfecting wipes on each medication cart available for use, and staff was educated at upon hire and annually, at minimum, on how to clean reusable equipment. A policy titled, Infection Prevention and Control Program, received as current from the Administrator as current on 1/20/26 at 10:15a.m. indicated, . The facility cleaning / disinfection policies include handling of equipment shared among residents (e.g., blood pressure cuffs, rehab therapy equipment, etc) . Facility has policies and procedures to ensure reusable medical devices are cleaned and reprocessed appropriately prior to use on another resident. 3.1-18(b)

Based on observation, record review and interview, the facility failed to ensure proper medication storage related to medications at the bedside for residents who did not self-administer medications and loose pills observed in the medication carts for 4 of 5 units. (Residents P and 145, Second, Third, Fourth, and Fifth Floors)Findings include: 1.During a random observation on 1/21/26 at 1:20 p.m., a syringe of normal saline wrapped in plastic was observed on Resident P's bedside stand. On 1/22/26 at 9:19 a.m., the syringe of normal saline remained on the resident's bedside stand. The record for Resident P was reviewed on 1/23/26 at 10:45 a.m. Diagnoses included, but were not limited to, type 2 diabetes, need for assistance with personal care, anxiety, and pressure ulcer of the sacral region. The Quarterly Minimum Data Set (MDS) assessment, dated 1/6/26, indicated the resident was cognitively intact. The resident did not have a care plan related to self-administering medications. The resident did not have a Self-Administration of Medication Assessment completed. During an interview on 1/23/26 at 2:58 p.m., the Third Floor Unit Manager indicated the resident was receiving IV (intravenous) antibiotics and the syringe of normal saline should not have been left in her room. 2. During observation of an intravenous medication administration for Resident 145 on 1/23/26 at 4:50 p.m., LPN 5 left a prefilled saline syringe in the resident's room after medication administration was complete. At that time, she indicated she thought it was ok to leave them in the room because there was no needle on them. During an interview on 1/27/26 at 3:50 p.m., the Director of Nursing (DON) indicated the syringes should not be left in the resident's room. 3. On 1/27/26 at 11:49 a.m., the 5th floor Odd Hall Medication Cart was observed with RN 1. There were 5 loose pills in the bottom of the drawers of the cart. At that time, RN 1 indicated it was the nurse's responsibility to ensure the carts were clean. 4. On 1/28/26 at 10:02 a.m., the 2nd floor Odd Hall Medication Cart was observed with LPN 7. There were 9 loose pills in the bottom of the drawers of the cart. At that time, LPN 7 indicated it was the nurse's responsibility to ensure the carts were clean. 5. On 1/28/26 at 10:13 a.m., the 3rd floor Odd Hall Medication Cart was observed with LPN 8. There were 34 loose pills in the bottom of the drawers of the cart. There was dark, sticky spillage in the bottom two drawers. At that time, LPN 8 indicated it was the nurse's responsibility to ensure the carts were clean, but sometimes the unit managers cleaned them. 6. On 1/28/26 at 10:20 a.m., the 4th floor Even Hall Medication Cart was observed with LPN 3. There were 6 pills loose in the third drawer. The bottom drawer had dark, sticky spillage with an additional 3 loose pills stuck in it. At that time, LPN 3 indicated they needed to clean out the cart drawers. A policy titled, Medication Storage, received as current from the Director of Nursing as current on 1/28/26 at 9:17 a.m., indicated, . Facility should ensure that medications and biologicals are stored in an orderly manner . Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet / cart or locked medication room that is inaccessible by residents and visitors. 3.1-25(m)

Based on observation, record review, and interview, the facility failed to ensure activities of daily living (ADLs) were completed for dependent residents related to facial hair, long and dirty fingernails, bathing, greasy hair, incontinence care, providing assistance with meals and adaptive equipment for eating for 10 of 13 residents reviewed for ADLs. (Residents P, O, H, G, M, K, Q, R, L and N)Findings include:1. During an interview on 1/21/26 at 1:20 p.m., Resident P indicated that she had not had a shower since she had been admitted in October, only bed baths, and she needed her hair washed. Observation at that time, indicated the resident's hair was matted in the back. The record for Resident P was reviewed on 1/23/26 at 10:45 a.m. Diagnoses included, but were not limited to, type 2 diabetes, need for assistance with personal care, anxiety, and pressure ulcer of the sacral region. The Quarterly Minimum Data Set (MDS) assessment, dated 1/6/26, indicated the resident was cognitively intact and dependent on staff for showering and bathing. A Care Plan, dated 10/10/25 and reviewed on 12/30/25, indicated the resident had an ADL self care performance deficit related to diabetes mellitus with neuropathy (nerve damage) and her need for assistance with transfers and bed mobility. The bathing documentation report that had been completed in the Task section of the record was provided by the facility. The months of October 2025, November 2025, December 2025, and January 2026 were reviewed. The resident's first documented shower was on 1/7/26 and the next shower was documented on 1/14/26. All of the other bathing documentation indicated the resident received partial and/or complete bed baths. There was no documentation indicating the last time the resident had her hair washed. During an interview on 1/27/26 at 2:00 p.m., the Nurse Consultant indicated the resident should have received a shower prior to January 7, 2026. 2. On 1/21/26 at 10:18 a.m., Resident O was observed in her room in bed. She was observed with a heavy growth of facial hair on her chin and her fingernails were long with chipped areas of nail polish. During an interview at that time, the resident indicated she didn't like her fingernails that long and she wanted the hair on her chin removed. On 1/22/26 at 9:17 a.m. and 1:30 p.m., the facial hair remained to the resident's chin and her fingernails remained long. On 1/23/26 at 9:49 a.m. and 10:20 a.m., the facial hair remained to the resident's chin and her fingernails remained long. During an interview on 1/23/26 at 10:20 a.m., the resident indicated the staff just wash her up and get her dressed. They don't ask her if she wants her fingernails cut or her whiskers removed. The record for Resident O was reviewed on 1/22/26 at 2:39 p.m. Diagnoses included, but were not limited to, stroke, mild intellectual disabilities, and anxiety. The Quarterly Minimum Data Set (MDS) assessment, dated 11/12/25, indicated the resident was moderately impaired for daily decision making and she was dependent on staff for showering, bathing, and personal hygiene. A Care Plan, last reviewed on 11/14/25, indicated the resident was limited in functional self care performance deficit related to dementia. Interventions included, but were not limited to, the resident was dependent upon one staff for weekly showers and she required extensive assist of one staff with personal hygiene and oral care. Bathing and nail care documentation was completed in the Task section of the record and documentation from 1/10/26 through 1/22/26 was reviewed. A complete bed bath was documented as being completed on 1/10, 1/11, 1/12, 1/13, 1/14, 1/15, 1/17, 1/18, 1/19, 1/20, 1/21 and 1/22/26. No showers were documented as being completed. Nail care was documented as being completed on 1/14, 1/15, 1/17, 1/18, 1/19, 1/20, and 1/21/26. During an interview on 1/23/26 at 10:21 a.m., the Third Floor Unit Manager indicated the resident should have been asked if she wanted her facial hair removed and her nails trimmed and she would take care of it herself today. She also indicated nail care should not have been documented as complete if it wasn't done. 3. During random observations on 1/20/26 at 12:30 p.m.,1/21/26 at 10:10 a.m., on 1/22/26 at 9:20 a.m., on 1/23/26 at 9:30 a.m., and 10:50 a.m., Resident H was observed sitting in a broda chair. At those times, her hair was unkempt and matted down in the back. The record for Resident H was reviewed on 1/23/26 at 10:20 a.m. Diagnoses included, but were not limited to, stroke, type 2 diabetes, major depressive disorder, intellectual disabilities and anxiety. The resident had refused to be interviewed. The 11/8/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making, dependent on staff for bathing, and needed substantial to max assist for personal hygiene. A Care Plan, revised on 6/18/25, indicated the resident had an ADL self-care performance related to stroke. There was no care plan indicating the resident refused showers, baths or having her hair washed. The CNA task section indicated the resident had a shower on 12/8 and 12/17/26. Those were the only two showers documented for all of 11/2025, 12/2025 and 1/2026. The CNA task section indicated a documented complete bed bath was completed for the resident on 11/1-11/9, 11/10-11/13, 11/17-11/19, 11/22, 11/23, 11/14, 11/26, 11/27, 12/1-12/4, 12/6-12/8, 12/11-12/14, 12/16, 12/25, 12/26, 12/30, 12/31, 1/3, 1/5, 1/6, 1/7, 1/8, 1/15, 1/13, 1/18, and 1/19/26 The shower book indicated the resident was to receive a shower on Mondays and Thursday. There was no documentation the resident's hair was washed or the resident refused to have her hair washed or be bathed. During an interview on 1/23/26 at 2:11 p.m., CNA 3 indicated she mostly worked the 3-11 shift, and that was when the resident received her showers. The CNA indicated they have a no rinse shampoo they used for complete bed baths. During an interview on 1/27/26 at 10:20 a.m., The 4th floor unit manager had no additional information to provide. During an interview on 1/27/26 at 2:00 p.m., the Nurse Consultant indicated the documentation in the task section was not accurate regarding the difference between a partial bed bath and a complete bed bath. 4. During an interview on 1/20/26 at 12:10 p.m., Resident G indicated her hair had not been washed in a very long time and she does not get a bath or shower at least two times a week. She only gets changed for incontinence one time a shift and that was towards the end of each shift. The last time she was changed was between 3:00 a.m. and 4:00 a.m. The resident's hair was matted in the back. During an observation on 1/22/26 at 9:23 a.m., the resident was observed in bed watching television. At that time, she indicated her hair still had not been washed and she was changed for incontinence right before the shift change around 6:30 a.m. During an observation on 1/22/26 at 1:11 p.m., the resident was observed in bed and indicated she was last changed around 10:20 a.m. that morning. The resident's hair was still matted down in the back. On 1/22/26 at 2:52 p.m., CNA 2 entered the resident's room to provide incontinence care for the resident. During an interview at that time, the CNA indicated she had last changed her some time before her lunch break and could honestly not remember. The CNA donned clean gloves to both hands and removed the incontinence brief. There was a large amount of dried dark yellow urine noted inside the brief. The resident was cleaned and a new brief was placed on her. CNA 2 indicated she was aware the resident was supposed to be checked and/or changed every two hours for incontinence. The record for Resident G was reviewed on 1/22/26 at 1:47 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, left side hemiplegia (paralysis), stroke, dementia with behaviors, type 2 diabetes, high blood pressure, anemia, constipation, and urinary incontinence. The Quarterly Minimum Data Set (MDS) assessment, dated 12/17/25, indicated the resident was cognitively intact for daily decision making and was dependent on staff for bathing and personal hygiene. A Care Plan, dated 9/30/25, indicated the resident was at risk for bladder incontinence related to dementia. The approaches were to change frequently and as needed. A Care Plan, dated 10/7/25, indicated the resident required assistance with ADLs, including toileting and bathing, related to stroke. The approaches were to offer assist with personal hygiene and provide showers two times a week. The CNA task section under bladder incontinence indicated the resident was incontinent and was only documented two times a day on 12/24, 12/25, 12/29, 12/31/25, 1/6/26, 1/9, 1/12, 1/18 and 1/20/26. The incontinence was only checked one time a day on 1/13/26. The resident only received a complete bed bath on 11/1-11/5 12/24, 12/25, 12/29, 12/31/25, 1/2, 1/3, 1/4, 1/5, 1/6, 1/9, 1/10, 1/11, 1/15, 1/16, 1/17, 1/18, 1/19, 1/20, and 1/21/26. There was no documentation the resident had her hair washed with those complete bed baths. During an interview on 1/23/26 at 2:10 p.m., the 3rd Floor Unit Manager indicated residents were to be checked or changed every two hours and a complete bed bath meant for the resident to have their hair washed. During an interview on 1/27/26 at 2:00 p.m., the Director of Nursing had no additional information to provide. 5. During random observations on 1/20/26 at 12:41 p.m., on 1/21/26 at 9:12 a.m.,1/22/26 at 9:24 a.m. and 1:18 p.m., and on 1/23/26 at 8:00 a.m. and 8:17 a.m., Resident M was observed in bed. At those times, the resident's hair was matted with dry flakes of skin noted. His fingernails on both hands were very long and dirty with a dark substance underneath them. During an observation of the breakfast meal on 1/23/26 at 8:17 a.m., the resident was observed feeding himself with normal silverware and no other adaptive equipment. He was only able to use his left hand, as his right hand was in shape of a fist and he could not move his arm by himself. He was able to eat his oatmeal from the styrofoam bowl until he could not get the last couple of bites because the bowl started move around and eventually fell on top of his abdomen. At that time, he was able to scrape the rest of the oatmeal out of the bowl because his lower abdomen was acting as a back drop for him. During an observation 1/23/26 at 1:45 p.m., the resident was observed up and dressed sitting in a wheelchair in the dining room. At that time, the insides of both ears were dirty with a yellow residual. There were flakes of dandruff on the back of his shirt and his hair was slightly matted in the back. During an interview on 1/23/26 at 1:45 p.m., the 3rd Floor Unit manager indicated a complete bed bath meant the resident should have been washed from head to toe including hair. She was unaware the resident needed adaptive equipment to help him eat. She indicated his nails should have been clipped and cleaned as needed. The record for Resident M was reviewed on 1/23/26 at 11:05 a.m Diagnoses included, but were not limited to, stroke, monoplegia of upper limb affecting right side, dysphagia (difficulty swallowing), COPD, chronic respiratory failure, major depressive disorder, dementia, and heart failure. The 12/2/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making, needed set up assistance with eating, and was dependent on staff for bathing and personal hygiene. A Care Plan, dated 9/29/25, indicated the resident had an ADL self-care performance deficit related to weakness and decreased physical mobility. The CNA task section for bathing indicated there was no documentation of refusals of showers or nail care. The resident received a complete bed bath on 11/1, 11/3, 11/4, 11/5, 11/6, 11/7, 11/8, 11/9, 11/10, 11/12-11/15, 11/18, 11/19, 11/20, 11/21-11/29, 12/1-12/13, 12/15-12/24 12/25, 12/26, 12/29, 12/30, 12/31, 1/1/26, 1/3, 1/4, 1/5-1/10, 1/12, 1/13, 1/14, 1/15, 1/16, 1/19, and 1/22/26. The resident received nail care on 12/25, 12/26, 12/30, 12/31, 1/1/26, 1/3-1/10, 1/12, 1/13, 1/16, and 1/22/26. During an interview on 1/27/26 at 2:00 p.m., the Director of Nursing had no additional information to provide. 6. During a random observation on 1/23/26 at 8:07 a.m., Resident K was observed in bed with the head of the bed low and her eyes were closed. Her breakfast tray was observed on over bed table untouched. At 8:15 a.m., the breakfast tray was still observed on the over bed untouched. During an interview at that time, the 4th Floor Unit Manager was unaware the resident had not been fed. She indicated the resident did eat all meals but needed to fed. The unit manager walked to the other hall and asked CNA 4 if he had fed the resident and he indicated No not yet. CNA 3 walked down the hall and both CNA 3 and CNA 4 indicated they both arrived to work at 7:00 a.m., and they both could not recall what time the breakfast trays arrived to the floor, but the normal time was at 7:15 a.m. Both CNAs indicated the resident needed to fed. During an interview on 1/23/26 at 8:20 a.m., the 4th Floor Unit Manager indicated she arrived to work at 7:30 a.m., and the trays were coming off the elevator. During an interview on 1/23/26 at 8:30 a.m., the Dietary Food Manager indicated all the trays arrived to the floors today on time, so the 4th floor received the cart at 7:15 a.m. The record for Resident was reviewed on 1/23/26 at 3:30 p.m. Diagnoses included, but not limited to, Alzheimer's disease, type 2 diabetes, major depressive disorder, dementia, and protein calorie malnutrition. The 11/18/25 Significant Change Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making and needed supervision or touching assistance for eating. She received hospice services. The CNA task section under eating in the last 14 days indicated the resident was coded as being dependent with 1 person physical assist with eating. During an interview on 1/23/26 at 10:50 a.m., CNA 4 indicated he was not aware that someone put her tray in the room so he did not know she needed to be fed right away. He indicated all of his residents were in bed for breakfast. During an interview on 1/27/26 at 2:00 p.m., the Director of Nursing had no additional information to provide. 7. During an interview on 1/20/26 at 11:10 a.m., Resident Q indicated his nails needed to be cleaned and trimmed. At that time, his nails were observed to be long and dirty and his hair was greasy and disheveled. During random observations on 1/22/26 at 9:14 a.m. and on 1/23/26 at 9:25 a.m., the resident was observed in bed. At those times his nails were long and dirty and his hair was greasy and disheveled. The record for Resident Q was reviewed on 1/23/26 at 9:50 a.m. Diagnoses included, but were not limited to, Parkinson's disease, emphysema, dementia, dysphagia (difficulty swallowing) heart disease, high blood pressure, and, anxiety disorder. The Quarterly Minimum Data Set (MDS) assessment, dated 11/19/25, indicated the resident was cognitively intact for daily decision making and dependent on staff for bathing and personal hygiene. A Care Plan, revised on 11/30/24, indicated the resident had an ADL self-care performance deficit related to Parkinson's disease. There was no care plan for the resident to be only bathed on Thursdays. There was no care plan the resident refused care. The CNA task under the section bathing indicated nail care was completed on 12/25, 12/28, 12/29, 12/31/25, 1/1, 1/2, 1/3, 1/7, 1/8, 1/12, 1/13. 1/14, 1/16, 1/17, 1/19, 1/20, 1/21, and 1/22/26. There was no documentation the resident refused nail care. The CNA task under the section bathing indicated the resident received a complete bed bath on 12/25, 12/26, 12/29, 12/30, 12/31, 1/1, 1/2-1/5, 1/7, 1/10-1/15, 1/17, 1/19, and 1/21/26. The resident received a shower on 12/25, 12/29, 12/31, 1/3, 1/7, 1/8, 1/12-1/14, 1/19, 1/20, 1/21, and 1/22/26. There was no documentation the resident's hair was washed or that he refused bathing. During an interview on 1/23/26 at 2:17 p.m., CNA 3 indicated the resident was supposed to get a shower on Thursdays only. She was told there was a care plan conference and resident agreed to have a shower on Thursday only. The resident would refuse to have his hair washed and nails trimmed at times. During an interview on 1/27/26 at 10:17 a.m., the 4th Floor Unit Manager indicated a complete bed bath was whatever he allowed them to do. She was then asked what a complete bed bath meant and the unit manager indicated wash from head to toe. The unit manager indicated there was a care plan meeting and there was supposed to be a care plan that the resident only wanted a shower on Thursdays. She was unaware there was no care plan for only being bathed on Thursdays. She had no additional information to provide after being informed of all the completed bed baths and showers that were documented in the CNA task section. During an interview on 1/27/26 at 2:00 p.m., the Director of Nursing had no additional information to provide. 8. On 1/21/26 at 10:07 a.m., Resident R was observed seated in a wheelchair in his room. He was unshaven and had dried blood around the left side of his nose. He indicated he had an infection in his nose and had not received a shower yet. On 1/28/26 at 10:40 a.m., the resident was in bed. His face was unshaven. He indicated he had not received a shower since he had been at the facility. He had asked for one last week and was told he would get one next week. The resident's record was reviewed on 1/28/26. Diagnoses included, but were not limited to, cellulitis and abscess of mouth, spinal stenosis and dependence on renal dialysis. The resident was admitted to the facility on [DATE]. The Brief Interview for Mental Status, dated 1/16/26, indicated the resident was cognitively intact. The bathing tasks for January 2026 lacked documentation the resident had received a shower or bath since admission, all dates were marked not applicable. During an interview on 1/28/26 at 10:45 a.m., LPN 4 indicated the resident was scheduled for showers on Thursday and Saturday evenings. She worked days and was unable to provide additional information why they had not been given. During an interview on 1/28/24 at 10:54 a.m., the Nurse Consultant was made aware the resident had not received any showers since admission. No additional information was provided. 9. During random observations on 1/20/26 at 11:15 a.m., 1/23/26 at 9:29 a.m., and 1/23/26 at 9:40 a.m., Resident L was observed to have long facial hair. The resident's record was reviewed on 1/27/26 at 10:52 a.m Diagnoses included but were not limited to, dementia, unspecified psychosis, and depression. The Quarterly Minimum Data Set (MDS) assessment, dated 11/20/25, indicated the resident had moderate cognitive impairment, and required moderate assistance with ADLs. The resident's record lacked documentation of resident refusal of care. A Care Plan, revised 6/14/25, indicated the resident had an ADL self-care performance deficit. The care plan did not indicate the resident had a preference to maintain her facial hair. During an interview on 1/27/26 at 3:50 p.m., the Director of Nursing (DON) was informed of the findings, and offered no further information. 10. During random observations on 1/21/26 at 9:08 a.m., 1/22/26 at 2:50 p.m., and 1/27/26 at 9:05 a.m., Resident N was observed to have long facial hair. The resident's record was reviewed 1/28/26 at 8:34 a.m Diagnoses included, but were not limited to, Alzheimer's disease, dementia, and adult failure to thrive. The Quarterly Minimum Data Set (MDS) assessment, dated 12/9/25, indicated the resident had moderate cognitive impairment, and required moderate assistance with activities of daily living (ADLs). The resident's record lacked documentation of resident refusal of care. A Care Plan, revised 9/2825, indicated the resident had an ADL self-care performance deficit. The care plan did not indicate the resident had a preference to maintain her facial hair. During an interview on 1/27/26 at 3:50 p.m., the Director of Nursing (DON) was informed of the findings, and offered no further information. This citation relates to Intake 2704995. 3.1-38(a)(2)(A) 3.1-38(a)(2)(C) 3.1-38(a)(2)(D) 3.1-38(a)(3)(B) 3.1-38(a)(3)(D) 3.1-38(a)(3)(E)

Based on observation, record review, and interview, the facility failed to keep the kitchen clean and in good repair related to food debris on shelves and refrigerator doors, lime build up on the outside of the dishwasher, lack of sanitation solution in the sanitizing buckets, and food not labeled and dated in the pantries located on the units for 1 of 1 kitchen and 5 of 5 units. (The Main Kitchen and the First, Second, Third, Fourth, and Fifth Floors) Findings include: 1. During the Kitchen Sanitation Tour on 1/20/26 at 9:07 a.m., with the Food Service Manager (FSM) the following was observed: a. There was dried spillage on the front door of the reach in freezer that housed the frozen health shakes. b. Two sanitation buckets registered zero parts per million (ppm) of quaternary solution.c. An accumulation of lime build up was observed on the outside of the dishwasher.d. The floor underneath the dishwasher had an accumulation of dirt and debris. e. The cabinet next to the dishwasher had food debris on the shelves. During an interview at that time, the FSM indicated the above was in need of cleaning and the sanitation buckets should have registered for chemical solution. 2. On 1/28/26 at 10:40 a.m., there was dried red juice spillage on the bottom shelf of the refrigerator located in the Third Floor Pantry. There was also a box of Kentucky Fried Chicken with no name and date, a ziplock bag of stale bread with a room number but no date, and two plastic containers of food with no name or date. 3. On 1/28/26 at 10:44 a.m., a plastic container of food was observed in the refrigerator in the Second Floor Pantry. The container had a resident's name but no date. During an interview at that time, the Second Floor Unit Manager indicated the container wasn't in the refrigerator yesterday when she cleaned and the resident's son must have brought it in last night. 4. On 1/28/26 at 10:50 a.m., a yellow substance was observed in a brown plastic bowl in the refrigerator in the Fourth Floor Pantry. The bowl was covered with plastic wrap and there was no name or date. There was a take out container with a resident's name on it but no date. 5. On 1/28/26 at 2:12 p.m., a bag of chicken wings was observed in the refrigerator of the Fifth Floor Pantry. The bag was not labeled or dated. 6. On 1/28/26 at 2:19 p.m., a take out container of soup with no name or date was observed in refrigerator 1 in the First Floor Pantry. Refrigerator 2 was observed with dried juice spillage. During an interview on 1/28/26 at 2:55 p.m., the Assistant Administrator indicated the food in the pantries were to be labeled and dated. The facility policy titled, Food Items Brought from Outside-Safe Storage was provided by the Administrator on 1/20/26 at 10:15 a.m. The policy indicated all resident foods and beverages shall be labeled with the resident's name and dated. 3.1-21(i)(3)

Based on observation, record review, and interview, the facility failed to ensure residents were assessed to self-administer medications and had Physician's Orders for the medication for 5 of 5 residents reviewed for self-administration of medication. (Residents P, 161, 155, Q and X)Findings include:1. During a random observation on 1/21/26 at 1:20 p.m., Resident P was observed in her room in bed. A bottle of Rolaids was observed on the resident's overbed table. During an interview at that time, the resident indicated she needed the Rolaids due to her stomach problems. During a random observation on 1/22/26 at 9:19 a.m., the bottle of Rolaids remained on the resident's overbed table. The record for Resident P was reviewed on 1/23/26 at 10:45 a.m. Diagnoses included, but were not limited to, type 2 diabetes, need for assistance with personal care, anxiety, and pressure ulcer of the sacral region. The Quarterly Minimum Data Set (MDS) assessment, dated 1/6/26, indicated the resident was cognitively intact. The resident did not have a care plan related to self-administering medications. A Physician's Order, dated 10/7/25, indicated the resident was to receive Calcium Carbonate (an antacid) Oral Tablet Chewable 500 milligrams (mg) give 2 tablets by mouth every 4 hours as needed for dyspepsia (indigestion). There was no physician's order for the resident to self administer the medication. A Self-Administration of Medication assessment had not been completed for the resident. During an interview on 1/23/26 at 2:58 p.m., the Third Floor Unit Manager indicated the Rolaids must have come up from the First Floor with the resident and the bottle shouldn't have been in the resident's room. 2. During a random observation on 1/20/26 at 11:11 a.m., Resident 161 was observed sitting in a chair in his room. At that time, there was a plastic medication cup with five pills sitting on the window sill. During an interview at that time, Resident 161 indicated the nurse gave him his pills while he was eating breakfast, and he told her to come back after he was finished eating. The nurse left the room with pills but came back after he was finished eating and handed him the cup and walked out of the room. He indicated he only took 5 of them at that time and left the other ones in the cup to take later. At 11:13 a.m., the 4th Floor Unit Manager and LPN 3 were called into the resident's room to observe the medication inside the cup. LPN 3 then asked the resident why he did not take the pills and he explained to her the same thing that he had indicated earlier. The record for Resident 161 was reviewed on 1/22/26 at 1:34 p.m. Diagnoses included, but were not limited to, type 2 diabetes, stroke, high blood pressure, heart disease, and dementia with moderate anxiety. The 1/7/26 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making. There was no self-administration of medication assessment or a physician's order for the resident to self-administer his own medications. During an interview on 1/20/26 at 11:15 a.m., LPN 3 indicated she was aware she was to stay with the resident while they consume their medications. 3. During a random observation on 1/20/26 at 10:41 a.m., Resident 155 was not in her room and was in the bathroom with the door closed. At that time, there was a plastic cup with 8 pills observed on the night stand. At 10:44 a.m. the medication cup was removed and taken to the nurse's station. LPN 3 was sitting behind the counter and when the medication cup of pills was placed on the counter she looked surprised. She took the medication cup of pills back to the room where the resident was in the bathroom to administer her the medication. The record for the resident was reviewed on 1/22/26 at 1:21 p.m. Diagnoses included, but were not limited to, heart disease, anorexia, major depressive disorder, high blood pressure, and anxiety. The 12/12/25 Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making. A 7/30/25 Self-Administration of Medication Assessment indicated the resident could self administer medications, but did not specify which ones. There was no order for the resident to self-administer her own medication prior to 1/20/26. During an interview on 1/20/26 at 10:44 a.m., LPN 3 indicated she was aware she was to stay with the residents while they consume their medications. During an interview on 1/20/26 at 10:45 a.m., the 4th Floor Unit Manager indicated nurses were to stay with the residents while they took their medications. 4. During an interview on 1/20/26 at 11:10 a.m., Resident Q indicated many times the nurse would come in and just leave his pills in the cup on the table and leave the room, so he did not know what he was taking. The record for Resident Q was reviewed on 1/23/26 at 9:50 a.m. Diagnoses included, but were not limited to, Parkinson's disease, emphysema, dementia, dysphagia (difficulty swallowing) heart disease, high blood pressure, and, anxiety disorder. The Quarterly Minimum Data Set (MDS) assessment, dated 11/19/25, indicated the resident was cognitively intact for daily decision making and dependent on staff for bathing and personal hygiene. There was no order for the resident to self-administer his own medications nor was there an assessment for the resident to self-administer his own medications. During an interview on 1/27/26 at 2:00 p.m., the Director of Nursing had no additional information to provide. 5. During observation of a medication pass on 1/22/26 at 9:53 a.m., LPN 6 placed Resident X's inhaler on her bedside table, and left the room. The resident self-administered the inhaler. At 10:00 a.m., LPN 6 returned to the resident's room, took the inhaler, and returned it to the medication cart. The resident's record was reviewed on 1/22/26 at 2:20 p.m. Diagnoses included, but were not limited to, chronic respiratory failure and blindness. The Quarterly Minimum Data Set (MDS) assessment, dated 12/19/25, indicated the resident was cognitively intact for daily decision making, required substantial assistance with activities of daily living (ADLs), and had severely impaired vision. A Physician's Order, dated 12/24/25, indicated albuterol sulfate inhaler (a breathing medication), 2 puffs inhaled two times a day. There was no order for self-administration. The record lacked a self-administration assessment. During an interview on 1/22/26 at 10:05 a.m., LPN 6 indicated she knew the resident was able to self-administer because she was familiar with the resident. She was not aware of a self-administration assessment. During an interview on 1/27/26 at 12:50 p.m., the DON indicated a resident needed to be assessed as safe to self-administer medications before being allowed to do so. A policy titled, Self-Administration of Medications—Clinically Appropriate, received as current from the Director of Nursing as current on 1/28/26 at 9:17 a.m., indicated, . The resident has right to self-administer medications if the interdisciplinary team has determined that this practice is clinically appropriate. When a resident requests to self-administer medication(s), it is the responsibility of the interdisciplinary team (IDT) to determine that it is safe before the resident exercises that right. A resident may only self-administer after the IDT has determined which medications may be self-administered. 3.1-11

Based on record review and interview, the facility failed to ensure skin tears were assessed and monitored and treatments were completed as ordered for 1 of 3 residents reviewed for non-pressure related skin conditions, interventions were in place for a resident with hypoglycemia (low blood sugar) for 1 of 1 resident reviewed for hospitalization, and medications were held without parameters for 2 of 5 residents reviewed for unnecessary medications. (Residents D, Y, X, and V)Findings include: 1.The closed record for Resident D was reviewed on 1/22/26 at 8:57 a.m. Diagnoses included, but were not limited to, dementia with behavior disturbance, stroke, and allergic contact dermatitis. The Quarterly Minimum Data Set (MDS) assessment, dated 11/27/25, indicated the resident was moderately impaired for daily decision making and she required partial to moderate assistance from staff for rolling left to right and for bed to chair transfers. A Care Plan, dated 3/20/24 and reviewed on 11/28/25, indicated the resident had an ADL (activities of daily living) self-care performance deficit related to the diagnosis of dementia and history of stroke with low back pain. Interventions included, but were not limited to, the resident required extensive assist by staff to turn and reposition in bed and to move between surfaces. A Physician's Order, dated 7/29/25 and listed as current on the December 2025 Physician's Order Summary (POS), indicated the resident was to wear geri-sleeves (protective skin covering) to the bilateral legs and arms when not wearing long pants or socks. May remove for hygiene. Ensure that resident is wearing sleeves and/or long pants or long socks every shift for skin tears. An Incident Note, dated 12/14/25 at 9:30 p.m., indicated the resident was being pushed in her wheelchair in her room to her bed by staff after being toileted. The writer had witnessed the resident hit her arm against the bed rail while being transported to her bed by the resident's assigned CNA, causing and sustaining two skin tears to the resident's right posterior upper and lower arm, along with a small abrasion to the resident's right ring finger. Orders were received to dress the wound and to monitor until healed. A Physician's Order, dated 12/14/25, indicated the resident's right upper and right lower posterior arm skin tears were to be cleansed with normal saline, pat dry, apply Xeroform (a type of non-adhering gauze dressing), dry gauze, and then wrap with kerlix daily until healed. A Wound Care Note, dated 12/15/25 at 1:28 a.m. and 2:20 p.m., indicated the resident had a new skin condition noted, there had been no reports of signs or symptoms of further injury or infection, no change in mental status or cognition, no reported change in ADL ability or mobility, and no change in orders related to the event. There was no documentation related to the skin tears in the Wound Round section of the resident's record. The December 2025 Treatment Administration Record (TAR) indicated the treatment to the resident's right arm was signed out as 9 (see nurse's notes) on 12/15 and 12/16/25. An Administration Note completed on 12/15/25 at 2:05 p.m., indicated the resident was being followed by wound care to complete the treatment to the right upper and lower arm. The same documentation was completed on 12/16/25 at 3:55 p.m. During an interview on 1/28/26 at 3:32 p.m., the Director of Nursing (DON) indicated the nurse coded a 9 on 12/15 and 12/16/25 because she did not complete the treatment due to the Wound Nurse was supposed to complete the treatment and she thought she had to document something on the TAR. The DON also indicated an assessment of the skin tears should have been completed and documented by Wound Care. The facility policy titled Skin Condition Assessment and Monitoring Pressure and Non-Pressure was provided by the DON on 1/28/26 at 3:54 p.m. The policy indicated, A wound assessment will be initiated and documented in the resident chart when pressure and/or other non-pressure skin conditions are identified by licensed nurse. 3. Resident Y's record was reviewed on 1/23/26 at 2:10 p.m. Diagnoses included, but were not limited to, diabetes mellitus and congestive heart failure. The admission Minimum Data Set assessment, dated 12/20/25, indicated the resident was cognitively intact and received hypoglycemics (medications used to lower blood sugar). An Alert Note, dated 12/20/25, indicated the resident was found to be clammy and not his normal self. Oxygen was applied and blood sugar level was obtained. Blood sugar was found to be low at 47 milligrams/deciliter (mg/dl). 911 was called and resident was transferred to the hospital. There was no indication in the record the physician had been notified, or interventions had been attempted prior to transfer. An Alert Note, dated 12/20/25, indicated the resident had been admitted to the hospital with diagnosis of hypoglycemia. During an interview on 1/27/26 at 12:05 p.m., the Director of Nursing (DON) indicated a resident with hypoglycemia should be assessed, blood sugar obtained, then attempt to give carbohydrates or administer emergency glucagon (glucose). The policy Hypoglycemia Protocol, dated 4/5/25, was received from the DON and indicated, .Give some form of glucose if resident is conscious .Contact physician if blood sugar is below 60 unless there are specific call parameters .If the resident is unable to swallow not fully conscious: Notify physician and prepare glucagon from the emergency drug kit for administration . 3. During observation of a medication pass on 1/22/26 at 9:37 a.m., LPN 6 checked Resident X's blood pressure, and indicated it was 153/58. At 9:53 a.m., LPN 6 administered one tablet of each of the following medications to Resident X: allopurinol (for gout), anastrozole (for breast cancer), atorvastatin (for cholesterol), escitalopram (for depression or anxiety), folic acid (a supplement), montelukast (for asthma), linagliptin (for diabetes), and vitamin D3. No metoprolol tartrate (a medication that reduces the workload of the heart and lowers blood pressure) or amlodipine besylate (a medication that improves blood flow through the heart and lowers blood pressure) were administered. The resident's record was reviewed on 1/22/26 at 2:20 p.m. Diagnoses included, but were not limited to, chronic respiratory failure, diabetes, breast cancer, blindness, and congestive heart failure. The Quarterly Minimum Data Set (MDS) assessment, dated 12/19/25, indicated the resident was cognitively intact for daily decision making, required substantial assistance with activities of daily living (ADLs), and had severely impaired vision. The January 2026 Medication Administration Record (MAR) indicated the resident was to receive metoprolol tartrate, 50 mg (milligrams) by mouth twice daily at 9:00 a.m. and 5:00 p.m., and amlodipine besylate, 10 mg every day at 9:00 a.m. There were no blood pressure parameter orders for holding either of the two medications. During an interview on 1/22/26 at 1:50 p.m., LPN 6 indicated she did not give the resident her metoprolol or amlodipine because the resident's diastolic blood pressure (bottom number of blood pressure reading) was below 60 and she did not want the resident to pass out. She indicated there were no ordered blood pressure parameters for holding either medication. During an interview on 1/27/26 at 12:50 p.m., the DON indicated a physician's order was required to hold a medication. 4. The record for Resident V was reviewed on 1/23/26 at 10:36 a.m. Diagnoses included, but were not limited to, hemiplegia (paralysis on one side of the body) following a stroke, diabetes, and adult failure to thrive. The 12/10/25 Quarterly Minimum Data Set (MDS) indicated the resident was cognitively intact for daily decision making and was dependent in activities of daily living (ADLs) and transfers. The January 2026 Medication Administration Record (MAR) indicated the following: a. Lantus insulin, 15 units each morning, to be given daily at 6:00 a.m. The documentation box was blank on 1/16, 1/17, 1/20, and 1/21. There were no notes or orders related to the blanks. b. Entresto (a medication used to reduce the risk of cardiovascular death), 1 tab twice a day. The 5:00 p.m. dose was held on 1/1, 1/4, 1/13, 1/17, and 1/18. There were no parameters or orders for holding the medication. c. Metoprolol 12.5 mg twice a day. The 5:00 p.m. dose was held on 1/1, 1/3, 1/4, 1/12, 1/13, 1/15, 1/17, 1/18, and 1/20. The 9:00 a.m. dose was held on 1/22/26. There were no parameters or orders for holding the medication. d. Humalog (a rapid-acting insulin) sliding scale (dosed according to blood sugar level) daily at 6:00 a.m., 11:00 a.m., and 4:00 p.m. The 6:00 a.m. blood sugar and administration documentation boxes were blank on 1/16, 1/17, 1/20, and 1/21. There were no notes or orders related to the blanks. A Care Plan, revised on 6/30/25, indicated the resident required daily insulin therapy related to a diagnosis of diabetes. Interventions included administering insulin as ordered. A Care Plan, revised on 6/30/25, indicated the resident had the potential for complications related to ischemic cardiomyopathy (heart disease that leads to heart failure). Interventions included to give medications as ordered. During an interview on 1/27/26 at 3:50 p.m., the DON was informed of the findings and offered no further information. This citation relates to Intakes 2698383 and 2699928. 3.1-37(a)

Based on observation, record review and interview, the facility failed to ensure interventions were in place and the correct treatment was provided for 2 of 4 residents reviewed for pressure ulcers. (Residents T and U)Findings Include:1.On 1/27/26 at 10:15 a.m., Resident T's wound care was observed with the Wound Nurse. The resident was positioned on his left side in his bed. There was a small pressure ulcer, approximately 0.5 centimeter long on his sacrum. The nurse cleansed the area with normal saline and gauze, patted it dry, then applied a hydrocolloid dressing to cover the wound.The resident's record was reviewed on 1/22/26 at 9:40 a.m. Diagnoses included, but were not limited to, fracture of the left humerus and cellulitis of the left lower extremity.The admission Minimum Data Set (MDS) assessment, dated 12/1/25, indicated the resident had moderate cognitive impairment and needed partial/moderate assist with bed mobility and transfers. A Physician's Order, dated 12/19/25, indicated to cleanse the sacrum with normal saline and/ or wound cleanser, apply skin prep to the surrounding skin and cover with a hydrocolloid.During an interview with the Wound Nurse following the wound care, she indicated she did not apply the skin prep as ordered. 2. On 1/22/26 at 10:38 a.m. and 1/23/26 at 8:45 a.m., Resident U was observed in bed. There was a standard mattress on the bed with a padded overlay. The resident's feet were on the mattress, there was no pillow present for offloading his heels or padded boots in place. The resident's record was reviewed on 1/22/26 at 2:55 p.m. Diagnoses included, but was not limited to, multiple sclerosis, cerebral infarction and peripheral vascular disease. The resident had a pressure ulcer to his sacrum /buttocks.The Quarterly Minimum Data Set assessment, dated 12/22/25, indicated the resident was cognitively intact, had range of motion impairment to both sides and was dependent for toileting and transfers.A Physician's Order, dated 5/10/23, indicated to suspend or offload heels while in bed. During an interview on 1/23/26 at 8:47 a.m., the Unit 2 Manager was made aware the resident's heels were not offloaded. She indicated he did not like to wear the boots, but there should be a pillow for offloading. This citation relates to Intake 2702705.3.1-40(a)(2)

Based on record review and interview, the facility failed to ensure as needed (PRN) anti-anxiety medications were not prescribed longer than 14 days. The facility also failed to ensure interventions were attempted prior to administering PRN anti-anxiety medications for 2 of 6 residents reviewed for unnecessary medications. (Residents P and B)Findings include: 1.The record for Resident P was reviewed on 1/23/26 at 10:45 a.m. Diagnoses included, but were not limited to, type 2 diabetes, need for assistance with personal care, anxiety, and pressure ulcer of the sacral region. The Quarterly Minimum Data Set (MDS) assessment, dated 1/6/26, indicated the resident was cognitively intact and she had received anti-anxiety medication within the last seven days. A Care Plan, dated 10/2/25 and reviewed on 12/30/25, indicated the resident used anti-anxiety medication related to having an anxiety disorder. A Physician's Order, dated 10/1/25, indicated the resident was to receive Xanax (an anti-anxiety medication) 0.25 milligrams (mg) every 24 hours PRN for agitation or anxiety until 11/26/25. The resident had received the Xanax 37 times during that time frame. A Physician's Order, dated 11/26/25, indicated the Xanax had been reordered and was to be administered every 24 hours PRN through 12/26/25. The resident had received the Xanax 17 times during that time frame. A Physician's Order, dated 12/27/25, indicated the Xanax had again been reordered and was to be administered every 24 hours PRN through 1/20/26. The resident had received the Xanax 13 times during that time frame. A Physician's Order, dated 1/27/26, indicated the resident was to receive the PRN Xanax every 24 hours for anxiety or restlessness. During an interview on 1/28/26 at 3:00 p.m., the Director of Nursing indicated the PRN Xanax initially should have been ordered for 14 days at a time and she would get a clarification order to see if the Xanax could be administered routinely. 2. The record for Resident B was reviewed on 1/22/26 at 9:40 a.m. at 9:40 a.m. Diagnoses included, but were not limited to, vascular dementia with behaviors, chronic kidney disease stage 4, traumatic subdural hemorrhage (often fatal, medical emergency where blood collects between the brain's outer covering and the brain surface, usually from ruptured bridging veins caused by severe head injury), hemiplegia (weakness) on the right side, delusional disorder, intellectual disabilities, psychotic disorder with delusions, and anxiety. The 9/2/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident had no behaviors and was moderately impaired for daily decision making. The Annual MDS assessment, dated 11/12/25, indicated the resident was moderately impaired for decision making. The resident had little interest doing things, felt down and tired, and had trouble concentrating. The resident had not displayed any hallucinations or delusions, but had physical, verbal and other behaviors that occurred in the last 1 to 3 days during the assessment reference period. The resident's behaviors significantly interfered with care and activities, and had an impact on others of significant risk of physical injury, disruption of care and the living environment. The resident's behaviors had worsened since last assessment and he needed substantial to max assist with transfers. The resident received antipsychotic, antianxiety, antidepressant, and an anticonvulsant medications. A Care Plan, revised on 11/20/25, indicated the resident displayed verbal behavioral symptoms not directed toward others as evidenced by yelling and using profanity towards self. The approaches were to provide diversional activities to reduce behavioral symptoms, redirect and intervene during periods of increased agitation, and separate the resident from others as needed. A Care Plan, revised on 11/20/25, indicated the resident took prn (as needed) anti-anxiety medications related to agitation and aggressive behaviors. A Physician's Order. dated 10/9/25, indicated Lorazepam tablet 0.5 milligrams (mg), give 0.5 mg by mouth every 12 hours as needed for agitation and aggressive behaviors for 14 days. The 10/2025 Medication Administration Record (MAR) indicated the Lorazepam was administered on the following days with no non-pharmacological interventions attempted prior: -10/10/25 at 8:58 a.m. and 11:15 p.m. -10/13/25 at 12:30 a.m. -10/16/25 at1:56 p.m. -10/17/25 at 11:03 p.m. -10/21/25 at 5:41 p.m -10/23/25 at 12:55 a.m. A Physician's Order, dated 11/4/25, indicated Lorazepam tablet 0.5 mg, give 0.5 mg by mouth every 12 hours as needed for agitation or anxiety for 30 days. The 11/2025 MAR indicated the Lorazepam was administered on the following days with no non-pharmacological interventions attempted prior: -11/4/25 at 1:26 p.m. - 11/6 at 11:23 am, -11/7/25 at 9:18 a.m. -11/8/25 at 12:37 a.m. -11/11/25 at 11:43 p.m. -11/15/25 at 4:05 p.m. -11/16/25 at 4:10 a.m. and 11:49 p.m. -11/18 at 2:23 a.m. 11/20/25 at 12:47 a.m. -11/21/25 at 3:05 a.m. -11/26/25 at 11:35 p.m. -11/27/25 at 11:24 p.m. -11/30/25 at 4:10 a.m. A Physician's Order, dated 12/2/25, indicated Lorazepam tablet 0.5 mg, give 0.5 mg by mouth every 12 hours as needed for agitation or anxiety for 30 days. The 12/2025 MAR indicated the Lorazepam was administered on the following days with no non-pharmacological interventions tried: -12/3/25 at 12:03 a.m. and 11:12 p.m. -12/5/25 at 1:28 a.m. -12/11/25 at 2:22 a.m. and 11:34 p.m. -12/17/25 at 11:18 p.m. -12/18/25 at 11:15 p.m. -12/20 at 11:53 p.m. -12.23/25 at 12:09 a.m. -12/26/25 at 1:30 a.m. During an interview on 1/27/26 at 2:00 p.m., the Nurse Consultant indicated prn anti-anxiety medications should only be ordered for 14 days. During an interview on 1/28/26 at 6:13 a.m., LPN 2 indicated she was the nurse on duty on 12/11/25 when the resident was observed hovering over his roommate's bed and yelling at him. She administered the prn Lorazepam at that time as well. She was aware staff were to try redirection or distraction before the administration of the prn anti-anxiety. She indicated the resident yelled all the time. During an interview on 1/28/26 at 11:30 a.m., the Nurse Consultant had no additional information to provide. 3.1-3(w)

Based on record review and interview, the facility failed to ensure a resident was involved in and informed of new medications ordered by the physician for 1 of 1 resident reviewed for care planning decision. (Resident 17)Finding includes: During an interview on 1/21/26 at 9:37 a.m., Resident 17 indicated she was given an iron pill but was never informed who ordered it. She indicated she some labs done and then after that the iron pill appeared with her daily medication. The record for Resident 17 was reviewed on 1/27/26 at 11:15 a.m. Diagnoses included but were not limited to, heart failure, dementia, high blood pressure, hypothyroidism, anemia, and osteoarthritis.The 12/1/25 Annual Minimum Data Set assessment indicated the resident was cognitively intact for daily decision making. A Physician's Order, dated 7/16/25, indicated Ferrous Sulfate tablet 325 milligrams (mg), give 1 tablet by mouth one time a day for low Iron.A Physician's Order, dated 10/18/25 and discontinued on 1/22/26, indicated Levothyroxine Sodium tablet 150 micrograms (mcg), give by mouth in the morning.There was no documentation the resident was notified of the above medication additions or changes. During an interview on 1/28/26 at 9:00 a.m., the Nurse Consultant had no additional information to provide.3.1-35(d)(2)(B)

Based on observation, record review, and interview, the facility failed to ensure professional standards of quality were maintained related to CNAs removing dressings to pressure ulcers for 1 of 5 residents reviewed for pressure ulcers. (Resident P)Finding includes: On 1/28/26 at 11:54 a.m., the Wound Nurse was observed providing wound care for Resident P. She prepared the supplies outside of the resident's room and donned a gown and gloves prior to entering. Upon entering the room, the resident was positioned on her left side and there was no dressing to the sacrum (a triangular bone at the base of the spine). CNA 5 was in the room at that time, she indicated she had just provided incontinence care and she removed the dressing because it was soiled. The Wound Nurse proceeded to treat the area to the sacrum. The record for Resident P was reviewed on 1/23/26 at 10:45 a.m. Diagnoses included, but were not limited to, type 2 diabetes, need for assistance with personal care, anxiety, and stage 4 pressure ulcer of the sacral region (skin breakdown that involves full-thickness tissue loss exposing underlying structures such as muscle, bone or tendon) of the sacral region.The Quarterly Minimum Data Set (MDS) assessment, dated 1/6/26, indicated the resident was cognitively intact and she had one stage 4 pressure ulcer that was present on admission. A Care Plan, reviewed on 12/30/25, indicated the resident had wounds to her left lateral ankle, left heel, sacrum, right upper and lower lateral calf, left lower medial shin, left lower lateral knee and left distal lateral leg. Interventions included, but were not limited to, follow facility policies/protocols for the prevention and treatment of skin breakdown.A Physician's Order, dated 11/13/25 and listed as current on the January 2026 Physician's Order Summary (POS), indicated the resident's sacral wound was to be cleansed with normal saline or wound cleanser, pat dry, apply skin prep to surrounding skin and apply Anasept (an antimicrobial skin and wound gel) soaked gauze to wound bed and cover with a dry dressing every day shift and as needed (PRN). During an interview on 1/28/26 at 3:00 p.m., the Director of Nursing indicated the CNA should not have removed the dressing to the resident's sacrum.The current Indiana Nurse Aide Curriculum indicated, the nurse aide would not administer any medications, perform treatment or apply or remove any dressings. Exception to the above would be the application of creams/ointments to intact skin as moisture barrier cream.3.1-35(g)(1)

Based on observation, record review, and interview, the facility failed to ensure an ongoing activity program was implemented for cognitively impaired and dependent residents for 2 of 2 residents reviewed for activities. (Residents 2 and K)Findings include: 1. On 1/22/26 at 9:34 a.m. and 1:39 p.m., Resident 2 was observed in his room in bed with his eyes open and his television turned on. On 1/23/26 at 10:40 a.m. and 2:30 p.m., the resident remained in his room in bed with his television turned on. The record for Resident 2 was reviewed on 1/27/26 at 9:15 a.m. Diagnoses included, but were not limited to, bone and prostate cancer, vascular dementia with mood disturbance, stroke, and major depressive disorder. The Annual Minimum Data Set (MDS) assessment, dated 8/21/25, indicated the resident had moderate cognitive impairment and music and animals such as pets were very important to him. The Quarterly MDS assessment, dated 11/6/25, indicated the resident remained moderately impaired for daily decision making and he had little interest or pleasure in doing things. He was also dependent on staff for bed to chair transfers. A Care Plan, dated 6/9/23 and reviewed on 12/4/25, indicated the resident had a variety of activity interests and general willingness to take part in group activity programs. Interventions included, but were not limited to, encourage and praise attendance, engagement and participation within programs, invite, encourage, and assist to programs of interest and preference. During an interview on 1/27/26 at 12:20 p.m., Activity Aide 1 indicated that she visited the resident daily. She also indicated the resident had really declined and was put on hospice. The One to One Activity Sheet had documentation in the top right hand corner which indicated the patient has severely declined. The One to One Sheet indicated the resident was seen on the following dates and what activity took place: -6/3/25 throwed [sic] ball back and forth from bed, resident enjoyed.-7/10/25 conversation-8/15/25 conversation-9/10/25 conversation-12/14/25 conversation-1/24/26 conversation During an interview on 1/27/26 at 5:00 p.m., the Activity Director indicated the resident had declined and he no longer got out of bed. Staff made sure his television was turned on and she would revise his care plan to reflect his current status and schedule one to one activities for him. 2. During a random observation on 1/20/26 at 10:57 a.m., Resident K was observed sitting upright in a broda chair in her room. There was no television or radio on and the resident was just staring forward. During random observations on 1/21/26 at 10:00 a.m. and 10:20 a.m., the resident was in bed with her eyes closed. There was no radio or television on. During random observations on 1/22/26 at 9:15 a.m. and 11:00 a.m., the resident was observed in bed. At those times the television was on with a cartoon show. During random observations on 1/23/26 at 8:07 a.m., 8:15 a.m., 9:30 a.m., and 10:50 a.m., the resident was observed in bed. At those times there was no radio or television on. On 1/23/26 at 2:00 p.m., the resident was observed up and dressed in the broda chair in front of the nurses' station. There was no activity happening. The record for Resident was reviewed on 1/23/26 at 3:30 p.m. Diagnoses included, but not limited to, Alzheimer's disease, type 2 diabetes, major depressive disorder, dementia, and protein calorie malnutrition. The 11/18/25 Significant Change Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily. She received hospice services and it was very important for her to listen to music. A Care Plan, revised on 12/2/25, indicated the resident had a variety of activity interests and general willingness to take part in group activity programs and at times prefer to engage in her own self-directed activities. The approaches were to encourage and praise attendance, engagement and participation within programs, invite, encourage and assist to programs of interest and preference, and offer programs that were new or outside of resident's past or assessed activity interests for potential leisure exploration and recreation variety. A Care Plan, revised on 12/2/25, indicated the resident displayed severe cognitive impairment and rarely or never made decisions. The approaches were to provide activities on a one to one basis and in small groups and turn on television or radio when the resident was in the room for increased stimulation as tolerated. The 1 to 1 documentation indicated the following and was completed by an activity aide: 11/1/25: one on one with resident not very open to activities11/15/25: 1 to 1 helped her find a TV show she liked11/30/25: 1 to 1 talked to the resident about some activities she would maybe enjoy12/6/25: brought some magazines to look at12/14/25: 1 to 1 just conversed with the resident a bit about old times12/21/25: watched tv with the resident 1/4/26: brought up activities again she refused1/18/26: the resident said she was tired so left her to rest There was no resident response to any of the above 1 to 1 documentation. In the task section under activities, 1 to 1 documentation was completed 12/29/25 through 1/26/26. During an interview on 1/27/26 at 11:30 a.m., the Activity Director indicated she was unaware the care plan was not up to date to reflect the resident. She indicated the resident resided on the 5th floor and was transferred to the 4th floor after she had declined. The resident was now on hospice, so she was not active at all in activities. She indicated all the 1 to 1 visits in the task section were all pop in visits with the resident and did not last long at all. She only had documentation of 1 to 1 visits done every 2 weeks. She was unaware of what should be done during the 1 to 1 visits. She indicated her staff needed to be educated on the visits. 3.1-33(b)(8)

Based on observation, record review and interview the facility failed to provide adequate supervision for a resident with swallowing precautions and failed to keep sharp objects out of a resident's room who resided on the memory care unit for 2 of 6 residents reviewed for accidents. (Residents M and 1)Findings include: 1. During a random observation on 1/21/26 at 9:12 a.m. Resident M was observed in bed eating breakfast. The resident was served eggs and some type of ground meat. The meal ticket indicated supervision with meals, no straws, and to check mouth after solids. The resident should be upright during the meal and to take small bites and alternate solids and liquids. The resident had a straw in his water cup. There was no staff in the room while he was eating. During a random observation 1/23/26 at 8:17 a.m., the resident was observed in bed eating his breakfast. He was served two scoops of scrambled eggs, a bowl of oatmeal and two pieces of toast. He was served a cup of thickened orange juice and carton of thickened milk. The resident was observed feeding himself with no staff supervision in the room. He ate his piece of white toast in 4 bites and did not take a drink. He then picked up the other piece of toast and ate that piece in 3 bites. After he was done eating the toast he took two drinks of orange juice. He then took a large bite of scrambled eggs and put it in his mouth, chewed half of it and then put another large scoop of eggs in his mouth. He then moved his tray around and picked up his spoon and started to eat the oatmeal. He ate all of the oatmeal without taking any sips of liquids. He then took 3 large sips of orange juice and covered his plate with the lid of the styrafoam container and pushed it away. During an interview on 1/23/26 at 8:29 a.m. with CNA 5, who was in the room assisting the roommate, indicated she was unsure if the resident needed assistance and supervision with his meals. She indicated He does pretty good by himself. She was then asked what the light pink and dark pink smiley faces above his bed meant and she indicated thicken liquids and swallowing precautions. The record for Resident M was reviewed on 1/23/26 at 11:05 a.m Diagnoses included, but were not limited to, stroke, monoplegia of upper limb affecting right side, dysphagia (difficulty swallowing), COPD, chronic respiratory failure, major depressive disorder, dementia, and heart failure. The 12/2/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and had a functional limited range of motion to his upper extremity on one side. The resident needed set up assistance with eating, and was dependent on staff for bathing and personal hygiene. The resident had coughing or choking during meals or when swallowing medications, and received a mechanically altered diet. The resident received oxygen while a resident. A Care Plan, dated 12/12/25, indicated the resident had a swallowing problem related to dysphagia. There were no physician orders for swallowing precautions. A Physician's Order, dated 7/1/25, and on the current 1/2026 Physician Order Summary, indicated no added salt, mechanical soft texture and nectar thick liquids with double portions at breakfast. A Speech Therapy evaluation plan and treatment for dysphagia therapy, dated 8/1/2020, indicated recommend mechanical soft textures with nectar thick liquids, with close supervision and to use general swallow techniques and precautions. During an interview on 1/23/26 at 8:30 a.m., The 3rd Floor Unit Manager indicated self feed with supervision meant someone had to be watching the resident eat. During an interview on 1/27/26 at 3:30 p.m., the Director of Nursing (DON) indicated they could not find the order in the computer, but the resident did have the smiley faces above his bed for both swallowing precautions and thickened liquids. 2. During random observations on 1/20/26 at 11:05 a.m., 1/21/26 at 9:31 a.m., and 1/23/26 at 9:39 a.m. a disposable razor was observed in a cup on Resident 1's over bed table. The resident indicated he shaved himself. He resided on the memory care unit. The resident's record was reviewed 1/23/26 at 2:19 p.m. Diagnoses included, but were not limited to, psychotic disorder, anxiety, dementia, and alcohol abuse The Medicare 5-Day Minimum Data Set (MDS) assessment, dated 12/27/25, indicated the resident had moderate cognitive impairment, required moderate assistance with activities of daily living (ADLs) and transfers. A Care Plan, revised on 12/24/25, indicated the resident became easily agitated with physical aggression as evidenced by throwing coffee on floor and / or at staff. Interventions included to remove any objects that may be thrown to maintain safety. A Care Plan, revised 7/30/25, indicated the resident was at risk for complications related to antiplatelet therapy use. Interventions included to use an electric razor. During an interview on 1/27/26 at 3:50 p.m., the Director of Nursing (DON) indicated the resident should not have a disposable razor in his room. 3.1-45(a)

Based on observation, record review and interview the facility failed to ensure a resident received the correct diet as ordered for 1 of 4 residents reviewed for nutrition. (Resident 16)Finding includes:On 1/20/26 at 12:10 p.m., Resident 16 was observed in bed in his room. A staff member entered the room and brought his lunch tray. He asked for it to be set on the table for later. The lunch was a slice of meatloaf, one scoop of mashed potatoes with gravy and vegetable. The tray ticket indicated Heart Healthy diet, double portions. At 12:17 p.m., LPN 4 observed the lunch tray and ticket and indicated it was not double portion.The resident's record was reviewed on 1/22/26 at 1:16 p.m. Diagnoses included, but were not limited to, diabetes mellitus and dependence on renal dialysis.The Quarterly Minimum Data Set assessment, dated 12/4/25, indicated the resident was cognitively intact and needed set up assist for eating. A Physician's Order, dated 11/10/25, indicated CKD (Renal) diet, regular texture. There was no order for double portions. During an interview on 1/22/26 at 1:34 p.m., the Dietary Manager indicated she had received an order that morning for CKD diet and had just changed the order. The previous order had been for Heart Healthy diet. She indicated there was no order for double potions. 3.1-46(a)(2)

Based on observation, record review, and interview, the facility failed to ensure the residents' oxygen was set at the correct flow rate for 2 of 2 residents reviewed for oxygen. (Residents M and X)Findings include: 1. During a random observation on 1/20/26 at 12:41 p.m., Resident M was observed in bed wearing oxygen via nasal cannula. At that time, the oxygen flow rate was set at 0.5 liters per minute. During a random observation on 1/21/26 at 9:12 a.m., the resident was observed in bed wearing oxygen via nasal cannula. At that time, the oxygen flow rate was set at 1 liter per minute. The record for Resident M was reviewed on 1/23/26 at 11:05 a.m Diagnoses included, but were not limited to, stroke, monoplegia of upper limb affecting right side, dysphagia (difficulty swallowing), COPD, chronic respiratory failure, major depressive disorder, dementia, and heart failure. The 12/2/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision received oxygen while a resident. A Care Plan, revised on 12/12/25, indicated the resident required oxygen therapy related to respiratory failure. The approaches were oxygen via nasal cannula as ordered by the physician. A Physician's Order, dated 1/15/25, indicated Oxygen via nasal cannula at two liters per minute. During an interview on 1/23/26 at 2:00 p.m., the 3rd Floor Unit Manager was aware the oxygen rate was wrong on 1/22/26 as she changed it back to two liters. 2. During an observation on 1/20/26 at 11:13 a.m., Resident X was wearing oxygen via nasal cannula that was set at 4 lpm (liters per minute). During an observation on 1/21/26 at 1:50 p.m., Resident X was wearing oxygen that was set at 3.5 lpm. The resident's record was reviewed on 1/22/26 at 2:20 p.m. Diagnoses included, but were not limited to, chronic respiratory failure, diabetes, blindness, and asthma. The Quarterly Minimum Data Set (MDS) assessment, dated 12/19/25, indicated the resident was cognitively intact for daily decision making, required substantial assistance with activities of daily living (ADLs) and moderate assistance with transfers, severely impaired vision. A Care Plan, revised on 7/22/25, indicated the resident required oxygen therapy. Interventions included to provide medications as ordered by the physician. A Physician's Order, dated 12/19/25, indicated oxygen via nasal cannula at 3 lpm continuously. During an interview on 1/22/26 at 1:50 p.m., LPN 6 indicated the resident's oxygen should be set at 3 lpm. During an interview on 1/27/26 at 3:50 p.m., the Director of Nursing (DON) was informed of the finding and offered no additional information. A policy titled, Oxygen Administration, received as current from the Director of Nursing as current on 1/28/26 at 9:17 a.m., indicated, . Oxygen is to be administered at the liter flow ordered by the physician. 3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure a scheduled pain medication was available and administered as ordered for 1 of 4 residents reviewed for pressure ulcers. (Resident F)Finding includes:Resident F's closed record was reviewed on 1/21/26 at 2:15 p.m. Diagnoses included, but were not limited to, diabetes mellitus, repeated falls, and unspecified protein calorie malnutrition.The Quarterly Minimum Data Set assessment, dated 11/17/25, indicated the resident was cognitively intact and had a stage 3 (full-thickness skin injury appearing as a deep crater where subcutaneous fat is visible, but muscle, tendon, or bone are not exposed) pressure ulcer.The Pain Care Plan, dated 6/19/23, indicated the resident was on pain medication related to cancer of left breast, chronic pain syndrome and arthritis. Interventions included, but were not limited to, administer analgesic medications as ordered.A Physician's Order, dated 4/9/24, indicated to give fentanyl transdermal patch (opioid pain medication), 50 micrograms/hour every 72 hours for pain.The November and December 2025 Medication Administration Record indicated the fentanyl patch was not administered on 11/21, 11/24, 11/27, 11/30, 12/3 and 12/6/25. Order Administration (OA) Notes indicated the following:11/21/25 - the medication was not available. 11/24/25 - message sent to the doctor to refill script.11/27/25 - unavailable, prescription needed, MD notified.12/3/25 - unavailable.12/6/25 - no script. During an interview on 1/22/26 at 3:15 p.m., the Director of Nursing indicated the Nurse Practitioner should have been notified and a script obtained. She later indicated they had received a new prescription for the fentanyl patch on 11/25/25, but the pharmacy didn't receive it. The Medication Orders policy was received but did not pertain to the above. This citation relates to Intake 2702705.3.1-37(a)

Based on record review and interview, the facility failed to ensure resident's right to make choices were honored related to showers given per preference for 1 of 1 resident reviewed for choices. (Resident U)Finding includes:During an interview on 1/20/26 at 10:44 a.m., Resident U indicated he preferred to have showers but was only being given bed baths since he had a stroke. The resident's record was reviewed on 1/22/26 at 2:55 p.m. Diagnoses included, but was not limited to, multiple sclerosis, cerebral infarction and peripheral vascular disease. The Quarterly Minimum Data Set assessment, dated 12/22/25, indicated the resident was cognitively intact, had range of motion impairment to both sides and was dependent for toileting and transfers.The Quarterly Preferences for Customary Routine and Activities, dated 5/8/25, indicated it was very important to the resident to choose between a tub bath, bed bath, shower or sponge bath. The bathing tasks for November and December 2025 and January 2026 indicated the resident received one shower on 12/11/25. The remaining days he was given either a partial bed bath or a complete bed bath. There was one refusal documented on 12/21/25.During an interview on 1/27/26 at 2:40 p.m., the Unit 2 Manager indicated the resident's transfer status changed after he had a stroke and he was no longer able to sit in the shower chair. He needed to use the reclining shower chair, which was too big to fit in the shower and that was why he was being given bed baths.During an interview on 1/27/26 at 3:55 p.m., the Nurse Consultant indicated the resident was only able to use the reclining chair that did not fit in Unit 2's shower. She indicated the shower on Unit 1 was larger and would accommodate the reclining shower chair. The resident would be taken to that shower from then on.3.1-3(u)(3)

Based on observation, record review, and interview, the facility failed to ensure adequate supervision and assistance were provided to a dependent resident who required total assistance of staff for bed mobility for 1 of 3 residents reviewed for accidents. (Resident B) This deficient practice resulted in a fall and the resident sustained a left femur fracture. Finding includes: A confidential interview indicated Resident B fell out of bed while being repositioned with only one staff member and the resident sustained a leg fracture, the same leg that was fractured during a fall in October 2024. An additional confidential interview indicated the resident was having surgery on 12/4/24 due to re-injuring the left leg. The record for Resident B was reviewed on 12/4/24 at 1:42 p.m. Diagnoses included, but were not limited to, displaced oblique fracture of the shaft of the left femur, vascular dementia with behavior disturbance, type 2 diabetes, protein-calorie malnutrition, and orthopedic aftercare. A Fall Risk Evaluation, dated 10/11/24, indicated the resident was at high risk for falls. The Significant Change Minimum Data Set (MDS) assessment, dated 10/17/24, indicated the resident was cognitively impaired for daily decision making and had range of motion (ROM) impairment to both sides of the lower extremities. The resident was dependent on staff for rolling left and right. Section J - Health Conditions, indicated the resident had a fracture related to a fall in the last six months. The resident was also receiving Physical and Occupational therapies. A Care Plan, dated 9/3/24 and reviewed on 10/17/24, indicated the resident was at risk for falls and injury from falls. Interventions included, but were not limited to, anticipate and meet needs. A Nurse's Note, dated 12/3/24 at 7:45 p.m., indicated LPN 1 was called to the room by a CNA. The CNA stated the resident slid to the floor out of the bed while staff was providing care. The resident was seen sitting on the floor on their buttocks next to their bed near the window. There were no visible injuries and no complaints of pain. The resident was not moved and an ambulance was called. At 7:47 p.m. and 7:50 p.m., attempts were made to reach the resident's family. At 7:52 p.m., ambulance staff arrived, pertinent papers were given, and report was given to the emergency room nurse. A Hospital Note, dated 12/4/24 at 7:40 a.m. and completed by the Case Manager, indicated the resident was admitted from the emergency department on 12/3/24. The resident's chief complaint was for evaluation of left leg pain after a fall or near fall at the nursing home. X-rays were obtained of the resident's left femur upon arrival to the hospital. The hospital Radiology Report pertaining to x-ray results of the left femur, dated 12/3/24, indicated the following: 1. Interval development of acute fracture of the subtrochanteric region and proximal diaphysis of the left femur (a type of hip fracture). Post surgical changes again noted. 2. Distal left femoral fracture was present on the study of 10/5/24. On 12/5/24 at 1:30 p.m., the resident's room was observed. Resident B's bed was closest to the window in the room and the bathroom was right next to the room door. The resident had a low air loss mattress (a mattress to prevent and treat pressure ulcers) and two assist rails were at the head of the bed. The fall investigation completed by the facility was dated 12/3/24 and 12/4/24. A statement obtained from QMA 1, on 12/3/24, indicated she was assisting CNA 1 with the resident. She needed more towels for care, and she went to the bathroom to get more towels. When she came out, the resident was sliding off the side of the bed. The QMA ran over and assisted the CNA in guiding the resident to the floor instead of letting them just fall. The resident complained of their knee hurting. The resident was covered up and their back was supported until the ambulance arrived. The resident was in a sitting position. A statement obtained from CNA 1, on 12/3/24, indicated the following, Myself and another staff member went into the patient's room to provide care for the patient, while I was turning the patient to clean her the other staff member was went [sic] to get more towels while the other staff member was doing that I had the patient already turn on her left side. With her legs crossed her hands were on the side rail (enabler). The patient is on a air mattress and started to slide down. I hollered for the other staff member to come help me. I ran to her left side and with my hands and both arms myself and the other staff member lowered her to the floor slowly. Resident was sitting up next to the bed. Nurse immediately notified vital signs were taken. I asked what hurt she stated everything. (sic) During an interview, on 12/4/24 at 2:30 p.m., the Second Floor Unit Manager indicated she was aware of the resident's fall from the night before. She indicated she was told two staff members went into the room to provide care due to the resident being care in pairs. CNA 1 and QMA 1 entered the room to provide care. During care, the QMA went to the bathroom to obtain some towels and the CNA was left at the bedside with the resident and that was when the resident rolled a little and started to slide out of the bed. The Unit Manager indicated CNA 1 was assigned to the resident and she was a float CNA, however, she indicated QMA 1 was familiar with the resident. During an interview, on 12/4/24 at 3:10 p.m., CNA 1 indicated she had been assigned to the resident on the evening of 12/3/24. She indicated she was a float CNA and worked as needed (PRN). She also indicated that she was not that familiar with the resident but she did know the resident was care in pairs. The CNA indicated she and QMA 1 entered the room to provide care. During care, the QMA went into the bathroom to get more towels. At that time, the resident was positioned on her left side facing the window. The QMA was on the left side of the bed prior to going to the bathroom to get towels. The CNA indicated she was standing between the two beds in the room and the QMA had been standing at the left side of the bed. The CNA indicated the resident's legs were crossed and the resident started to move their leg and was observed sliding out of the bed. The CNA indicated she yelled for help and ran to the other side of the bed and helped ease the resident to the floor. The resident was in a seated position on the floor with their legs extended and staff supporting their back. During an interview, on 12/5/24 at 2:11 p.m., the Director of Nursing (DON) indicated CNA 1 had reenacted what happened and the CNA made it sound like she was on the same side of the bed as the resident. After reading the CNA's statement, she indicated the CNA was indeed on the opposite side of the bed and had to run around to the other side of the bed to assist the resident. The DON indicated the CNA should have moved to the left side of the resident's bed when the QMA went to the bathroom to get more towels. No policy was provided prior to exit. This citation relates to Complaints IN00448523 and IN 00448529. 3.1-45(a)(2)

A. Based on observation, record review, and interview, the facility failed to ensure mechanical lift straps were safe for use prior to a transfer of a dependent resident for 1 of 1 resident reviewed for falls. (Resident B) This deficient practice resulted in a strap breaking during a transfer, the resident falling from the lift, and the resident sustaining a left femur fracture. B. Based on observation, record review, and interview, the facility failed to ensure hot water temperatures were below 120 degrees Fahrenheit on 2 of 4 floors throughout the facility. (The 5th and 2nd floors) Findings include: A. A confidential interview indicated Resident B fell from a mechanical lift when the sling straps broke, and the resident sustained a leg fracture. On 10/15/24 at 2:54 p.m., Resident B was observed in bed. A blue leg immobilizer was observed on the resident's left leg. The record for Resident B was reviewed on 10/17/24 at 1:26 p.m. Diagnoses included, but were not limited to, displaced oblique fracture of the shaft of the left femur, vascular dementia with behavior disturbance, type 2 diabetes, protein-calorie malnutrition, and orthopedic aftercare. The Quarterly MDS assessment, dated 8/25/24, indicated the resident was cognitively impaired for daily decision making and used a mechanical lift for transfers. The resident was dependent on staff for bed mobility and transfers. There had been no falls since the last assessment. A Care Plan, dated 9/3/24, indicated the resident was at risk for falls and injury from falls. Nurse's Notes, dated 10/5/24 at 9:00 a.m., indicated the nurse was summoned to the resident's room. The two CNA's who were in the resident's room at that time indicated the resident fell . The CNA's indicated the resident fell during a transfer from the bed to the wheelchair while using the mechanical lift. The mechanical sling strap broke and the resident's left leg fell from the sling. The resident was complaining of pain to the left leg. The Physician was notified, orders were obtained to send the resident to the emergency room for evaluation, and 911 was contacted for transport. Hospital x-ray results of the left knee, dated 10/5/24, indicated the resident had a new left femur fracture. The resident was identified as having severely demineralized bones. The investigation completed by the facility was dated 10/5/24. The investigation documentation indicated two staff members were transferring the resident via the mechanical lift. There were no tears or rips to the mechanical sling prior to starting the transfer. As staff started to lift the resident and move them, the blue strap on the left side broke and the resident's leg hit the floor. The resident was then lowered to the floor. As the resident was being unhooked from the mechanical sling pad, two more blue straps tore. Both employees assisting with the transfer indicated they did not observe any fraying or tears to the mechanical lift sling pad prior to starting the transfer. There was no documentation which indicated the mechanical lift sling straps were checked prior to the transfer. A facility post-incident audit, dated 10/5/24, identified one additional mechanical lift sling was identified to have damage, was taken out of service, and replaced. Starting on 10/5/24, staff were re-educated on the use of the mechanical lift and maintaining slings, such as checking for damage before use. Ongoing audits of the mechanical lift sling pads were initiated. Laundry staff were responsible for inspecting the slings when they would need to be laundered. If the sling was torn or frayed, the sling would be taken out of service. Staff were also to inspect the mechanical lift slings prior to use. A Fall Interdisciplinary Team (IDT) Note, dated 10/8/24 at 10:18 a.m., indicated the resident was transferred by two CNA's via the mechanical lift from the bed to the wheelchair. The resident had a witnessed fall to the floor. Upon assessment, the resident complained of pain to the left hip. The resident was not moved and their position was maintained until EMS arrived. The root cause of the fall was a fall during a transfer from the bed to the wheelchair. The IDT note did not indicate the fall was due to a broken mechanical sling strap. Physician's Orders, dated 10/11/24, indicated the resident was non-weight bearing to the left femur and the left leg immobilizer was to stay in place, but could be removed for hygiene and skin checks. A Care Plan, dated 10/14/24, indicated the resident was at risk for complications, including changes in mobility, secondary to oblique fracture of the left femur status post-roding and surgical aftercare. Interventions included, but were not limited to, anticipate and meet needs, be sure call light was within reach, and respond promptly to all requests for assistance. During an interview on 10/18/24 at 2:55 p.m., CNA 2 indicated the resident was transferred with two staff assistance. The CNA also indicated that the mechanical lift sling was checked prior to transferring the resident and no frays were noted. During an interview, on 10/21/24 at 4:20 p.m., Housekeeper 1 indicated mechanical lift slings were not inspected by laundry staff for damage prior to 10/5/24. Housekeeper 1 indicated, after 10/5/2024, the slings were labeled with a number, and after the slings were washed the laundry staff should inspect the slings for damage then hang them to dry. During the interview, a sheet of paper, dated 10/2024, was observed taped to a dryer. The paper indicated the mechanical lift slings were observed to have no damage on 10/2/24, 10/6/24, 10/13/24, 10/15/24 through 10/17/24, and 10/20/24 through 10/21/24. The paper indicated the slings were not inspected for damage between 10/3/24 and 10/5/24. During an interview, on 10/22/24 at 8:35 a.m., the Laundry Supervisor indicated the laundry staff was responsible for monitoring the mechanical lift sling straps prior to and after 10/5/24. The Laundry Supervisor indicated he was not sure documentation could be provided to show the mechanical lift slings were inspected between January 2024 and 10/5/2024. During an interview, on 10/22/24 at approximately 9:35 a.m., the Laundry Supervisor provided mechanical lift audit sheets, dated January 2024 through April 2024, and May 2025 through October 2025. The October 2024 mechanical lift audit sheets were not provided by the Laundry Supervisor to determine if the lift slings were effectively inspected for damage prior to 10/5/24. During an interview, on 10/22/24 at 3:04 p.m., the Administrator indicated the mechanical lift slings were inspected by laundry staff prior to the incident with the resident on 10/5/24. She indicated when the mechanical lift slings were sent to laundry, the slings were to be inspected after washing. If any fraying or tears were noted, the sling was to be taken out of service and replaced. The Administrator indicated the Laundry Supervisor stated the audits were being completed prior to the incident and she took his word for it, he did not provide her with any audit sheets. During a phone interview on 10/22/24 at 3:20 p.m., the Laundry Supervisor indicated he may have been in a hurry, and he didn't know why the May through October audit sheets were dated 2025. He also indicated he may not have been wearing his glasses and that was why the wrong lines were checked for the month of October, he did not state that he or staff had checked them on those dates. The current facility policy related to the mechanical lift did not specify how often the Hoyer slings were to be inspected. A professional reference, titled Patient Lifts Safety Guide, found at https://www.fda.gov/files/medical%20devices/published/Patient-Lifts-Safety-Guide.pdf, indicated, .Examine sling and attachment areas for tears, holes and frayed seams. DO NOT USE sling with any signs of wear . B1. On 10/16/24 at 11:25 a.m., the hot water temperature in the bathroom of room [ROOM NUMBER] was hot to touch. At 11:34 a.m., the Maintenance Supervisor arrived on the fifth floor, which was the secured memory care unit, and checked the water temperature. The bathroom water temperature in room [ROOM NUMBER] registered 134.5 degrees Fahrenheit. At 11:35 a.m., the Maintenance Supervisor measured the bathroom hot water temperature in room [ROOM NUMBER]. The temperature was 137 degrees Fahrenheit. During an interview, on 10/16/24 at 11:40 a.m., the Maintenance Supervisor indicated the water was usually hotter on the fifth floor and it cooled down on the lower floors due to the boiler being located above the fifth floor. He also indicated he checked the water temperatures daily. Observation of the holding tanks on 10/16/24 at 11:40 a.m., indicated one water tank was holding at 120 degrees Fahrenheit, and the second holding tank was registering 134 degrees Fahrenheit. The electronic temperature gauge was set at 134 degrees Fahrenheit. The temperature was turned down at that time to register between 105- and 110-degrees Fahrenheit. The Maintenance Supervisor indicated it would take some time for the water to cool down and he did not know who set the thermostat to 134 degrees Fahrenheit. The Maintenance Supervisor indicated the thermostats should have been set between 110-115 degrees Fahrenheit to ensure the temperature was maintained between 100-120 degrees Fahrenheit. During an interview on 10/16/24 at 1:30 p.m., the Administrator indicated the water temperatures were being checked hourly on all units and staff had already been inserviced related to checking the water temperatures. The Administrator indicated the Maintenance Supervisor was responsible for checking the water temperature weekly. A Water Temperature Audit Sheet, provided by the Administrator, indicated on 10/16/24 at 1:02 p.m., the bathroom water temperature in room [ROOM NUMBER] registered 120.8 degrees Fahrenheit. 10770 B2. On 10/16/24 at 11:36 a.m., the hot water temperature in the bathroom of room [ROOM NUMBER] was hot to touch. At 11:40 a.m., the Second Floor Unit Manager felt the water and agreed it was hot to touch, as she had to pull her hand away from the running water. During an observation, on 10/16/24 between 11:45 a.m. and 11:55 a.m., the Maintenance Director was observed to measure the hot water temperature on the second floor with the following results: - room [ROOM NUMBER]: 136 degrees Fahrenheit. - room [ROOM NUMBER]: 137 degrees Fahrenheit. - room [ROOM NUMBER]: 136 degrees Fahrenheit. - room [ROOM NUMBER]: 137 degrees Fahrenheit. During the Environmental Tour, on 10/22/24 at 10:30 a.m., the Maintenance Supervisor was observed to measure hot water temperatures in random rooms on the second floor. The water temperatures measured 114 degrees Fahrenheit. Water temperatures in random rooms on the fifth floor measured 114.5 degrees Fahrenheit. During an interview, on 10/22/24 at 11:00 a.m., the Maintenance Supervisor indicated a water line was torn, was immediately repaired, the hot water tank temperature was turned down, and the water temperature of the holding tank was 115 degrees Fahrenheit. This citation relates to Complaints IN00444806, IN00444914, and IN00445179. 3.1-45(a)(1) 3.1-45(a)(2)

Based on record review and interview, the facility failed to complete ongoing assessments and ensure prompt treatment of [REDACTED]. (Residents T and H) Findings include: 1. The closed record for Resident T was reviewed on 1/6/21 at 11:40 a.m. The resident was admitted to the COVID-19 unit on 12/3/20. [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment, dated 12/9/20, indicated the resident was not cognitively intact and had no behaviors. The resident needed extensive assist with 1 person physical assist for bed mobility. Locomotion on and off the unit and how the resident transferred himself did not occur during the assessment period. The resident had no history of falls prior to admission to the facility. The Care Plan, dated 12/9/20, indicated the resident was at risk for falling related to mobility dysfunction, neuromuscular weakness and [MEDICAL CONDITION]. The approaches were for a chair alarm (12/26/20), bed alarm and bolsters to bed (12/12/20), moved to room closer to nurses' station and sent to the emergency room (12/11/20) and to provide the resident an environment free of clutter (12/9/20). Nurses' Notes, dated 12/11/20 at 7:00 a.m., indicated the resident was observed on the floor next to the bed laying on his back with a laceration to the right side above the eyebrow. There was bleeding at the site and a pressure bandage was applied. 911 was called to take the resident to the hospital for evaluation and treatment. The Physician and family were made aware. Nurses' Notes, dated 12/11/20 at 12:30 p.m., indicated the hospital called and stated the resident would be returning to the facility and had 2 sutures above the right eyebrow. Nurses' Notes, dated 12/12/20 at 5:20 p.m., indicated the resident was observed on the floor in his room beside the bed. The resident stated he was trying to change his underwear and was trying to catch the train. The writer called floor care to obtain bolsters for the bed as well as bed alarms. The resident would be moved closer to the nurses' station. The resident had a bruise over his right eye. Nurses' Notes, dated 12/12/20 at 7:23 p.m., indicated the resident was resting peacefully in bed with no issues. Nurses' Notes, dated 12/13/20 at 12:18 p.m., indicated the resident was alert and oriented to self and was confused to time and place. The resident was easily redirected and remained on Droplet Isolation for COVID-19. There was no other follow up assessment or documentation regarding the resident's laceration or the sutures from the fall on 12/11/20. There were no neurological assessments of the resident after the fall with injury on 12/11/20 available for review. A Fall Risk assessment, dated 12/12/20, indicated the resident was disoriented times 2, had no visual impairment, and had a balance problem while standing and walking. The resident was confined to a chair and does have a history of 1 or 2 falls in the last month. The resident's fall risk score was a 20, indicating a high fall risk. A Fall Root cause analysis form, dated 12/11 and 12/12/20 (same form) indicated on 12/11 the resident was observed on floor with a laceration to the head, he didn't state what he was attempting to do at the time of occurrence. On 12/12/20 the resident observed on floor next to bed, stated he was trying to change his underwear and was going to catch the train. New interventions put into place after the falls were a room move, and sent to the emergency room , bolsters and alarms to the bed. Nurses' Notes, dated 12/25/20 at 12:47 p.m., indicated the resident was transferred to the Special Care (Dementia) Unit on 12/22/20. Nurses' Notes, dated 12/26/20 at 1:58 p.m. (Recorded as Late Entry on 12/27/20 at 10:11 p.m.), indicated the resident was sitting across from Nurses' Station in his wheelchair. This writer walked past the resident and he leaned forward out of his chair and laid on the floor. This writer was unable to stop the resident from laying on the floor. When the resident was assessed he was noted to have a hematoma (bruise) to the right side of his head with very little swelling. The resident was returned back to his wheelchair and vital signs where taken. An ice pack was applied to resident's right side of his head. The Physician and POA had been made aware of the fall. A fall event, dated 12/26/20 at 2:01 p.m., indicated the resident was sitting in his wheelchair and leaned forward and fell out of his chair. The resident was confused and unable to ambulate at the time. The initial assessment indicated the resident had a hematoma to the right side of his head. He had full range of motion of all his extremities without pain or limitation. There was no rotation/deformity, or shortening of his extremities noted. The resident was observed with bruising on his head, trunk, lower body, and on his extremities. There were no signs the resident had any pain. A Fall Root cause analysis form, dated 12/26/20, indicated the resident was observed leaning forward and falling from wheelchair, resulting in a hematoma. New interventions put into place was a chair alarm. A neurological assessment form was initiated on 12/26/20 at 1:58 p.m., and continued until 12/28/20 at 2:45 p.m. (48 hours post fall). The assessment was incomplete and did not assess the resident's pupil response or his motor response regarding his extremities including upper and lower. Nurses' Notes, dated 12/27/20 at 5:30 p.m., 8:00 p.m., and 9:41 p.m., indicated information regarding the resident's blood sugar. There was no follow up assessment of the resident's hematoma, swelling, or his lower extremities. There was no follow up assessment in Nursing Progress Notes on 12/28/20 of the resident's hematoma, swelling or lower extremities. Nurses' Notes, dated 12/29/20 at 5:44 p.m., indicated No complaints of pain voiced from recent laying on the floor. No new open areas or bruises noted. No signs of [DIAGNOSES REDACTED] or [MEDICAL CONDITION] noted. The next entry in Nurses' Notes was on 12/30/20 at 12:21 p.m., which indicated Resident noted in dining area not responding to verbal or tactile stimuli. Upon assessment resident's whole body was limp and pupils dilated. No palpable pulse however resident is taking deep breaths. B/P (blood pressure) noted 74/43, respirations 14, radial pulse noted weak during palpation with a reading of 64, oxygen saturation detected intermittently ranging between 92%-96% for change of condition. Resident sent to hospital (name). Family (name) and Physician made aware. The Hospital emergency room notes, dated 12/30/20 indicated patient with clear signs of trauma without any report of trauma. EMS reported no fall by ECF but EMS was concerned given signs of head trauma. Musculoskeletal exam revealed [MEDICAL CONDITION] deformity. An X-ray report of the right hip, dated 12/30/20, indicated nondisplaced [MEDICAL CONDITION] femoral neck. A CT of the head report, dated 12/30/20, indicated a subgaleal hematoma overlying the right side of the frontal bone without evidence of an underlying fracture. Interview with Director of Nursing on 1/7/20 at 10:27 a.m., indicated she was off on 12/26/20 and 12/27/20 and returned to work on 12/28/20. She does not attend the Monday morning meetings due to preparing COVID-19 numbers. She indicated she was not made aware of the fall on 12/26 and the on call manager would have been made aware of the fall. She was only made aware of falls when there was a major injury such as bleeding or having to go to the hospital. The Assistant Director of Nursing (ADON) was the interim Unit 5 Manager at the time of the fall. The DON indicated there was no follow up assessment of the resident's lower extremities or his hematoma after the fall on 12/26/20. There were no post neurological assessments of the resident's fall on 12/11/20 and the 12/26/20 neurological assessments were incomplete. Nurses were to assess and monitor the resident for 72 hours after a fall. Interview with the ADON on 1/7/20 at 11:00 a.m., indicated she was the interim unit manager at the time the resident fell . She was made aware of the fall on Monday 12/28/20 after going through the 24 hour report sheet from the weekend. She communicated the fall with the Restorative Nurse who would do a root cause analysis. The ADON indicated she was to make sure the Fall Event and the Fall Observation forms were completed by the nurse. She did not ensure there had been an ongoing assessment for 72 hours post fall of the resident's hematoma or lower extremities. Interview with the Restorative Nurse on 1/7/20 at 11:00 a.m., indicated she was involved with staff COVID-19 testing on Mondays and was not made aware of the resident's fall from 12/26/20. She was off work on 12/29 and did not complete the fall root cause analysis until 12/30/20 after the resident had already been sent to the hospital. She did not physically assess the resident while completing the root cause analysis. The current and revised 8/2008 Falls-Clinical Protocol policy, provided as current by the Director of Nursing on 1/7/20 at 3:00 p.m., indicated The staff with the Physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as a late fracture or subdural hematoma have been ruled out or resolved. The staff and Physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. 2. The record for Resident H was reviewed on 1/5/21 at 9:30 a.m. [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment, dated 11/20/20, indicated the resident was not cognitively intact and had no behaviors. She was an extensive assist with a 2 person physical assist for bed mobility, transfers, dressing, and toileting. The resident was frequently incontinent of bowel and bladder, and had 1 fall with no injury since the last assessment. The resident received an antipsychotic medication in the last 6 days. Nurses' Notes, dated 12/6/20 at 5:36 a.m., indicated the resident was restless all shift and made several attempts to get out of bed. The resident's bed alarm sounded at 5:30 a.m., per report the resident was witnessed on the floor next to the bed. No new bruises or complaints of discomfort. The resident was assessed post fall on 12/6/20 at 1:53 p.m. and at 9:41 p.m. and on 12/7/20 at 4:32 a.m. This was the last entry in Nurses' Notes regarding the resident's fall on 12/6/20. There were no follow up assessments after 4:32 a.m. on 12/7/20. Interview with the Unit 5 Manager on 1/6/21 at 10:45 a.m., indicated there was no follow up assessment or documentation for 72 hours post the fall on 12/6/20. Interview with the Director of Nursing on 1/7/20 at 2:30 p.m., indicated the resident was to be assessed and monitored for 72 hours post fall. All notes should be available in Nursing progress notes. This Federal tag relates to Complaint IN 798. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to provide adequate supervision to prevent elopement of a cognitively impaired resident with a Wander Guard (device to alarm if a resident has left the building) in place. The whereabouts of the resident were unknown to any facility staff for approximately 4 hours and 30 minutes. (Resident B) The Immediate Jeopardy began on 7/06/20 when Resident B, who was assessed as at risk for elopement and had a Wander Guard in place, rode the elevator off of the floor he resided on, signed himself out at the desk, and a staff member entered the exit code at the front door, allowing the resident to exit the building. The resident was noted to be missing one hour and 15 minutes later, a search began and the police were notified. The resident was located four hours and 30 minutes after he left the facility at a park approximately one mile from the facility. The Administrator, Assistant Administrator, Director of Nursing and the Nurse Consultant were notified of the Immediate Jeopardy on 7/16/20 at 1:26 p.m. Findings include: The record for Resident B was reviewed on 7/15/20 at 8:55 a.m. [DIAGNOSES REDACTED]. The resident was receiving Hospice services. The 6/9/2020 MDS (Minimum Data Set) Significant Change assessment indicated the resident's cognitive skills for decision making were moderately impaired. Resident B was independent with walking in his room, bed mobility and transfers. The resident expressed he had been feeling tired or having less energy in the past several days. He received antidepressant and opioid medications 3 days during the 7 day reference period. A care plan, initiated on 3/24/20 and last revised with a target goal date of 9/30/20, indicated the resident was at risk for elopement related to increased confusion, lack of safety awareness, and impulsive nature which may be related to progression of his disease related to a [DIAGNOSES REDACTED]. Review of a police report indicated the local police department was notified on 7/06/20 at 4:42 p.m. and proceeded to the facility. The police report indicated staff reported Resident B missing from the facility. Social Service staff 2 advised the police that RA (Resident Assistant) 1 was working the door area. RA 1 told the police Resident B had signed out in the log book at 2:27 p.m. and left the building. The police viewed security footage from a drive thru fast food business across the street. A male matching Resident B's build was seen exiting the facility. The resident was found approximately 4.5 hours later at 7:00 p.m He was wearing a black sweatshirt, blue jeans, and a black and white winter stocking cap when he was located. Review of accuweather.com on 7/16/20 indicated the high temperature in the area was 91 degrees F on 7/06/20. A Nursing Progress note, completed on 7/6/20 at 7:19 p.m. indicated Resident B was assessed by nursing staff. No apparent cuts, scratches, scrapes or bruising was noted. The resident denied any pain or discomfort. A Nursing Progress note, completed on 7/6/20 at 7:29 p.m., indicated the resident's Wander Guard was checked and functioning. The resident was moved to a room on the Memory Care dementia unit. Documentation from the facility's investigation, dated 7/7/20, indicated Resident B left the faciity on [DATE]. Seven employees and Resident B were interviewed. Resident B stated upon return to the DON (Director of Nursing) he was going to the doctor and then to the harbor with my friends. The ambulance service was contacted by the facility related to the incident. A manager at the ambulance service stated he would inservice the drivers regarding the need to be aware of their surroundings. The follow up indicated Resident B had signed out at the front desk at 2:30 p.m. When interviewed on 7/16/20 at 12:50 p.m., RA 2 indicated she had worked the day Resident B left the facility. Two ambulance staff and Resident B came from the elevator area and approached the desk. RA 2 indicated she heard the ambulance staff say, he's with us and he prefers to walk. The resident then walked out the door as they were being opened by her for the ambulance staff. When interviewed on 7/16/20 at 11:05 a.m., RA 1 indicated she was working at the check-in table inside the entrance of the building on 7/6/20 when Resident B left the building. The resident signed out on the log to be completed when residents and vendors leave the facility. Ambulance transfer members were also present. No alarms sounded from the elevator. RA 2 turned off the alarm at the front door exit for the ambulance staff and they left. RA 1 did not observe Resident B exit, though she did confirm that RA 2 cut the alarm off at this time. There was no Elopement Book available at the table for staff reference. RA 1 indicated RA 2 was not working the front desk at this time. She came down from her unit on her break to talk to RA 1. When interviewed on 7/16/20 at 11:35 a.m., the Director of Nursing indicated they confirmed Resident B had entered the elevator on the 4th floor. Ambulance staff informed the facility Resident B did ride down the elevator with them on 7/6/20. The ambulance staff were leaving after dropping off another resident on the 4th floor after he attended an appointment. The Director of Nursing indicated if the resident had a Wander Guard on, when he got in the elevator, he nor the ambulance staff would be able to exit the elevator without someone on the elevator punching in a code. Telephone attempts made to speak with the transport staff were unsuccessful. The facility Elopement and Search Policy (Code Pink) was reviewed on 7/17/20 at 8:15 a.m. All Nursing personnel were responsible for knowing the whereabouts of residents for which they are assigned. Department Supervisors are responsible for conducting resident rounds. Observations are made at no less than two hour intervals by nursing staff. Elopement prevention devices are to be checked daily for function. In an event a resident cannot be located a Code Pink is to be implemented over the paging system. When the resident is found a licensed nurse will announce the Code Pink is clear. A clinical assessment will be completed by a licensed nurse. Appropriate security measures will be implemented. The Immediate Jeopardy that began on 7/6/20 was removed on 7/17/20 when the facility assessed all residents with wanderguard to ensure proper functioning and current staff members, as well as vendors, were inserviced on the facility Elopement Policy and Protocol, including the addition of an Elopement Book and ability to exit confirmation procedure at the check out desk. The Immediate Jeopardy was removed on 7/17/20, 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 updated elopement procedures and monitoring of the check out desk procedure was ongoing. This Federal tag relates to Complaint IN 122. 3.1-45(a)(2)

Based on record review and interview, the facility failed to provide the necessary treatment to prevent the development of pressure ulcers related to failure to assess and treat a new area of excoriation which resulted in the development of an Unstageable ulcer and hospitalization for 1 of 3 residents reviewed for pressure ulcers. (Resident E) Finding includes: The closed record for Resident E was reviewed on 2/13/18 at 9:41 a.m. The resident was admitted on [DATE] and discharged to the hospital on [DATE]. [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment, completed on 1/25/18, indicated the resident's cognitive skills for decision making were severely impaired. Extensive assistance of two staff was required for transfers, bed mobility, dressing, toilet use, and personal hygiene. The resident was always incontinent of bowel and bladder, had impairment in range of motion, and was at risk for pressure ulcer development. No current pressure ulcers were present. A Care Plan, initiated on 1/25/18, indicated the resident was at risk for development of pressure ulcers related to immobility and incontinence of bowel and bladder. Interventions included, but were not limited to, minimize skin exposure to moisture by checking every two hours and providing care as needed and encourage repositioning at least every two hours when in bed. Bath and Skin Reports, for January and February 2018 indicated shower entries were completed on 1/29/18 and 2/2/18 and were signed by LPN 2. Excoriation was observed. The section marked list actions taken was not completed on the above dates. Showers administered prior to the above dates showed no skin concerns. A Nursing Progress Note, completed by Wound Nurse 1 on 2/5/17 at 2:45 p.m., indicated the resident was seen per request of the floor Nurse for wounds to the resident's bottom. A CNA was providing care at the time and the area was area was observed. Red excoriation was present around a nonstageable (sic)(full thickness tissue loss in which the base of the ulcer is covered black yellow, tan, gray, green, or brown slough and/or tan,brown or black eschar) pressure ulcer wound to the coccyx. The entire area measured 8 cm x 7.5 cm with undetermined depth. The center of the wound was yellow/gray slough. Nursing Progress Notes, dated 1/19/18 through 2/5/17, revealed no documentation of open areas or skin excoriation. Physician orders were obtained on 2/5/18 to clean the coccyx with normal saline, pat dry, apply a thick layer of Calmoseptime to the area. No Physician orders were in place for treatment to the coccyx or perineal areas prior to 2/5/18. During an interview on 2/14/18 at 12:38 p.m., Wound Nurse 1 indicated Unit Manager 3 requested her to evaluate Resident E, as the family had concerns with a pressure ulcer. The resident had open excoriation around the coccyx area. An area of slough measuring approximately 2 cm x 1 cm was noted in the center of the area. The entire wound area was approximately 8 cm x 15 cm. The wound was Unstageable due to the presence of the slough. No previous requests had been made for a Wound Nurse to evaluate the resident for any other skin alterations prior to 2/5/18. During an interview on 2/14/18 at 1:05 p.m., Unit Manager 3 indicated she was first informed of excoriation and open area on 2/5/18. The area was observed with slough noted above the anal area. No bleeding or drainage was present. The family requested the resident be sent to the hospital. No Nurses or CNA's had reported any excoriation on 1/29/18 thru 2/2/18. The Nurse who signed excoriation observed on 1/29/18 and 2/2/18 should have initiated an Event Note at the time, along with notification to the Physician and the family to ensure on going assessments were completed. During an interview on 2/14/18 at 1:13 p.m., CNA 1 indicated she had provided a shower for Resident E. Excoriation was observed on his bottom and was reported to the Nurse. CNA 1 could not recall the exact date, though she thought it was the day the Wound Nurse saw the resident. During an interview on 2/14/18 at 1:19 p.m., LPN 2 indicated the first day she observed excoriation present was 1/29/18. The peri area was red and excoriated. During the next shower given the area remained excoriated. The LPN indicated she had not checked to determine if the area was new or a treatment had been obtained as per protocol for impaired skin integrity. A Skin Event should have been initiated when the excoriation was first observed and this was not completed as required. The Physician, family, and Wound Consultant should have been notified when the excoriation was first observed. During an interview on 2/14/18 at 1:30 p.m., the Director of Nursing indicated the Nurse who observed the excoriation to the coccyx area should have initiated a Skin or any Event Note to complete an assessment of the area. Any change in condition or any new skin assessment should have been initiated when excoriation was first observed. This Federal tag relates to Complaint IN 611. 3.1-40(a)(2)

Based on observation, record review, and interview, the facility failed to ensure resident were free from accidents related to a fall out of bed which resulted in a fracture and failed to ensure the correct wheelchair and interventions were in place for a resident with a history of falls for 2 of 3 residents reviewed for accidents. (Resident #23 and #169) Findings include: 1. On 1/06/16 at 1:19 p.m., Resident #23 was observed sitting up in a broda wheelchair. At that time, the resident was observed with a sling to the right arm. The record for Resident #23 was reviewed on 1/07/16 at 1:44 p.m. The resident's [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was severely impaired for decision making. The resident needed extensive assistance with a 2 person physical assist for bed mobility, transfers, and dressing. The resident had no history of falls since admission. A fall risk assessment dated [DATE] indicated the resident was a high risk for fall with a score 18. The current plan of care dated 12/17/15 indicated the resident was at risk for falls related to the medication profile and disease process. Nurse's Notes dated 12/17/15 at 12:10 p.m., indicated Writer seen by wound nurse. Resident placed on right side in middle of bed and noted to be in need of complete change. Writer went to get supplies and help. Writer returned and resident has slid from bed unwitnessed onto floor. No bleeding or apparent injuries noted. Physician notified and resident sent out for X-rays and evaluation. (sic) The resident returned to the facility on [DATE] with a new [DIAGNOSES REDACTED]. The X-ray report dated 12/17/15 from the hospital of the right shoulder indicated post fall with injury. Impression: Non displace acute fracture through the greater tuberosity of the right humerus. The fall audit provided by the Director of Nursing was reviewed on 1/08/16 at 11:08 a.m. The report indicated the resident had slipped off the air mattress and fell to the floor on 12/17/15 at 12:10 p.m The resident was found on the floor, laying on the right side (weak side) in the resident room alone and unattended. The resident was not in the middle of the bed when left alone. The resident was left in bed on her side near the edge and rolled off bed. Interview with the Restorative Nurse on 1/08/16 at 11:38 a.m., indicated the resident was not a large person, but had a bigger abdomen and being left on one of her sides was too close to the edge of the bed and she had a greater chance of rolling out of bed. She indicated the resident did not have side rails on the bed just assist rails (Halos). She further indicated the resident had right sided weakness and therefore could not move her arm on that side. The Restorative Nurse indicated the wound nurse should have repositioned the resident back to the middle of the bed and on her back to ensure she was in the middle of bed before she left the room to get more supplies. Interview with the Director of Nursing on 1/11/16 at 11:20 a.m., indicated the resident should have been placed on her back and not left on her side when the nurse had left the room. Interview with Wound Nurse #1 on 1/12/15 at 8:50 a.m., indicated she was the wound nurse taking care of the resident that day. She further indicated the resident was left on her right side when she left the room and was not placed in the middle of the bed. 2. On 1/11/16 at 10:54 a.m., in the dining room, Resident #169 was observed in a wheelchair without a Dycem (non slip mat) to sit on. Interview with Unit Manager at that time, indicated the chair the resident was sitting in was not the resident's chair. The resident's chair had been washed over night and was placed in the shower room to dry. She further indicated that the resident should have a Dycem in the chair. Interview on 1/11/16 at 11:00 a.m., with LPN #2 indicated the resident had been up in the wheelchair about an hour. The resident's record was reviewed on 1/8/16 at 12:04 p.m. The resident's [DIAGNOSES REDACTED]. The 14 day Minimum Data Set (MDS) assessment dated [DATE], indicated the resident had a Brief Interview for Mental Status (BIMS) score of 0 with severe impairment. The Care Plan dated 12/12/15 was reviewed. It indicated the resident was at risk for further falls related to the education profile and disease process. The resident has a history of falls with hip pinning. The interventions were to apply bed bolsters to residents bed, place floor mats next to bed while resident was in bed, keep call light in reach at all times, and maintain bed in lowest position. The care plan interventions were updated on 1/2/16 to include a Dycem in the resident's wheelchair. Nursing Progress Notes dated 1/2/16 at 9:00 a.m., indicated while resident was sitting up in her wheelchair near nurses station she was noted reaching for something on the floor (nothing on floor) and accidentally fell out of her wheelchair. Resident was assessed and noted to have a 1.0 cm x 0.5 cm laceration above right eye with some swelling, and small amount of bleeding. No further injuries noted, residents range of motion within normal limits, no complaints of pain, resident said she did not know what she was reaching for. Called Physician and received orders for Bacitracin and band aid to area above right eye. Called son POA (Power of Attorney) and informed. Another entry in Nursing Progress Notes dated 1/3/16 at 8:40 a.m., indicated safety devices in place as ordered resident was alert and verbally confused, neurological checks were within normal limits. The facilities investigation dated 1-2-16 at 9:00 p.m., indicated the resident reached down to the ground and fell near the wheelchair. The mental status of the resident was confused and her psychological status was alert. The floor was dry and resident had shoes on. The last time the resident was taken to the toilet was at 6:30 p.m. The fall was witnessed by a staff member. Interventions for the future was to monitor the resident closely. Care plan updated. Falls team meeting notes was to add Dycem to the resident's wheelchair. 3.1-45 (a)(2)

Based on observation, record review, and interviews, the facility failed to provide the necessary treatment and services related to pain management for a resident who had a history of [REDACTED]. The facility also failed to assess and monitor a resident with [MEDICAL CONDITION] Ventricular an (AV) shunt while receiving [MEDICAL TREATMENT] for 1 of 1 residents reviewed for [MEDICAL TREATMENT]. (Residents #233 and #243) Findings include: 1. On [DATE] at 8:30 a.m. Resident #243 was observed in bed. At that time, the resident's eyes were closed and she was dressed in a hospital gown. The resident was also observed with plastic air boots to both of her feet. Interview with CNA #2 at that time, indicated the resident was receiving hospice and had not really eaten since Sunday. She indicated the resident used to scream out loud in pain (very loud) when she was turned or moved in bed. Interview with the resident's Power of Attorney (POA) on [DATE] at 8:10 a.m., indicated her aunt had passed away early in the morning. She further indicated she had a concern with her Aunt's pain management. She indicated she just wanted her Aunt to be comfortable and without pain. The record for Resident #243 was reviewed on [DATE] at 9:33 a.m. The resident was admitted to the facility on [DATE]. The resident was readmitted to the facility on [DATE] from the hospital. The resident had expired at the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was not alert and oriented. The resident needed extensive assist with two person physical assist with bed mobility, and transfers and was totally dependent on staff for dressing, toilet use, personal hygiene and bathing. The resident had impairment to both of her lower extremities and was incontinent of bowel and bladder. The resident received pain medication and prn pain medications for moderate pain. Review of the pain assessment dated [DATE] indicated the resident's pain medication was Tylenol with no complaints of pain from assessment. Review of another pain assessment dated [DATE] indicated the resident's pain med was Tylenol as needed with no complaints of pain from assessment. Review of an initial pain assessment dated [DATE] indicated the resident had pain in her left hip. The resident was receiving [MEDICATION NAME] ,[DATE] milligrams (mg) four times a day. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident received the medication two times on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE]-,[DATE], ,[DATE]-[DATE] . Review of the MAR for the dates of [DATE]-[DATE] indicated the resident received the [MEDICATION NAME] ,[DATE] mg two times on ,[DATE]-,[DATE], ,[DATE]-,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and [DATE]. The resident received the medication one time a day on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] and [DATE]. Review of the MAR for the dates of [DATE] through [DATE] indicated the resident received the [MEDICATION NAME] ,[DATE] mg on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and [DATE] Review of Nursing Progress notes dated [DATE] indicated the resident was going to be a direct admission to the psychiatric unit at the hospital. While at the hospital, the resident fell and fractured her left hip. The resident returned to the facility after surgery on [DATE]. Review of the MAR for [DATE] through [DATE] indicated the resident was receiving [MEDICATION NAME] (a medication used for pain) ,[DATE] mg one tablet four times a day at 12:00 a.m., 6:00 a.m., 12:00 p.m., and 6:00 p.m. Review of Nursing Progress notes dated [DATE] indicated the resident was direct admission to a gero-psychiatric unit at the hospital. The resident left the faciity on [DATE] and returned on [DATE]. Review of Physician order [REDACTED]. There was another order for Tylenol 325 mg one tablet every six hours prn pain. Review of physical therapy progress notes dated [DATE] indicated the resident's pain was severe. A physical therapy note dated [DATE] indicated the resident's pain was severe. Another physical therapy note dated [DATE] indicated the resident still complains of severe pain. A physical therapy note dated [DATE] indicated the resident complained of severe pain that interfered with treatment. A progress notes dated [DATE] indicated the resident complains of severe pain in her left lower extremity, low back, and right hip. The tolerance for treatment was decreasing secondary to pain. The resident's left knee contracture worsened since wheelchair leg rests were removed last week. A physical therapy note dated [DATE] indicated the resident had muscle spasms on both lower extremities. The treatment was very intense that increases the resident's pain level, and decreases resident participation. Another physical therapy note dated [DATE] indicated the resident complains of increased muscle spasms and severe pain. Noticed a decrease in range of motion of left knee with difficulties for staff to maintain positioning with leg rests (due to pain). Will continue one more week and then probably discontinue. The last physical therapy note dated [DATE] indicated the resident had severe pain in her left knee and had an increase in muscle spasms in her left lower extremity. The resident had no changes in range of motion of left knee. The resident was discharged from therapies on [DATE]. Interview with Physical Therapist #1 on [DATE] at 11:57 a.m., indicated when a resident has severe pain during a therapy session they were to report the pain to the nurse. The therapist further indicated she did report the resident's pain to the nurse but it was not documented anywhere in her notes. She further indicated the resident's pain level was so severe it did not allow the resident to progress in therapy. She also indicated the resident had such severe contractures to her left leg that would cause her pain and caused a decrease in participation. Interview with the Rehabilitation Director on [DATE] at 11:57 a.m., indicated the resident's case was discussed in the therapy department and agreed with Physical Therapist #1 the resident's pain was so severe it would not allow the therapists to proceed with her therapy. The Rehab Director further indicated the therapists should be informing the staff nurses when their patients were having pain. Review of the MAR indicated [REDACTED]. The resident received two tablets of Tylenol on [DATE], one tablet of Tylenol on ,[DATE] at 5:45 a.m., and [DATE] at 10:00 a.m.,. The resident received two tablets of Tylenol on [DATE] (no time). These were the only documented administration of Tylenol for the resident's pain during her Physical Therapy sessions from ,[DATE]-[DATE]. Review of the ,[DATE], ,[DATE] and ,[DATE] MARS indicated the resident was only receiving Tylenol on an as needed basis for her severe pain. Review of the Psychiatrist's progress note dated [DATE] indicated the "staff reported she cries at times, now due to pain." Review of Physician order [REDACTED]. Review of the Hospice Orders dated [DATE] indicated start [MEDICATION NAME][MEDICATION NAME](a pain medication) 15 mg by mouth twice a day for pain and prn. Review of the Hospice Nursing assessment dated [DATE] indicated the resident had pain present that "hurts even more." The patient was able to point to her knees when asked about the pain. Review of the MAR indicated [REDACTED]. The resident received the medication as needed one time on [DATE], Review of Nursing Progress Notes dated [DATE] at 9:00 p.m., indicated "Called Hospice Nurse to get order to increase [MEDICATION NAME]. New order for [MEDICATION NAME] to be given at 9:00 a.m., and 9:00 p.m., and PRN. Review of Physician order [REDACTED]. The next documented entry in Nursing Progress Notes was not until [DATE] at 9:00 p.m., which indicated the family had requested the resident's diet be changed. Also the Hospice nurse was at the facility earlier in the evening and increased the resident's pain medication. Review of the Hospice General Note dated [DATE] at 12:00 p.m., indicated the facility staff report the resident was having frequent breakthrough pain. The Hospice Nurse attempted getting an order to increase the [MEDICATION NAME][MEDICATION NAME] the Physician. The nurse was awaiting the return phone call from the Physician and indicated that she would follow up on the orders this afternoon. There was no further documentation from the Hospice Nurse until [DATE] (two days later) when the resident's pain medication was increased. The facility staff nurses nor the Hospice Nurse followed up with the Physician on increasing the resident's pain medication. Review of Physician order [REDACTED]. Interview with RN #1 [DATE] at 2:15 p.m. indicated she works primarily on the 5th floor. She indicated the resident was dependent on staff for all of her needs. RN #1 indicated the resident would cry out in pain and say "my leg". She indicated they had only given her Tylenol for pain prior to Hospice. Interview with CNA #3 on [DATE] at 2:20 p.m., indicated she had taken care of the resident before. She further indicated the resident would cry out in pain and indicated her legs were hurting. The CNA indicated she was to inform the nurse when resident's complained of pain. She indicated nursing staff knew the resident was in pain because they had heard her crying. Interview with the 5th floor Unit Manager on [DATE] at 11:37 a.m. indicated she was unaware the resident only had Tylenol for pain ordered after she returned from the inpatient hospital stay from ,[DATE]-[DATE]. She was further unaware the resident had complaints of severe pain while in Physical Therapy. The Unit Manager indicated she was on a leave of absence from ,[DATE] until [DATE]. 2. Resident #233 was observed on [DATE] at 8:55 a.m. He was in bed. Interview with the resident at that time, indicated he goes to [MEDICAL TREATMENT] three times a week. He indicated he has been going to [MEDICAL TREATMENT] for about 2 years. The record for Resident #233 was reviewed on [DATE] at 3:09 p.m.. The resident had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated the resident had a Brief Interview for Mental Status (BIMS) score of 12, which indicated he was moderately cognitively impaired. It also indicated he had [MEDICAL CONDITION] and received [MEDICAL TREATMENT]. The Skin Assessment form dated [DATE], indicated the resident had an AV(arteriovenous) fistula (a surgically formed graft connecting the artery to the vein, used for [MEDICAL TREATMENT]) in his right upper extremity. Review of the Nurses Observations notes dated [DATE] through [DATE], indicated there was no assessment of the resident's AV fistula. There was no evidence the staff assessed the AV fistula for a thrill (a pulse felt at the AV fistula site) or a bruit (a sound heard when a stethoscope was placed on the AV fistula). There was no evidence the staff routinely assessed the AV fistula for bleeding, patency or function. There was no evidence the resident's AV fistula was assessed routinely and documented on the Medication Administration Records, on the Treatment Administration Records or on the [MEDICAL TREATMENT] communication forms Review of the Nurse Practitioner's progress note dated [DATE], indicated the resident was seen and examined. She had assessed the resident's AV fistula. She indicated the resident had a, "positive thrill and bruit auscultated to the right upper arm graft." Review of the current care plans indicated there was no care plan for monitoring and assessment of the resident's AV fistula. Interview with RN #1 on [DATE] at 8:47 a.m., indicated she was the nurse providing care for the resident on that day. She indicated she had been the nurse providing care for the resident in the past. She indicated she had not assessed and monitored the resident's AV shunt in the past. Interview with LPN #2 on [DATE] at 9:39 a.m., indicated she frequently was in charge of residents who required [MEDICAL TREATMENT]. She indicated there should be a place on the Treatment Administration Record to document assessments of the resident's AV shunt. Interview with the 5th Floor Unit Manager on [DATE] at 8:53 a.m., indicated there was no evidence the nursing staff routinely assessed the resident's AV shunt for patency and monitored the area for complications. She further indicated there were no facility policies for [MEDICAL TREATMENT] and/or shunt care. 3XXX,[DATE](a)

Based on interview, the facility failed to identify non-compliance for pain management to control a resident's pain after a [MEDICAL CONDITION] and during physical therapy through the facility's quality assurance protocol. (Resident #243) Findings include: Interview with the Administrator on [DATE] at 2:07 p.m. indicated the facility's Quality Assurance Committee meets quarterly and consists of herself, the Director of Nursing, and the department heads as well as the Medical Director, a representative from the laboratory and pharmacy. The Administrator indicated at the time, the control of residents's pain had not been discussed, addressed or identified as being a problem in Quality Assurance. She further indicated there had been no action plan or system put into place to identify the problem of controlling pain for residents after a [MEDICAL CONDITION] and during physical therapy. Continued interview with the Administrator on [DATE] at 2:07 p.m., pain was certainly discussed at a smaller level, but not during the quarterly meetings. She indicated the communication process between the therapy department and the nursing department needs to be better. Should a resident have pain during therapy, it should be communicated to the nurses verbally as well as documented. She indicated there was no written form of documentation from the therapy department, identifying when a resident needs something for increased pain. She also indicated ongoing communication with the Hospice Nurses needs to be improved so her staff were informed of any changes or new Physician Orders. Resident #243 was admitted to the facility on [DATE]. The resident was readmitted to the facility on [DATE] from the hospital. The resident had expired at the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident received the medication two times on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE]-,[DATE], ,[DATE]-[DATE] . Review of the MAR for the dates of [DATE]-[DATE] indicated the resident received the [MEDICATION NAME] ,[DATE] mg two times on ,[DATE]-,[DATE], ,[DATE]-,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and [DATE]. The resident received the medication one time a day on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] and [DATE]. Review of the MAR for the dates of [DATE] through [DATE] indicated the resident received the [MEDICATION NAME] ,[DATE] mg on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and [DATE] Review of Nursing Progress notes dated [DATE] indicated the resident was going to be a direct admission to the psychiatric unit at the hospital. While at the hospital, the resident fell and fractured her left hip. The resident returned to the facility after surgery on [DATE]. Review of Nursing Progress notes dated [DATE] indicated the resident was direct admission to a gero-psychiatric unit at the hospital. The resident left the faciity on [DATE] and returned on [DATE]. Review of Physician order [REDACTED]. There was another order for Tylenol 325 mg one tablet every six hours prn pain. Review of physical therapy progress notes dated [DATE] indicated the resident's pain was severe. A physical therapy note dated [DATE] indicated the resident's pain was severe. Another physical therapy note dated [DATE] indicated the resident still complains of severe pain. A physical therapy note dated [DATE] indicated the resident complained of severe pain that interfered with treatment. A progress notes dated [DATE] indicated the resident complains of severe pain in her left lower extremity, low back, and right hip. The tolerance for treatment was decreasing secondary to pain. The resident's left knee contracture worsened since wheelchair leg rests were removed last week. A physical therapy note dated [DATE] indicated the resident had muscle spasms on both lower extremities. The treatment was very intense that increases the resident's pain level, and decreases resident participation. Another physical therapy note dated [DATE] indicated the resident complains of increased muscle spasms and severe pain. Noticed a decrease in range of motion of left knee with difficulties for staff to maintain positioning with leg rests (due to pain). Will continue one more week and then probably discontinue. The last physical therapy note dated [DATE] indicated the resident had severe pain in her left knee and had an increase in muscle spasms in her left lower extremity. The resident had no changes in range of motion of left knee. The resident was discharged from therapies on [DATE]. Interview with the Director of Nursing on [DATE] at 11:47 a.m., indicated there should have been better communication between the therapy department and the nursing staff to control the resident's pain. 3XXX,[DATE](b)(2)

Based on record review and interview, the facility failed to ensure the resident's drug regimen was free from unnecessary drugs related to the indication for the use of a hypnotic (a sleeping pill) and monitoring cardiac medications. The facility also failed to ensure blood thinners were monitored related to [MEDICATION NAME] therapy that resulted in a critical [MEDICATION NAME] level and blood in a resident's urine for 3 of 10 residents reviewed for unnecessary drugs. (Residents #76, #125, and #239) Findings include: 1. The record for Resident #76 was reviewed on 1/9/13 at 10:08 a.m. The resident had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated the resident received anticoagulant (blood thinning) medications daily. Review of the updated 10/17/12 plan of care indicated there was a care plan for [MEDICATION NAME] therapy with the nursing approaches to monitor for bruising and any other skin conditions. There was a physician's orders [REDACTED]. PT/INR ([MEDICATION NAME]/International Normalized Ratio) (a lab test to assess bleeding) in one week." Review of the laboratory test results indicated there was no PT/INR obtained on 11/23/12, one week after the physician's orders [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident was administered [MEDICATION NAME] 6 mg alternating with [MEDICATION NAME] 7 mg from 11/16/12 through 12/4/12. There was a Pharmacy Consultant Recommendation dated 12/4/12, that indicated, "On 11/16/12, an order was written for a PT/INR in one week (last lab in the chart was from 11/16/12). Recommendation: Unless otherwise indicated, please follow up with the lab and have results forwarded to the facility." There was a Physician order [REDACTED].O. (by mouth) every other day. Do PT/INR in a.m." The PT/INR was obtained on 12/6/12. Review of the PT/INR dated 12/6/12, indicated, "[MEDICATION NAME]-[MEDICATION NAME] > (greater than) 120.0 CH (critically high) INR [MEDICATION NAME] >11.0 CH." The Physician was notified on 12/6/12 of the critically high PT/INR result. The Physician visited the resident. The Physician's Progress note dated 12/6/12, indicated, "For acute visit, called to see re: (regarding) abnormal labs INR >11.0 pt. (patient) seen examined AAO X 1 (alert and oriented times 1) . . . Assessment: 1)[MEDICATION NAME] toxicity -see orders will review [MEDICATION NAME] -monitor closely for signs of bleeding 2) A-fib ([MEDICAL CONDITION]) stable continues NSR (normal sinus rhythm)" The Physician order [REDACTED]." The 12/7/12 lab report indicated the Pro-time [MEDICATION NAME] was 40.2 and the INR [MEDICATION NAME] was 4.1. The Physician was notified of the 12/7/12 lab results. There was a physician's orders [REDACTED]." The lab report dated 12/10/12, indicated the PT [MEDICATION NAME] was 16 and the INR [MEDICATION NAME] was 1.5. The Nurses Observations notes were reviewed. There was an entry dated 12/6/12 at 2:30 p.m., that indicated, "Dr. (physician's name) visited relayed lab result PT >120 and INR>11 received orders noted and carried out. MD seen (sic) resident slight bruising rt (right) wrist and with [MEDICAL CONDITION] (swelling) (sic), family aware no active bleeding any kind noted." The next entry was dated 12/6/12 at 3 p.m. and indicated, "No sign of acute distress." The entry dated 12/6/12 at 10:15 p.m., indicated, "Administered the ordered mephytoin (Vitamin K) 5 mg tablet at 5 p.m. at 10:15 p.m., CNA called stating that there is blood in the urine, assessed the resident urine and observed that resident has hematuria (blood in the urine). Resident voice (sic) out no pain in urinating nor any other discomfort. Is alert and oriented . . . resting call light within reach." The next entry was dated 12/7/12 at 2 a.m. and indicated, "Resident resting quietly in bed with call light in reach. Noted hematuria continues in the urine, no clots noted denies any discomfort at this time will continue to observe for any changes." Interview with Quality Assurance Nurse #1 on 1/9/13 at 4:17 p.m. indicated the PT/INR that was to be obtained on 11/23/12 to assess the resident's bleeding status was not obtained. She indicated that when the PT/INR was obtained the level was critical and the resident then had hematuria. Interview with the Director of Nursing on 1/9/13 at 4:53 p.m., indicated she was not aware the lab had not been obtained as ordered for Resident #76. The 5th Floor Unit Manager was interviewed on 1/10/13 at 2:00 p.m. She indicated the resident had hematuria on 12/6/12 and on 12/7/12. 2. The record for Resident #239 was reviewed on 1/10/13 1:39 p.m. The resident had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated the resident has a Brief Interview for Mental Status (BIMS) score of 3, which indicated she had severe cognitive impairment. Review of the physician's orders [REDACTED]." The Nurses Observation notes dated 12/21/12 through 1/10/13 were reviewed. There was one entry dated 12/25/12 at 10:30 p.m., that indicated, "Resident stated to this writer, "I'm so tired, I can't sleep at night. This writer [MEDICATION NAME] mg currently discontinued. Note left for Dr. (physician's name)." Continued review of the Nurses Observation notes indicated there were no other episodes of complaints of inability to sleep. Review of the Behavior/Intervention Monthly Flow Records for December 2012 and January 2013 indicated there were no behaviors of [MEDICAL CONDITION] noted. Review of the current care plan indicated there was no care plan for [MEDICAL CONDITION]. Review of the record indicated there was no evidence that non-pharmaceutical interventions were attempted prior to the use of the Ambien. Interview with the 5th Floor Unit Manager on 1/10/13 at 1:20 p.m., indicated there was no care plan for [MEDICAL CONDITION]. She also indicated there was no evidence that non-pharmaceutical interventions for [MEDICAL CONDITION] were attempted prior to the use [MEDICATION NAME] night. She also indicated there was only one entry in the Nurses Observation notes related to difficulty sleeping. 3. The record for Resident #125 was reviewed on 1/9/13 at 8:53 a.m. The resident's [DIAGNOSES REDACTED]. Review of the January 2013 physician's orders [REDACTED]. The resident was also to receive 125 mcg of [MEDICATION NAME] 4 days per week. Review of the December 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 12/15 the residents heart rate was 56, on 12/17 the resident's heart rate was 57, and on 12/30/12 the resident's heart rate was 58. The resident had received 125 mcg of [MEDICATION NAME] at those times. Review of the 2010 Nursing Spectrum Drug Handbook, indicated to assess the apical pulse (heart rate) for 1 full minute. If the rate was less than 60 beats/minute, withhold dose and notify prescriber. Interview with the 2nd Floor Unit Manager on 1/15/13 at 11:00 a.m., indicated the [MEDICATION NAME] had been given even though the resident's heart rate was less than 60 on the above dates. 3.1-48(a)(3)

Based on observation, record review and interview, the facility failed to ensure interventions were in place for supervision of a resident who had eloped, failed to assess the resident annually for risk of elopement and failed to assess prior to removing a wanderguard for 1 of 4 residents reviewed who were at risk of elopement in a sample of 6. (Resident #C) The immediate jeopardy began on 8/18/11 when no elopement assessment was completed and wanderguards were discontinued for a resident with a history of elopement. The Executive Director, Administrator, Assistant Administrator and Director of Nursing were notified of the immediate jeopardy at 4:30 p.m. on 8/22/11. The immediate jeopardy was not removed by the exit date of the survey. Findings include: Resident #C was observed on 8/22/11 at 11:02 a.m., in activities on the second floor playing BINGO. There was no wanderguard on her or on her wheelchair. On 8/22/11 at 12:15 p.m., Resident #C was observed on the ground floor in the main dining room eating lunch. There was no wanderguard observed on her or on her wheelchair. On 8/22/11 at 3:20 p.m., Resident #C was observed self propelling her wheelchair on the ground floor from activities to the elevator. She stopped her wheelchair behind another resident and was waiting with several other residents in the hallway. Staff were observed in the hallway with the residents. The record for Resident #C was reviewed on 8/22/11 at 11:05 a.m. The resident's [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. A nursing note, dated 7/12/11 at 11:30 a.m., indicated the resident had increased confusion and went into another resident's room, she was soaking wet and yelling out at this resident. The resident was redirected to go to her room and the nurse would come and help her. At 12:00 p.m., the resident was changed and remained up. The resident was reassured that staff were there to take care of her. She wanted her roommate to change her clothes. The nurse informed her staff was here for that and the roommate could not help her. A nursing note, dated 7/24/11 at 2:50 p.m., indicated the nurse was "notified that res (resident) was outside of facility off of property by herself. This writer went to get res (resident). Res (resident) a/o (alert/oriented), skin w/d (warm/dry)." The resident's vital signs were temperature 98, pulse 78, respirations 20, and blood pressure 126/60. There was no acute distress noted. At 3:15 p.m., the resident's skin check was completed with no bruising noted. The resident indicated she was in no pain. At 3:17 p.m., the physician was notified. At 3:20 p.m., the resident's family was notified. At (no time indicated) a new order was received for a wanderguard. At 3:30 p.m., the wanderguard was applied to the resident's wrist and wheelchair as ordered. At 6:00 p.m., the resident had dinner in her room. At 6:10 p.m., the resident's family was visiting. At 7:00 p.m., the resident removed her wanderguard from her wrist. The resident was in her room in her wheelchair watching television. A nursing note, dated 7/25/11 at 9:00 a.m., indicated, the wanderguard remains to wheelchair. "Res (resident) states she is going to the Dollar Store next time its (sic) closer. Res (Resident) informed she is not to leave facility without staff or family." At 12:15 p.m., the resident was given her lunch tray by a CNA. The resident was in her wheelchair and set up to eat prior to CNA leaving the room. At 12:45 p.m., the resident was at the nurse's station in her wheelchair stating she did not have lunch and that her lunch was in the bathroom. The CNA indicated the resident was set by her bed and window and the resident moved the tray. The resident was ordered another lunch tray. A nursing note, dated 7/26/11 at 6:30 a.m., indicated, the resident was in her wheelchair in room, alert, verbally responsive, skin was warm and dry. She was informed to stay on the unit for meals. The resident verbalized understanding. At 7:30 a.m., the resident was up in her wheelchair attempting to go down to the main dining room for breakfast. Shed stated to writer, "I can do as I please and do you really think that I don't know what I'm doing, I know exactly what I'm doing. I'll leave when I want to leave and (Roommate's name) is staying upstairs (sic) with me." It was explained to the resident why she was not able to go downstairs. Resident calmed down and stated, "Oh whatever and said alright." A nursing note, dated 7/27/11 at 3:00 p.m., indicated the resident's wanderguard to person was discontinued due to resident removal. At 11:30 a.m., the wanderguard to the resident's wheelchair was in place. A nursing note, dated 7/28/11 at 3:10 p.m. indicated, the resident was at the nurse's station wanting to leave the facility to go to the store. The resident was redirected by staff and Administrator was made aware. At 3:20 p.m., activities will take the resident out tomorrow. A nursing note, dated 8/7/11 at 4:30 p.m., indicated the resident said "she was going to leave (sic) facility when she went to activity. The writer spoke with res (resident) and informed her that she could not leave the facility without family or staff. Res (resident) got angry and went back to her room." A nursing note, dated 8/15/11 at 7:45 a.m., indicated the resident was upset this morning and took her breakfast tray and put it on the floor in the middle of the hallway. At 7:50 a.m., the nurse spoke to the resident and had her pick up the tray out of the hallway. The resident picked the tray up and handed it to the nurse. A nursing note, dated 8/18/11 at 2:30 p.m., indicated the resident's wanderguard was discontinued and noted by social service. The resident's family was informed. At 2:40 p.m., MDT (Multidisciplinary Team) discussion today regarding wanderguard. The resident and family requested wanderguard be removed. The resident stated, "She will not leave the facility unattended, states she would like to go to dining room for meals and wants to attend activities. MDT feels that wanderguard should be removed at this time. Resident education done at this time. A Psychiatry note, dated 7/13/11, indicated "I reviewed the nursing notes over the last month and no sleeping problems are reported. The resident urinated on self and per nursing report was observed using foul language because her roommate wouldn't help her change her clothing. I continue charting on her behaviors. She is not on the prn (as needed) Seroquel (anti-psychotic) stated earlier this year for behavioral issues." Addendum: The activity staff reported the resident was having memory problems, not able to play BINGO as before. She expects her roommate to help her and becomes angry. Resident to have urine checked and if no infection restart prn Seroquel." A Psychiatry note, dated 8/11/11, indicated, "Pt (patient) seated in room. Discussed with her the incident when she left facility to go to Target. She said she didn't know she couldn't go stating 'I used to go to Target and the Dollar Store with my mother.' She said '5 minutes more (sic) they would have never known.' She stated 'I told them I would not do it again. They are being childish about it. It makes me want to do something else.' I explained she must now be restricted as a result of her own action. She was not accepting of this. She did laugh about it when I joked about it in order to lighten up the moment. She brought up her mother as if she were alive. Her memory was impaired. She now has a wanderguard on her wheelchair. She reportedly cut the one off her arm." A quarterly Minimum Data Set Assessment, dated 7/21/11, indicated she was understood and she understands. She scored an eleven out of fifteen on the BIMS (Brief Interview for Mental Status) which indicated she was moderately impaired cognitively. The resident missed the correct year by one year, she was accurate to the month within five days, and she was able to recall one of the three words given at the beginning of the assessment with no cueing, she needed cueing for the second word, and could not recall the third word. A Mini-Mental State Examination (MMSE), dated 7/25/11, indicated a score of 18 out of 30 which would indicate the resident had moderate cognitive impairment. She answered correctly two of the following: year, season, date, day, and month. She answered correctly two of the following: state, country, town or city, hospital, and floor. She scored a two out of five when asked to spell the word "WORLD" backwards. When given three items to recall she could only recall one of the items. She could not copy a figure of intersecting pentagons. The resident's plan of care card indicated the resident was to have a wanderguard on her wheelchair. An Elopement Risk Assessment, dated 6/22/09, indicated this was an initial assessment and the resident was at risk and a wanderguard was in place. There were no other Elopement Risk Assessments in the resident's record. A care plan, initiated on 7/24/11, indicated a problem of exiting the facility alone. The approaches included, but were not limited to, reminding the resident it was dangerous to exit the building alone, wanderguard on bottom of wheelchair due to resident removing the wanderguard from her wrist, check wanderguard placement, and notify physician of any new orders. A social service note, dated 7/20/11, indicated the resident was alert and oriented times two with confusion. There had been no behaviors present over the last seven days. The resident was seen by the psychologist on 7/13/11 and received a new order for Seroquel (anti-psychotic) as needed due to agitation. A social service note, dated 7/25/11, indicated the resident was noted outside the facility and off property without assistance. Nursing went to get the resident and returned her to the facility with no injury. The resident indicated she wanted to go shopping and later indicated she wanted to go for a walk and was tired of being inside. A new order was received for a wanderguard. The resident later removed the wanderguard to wrist and a wanderguard to wheelchair was applied. Nursing has discussed situation and safety concerns with the resident and she stated she will leave when she wants to. In morning meeting concerns were discussed and limiting resident's activity throughout the facility until resident safety can be better assessed. Social Service suggested a family meeting and family wanted to hold off at this time. The family was in agreement with facility attempts to keep resident safe with wanderguard, and limiting activities. Family indicated they visited yesterday and discussed concerns with the resident. The family indicated they will attempt to take the resident out on pass with family monthly as weather permits. Social service met with resident and discussed concerns. There resident had some confusion and noted difficulty with word finding. A social service note, dated 7/26/11, indicated the resident continues to exhibit periods of confusion and resident having difficulty with word finding and becomes frustrated in conversation at times. A new order was received to start Namenda (used to treat moderate to severe dementia). A social service note, dated 8/16/11, indicated social service was informed by nursing the resident was upset and requesting wanderguard be removed. Resident had been refusing meals at times. The wanderguard placement was discussed with MDT and family. The family was informed of risks of removing wanderguard but explained facility desire to maintain resident's independence and dignity. The concerns of the resident refusing meals and the concern of the wanderguard having a negative affect on the resident were discussed. The resident indicated she will not leave the facility again unassisted and stated to social service today she wishes she would not have left. The family feels the resident will not attempt to leave the facility again and was remorseful about the situation. Family would like the wanderguard removed. A social service note, dated 8/18/11, indicated MDT and Psychiatrist discussed with social service the removal of the wanderguard. Resident and family want the wanderguard removed. After further discussion, MDT feels that wanderguard should be removed at this time. The resident was educated on safety of not leaving the building unattended. The resident agrees and understands. Review of a reportable incident on 8/22/11 at 2:00 p.m., indicated on July 24, 2011 at 1:58 p.m., staff was made aware by another family member that Resident #C was observed at the adjacent shopping center. In viewing the video footage the resident exited the building through the patio in her wheelchair at 1:58 p.m. The resident crossed the parking lot to the shopping center sidewalk and proceeded to the far end of the strip mall. At 2:39 p.m., staff followed and the resident was returned to the facility without injury at 2:49 p.m. A Memo to the Indiana State Department of Health, dated 7/28/11, indicated "To recount the circumstance, staff was made aware by her roommate's family that (Resident #C's name) was observed entering the adjacent shopping center. In reviewing the video footage, (Resident #C's name) exited the building through the patio doors in her wheelchair at approximately 1:58 p.m., with the assistance of another resident's spouse. (Resident #C's name) proceeded in her wheelchair across the parking lot up onto the sidewalk and to the store. At 2:39 p.m., (Resident #C's name) nurse exited the same patio doors and returned with (Resident #C's name) at 2:49 p.m. (Resident #C's name), upon her return was in good spirits and without injury. The facility applied a wanderguard to (Resident #C's name) and her family and physician were made aware of the situation. In speaking with (Resident #C's name) about the incident she states she was upset because she and her roommate had plans to attend an activity together and when her roommate's family came in, she (the roommate) left to go to the store without her. The facility has requested that (Resident #C's name) not leave the unit for a period of time unless supervised by family or staff. Activity staff has agreed to take (Resident #C's name) shopping on a monthly basis and family is willing to do the same. The individual that assisted (Resident #C's name) in exiting the facility unattended has been educated on the risks of doing so and has verbalized understanding. The facility is committed to providing a safe environment for all our residents without compromising their quality of life. We will observe (Resident #C's name) for the next two weeks and evaluate her ability to safely leave the unit unattended as she has expressed a desire for independence but sometimes lack good decision making skills." The Elopement Risk Assessment Policy was provided by the Administrator on 8/22/11 at 2:40 p.m. The Social Service Department was responsible for the procedure. The purpose: "To appropriately identify those at risk for elopement." The procedure included, but was not limited to, the following: "1.0 All new admissions will be assessed by Social Service during the completion of the Social History." "2.0 All other residents will be assessed by Social Service regardless of past "no" risk scores when changes in cognitive or behavioral status or when a new [DIAGNOSES REDACTED]. 4.0 All residents will be assessed annually." Interview with LPN #1 on 8/22/11 during the initial tour at 10:10 a.m., indicated she was very scared when she found out Resident #C had left the facility. She was the nurse who went to get the resident and returned her to the facility. She further indicated the resident thought the situation was funny and did not seem to see the danger she was in at the time. The resident had informed the LPN that if she had five more minutes she would have been back and no one would have known she was gone. Interview with Social Service #1 on 8/22/11 at 12:00 p.m., indicated the most recent Elopement Risk Assessment for Resident #C was 6/22/09. She further indicated she was the staff member who would have completed the assessments and there were no other assessments. Interview with the Administrator on 8/22/11 at 12:15 p.m., indicated the ground floor doors do not have a wanderguard alarm. The resident was not kept from the main dining room due to the wanderguard it was due to the staff monitoring the resident's behavior and her indicating she was still going to leave. It was then indicated with her stating she was going to leave and the doors not being activated by the wanderguard system it was felt in the best interest of the resident to keep her on the unit to monitor her behavior. Interview with the Director of Nursing and Administrator on 8/22/11 at 2:30 p.m., indicated she thought the resident's wanderguard from 6/22/09 was discontinued in January 2010. It was indicated the resident left the facility because she was angry her roommate would not be in the facility for the activity they had planned to do together and her roommate was going out with her family. It was further indicated the roommate's family will at times take Resident #C out with them when they go out. It was then indicated Resident #C had come along way from when she first came to the facility with her behaviors. Resident #C was also very territorial. It was also indicated when the resident would get on the elevator and her wanderguard would sound she would say, "That's me." Interview with the Assistant Administrator on 8/22/11 at 3:15 p.m., indicated she was not sure if or what interventions were put into place for Resident #C when her wanderguards where discontinued. Interview with the current Second Floor Unit Manager, the new Second Floor Unit Manager, Social Service #1, Administrator, and Assistant Administrator on 8/22/11 at 3:45 p.m., indicated the resident was a focused resident and she was to have periodical and interval checks being completed after her wanderguard was discontinued. It was further indicated that this meant checking on the resident during the day and multiple times at night. The resident was in activities all day so the checking was less frequent. The facility did not indicate who would do the checking on the resident or the frequency of the checks. It was also indicated the resident was having behaviors and not eating due to the wanderguards and being monitored on the unit. It was also indicated the resident not only took off her wanderguard, but was also trying to take the wanderguard off of her wheelchair. It was thought that in the best interest of the resident and to give the resident independence the wanderguard should be discontinue. There were no other interventions indicated after the wanderguard was discontinued. It was then stressed that the resident wanted her independence and did not like staff being with her all of the time. Interview with the Activity Director on 8/23/11 at 9:45 a.m., indicated the resident had been taken to the store. She did not know exactly when the outing took place and activity notes are done monthly so they would not be in the chart yet. She further indicated the resident was taken out of the facility by staff. This Federal tag relates to complaint IN 249. 3.1-45(a)(2)