Every finding on record at Newburgh Health and Rehab

Based on interview and record review, the facility failed to ensure sufficient dietary support staff were employed and had relevant training to carry out safe functions of food and nutrition services for 1 of 1 kitchens reviewed. Nursing staff and facility leadership staff without training in dietary services completed meal service preparation, meal service, and sanitization at the end of the meal for 19 days in May. (Kitchen)Finding includes:Anonymous interview on 6/15/26 at 1:25 P.M. indicated nursing staff were cooking the food for the residents. The meals were not edible, cold, and never served on time.On 6/16/26 at 8:43 A.M., the Dietary Schedule for 5/24/26 through 6/16/26 was reviewed. An evening cook was not scheduled for 5/24/26 or 5/25/26.Interview on 6/16/26 at 9:31 A.M., the Kitchen Manager indicated her first day at the facility was 5/24/26. Prior to that, nursing staff cooked the residents' food due to a lack of dietary staff.At that time, food temperature logs for 5/1/26 through 6/15/26 were reviewed. Final cooked temperatures and holding temperatures were not recorded for the following days:5/2/26 (breakfast, lunch, and dinner)5/4/16 (dinner - holding temperature)5/8/26 (breakfast, lunch, and dinner)5/9/26 (breakfast, lunch, and dinner)5/10/26 (breakfast, lunch, and dinner)5/11/26 (breakfast, lunch, and dinner)5/13/26 (breakfast, lunch, and dinner)5/15/26 (dinner)5/19/26 (dinner)5/20/26 (lunch)5/21/26 (breakfast, lunch, and dinner)5/22/26 (lunch and dinner)5/23/26 (breakfast, lunch, and dinner)5/24/26 (breakfast, lunch, and dinner)5/25/26 (dinner)5/26/26 (breakfast, lunch, and dinner)5/27/26 (breakfast, lunch, and dinner)5/28/26 (breakfast and lunch)5/29/26 (breakfast and lunch)5/30/26 (dinner)5/31/26 (breakfast, lunch, and dinner)Interview on 6/16/26 at 9:36 A.M., the Administrator indicated that all facility staff picked up shifts in the kitchen for about two weeks. The Dietitian created an emergency menu that was implemented and that nursing staff cooked. She was not sure if nursing staff who worked in the kitchen knew proper food handling protocols and policies, and she was not sure there was always someone who had a food service certificate working in the kitchen.Interview on 6/16/26 at 1:41 P.M., Licensed Practical Nurse (LPN) 5 indicated that she washed dishes in the kitchen on several occasions over the last few weeks but received no training related to general kitchen duties, safe food handling, or sanitization rules prior to performing kitchen duties.Interview on 6/16/26 at 1:43 P.M., Certified Nurse Aide (CNA) 8 indicated that she washed dishes in the kitchen on several occasions over the last few weeks. She indicated Medical Records 11, Qualified Medication Aide (QMA) 9 and QMA 10 cooked. There was no general kitchen service, safe food handling, or sanitization rules training provided prior to performing kitchen duties.Interview on 6/16/26 at 2:44 P.M., the Administrator indicated all but two dietary staff were fired on 5/6/26. To cover the lack of dietary staff, department heads worked in the kitchen on 5/7/26, and nursing staff covered kitchen duties beginning on 5/8/26. Nursing staff continued to cover dietary-related services until a full dietary staff was hired on or around 5/26/26.At that time, a Dietary Coverage schedule from 5/8/26 through 5/25/26 was reviewed. The following meals were prepared, served, and sanitized by employees without dietary training, qualifications, and food service certification:On 5/8/26 (census 53): Breakfast Service - Staff Development Coordinator (SDC), Assistant Director of Nursing (ADON), and Qualified Medication Aide (QMA) 9Lunch Service - QMA 9, Medical Records 15, and Business Office Manager (BOM)Dinner Service - Admissions, BOM, and QMA 9On 5/9/26 (census 53):Breakfast Service - Administrative Assistant 18, QMA 9, Certified Nurse Aide (CNA) 8, and QMA 16Lunch Service - Minimum Data Set (MDS) Coordinator, Administrator, and a Non-EmployeeDinner Service - Social Service Director (SSD) and Director of Nursing (DON)On 5/10/26 (census 53):Breakfast Service - QMA 10, Administrator, and QMA 9Lunch Service - Administrator and a Non-EmployeeDinner Service - Administrator, QMA 10, and DONOn 5/11/26 (census 53):Breakfast Service - Medical Records 11 and QMA 9Lunch Service - Medical Records 11 and QMA 9Dinner Service - QMA 16, CNA 9, and Licensed Practical Nurse (LPN) 5On 5/12/26 (census 53):Breakfast Service - Medical Records 11 and QMA 9Lunch Service - Medical Records 11 and QMA 9Dinner Service - Medical Records 11, QMA 9, QMA 16, and CNA 8On 5/13/26 (census 53):Breakfast Service - Medical Records 11 and QMA 16Lunch Service - Medical Records 11Dinner Service - QMA 16, MDS Coordinator, LPN 5, CNA 8On 5/14/26 (census 54):Breakfast Service - Medical Records 11 and ADONLunch Service - Medical Records 11 and ADONDinner Service - Medical Records 11, CNA 8, and QMA 16On 5/15/26 (census 54):Dinner Service - Housekeeper 17, CNA 8, QMA 10, and QMA16 On 5/16/26 (census 53):Breakfast Service - QMA 16 and QMA 9Lunch Service - QMA 16 and QMA 9Dinner Service - QMA 9, Housekeeper 17, and CNA 8On 5/17/26 (census 53):Breakfast Service - QMA 16 and QMA 9Lunch Service - QMA 9Dinner Service - QMA 10, QMA 9, CNA 8, and Housekeeper 17On 5/20/26 (census 54):Breakfast Service - QMA 9Lunch Service - QMA 9Dinner Service - Medical Records 11On 5/22/26 (census 54):Dinner Service - no staff listedOn 5/23/26 (census 55):Breakfast Service - QMA 9Lunch Service - QMA 9Dinner Service - QMA 9On 5/24/26 (census 53):Breakfast Service - QMA 9Lunch Service - QMA 9Dinner Service - QMA 9On 5/25/26 (census 55):Breakfast Service - Medical Records 11Lunch Service - QMA 9Interview on 6/17/26 at 10:44 A.M., the Administrator indicated staff were not trained prior to working in the kitchen.On 6/16/26 at 3:23 P.M., the Administrator provided a current Food & Beverage Temperature Control policy, dated 2026, that indicated To ensure residents receive safe food served at acceptable temperatures. Food and beverage temperatures should be taken and logged upon being cooked and again prior to meal service.On 6/16/26 at 3:46 P.M., the Administrator provided a current undated Orientation to the Dietary Department employee requirements. Requirements included, but were not limited to:Review of sanitization rules in the kitchenExplanation of correct procedure for setting up traysReview of food preparation principlesTherapeutic dietsReading and following recipesUse of proper dipper and portion sizesProper storage of refrigerator and freezer items (thawing)Checking temperatures of refrigerator and freezerFirst in First out ruleProper Use of.Dish MachineProper Use of.Steam tableProper Use of.Plate warmerFloor cleaning proceduresDish room proceduresKitchen shut down procedures (i.e.: emergencies)On 6/17/26 at 6:43 A.M., the Administrator provided a current undated CNA Skills Check List, a current undated QMA Skills Check List, and a current undated Orientation Check List for Registered and Licensed Nurses. The list did not include any of the skills listed in the Orientation to Dietary Department requirements.This citation relates to intake 3041445. 410 Indiana Administrative Code (IAC) 16.2-3.1-20(h)410 IAC 16.2-3.1-21(i)(2)

Based on observation, interview, and record review, the facility failed to ensure that food was served at palatable temperatures for 1 of 1 trays tested for temperature. (East Hall Unit)Findings include:On 6/15/26 at 12:50 P.M., a test tray was obtained from the East Hall Unit. The hot food tasted cold. Temperatures were:BBQ sandwich- 131.4 degrees Fahrenheit (F)Green beans-109.8 degrees FCubed potatoes-110 degrees FSoup-120 degrees FChocolate pudding 68.9 degrees FCup of hot water-103.8 degrees F During an interview on 6/15/26 at 1:10 P.M. with the Dietary Manager indicated that hot foods should be 135 degrees F or greater and cold foods should be 41 degrees F or lower.On 6/16/26 at 10:15 A.M., the Administrator provided a current, non-dated policy Food and Beverage Temperature Control. The policy indicated .hot foods are to be served at 135 degrees F or higher and cold food/beverages should be served at 41 degrees F or lower.This citation relates to Intake 3041445410 Indiana Administrative Code (IAC) 16.2-3.1-21(a)(2)

Based on observation, record review and interview, the facility failed to ensure a resident had been provided with a safe, clean environment by not providing clean bed linens for 1 of 1 resident. Damp, soiled, and stained bed pad and linen were observed during a random observation of a resident's bed. (Resident V) Findings include:Anonymous interview on 6/15/26 at 1:25 P.M., indicated staff left dirty and wet bed pads on Resident V's bed. Observation on 6/17/26 at 9:35 A.M., Resident V's made up bed was observed with the sheets pulled up over a damp bed pad that smelled of urine and when the sheets were pulled back a yellow stained bottom sheet was observed. On 6/17/26 at 10:30 A.M., Resident V's clinical record was reviewed. Resident V diagnosis included, but was not limited to, overactive bladder. The current annual MDS (Minimum Data Set) indicated Resident V was cognitively intact. The current care plan for incontinence bladder interventions were reviewed on June 15, 2026, those included; clean peri-area with each incontinence episode dated 5/14/25.Check as scheduled/PRN (pro re nata/ as needed) for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinent episodes dated 5/14/25. Interview on 6/17/26 at 10:20 A.M., Certified Nurse Aide (CNA) 7 indicated bed linen will get changed on the shower days, but if the linen is soiled it will be removed immediately and as needed. On 6/17/26 at 10:57 A.M., the Administrator provided a current policy Safe and Homelike Environment revised 1/26. The policy indicated .The facility will provided and maintain bed and bath linens that are clean and in good condition. This citation relates to Intake 3041445. 410 IAC (Indiana Administrative Code) 16.2-3.1-19(f)(5)

Based on interview and record review, the facility failed to ensure residents dependent on staff for ADLs (Activities of Daily Living) were showered for 3 of 3 residents reviewed for ADL care. (Resident S, Resident T, and Resident U)Findings include:1. On 6/15/26 at 9:54 A.M., Resident S's clinical record was reviewed. Diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side.The most current Quarterly Minimum Data Set (MDS) Assessment, dated 5/14/26, indicated Resident S was cognitively intact and was dependent on staff (staff does all the work) for showering.Current care plans included, but were not limited to:Resident S requires assistance with self-care and mobility tasks related to left side hemiplegia, hemorrhagic stroke, dated 11/5/25The Point of Care (POC) (a charting system for Certified Nurse Aides) Task Response for Showering and shower records were reviewed. Resident S did not receive a shower or complete bed bath on the following days since 5/29/26:6/5/262. On 6/15/26 at 10:06 A.M., Resident T's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's disease.The most current Significant Change Minimum Data Set (MDS) Assessment, dated 3/13/26, indicated Resident T was not assessed for cognitive impairment and required substantial to maximal assistance of staff (staff does more than half the work) for showering.Current care plans included, but were not limited to:Resident T requires assistance with self-care and mobility tasks following fall with left hip fracture, dated 12/25/25The Point of Care (POC) (a charting system for Certified Nurse Aides) Task Response for Showering and shower records were reviewed. Resident T did not receive a shower or complete bed bath on the following days since 5/29/26:6/5/266/9/266/12/263. On 6/15/26 at 10:23 A.M., Resident U's clinical record was reviewed. Diagnoses included, but were not limited to, right knee contracture and intellectual disability.The most current admission Minimum Data Set (MDS) Assessment, dated 3/19/26, indicated Resident U was cognitively intact and was dependent on staff (staff does all the work) for showering.Current care plans included, but were not limited to:Resident U requires assistance with self-care and mobility tasks related to cellulitis, dated 4/13/26 The Point of Care (POC) (a charting system for Certified Nurse Aides) Task Response for Showering and shower records were reviewed. Resident U did not receive a shower or complete bed bath on the following days since 5/29/26:6/5/26On 6/15/26 at 11:07 A.M., the Plan of Corrections Auditing binder was reviewed. Documentation indicated Resident S, Resident T, and Resident U received showers on Tuesdays and Fridays. A Shower Monitor document beginning 5/29/26 indicated showers were not audited on the following days:5/30/265/31/266/3/266/4/266/5/266/6/266/7/266/8/266/9/266/10/266/11/266/12/266/13/266/14/26Anonymous interview on 6/15/26 at 1:25 P.M. indicated something was happening internally in the facility and residents were not receiving the bare minimal of care. Residents were not being bathed twice a week and appeared dirty.Interview on 6/16/26 at 9:43 A.M., the Administrator indicated staff were supposed to document showers on shower records and then transfer them into the POC Task Response in the residents' electronic health record (EHR). She indicated there was staff changeover at the end of May/beginning of June and things got missed.On 6/16/26 at 1:24 P.M., the Administrator provided a current Resident Showers policy, revised 6/2026, that indicated It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice . Residents will be provided showers as per request or as per facility schedule protocols.This citation relates to intake 3032800 and intake 3041445.410 Indiana Administrative Code (IAC) 16.2-3.1-38(b)(2)

Based on interview, observation, and record review, the facility failed to ensure designation of a certified Infection Preventionist (IP). The facility did not currently employee a staff member who dedicated at least part time to the role of IP or perform facility tracking of infections.Finding includes:During an interview on 6/15/26 at 12:28 P.M., RN 4 indicated she helped with infection control tasks as needed and did not dedicate specific hours per week to infection prevention tasks such as facility tracking of infections and antibiotics, but reviewed progress notes from previous shifts for signs of infections. During an interview on 6/15/26 at 12:49 P.M., the Administrator indicated the previous Infection Preventionist left the position last month (May) and a new Infection Preventionist had not started yet. During an observation on 6/16/26 at 9:51 A.M., the facility's infection prevention tracking and staff education binder was reviewed. RN 4 confirmed tracking of facility infections, antibiotic use, and staff education had not been completed since April 2026. On 6/16/26 at 1:18 P.M., the Administrator provided a job description titled Infection Control Director that indicated The Infection Control Director is responsible for developing, implementing, and overseeing the infection control program within the skilled nursing facility. This role ensures that all infection prevention and control measures are adhered to, in compliance with federal, state, and local regulations. The Infection Control Director works to prevent and minimize the risk of infections among residents and staff through education, policy development, and monitoring. On 6/16/26 at 1:24 P.M., the Administrator provided a policy titled Infection Surveillance, dated 1/26, that indicated The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance Committee, and public health authorities when required. Monthly time periods will be used for capturing and reporting data. Line charts will be used to show data comparisons over time and will be monitored for trends. All resident and infections will be tracked. Separate, site-specific measures may be tracked as prioritized from the infection control risk assessment. Outbreaks will be investigated.

Based on interview and record review, the facility failed to ensure the Dietary Manager was certified for 1 of 1 Dietary Manager Qualifications reviewed. Finding includes:During an interview on 4/13/26 at 9:05 A.M., the Dietary Manager indicated that she did not have kitchen manager certification, but she was enrolled in a class to obtain it.On 4/16/26 at 11:13 A.M., the Dietary Manager's employee file was reviewed. The Dietary Manager began employment with the facility on 3/5/26 and was enrolled in a Certified Dietary Manager (CDM) course on 2/17/26. Her job application to the facility indicated that she was not a CDM and was still in school to obtain the certification.On 4/17/26 at 10:35 A.M., the Administrator provided a current Certified Dietary Manager (CDM) Job Description policy, dated 2025, that indicated Graduate of a Foodservice Manager Training Program or a 2-year or 4-year foodservice management or nutrition program. Successful completion of CDM Credentialing Exam with active CDM, CFPP (Certified Food Protection Professional) certification status. 410 Indiana Administrative Code (IAC) 16.2-3.1-20(e)

Based on observation, record review, and interview, the facility failed to ensure that quarterly care conferences were conducted on 3 of 5 residents reviewed for unnecessary medications, 1 of 3 residents reviewed for MDS (Minimum Data Set) and 1 of 2 reviewed for choices. (Resident 8, Resident 25, Resident 38, Resident 7, Resident C) Findings include:1. On 4/14/26 at 9:19 A.M., Resident 8's clinical record was reviewed. Resident 8 was admitted on [DATE]. Diagnosis included, but was not limited to, hypertension. The most recent Significant Change MDS (Minimum Data Set) Assessment, dated 3/13/26, indicated Resident 8's cognition was not assessed, the resident required partial assistance for toileting, and substantial assistance from staff (staff do more than half of the work) for bathing. The clinical record lacked a care plan conference held since admission. 2. On 4/14/26 at 9:10 A.M., Resident 7's clinical record was reviewed. Diagnoses included, but were not limited to, nontraumatic intracerebral hemorrhage and bipolar disorder. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 2/11/26, indicated Resident 7 was cognitively intact and was dependent on staff (staff do all the work) for toileting and bathing. The last care plan conference was completed on 11/25/25 with family in attendance. On 4/16/26 at 10:06 A.M., the Social Service Director (SDD) provided notes from the last completed care plan conference, dated 11/25/25. 3. On 4/14/26 at 1:20 P.M., Resident C's clinical record was reviewed. Diagnoses included, but were not limited to, cerebrovascular disease. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 3/4/26, indicated Resident C was not assessed for cognitive impairment, required setup assistance for transferring and eating, and required substantial to maximal assistance of staff (staff does more than half of the work) for toileting. The last care plan conference was completed on 10/14/25. On 4/16/26 at 10:06 A.M., the Social Service Director (SSD) provided notes from the last completed care conference, dated 10/14/25. 4. On 4/14/26 at 1:35 P.M., Resident 25 clinical record was reviewed. Diagnoses included, but were not limited to, wedge compression fracture of the second lumbar vertebra, unspecified dementia, and Alzheimer's Disease. The current Significant Change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident 25 was cognitively intact. Resident 25 needed set help for eating, needed partial to moderate assistance for dressing, hygiene, and toileting, and substantial to maximum assistance for transferring. On 4/16/26 at 10:06 A.M., the Social Service Director (SDD) provided notes from the last complete care plan conference. The last care conference was dated on 7/22/25. 5. On 4/15/26 at 9:45 A.M., the clinical record for Resident 38 was reviewed. Diagnoses included, but were not limited to, muscle weakness and chronic combined systolic (congestive) and diastolic (congestive) diastolic heart failure. The current Quarterly MDS assessment dated [DATE] indicated Resident 38 was cognitively intact. Resident 38 needed set up assistance eating, needed substantial to maximum assistance for hygiene and dressing, and was dependent on transferring. On 4/16/26 at 10:06 A.M., the Social Service Director (SDD) provided notes from the last complete care plan conference. The last care conference was dated on 12/23/25. During an interview on 4/16/26 at 9:29 A.M., the SSD indicated that between when the last SSD left the position and when he started in the position, care plan conferences were not completed. On 4/17/26 at 10:40 A.M., the Administrator provided a current policy Care Planning dated 2/2026. The policy indicated .the facility will discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences, and allow them to see the care plan, initially, at routine intervals, and after significant changes. The facility will make an effort to schedule the conference at the best time of the day for the resident/resident's representative. The facility will obtain a signature from the resident and/or resident representative after discussion or viewing of the care plan . 410 Indiana Administrative Code (IAC) 16.2-3.1-35(d)(2)(B)

Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) Assessments were completed accurately for 3 of 4 residents reviewed for skin conditions and 1 of 3 residents reviewed for falls. (Resident C, Resident 7, Resident 8, Resident 49) Findings include:1. On 4/14/26 at 1:20 P.M., Resident C's clinical record was reviewed. Diagnoses included, but were not limited to, cerebrovascular disease. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 3/4/26, indicated Resident C was not assessed for cognitive impairment but was coded to indicate an assessment should be completed. During an interview on 4/16/26 at 2:20 P.M., the MDS Coordinator indicated that Resident C could have been assessed for cognitive impairment but wasn't because there was not any staff available to administer the test at the time the assessment was due. During an interview on 4/17/26 at 9:06 A.M., the Administrator indicated that a corporate MDS staff member completed MDS assessments during the time the facility did not have an in-house MDS Coordinator on staff. In-house nursing staff were responsible for completing the cognitive assessments. 2. On 4/14/26 at 9:10 A.M., Resident 7's clinical record was reviewed. Diagnoses included, but were not limited to, bipolar disorder. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 2/11/26, indicated Resident 7 was cognitively intact and did not receive an antianxiety medication during the 7-day lookback period. Physician orders included but were not limited to:hydroxyzine (an antianxiety medication) 25 milligrams (mg) tablet - Give one tablet by mouth three times a day for anxiety, dated 12/4/25 and discontinued on 3/1/26 The February 2026 electronic Medication Administration Record (eMAR) indicated Resident 7 received hydroxyzine 25 mg three times a day from 2/5/26 to 2/11/26. During an interview on 4/16/26 at 2:10 P.M., the MDS Coordinator indicated that Resident 7 received an antianxiety medication, but it was not coded. 3. On 4/14/26 at 9:19 A.M., Resident 8's clinical record was reviewed. Resident 8 was admitted on [DATE]. Diagnosis included, but was not limited to, hypertension. The most recent Significant Change MDS, dated [DATE], indicated Resident 8 required partial assistance for toileting, and substantial assistance from staff for bathing. The assessment indicated Resident 8's cognition should be assessed; the answers indicated Resident 8's cognition was not assessed. During an interview on 4/16/26 at 2:21 P.M., the MDS Coordinator indicated Resident 8's cognition was not assessed but should have been assessed during the most recent MDS assessment. 4. On 4/14/26 at 1:58 P.M. Resident 49's clinical record was reviewed. Diagnosis included, but was not limited to, osteoarthritis. The most recent admission MDS Assessment, dated 3/19/26, indicated Resident 49 was cognitively intact, was dependent on staff (staff do all of the work) for toileting, bathing, and transfers, and had no skin conditions. Physician orders included, but were not limited to: Right lateral Shin: Clean with normal saline, apply Santyl (ointment) to wound bed, cover with absorbent pad and wrap with Kerlix (gauze) every day shift for wound healing; Start date 3/17/26 During an interview on 4/16/26 at 2:21 P.M., the MDS Coordinator indicated Resident 49's wound should have been coded on the most recent MDS Assessment. On 4/17/26 at 10:36 A.M., the Administrator provided a policy titled Conducting an Accurate Resident Assessment, dated 2/2026, that indicated Accuracy of assessment means that the appropriate, qualified health professionals correctly document the resident's medical, functional, and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status using the appropriate Resident Assessment Instrument 410 Indiana Administrative Code (IAC) 16.2-3.1-31(c)

Based on observation, interview, and record review, the facility failed to ensure proper storage and labeling of medication for 4 of 4 medication carts observed. Loose pills and unlabeled medications were observed in the medication carts. (Front [NAME] Hall, Back [NAME] Hall, Front East Hall, Back East Hall, Resident 22, Resident 25, Resident 39) Findings include: On 4/13/25 at 8:55 A.M., the following loose pills were observed in the [NAME] Front Medication Cart:4 1/2 small white pill1/2 white oval pill1 small round white pill with number L 161/2 large white oval pill1 small round brown pill with *7251 small round white pill with number 9131 small white pill with numbers 3461/2 small round pink pill1 small round white pill with letter U1 small round white pill with Numbers 33461 blue and white capsule with the number PRIMA 361/2 small blue oval pill1 oval white pill with numbers 564 On 4/13/26 at 9:10 A.M., the following loose pills were observed in the [NAME] Back Hall Medication Cart:1/2 small round pill1 green oval pill with LU1 large white pill with the number 4831 small peach pill1 small white pill with the numbers 321 large white pill with the number PH 3201 small oval pill with the number 1111/4 yellow pill1/2 small white oval 1 bottle of fiber pills with [Resident 39] name but no label The following supplements with [Resident 22] name were found with no labels:2 bottles of Saw Palmetto1 bottle of Carnivora1 bottle of Graviola1 bottle of Catalova1 bottle of Organic Bone Minerals1 bottle of Collinsonia 1 bottle of Proto1 bottle of Tempa Cleanser On 4/13/26 at 9:20 P.M., the following loose pills were found in the East Front Medication Cart:1 Ferrous Sulfate pill1 tan and white colored capsule1 large white pill with number PH 0201 medium round yellow pill with the numbers EP1271 bottle of Baby Aspirin with [Resident 25] name with no label1 bottle of Fiber with [Resident 25] name with no label On 4/13/26 at 9:25 A.M., the following loose pills were found in the East Back Medication Cart:1 round peach pill with H392 small white oval pills1 round medium white pill with the number 551 brown pill with 8.61/2 large white pill1 round oval peach pill with the number UL 125 During an interview on 4/13/26 at 9:30 A.M., Licensed Practical Nurse (LPN) 5 indicated there should be no loose pills in the carts and that she destroys the pills in a drug buster solution. During an interview on 4/15/26 at 3:00 P.M., the Director of Nursing (DON) indicated the bottles of supplements should have label and have a physician's order. On 4/17/26 at 10:36 A.M., the Administrator provided a current policy Medication Storage dated 2/26. The policy indicated .medications: discontinued, outdated, defective, or deteriorated .are destroyed . '' 410 Indiana Administrative Code (IAC) 16.2-3.1-25(j)410 Indiana Administrative Code (IAC) 16.2-3.1-25(o)

Based on observation, interview, and record review, the facility failed to store food under sanitary conditions and monitor equipment for proper sanitization levels for 1 of 1 kitchens observed. Food was left open to air, expired food was not disposed of, and dishwasher chemical sanitization logs were not filled out. (Kitchen) Finding includes:During the initial tour on 4/13/26 at 9:05 A.M., the following was observed:The low-temperature chemical dishwasher April 2026 log was hanging on the wall across from the dishwasher. It was blank. At that time, the Dietary Manager indicated that staff should be filling it in each time they tested the dishwasher for sanitization levels. Staff tested the dishwasher for sanitization levels before each meal.In the walk-in dairy refrigerator: Sliced cheese open to air with no dateShredded cheese open to airIn the walk-in vegetable refrigerator:Coleslaw carton with a use by date of 4/9/26In the dry storage room:Bulk sugar container open to airBulk oatmeal container open to airOn 4/17/26 at 10:36 A.M., the Administrator provided a Mechanical Ware Washing (Dish Machine) policy, dated 2025, that indicated The proper cleaning and sanitizing of dishes in the dietary department is extremely important to the health and safety of residents . Record the PPM (parts per million), wash and rinse temperatures for the low temperature dish machine . The.PPM of the sanitizer (if a low-temperature machine) should be tested and logged before washing dishes from each meal to ensure the dish machine is properly sanitizing dishes . Dish machine logs should be posted and updated throughout the day.On 4/17/26 at 10:36 A.M., the Administrator provided a Storage Labeling and Dating policy, dated 2025, that indicated Product inventory must be stored, labeled, dated, rotated, and discarded properly according to federal and state guidelines . Containers for bulk items like flour and sugar should be leak-proof, non-absorbent, tight fitting, and NSF (National Science Foundation) approved . Items that have exceeded the manufacturer's expiration date or UB (use by) date should be discarded.On 4/17/26 at 10:47 A.M., the Administrator provided a Food Safety Requirements policy, dated 2/2026, that indicated Practices to maintain safe refrigerated storage include: .Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/discarded; and Keeping foods covered or in tight containers.410 Indiana Administrative Code (IAC) 16.2-3.1-21(i)(2)410 IAC 16.2-3.1-21(i)(3)

Based on interview and record review, the facility failed to ensure comprehensive Minimum Data Set (MDS) Assessments were completed timely for 1 of 3 closed records reviewed and 1 of 3 residents reviewed for wounds. (Resident C and Resident 49) Findings include:1. On 4/14/26 at 1:20 P.M., Resident C's clinical record was reviewed. Diagnoses included, but were not limited to, cerebrovascular disease. Resident C was discharged from the facility to the hospital on 3/27/26 and did not return to the facility. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 3/4/26, indicated Resident C was not assessed for cognitive impairment and required substantial to maximal assistance (staff does more than half the work) for toileting. A Discharge MDS Assessment was not completed. During an interview on 4/16/26 at 2:20 P.M., the MDS Coordinator indicated that the previous MDS Coordinator did not complete Resident C's Discharge MDS Assessment. 2. On 4/14/26 at 1:58 P.M. Resident 49's clinical record was reviewed. Diagnosis included, but was not limited to, osteoarthritis. The most recent admission MDS Assessment, dated 3/19/26, indicated Resident 49 was cognitively intact and was dependent on staff (staff do all of the work) for toileting, bathing, and transfers. The admission MDS Assessment was completed on 4/13/26. During an interview on 4/16/26 at 2:21 P.M., the MDS Coordinator indicated the admission MDS Assessment was completed late. On 4/17/26 at 10:36 A.M., the Administrator provided a policy titled Conducting an Accurate Resident Assessment, dated 2/2026, that indicated Accuracy of assessment means that the appropriate, qualified health professionals correctly document the resident's medical, functional, and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status using the appropriate Resident Assessment Instrument 410 Indiana Administrative Code (IAC) 16.2-3.1-31(d)(1)

Based on observation, record review, and interview, the facility failed to ensure enhanced barrier precautions were implemented during 1 of 2 random observation of care and infection control practices were not implemented during 1 of 2 insulin administrations. Findings include: 1. During an observation on 4/13/26 at 11:22 A.M., CNA 2 and QMA 4 entered Resident 3's bathroom. Resident 3 was cleaned up and assisted off of the toilet and on to the sit to stand lift. Resident 3 was moved from the bathroom to the wheelchair in the bedroom. Resident 3 was not offered to wash his hands; CNA 2 and QMA 4 wore gloves but did not wear gowns during the care and transfer of Resident 4. On 4/14/26 at 10:40 A.M., Resident 3's clinical record was reviewed. Diagnoses included, but were not limited to, dementia with behavioral disturbances, anxiety, and post traumatic stress disorder. The most recent Discharge MDS, dated [DATE], indicated Resident 3's cognition was not assessed, the resident required partial assistance for toileting (staff do at least half of the work) and was dependent on staff for transfers (staff do all of the work). Physician orders included, but were not limited to: Enhanced Barrier Precaution due to wounds; Start date 10/22/25 During an interview on 4/17/26 at 9:00 A.M., the Infection Preventionist indicated staff should use Enhanced Barrier Protection (EBP) when a resident has a wound, catheter, feeding tube or as otherwise indicated per protocol. 2. On 4/15/26 at 7:15 A.M., during a medication pass, Licensed Practical Nurse (LPN) 7 was observed not using an alcohol swab to prepare the rubber injectable port of a Lantus and lispro insulin pen prior to placing the needle to administer insulin to Resident 10. During an interview on 4/15/26 at 7:30 A.M., LPN 7 indicated she should have prepped the pen stopper with alcohol prior to placing the needle. During an interview on 4/17/26 at 9:29 A.M., the Director of Nursing indicated that the nurse should have cleaned the rubber injectable port before the needle is placed prior to administering the medications. On 4/17/26 at 10:36 A.M., the Lispro Kwik Pen insert was reviewed and indicated the rubber seal should be wiped with an alcohol swab. On 4/17/26 at 10:36 A.M., the Administrator provided a policy titled Enhanced Barrier Precautions, dated 2/2026, that indicated PPE for enhanced barrier precautions is only necessary when performing high-contact care activities 4. High-contact resident care activities include: a. Dressing, b. Bathing, c. Transferring, d. Providing hygiene, f. Changing briefs or assisting with toileting 410 Indiana Administrative Code (IAC) 16.2-3.1-18(b)(1)

Based on interview and record review, the facility failed to notify the provider of weight changes outside of order parameters for 1 of 2 residents reviewed for weight change. (Resident 5) Finding includes:On 4/14/26 at 9:58 A.M., Resident 5's clinical record was reviewed. Diagnoses included, but were not limited to, congestive heart failure and chronic kidney disease.The most current Discharge Minimum Data Set (MDS) Assessment, dated 3/10/26, indicated Resident 5's cognitive function was assessed by staff and the resident's memory was OK and he was independent in making decisions about his daily life. He required supervision of staff for transferring and partial to moderate assistance (staff does less than half the work) for toileting. He weighed 226 pounds (lbs) and had no weight loss.A nutritional risk care plan, initiated 12/18/25, included an intervention to monitor weights as ordered.A fluid overload care plan, initiated 12/14/25, included an intervention to weigh as scheduled.Physician orders included but were not limited to:Fax weekly weights to Nursing Home Triage (NHT) every Tuesday day shift related to congestive heart failure, dated 12/16/25Notify Nursing Home Triage (NHT) if weight gain of three pounds in 24 hours or five pounds in one week as needed related to congestive heart failure, dated 12/13/25The electronic Medication Administration Record (eMAR) for December 2025, January 2026, February 2026, March 2026, and April 2026 was reviewed. Weekly weights were not faxed to NHT on the following days:1/13/262/10/262/24/26The Weight Summary for 12/14/25 through 4/14/26 was reviewed. On 2/24/26, Resident 5 weighed 215.6 lbs. On 3/2/26, Resident 5 weighed 224.9 lbs, resulting in a 9.3 lb weight gain in a week.The clinical record lacked documentation to indicate the provider was notified that Resident 5 gain over five lbs in a week.During an interview on 4/16/26 at 12:40 P.M., the Director of Nursing (DON) indicated that weekly weights were not faxed on 1/13/26, 2/10/26, and 2/24/26, and a notification to the provider did not occur on 3/2/26 after the resident gained over five lbs in a week.On 4/17/26 at 10:36 A.M., the Administrator provided a current Notification of Changes policy, dated 2/2026, that indicated The facility must.consult with the resident's physician.when there is a change requiring such notification . Circumstances requiring notification include: .Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status.On 4/17/26 at 11:17 A.M., the Administrator provided a current Weight Management policy, dated 2/2026, that indicated The physician should be informed of a significant change in weight.410 Indiana Administrative Code (IAC) 16.2-3.1-5(a)(2)

Based on interview and record review, the facility failed to ensure residents ordered an as needed (PRN) anti-anxiety medication had a specific duration, or stop date, for the medication prescribed for 2 of 2 residents reviewed for hospice and 1 of 2 residents reviewed for choices. (Resident 4, Resident 48, and Resident 7) Findings include: 1. On 4/15/26 at 9:13 A.M., Resident 4's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's Disease. The most recent Significant Change MDS (Minimum Data Set) Assessment, dated 3/24/26, indicated Resident 4 was rarely understood and was dependent on staff for eating, bathing, toileting, and transfers (staff do all of the work). Physician orders included, but were not limited to: Lorazepam (an antianxiety medication) oral tablet 0.5 MG (milligrams) Give one tablet by mouth every 30 minutes as needed for anxiety/restlessness; Start date 3/15/26 The order lacked a stop date for PRN lorazepam. Resident 4's electronic medication administration record (eMAR) from March 2026 through April 2026 was reviewed. As needed lorazepam was not received during that time. 2. On 4/14/26 at 8:43 A.M., Resident 48's clinical record was reviewed. Diagnoses included, but were not limited to, heart failure. Resident 48 was admitted into hospice services on 4/18/24. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 1/9/26, indicated Resident 48 had severe cognitive impairment and received an antianxiety medication during the 7-day lookback period. Physician orders included but were not limited to: lorazepam (an antianxiety medication) 0.5 milligrams (mg) oral tablet - Give half of a tablet by mouth every two hours as needed (PRN) for anxiety/restlessness. May dissolve in water if unable to swallow - while receiving hospice services, dated 3/20/25. The order lacked a stop date for the medication. The electronic Medication Administration Record (eMAR) from November 2025 to April 2026 was reviewed. PRN lorazepam was not received during that time. 3. On 4/14/26 at 9:10 A.M., Resident 7's clinical record was reviewed. Diagnoses included, but were not limited to, bipolar disorder. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 2/11/26, indicated that Resident 7 was cognitively intact and did not receive an antianxiety medication during the 7-day lookback period. Physician orders included but were not limited to:hydroxyzine (an antianxiety medication) 10 milligrams (mg) oral tablet - Give one tablet by mouth every twelve hours as needed (PRN) for itching, dated 12/4/25. The order lacked a stop date for the medication. The electronic Medication Administration Record (eMAR) from January 2026 to April 2026 was reviewed. Resident 7 received PRN hydroxyzine on the following days:1/18/26 at 12:13 A.M.2/15/26 at 3:41 P.M.2/16/26 at 4:24 P.M.3/5/26 at 4:25 A.M.3/7/26 at 3:51 P.M.3/9/26 at 7:06 P.M. During an interview on 4/16/26 at 8:59 A.M., the Director of Nursing (DON) indicated that if a resident was not receiving hospice services, medications should have a 14 day stop day. If a resident was receiving hospice services, the order should specify the duration of hospice. On 4/17/26 at 10:49 A.M., the Administrator provided a current Use of Psychotropic Medication(s) policy, dated 2/2026, that indicated PRN orders for psychotropic medications, excluding antipsychotics, shall be limited to no more than 14 days, unless the attending physician or prescribing practitioner believes it is appropriate to extend the order beyond the 14 days. The medical record should include documentation from the physician or prescriber for the rationale for the extended time period and indicate a specific duration. 410 Indiana Administrative Code (IAC) 16.2-3.1-48(a)(2)

Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were completed no less than once every 3 months for 1 of 1 residents reviewed for Resident Assessment. (Resident 6)Finding includes: On 4/6 at 11:26 A.M., Resident 6's clinical record was reviewed. Diagnoses included, but were not limited to, disorder of the kidney and ureter and essential primary hypertensionThe most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] but was not completed until 4/10/26. During an interview on 4/17/26 at 10:35 A.M., the Social Services Director indicated care plan conferences needed to be done every 3 months.On 4/17/26 at 10:40 A.M., the Administrator provided a current policy Care Planning dated 2/2026. The policy indicated . The facility will discuss the care plan with the resident and/or representative at regularly scheduled care plan conferences, initially, at routine intervals, and after significant changes .410 Indiana Administrative Code 16.2-3.1-31(d)(3)

Based on observation, record review, and interview, the facility failed to implement care plan interventions for 1 of 4 residents reviewed for accidents and 1 of 1 resident reviewed for restraints, and develop a care plan for 1 of 5 residents reviewed for unnecessary medications. Interventions for call lights to be within reach were not implemented and there was no care plan developed for antianxiety and antidepressant medications use. (Resident 3, Resident 2, and Resident 38)Findings include:1. During an observation on 4/13/26 at 11:22 A.M., CNA 2 and QMA 4 were observed using a sit to stand lift to transfers Resident 3 from the bathroom to the wheelchair. Resident 3's call light was under the bed and out of reach. During an observation on 4/15/26 10:20 A.M., Resident 3 was observed in bed and the call light was on the floor under the foot of the bed. During an observation on 4/16/26 at 8:52 A.M., Resident 3 was laying in bed; two wheelchairs were in the resident's within line of sight and the call light was hung over the foot of bed. On 4/14/26 at 10:40 A.M., Resident 3's clinical record was reviewed. Diagnoses included, but were not limited to, dementia with behavioral disturbances, anxiety, and post traumatic stress disorder. The most recent Discharge MDS (Minimum Data Set) Assessment, dated 2/25/26, indicated Resident 3's cognition was not assessed, the resident required partial assistance for toileting (staff do at least half of the work) and was dependent on staff for transfers (staff do all of the work). The care plan included, but was not limited to: (Resident) at risk for falls due to: Confusion at times, dementia, gait/balance problems, pain, psychoactive drug use, use of assistive device; Date Initiated: 5/9/22 Interventions included, but were not limited to: Call system and bedside table in reach. Explain use of it upon admission and reinforce as needed; Date Initiated: 5/9/22 Wheelchair out of site (bathroom) when he goes to bed; Date Initiated: 10/7/25 2. During an observation on 4/13/26 at 11:22 A.M., Resident 2's call light was wrapped around the headboard post and the resident was in his wheelchair at end of bed. On 4/14/226 at 8:46 A.M., Resident 2's clinical record was reviewed. Diagnosis included, but was not limited to, dysphagia. The most recent Annual MDS Assessment, dated 3/20/26, indicated the resident was moderately cognitively impaired and was dependent on staff (staff do all of the work) for eating, toileting, bathing, and transfers. The care plan included, but was not limited to: (Resident) is at risk for falls; Date Initiated: 6/23/22 Interventions included, but were not limited to: Call system and bedside table in reach. Explain use of it upon admission and reinforce as needed. Date Initiated: 6/23/22 3. On 4/15/26 at 9:45 A.M., the clinical record for Resident 38 was reviewed. Diagnoses included, but were not limited to, muscle weakness and chronic combined systolic (congestive) and diastolic (congestive) diastolic heart failure. The current Quarterly MDS assessment dated [DATE] indicated Resident 38 was cognitively intact. Resident 38 needed set up assistance for eating, needed substantial to maximum assistance for hygiene and dressing, and was dependent on transferring. During the 7-day look back period the use of antianxiety and antidepressant medications was indicated. Current physician orders included, but were not limited to:Sertraline HCl Oral Tablet (antidepressant) 100 Milligrams (MG), give 1 tablet by mouth in the morning dated 3/2/26. Klonopin Oral Table (antianxiety) 0.5 MG, give 0.5 tablet by mouth in the morning for anxiety 0.5 = 0.25mg dated 3/2/26. Clonazepam Oral Tablet (antianxiety) 0.5 MG, give 1 tablet by mouth at bedtime dated 9/16/25. There are no current care plans for antianxiety and antidepressant drugs. During an interview on 4/17/26 at 10:35 A.M., the Social Services Director indicated care plans are initiated upon admission, quarterly, and with a significant change. On 4/17/26 at 10:35 A.M., the Administrator provided a current policy Comprehensive Care Plans dated 2/2026. The policy indicated . the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment . 410 Indiana Administrative Code (IAC) 16.2-3.1-35(b)(1)410 Indiana Administrative Code (IAC) 16.2-3.1-35(b)(2)

Based on interview and record review, the facility failed to ensure residents dependent on staff for ADLs (activities of daily living) were showered for 1 of 3 residents reviewed for ADL care. (Resident C) Finding includes:During an anonymous interview on 4/14/26 at 1:20 P.M., it was indicated that Resident C was transported to the hospital from the facility on 3/27/26. Upon arrival in the emergency room, Resident C appeared generally unkempt.On 4/14/26 at 1:25 P.M., Resident C's clinical record was reviewed. Diagnoses included, but were not limited to, cerebrovascular disease.The most current Quarterly Minimum Data Set (MDS) Assessment, dated 3/4/26, indicated Resident C was not assessed for cognitive impairment and required partial to moderate assistance of staff (staff does less than half the work) for bathing.A current assistance with self-care and mobility tasks care plan, dated 12/15/25, indicated Resident C required substantial to maximal assistance (staff does more than half the work) for bathing.On 4/16/26 at 12:30 P.M., Licensed Practical Nurse (LPN) 6 provided shower documentation for March 2026. Resident C did not receive or refuse a shower or complete bed bath on the following days in March 2026:3/10/263/14/263/17/263/24/26During an interview on 4/16/26 at 12:46 P.M., the Director of Nursing (DON) indicated that residents got showers at least twice a week.During an interview on 4/16/26 at 1:34 P.M., the DON indicated Resident C's assigned shower days were Tuesdays and Saturdays. On 4/17/26 at 10:36 A.M., the Administrator provided a current Resident Showers policy, dated 2/2026, that indicated Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety.This citation relates to Intake 2970173.410 Indiana Administrative Code (IAC) 16.2-3.1-38(b)(2)

Based on interview and record review, the facility failed to ensure pharmacist medication recommendations were reviewed and acted upon by the physician for 1 of 5 residents reviewed for unnecessary medications. (Resident 8) Finding includes: On 4/14/26 at 9:19 A.M., Resident 8's clinical record was reviewed. Resident 8 was admitted on [DATE]. Diagnosis included, but was not limited to, pulmonary embolism.The most recent Significant Change MDS, dated [DATE], indicated Resident 8's cognition was not assessed, the resident required partial assistance for toileting, substantial assistance from staff for bathing, and received anticoagulant medication during the lookback period. Physician orders included, but were not limited to:Eliquis (an anticoagulant medication) oral tablet 2.5 MG (milligrams) Give one tablet by mouth in the morning related to pulmonary embolism; Start date 3/13/26On 4/15/26 at 12:13 P.M., the Administrator provided a pharmacy document titled New admission Review, dated 3/13/26. The document indicated the pharmacist recommended Resident 8's Eliquis be evaluated due to it being outside the typical dose. The clinical record lacked approval or rationale for denying the pharmacist recommendation. During an interview on 4/17/26 at 9:04 A.M., the Director of Nursing indicated the physician reviewed the pharmacy recommendation on 4/16/26 and accepted the pharmacist recommendation. On 4/17/26 at 10:36 A.M., the Administrator provided a policy titled Medication Regimen Review, dated 2/2026, that indicated The pharmacist shall communicate any irregularities to the facility in the following ways: a. Verbal communication to the attending physician, Director of Nursing, and/or staff of any urgent needs. b. Written communication to the attending physician, the facility's Medical Director, and the Director of Nursing. Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities410 Indiana Administrative Code (IAC) 16.2-3.1-25(i)

Based on interview and record review, the facility failed to ensure a resident with signs and symptoms of fluid overload were monitored according to physician order for 1 of 2 residents reviewed for significant weight change. (Resident 5) Finding includes:On 4/14/26 at 9:58 A.M., Resident 5's clinical record was reviewed. Diagnoses included, but were not limited to, congestive heart failure and chronic kidney disease.The most current Discharge Minimum Data Set (MDS) Assessment, dated 3/10/26, indicated Resident 5's cognitive function was assessed by staff and the resident's memory was OK and he was independent in making decisions about his daily life. He required supervision of staff for transferring and partial to moderate assistance (staff does less than half the work) for toileting. He weighed 226 pounds (lbs) and had no weight loss.A nutritional risk care plan, initiated 12/18/25, included an intervention to monitor weights as ordered.A fluid overload care plan, initiated 12/14/25, included an intervention to weigh as scheduled. (Signs and symptoms of fluid overload include rapid weight game, edema, and shortness of breath.)Physician orders included but were not limited to:Obtain early morning daily weights in the morning related to congestive heart failure, dated 12/14/25A dietary note, dated 12/18/25 at 10:52 A.M., indicated that Resident 5 had edema and was anticipated to have weight fluctuations due to his diagnosis of congestive heart failure (CHF) and use of diuretic therapy. Daily weights were ordered to monitor for changes.A dietary note, dated 1/8/26 at 2:35 P.M., indicated Resident 5 had pitting edema and triggered for significant weight gain over 90 days.A dietary note, dated 1/15/26 at 10:31 A.M., indicated Resident 54 lost ten pounds in a week due to receiving extra doses of furosemide (a diuretic medication). A 1500 milliliters per day fluid restriction was initiated. Edema was improving.A dietary note, dated 1/22/26 at 10:06 A.M., indicated Resident 5 continued to have pitting edema and took furosemide daily.A dietary note, dated 2/26/26 at 2:41 P.M., indicated Resident 5 triggered for significant weight loss over six months. Weight fluctuations were anticipated due to his diagnoses of CHF, pitting edema, and use of diuretic therapy. Changes were monitored through daily weights.A dietary note, dated 4/2/26 at 12:06 P.M., indicated Resident 5 was readmitted to the facility from the hospital where he had a percutaneous endoscopic gastrostomy (PEG) tube placed. He triggered for significant weight gain over 30 days, but rapid weight fluctuations up and down have been common for resident due to fluids with CHF/edema and diuretic therapy. Daily weights are ordered to monitor changes.A weight change note, dated 4/9/26 at 3:30 P.M., indicated current weight is 209 lbs this week which is down from 236 lbs last week. Noted that rapid and large weight fluctuations have been common due to fluids from edema and diuretic therapy. Daily weights are ordered to monitor changes. The electronic Medication Administration Record (eMAR) for December 2025, January 2026, February 2026, March 2026, and April 2026 was reviewed. A daily morning weight was not obtained on the following days:12/16/2512/22/2512/26/251/17/261/21/261/22/262/3/262/17/262/18/262/20/262/21/262/25/263/4/263/5/263/6/264/2/264/3/264/4/26During an interview on 4/16/26 at 12:40 P.M., the Director of Nursing (DON) indicated that daily weights were not obtained on the 18 days listed and were either just not done or the resident was marked asleep. At that time, the DON indicated that staff were expected to try again or pass it along to the next shift if a resident needed to be weighed and was asleep.On 4/17/26 at 11:03 A.M., the Administrator provided a Weight Monitoring policy, dated 2/2026, that indicated Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise . Interventions will be identified, implemented, monitored and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status . Weights should be recorded at the time obtained . If clinically indicated - monitor weight daily.410 Indiana Administrative Code (IAC) 16.2-3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure medications were given at the ordered time for 2 of 3 residents during morning medication pass, and signed as given on the Electronic Medication Administration Record (EMAR) for 1 of 3 residents reviewed for pharmaceutical services. (Resident B, Resident C, Resident D) Finding includes: 1. On 2/9/26 at 10:58 a.m, QMA 2 (Qualified Medication Aide) was observed preparing medications for Resident D. The following medications were observed to be taken out of the packaging and put into a medication cup: aspirin (nonsteroidal anti-inflammatory) 81 mg (milligram) ferrous sulfate ((mineral supplement) 325 mg QMA 2 was observed to look for Resident D's Lasix (diuretic) 40 mg in the medication cart. LPN 3 came to the cart, and QMA 2 left to go look for more of the medication. At 11:04 a.m., LPN 3 (Licensed Practical Nurse) indicated she had already given Resident D her morning medications, and she would let QMA 2 know when she got back to the cart. LPN 3 indicated she had been passing morning medications and had been called away to do other things. The QMA 2 then took over. LPN 3 indicated she had not signed off on the EMAR for the medications she gave that morning. The EMAR was red, indicating the medications had not been signed by LPN 3 as given.2. On 2/9/26 at 11:10 a.m., QMA 2 was observed to prepare the following medications for Resident B: clonazepam (anti-anxiety/anticonvulsant) 0.5 mg escitalopram oxalate (antidepressant) 10 mg escitalopram oxalate (antidepressant) 20 mg glimepiride (antidiabetic) 1 mg tamsulosin HCI (alpha-blocker) 0.4 mg metformin (antihyperglycemic agent) HCI 500 mg meclizine HCL (antiemetic/antivertigo) 25 mg On 2/9/26 at 11:39 a.m., QMA 2 was observed to prepare the following medications for Resident C:aspirin (nonsteroidal anti-inflammatory) 81 mg Tylenol (analgesic/antipyretic) 325 mg (2) atenolol (beta-blocker) 25 mg citalopram hydrobromide (antidepressant) 10 mg celecoxib (nonsteroidal anti-inflammatory) 100 mg docusate sodium (stool softener) 100 mg Refresh tears ophthalmic solution 1 drop in both eyes cranberry capsule (dietary supplement) 500 mg The medications observed prepared for Resident B and Resident C were scheduled on the EMAR for 8:00 a.m. On 2/9/26 at 12:37 p.m., the Director of Nursing provided the current policy for administering medications with a revision date of December 2012. The policy included but was not limited to: .Medications must be administered in accordance with the orders, including any required time frame. Medications must be administered within one (1) hour before or after their prescribed time, unless otherwise specified (for example, before and after meal orders) .The individual administering the medication must initial the resident's MAR (Medication Administration Record) on the appropriate line after giving each medication and before administering the next ones .This citation relates to Intake 2693241. 3.1-25(b)(3)

Based on observation, interview, and record review, the facility failed to ensure a resident did not develop a Stage 3 pressure ulcer, and failed to notify the physician timely of a deterioration in the pressure ulcer, for 1 of 3 residents reviewed with pressure ulcers, in a sample of 4. (Resident B) Findings include: On 6/6/18 at 8:55 A.M., during the initial tour, the Unit Manager indicated Resident B had a pressure ulcer. On 6/6/18 at 10:50 A.M., the clinical record of Resident B was reviewed. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 2/19/18, indicated Resident B had a memory impairment, and required extensive assist of two+ staff for bed mobility and transfer. She was occasionally incontinent of bowels and bladder. She had no pressure ulcers. Progress Notes included the following notations: 3/5/18 at 2:09 P.M.: Resident has a opened shear area to rear upper thigh proximal to buttock measuring 2.0 cm (centimeters) x 1.0 cm x 0.2 cm. Red tinged drainage noted. Area is tender to touch. MD notified A physician's orders [REDACTED]. Cleanse with Normal Saline, apply Hydrogel to wound bed and apply foam dressing. Change Daily and PRN (as needed) A Non Pressure Wound Assessment, dated 3/26/18, indicated: .Site Right thigh (rear) Sheared area to back of the thigh. Length in centermeters (sic) 0.9 (cm), Width in centermeters 0.3 (cm), Depth .0.1 (cm) .Characteristics of drainage? Clear (serous), Amount of drainage Scant amount, Describe wound bed, pink/pale Progress Notes continued: 4/11/18 at 5:27 A.M.: Resident slept most of the shift in her wheelchair A Non Pressure Wound Assessment, dated 4/23/18, indicated: Site Right thigh (rear) Sheared area to back of the thigh. Length .1.6 (cm), Width .1.5 (cm), Depth 1 (cm) .Describe wound bed, slough; soft, moist, yellow .Progress of wound no change. Documentation that the physician was notified of the presence of slough or the increase in size in the wound was not found in the clinical record. A Non Pressure Wound Assessment, dated 4/30/18, indicated: Site Right thigh (rear) Shearing to back of the thigh. Length .2.0 (cm), Width .2.5 (cm), Depth 0.1 (cm) .Characteristics of drainage? Blood tinged (Sanguineous), Amount of drainage Small amount .Describe wound bed, dark pink/red tissue. Describe surrounding skin red skin surrounding wound .Progress of wound Deteriorated: Request change in treatment. Documentation that the physician was notified of the deteriorating wound, or an order for [REDACTED]. A Non Pressure Wound Assessment, dated 5/9/18, indicated: Site Right thigh (rear) Shearing from commode seat. Length .2.5 (cm), Width .2.5 (cm), Depth UTD (unable to determine) .Characteristics of drainage? yellow, Amount of drainage Small amount .Describe wound bed, slough: soft, moist, yellow. Describe surrounding skin red skin surrounding wound .Progress of wound Deteriorated: Request change in treatment. A Progress Note, dated 5/9/18 at 8:10 A.M., indicated: Dressing covering the sheared wound to the back of the right thigh changed per MD order. Removed dressing noted to have a moderate amount of yellow serous drainage. Wound bed is now 90% gray slough/10% granulation tissue. Periwound is red but intact skin. Tender to the touch. Measures 2.5 cm x 2.5 cm x UTD (unable to determine) depth. (Name of MD) updated on the change in the wound and requesting to change the treatment from Hydrogel to TheraHoney gel. A Non Pressure Wound Assessment, dated 5/14/18, indicated: Site Right thigh (rear) shearing from commode. Length .3.0 (cm), Width .3.5 (cm), Depth UTD .Characteristics of drainage? clear, Amount of drainage Small amount .Describe wound bed, slough: soft, moist, yellow .Progress of wound, no change. Documentation that the physician was notified of the increase in the wound size was not found in the clinical record. A Non Pressure Wound Assessment, dated 5/21/18, indicated: Site Right thigh (rear) Shearing from commode. Length .5.0 (cm), Width .3.5 (cm), Depth UTD (unable to determine) .Characteristics of drainage? yellow, Amount of drainage moderate amount .Describe wound bed, slough: soft, moist, yellow. Describe surrounding skin red skin surrounding wound .Progress of wound, Deteriorated: Request change in treatment. Documentation that the physician was notified of the deterioration in the wound, or orders of a different treatment, was not found in the clinical record. Progress Notes continued: 5/27/18 at 3:19 P.M.: Daughter-in-law came in facility checking on resident and asked to see 'the sheering' (sic) to resident's right hip wound. Front hall nurse and CNA brought resident to her room .Wound undressed and daughter-in-law observed wound bed. Wound bed noted to be 90% necrotic with scattered slough noted. Edges noted with scattered small areas of granulation. Daughter-in-law upset wanting to speak to wound nurse. Redressed wound per order. Resident turned to left side. LM (left message) with wound nurse and DON that daughter-in-law would like to speak to one of them. 5/28/18 at 12:20 A.M.: .(Name of physician) on call phoned and made aware of current status of wound. N/O (new order) rec'd for oral atb (antibiotic) at this time 5/28/18 at 10:00 A.M.: Spoke with son and granddaughter regarding status of wound. Discussed need for treatment change. Wound appears slightly improved today 5/28/18 at 10:17 A.M.: (Name) residents (sic) son came in to visit resident. (Name) stated 'I want mom to stay in bed today and rest. I would just like her to be repositioned and turned on her side in bed.' 5/28/18 at 12:35 P.M.: Verbal order taken from MD (name). Cleanse wound to right rear thigh with NS (normal saline), patch wound with soaked wet 4 x 4 dressing followed by dry dressing. For one administration. Follow up with MD (name) on 5/29/2018. 5/28/18 at 1:00 P.M.: .Area approximately 3 cm length x 3 cm width. Unable to determine depth. Area with 90% yellow slough with scattered dark slough mostly in center .Redness noted at wound edges and around dressing area .Area was observed last evening @ 1930 (7:30 P.M.). Redness has improved. Dark areas not as dark. 5/29/18 at 7:22 A.M.: Wound to the right rear thigh is 20% granulation tissue/80% thick gray slough. Scant amount of bleeding noted in the granular tissue. Moderate amount of yellow serous drainage noted from the slough .(Name of primary physician) updated and request (sic) change in treatment order. 5/29/18 at 9:10 A.M.: MD responded .New orders received for resident to be seen by (name) Wound care center and to change dressing to R (right) rear thigh to Santyl, Hydrogel gauze followed by ABD pad secured with tape A Non Pressure Wound Assessment, dated 5/29/18, indicated: Site Right thigh (rear) Shearing (abrasion) from commode seat) Length .5.0 (cm), Width .4.0 (cm), Depth UTD .Characteristics of drainage? yellow, Amount of drainage Small amount .Describe wound bed, slough: soft, moist, grey .Progress of wound Deteriorated: Request change in treatment Progress Notes continued: 5/30/18 at 11:14 A.M.: RD (registered dietician) consulted for nutrition r/t (related to) wound. Pt (patient) receives a no concentrated sweets diet. She has lost a few pounds recently .RD recommends testing out sugar free shakes for some extra protein for wound care. Will monitor. 5/30/18 at 2:57 P.M.: Wound classification changed from non pressure to pressure due to the wound bed has formed thick, gray slough and is unstageable. Wound originated as a shear from sticking to the commode seat but has transformed due to the pressure of sitting on it in the w/c (wheelchair) and the recliner. Resident has an appointment tomorrow with (name of wound care center) for evaluation of the rear thigh wound. A Weekly Pressure Wound document, dated 5/30/18, indicated: Enter date when area first observed, 03/05/2018 .Was wound present on admission? No. Site Right thigh (rear), Type Pressure, Length 5.0 (cm), Width 4.0 (cm), Depth UTD, Stage Unstageable. Describe drainage, Serous. Amount of drainage, Moderate. Indicate color of wound, necrotic/slough. Describe surrounding skin, discoloration Progress Notes continued: 5/31/18 at 1:07 P.M.: Dressing covering wound to the right rear thigh changed per MD order. Moderate amount of serosanguineous drainage noted on the removed dressing. Wound bed is now 30% red granulation tissue/70% thick gray slough .Wound is tender when cleansed .Currently measures 5.0 cm x 4.0 cm x UTD. (Name) wound clinical appointment was changed to 06/01/2018. 6/1/18 at 3:15 P.M.: Received a new order from (name of physician) to give resident Juven Packet (a supplement to aid in wound healing) BID (twice daily). A Weekly Pressure Wound document, dated 6/4/18, indicated: . Site Right thigh (rear), Type Pressure, Length 4.4 (cm), Width 4.0 (cm), Depth 1.1 (cm), Stage III (3). Describe drainage, Serosanguineous. Amount of drainage, Moderate. Indicate color of wound, necrotic/slough .Wound bed is 50% beefy red granulation tissue/50% yellowish-gray slough. Moderate amount of serosang (sic) drainage A Care Plan, initially dated 2/28/17 and updated for a goal target date of 8/27/18, indicated: Focus: She is at risks for skin breakdown .R/T (related to) incontinence and impaired mobility. The Interventions included: Full body skin audit weekly. Pressure reducing cushion in her wheelchair. Pressure reducing mattress on her bed. Turn and reposition every two hours back to left and PRN. A Care Plan, dated 5/30/18, indicated, Resident has an o/a (open area) to right rear thigh. The one Intervention indicated, Monitor o/a to right rear thigh. A Care Plan, dated 5/31/18, indicated, Alteration in skin integrity R/T decreased mobility as seen by pressure ulcer to the right thigh (rear). The Interventions included: 6/1/18 Administer Juven as ordered. 6/4/18 Administer Multivitamin as ordered. 5/31 Dietary supplement: sugar free house shakes with meals. 5/31/18 Notify MD of non response to treatment or worsening of area. 6/1/18 Nursing measure: Apply ARRO air mattress to bed with bolster mattress cover. A Care Plan documenting the sheared open area found on 3/5/18 was not found in the clinical record. On 6/6/18 at 1:20 P.M., LPN 1 was observed performing a dressing change on Resident B's right rear upper thigh area. Resident B was observed lying on an air mattress. The old dressing had a large amount of drainage. The pressure ulcer wound bed was over 50% yellow slough, with depth. LPN 1 indicated the resident had recently been to a wound clinic, and that the dressing was changed once a day. LPN 1 indicated the wound started as a shear. On 6/6/18 at 1:30 P.M., during an interview with a family member of Resident B, she indicated the facility had just put the resident on an air mattress the previous day. The family member indicated the family was told the resident's pressure area was a skin tear, or sheared area. The family member indicated they had no idea the area had deteriorated into a Stage 3 pressure ulcer. The family member indicated once the family saw the ulcer on 5/27/18, and were upset, the facility changed the treatment orders, added vitamins, and made the wound clinic appointment. On 6/6/18 at 3:30 P.M., during an interview with LPN 1, she indicated she was the facility's wound care nurse. She indicated she was monitoring the wound on Resident B since it first developed. She indicated it was thought that the area developed when the resident was sitting on a toilet seat, and sheared the skin. She indicated she did not ask for a different treatment on (MONTH) 30, because although the area was larger, the wound bed looked the same. She acknowledged once the yellow slough appeared, she should have documented it as pressure. LPN 1 indicated she had changed the treatment to Therahoney when the slough appeared. LPN 1 indicated she was gone on vacation from 5/24 to 5/27, and when she returned, the treatment order had been changed. LPN 1 indicated she herself did the weekly wound assessments, without involvement from other staff. LPN 1 indicated the resident had gone to a Wound Care Clinic on 6/1/18, and provided documentation from the clinic at that time. The Wound Care Clinic documentation, dated 6/1/18, included: Pt (patient) presents for initial evaluation of ulceration to right buttock that has been present for about 3 weeks which reportedly started as a shear .they have treated with Hydrogel, then honey and now Santyl for the last 2 days. She has had minimal improvement. She is also on Bactrim DS (an antibiotic). There has been no fever, chills .or drainage from wound. Staff reports she has a pressure relief mattress and wheelchair cushion. Reports very poor appetite and intake .Wound Check: This is a new problem. The current episode started 1 to 4 weeks ago .Exacerbated by: pressure .Physical Exam .Right buttock: Stage III Pressure ulcer measuring 47 x 38 x 22 mm (millimeters) deep. Eschar, [MEDICATION NAME]. Periwound with blanchable [DIAGNOSES REDACTED] (redness) .wound is selectively and excisionally debrided of necrotic tissue .culture obtained .Plan: Continue Santyl ointment once daily with dressing. LTC (long term care) to ensure proper pressure relief in place with mattress and wheelchair cushion, keep pt off buttocks as much as possible. Once wound is a bit more clean with less slough, will likely place a VAC (wound vac) On 6/7/18 at 10:05 A.M., during an interview with LPN 2, she indicated she was working on 5/27/18. She indicated Resident B's family came in and wanted to see her buttocks. She indicated the family couldn't believe what the wound looked like and were pretty upset. LPN 2 indicated the family stated, The last they heard it was a sheared area. LPN 2 indicated she was not the nurse who usually cared for Resident B, and that was the first time she had seen the area She indicated she instructed the staff to keep the resident turned from her side to her back. On 6/7/18 at 10:20 A.M., during an interview with RN 1, she indicated she usually did the resident's treatment to the pressure ulcer on the weekends. She indicated, It started out pretty small, then just got worse and worse. RN 1 indicated the area had looked the same for awhile, for at least 3 weeks, and she had not noticed a real change when the family came in and saw the area. RN 1 indicated the area had some necrotic tissue, with some yellow slough. On 6/7/18 at 2:20 P.M., the Administrator indicated the facility had a wound care nurse consultant, who also looked at Resident B's wound. She indicated the physician would have signed off on the consultant's recommendations. When informed there was no documentation in the clinical record from a wound care nurse consultant, she indicated she would find the documentation. The Administrator also indicated the resident liked to sit in her recliner all the time, and she was also a diabetic. On 6/7/18 at 2:30 P.M., the Administrator provided 3 Wound Care Evaluation documents. She indicated the documents were in LPN 1's office. The documents included: Wound 1, Thigh, Right Posterior, Date Onset 3/5/2018, Assessment Date 3/26/2018, Exudate (drainage) Min (minimum), Full Thickness, Tissue Injury - Trauma, Size (L x W cm) 0.90 x 0.30, Depth <.2 .Facility Acquired, Wound Bed: Yellow 100%, Adherent [MEDICATION NAME] Slough .Daily dressing change needed due to dressing becoming dislodged/compromised at site due to sheer (sic) and friction. Hydrogel assist with autolytic debridement Assessment Date 4/23/2018 .Size 1.60 (cm) x 1.50 (cm), Depth <.2 (cm) .Wound Bed: Yellow 100 % .Daily dressing change needed due to dressing becoming dislodged/compromised at site due to sheer and friction. Hydrogel assist with autolytic debridement Assessment Date 5/14/2018, Exudate Min .Size 3.00 (cm) x 3.50 (cm), Depth UTD (unable to determine) .Dressing change daily to include: Apply Therahoney to wound bed only. Cover with super absorbent dressing. On 6/7/18 at 2:30 P.M., the Director of Nurses (DON) provided a document,Shear Force initiative, undated. The document included: .Although pressure ulceration is associated with shear, it is as yet unclear as to the exact relationship between shear and its duration that causes damage .Practical suggestions to reduce the amount of shear force exerted on the tissue: Assist the patient to adopt a stable posture using aids when necessary On 6/7/18 at 2:40 P.M., during an interview with the Administrator, the DON, and LPN 1, LPN 1 indicated the physician did not see what the wound care nurse consultant recommended. She indicated the wound care consultant usually came once a month. LPN 1 indicated if there was not documentation that the physician was notified of a deterioration in the wound, then it probably was not done. On 6/7/18 at 10:30 A.M., the Administrator provided the current facility policy, Prevention of Pressure Ulcers, dated 2001 and revised (MONTH) 2010. The policy included: . Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue .If pressure ulcers are not treated when discovered, they quickly become larger, become very painful for the resident, and often times become infected. Pressure ulcers are often made worse by continual pressure, heat, moisture .decline in nutrition/hydration status .Pressure ulcers are a serious skin condition for the resident. The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician and family, and addressed . At that time, the Administrator provided an additional policy, Pressure Ulcer Treatment, revised (MONTH) 2010. The policy included: Stage III Pressure Ulcer: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling .Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed .If wound does not improve in 2-3 weeks, notify physician. Consider a skin consult with a wound specialist This Federal tag relates to Complaint IN 149. 3.1-40(a)(1) 3.1-40(a)(2)

Based on interview and record review, the facility failed to ensure residents received adequate supervision for 1 of 4 residents reviewed for falls in a total sample of 5 who met the criteria. A resident was left unattended in a wheelchair resulting in a fall with a left hip fracture. (Resident #117) Findings include: On 2/7/16 at 8:00 a.m., Resident #117's clinical record was reviewed. Resident #117's [DIAGNOSES REDACTED]. Resident #117's most recent Quarterly MDS (Minimum Data Set) Assessment, dated 1/16/17. The MDS indicated Resident #117 had severe cognitive impairment. The MDS further indicated Resident #117 had one fall since the prior assessment, without injury. The Progress Notes included, but were not limited to: 2/6/17 at 12:15 a.m.: Alarms sounding. Resident noted to be on floor near closet lying on her back with knees bent. Wheelchair sitting near dresser by room. Complaints of left hip/leg pain and refuses to straighten leg. Assisted to bed by two staff members. Stated she was trying to get to her bed but the floors are so slick I slide out of my chair. 2/6/17 at 12:50 a.m.: Transferred to (Name of Hospital) per (Name of Ambulance Service) at this time 2/6/17 at 3:00 a.m.: Call received from (Name of Hospital), resident has been admitted with left hip fracture The Fall Report, dated 2/6/17, included, but was not limited to: Unwitnessed fall . The Care Plans included, but were not limited to: She is at risk for falls related to falls in past. The interventions included, but were not limited to: do not leave alone in room in wheelchair, initiated on 10/25/16. On 2/7/17 at 8:30 a.m., the DON indicated the resident had been left in her room alone in her wheelchair. The DON further indicated the resident should not have been left alone. The DON further explained that LPN #5 and CNA #3 had assisted Resident #117 to the bathroom. The DON indicated LPN #5 had reported the resident had wanted to brush her teeth, LPN #5 had left the room quickly to put something on the desk, and the resident's alarm had begun to sound. On 2/7/17 at 11:04 a.m., the DON provided the Falls-Clinical Protocol policy, revised 4/2007. The policy included, but was not limited to: Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls . 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a gastrostomy tube (feeding tube) stoma was appropriately cared for, in that purulent drainage and insects were found around the site, resulting in treatment with an antibiotic cream; and failed to ensure a gastrostomy tube dressing was applied as ordered by the physician, for 2 of 3 residents reviewed with [DEVICE]s, in a sample of 5. Residents B and C Findings include: 1. On 7/29/13 at 10:20 A.M., the Assistant Director of Nursing (ADON) indicated Resident B had a feeding tube. The clinical record of Resident B was reviewed on 7/29/13 at 11:30 A.M. [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 6/17/13 indicated the resident scored a 3 out of 15 for cognition, with 15 indicating no memory problems. The resident required extensive assistance of one staff for transfer, dressing, and personal hygiene. A physician's orders [REDACTED]." An additional physician's orders [REDACTED].@ 80 cc/hr per [DEVICE] from 2000 (8:00 P.M.) to 0600 (6:00 A.M.)." Nurse's Notes included the following notations: 7/20/13 at 4:30 P.M.: "Purulent drainage noted at the [DEVICE] insertion site, N.O. (new order) from MD to treat (with) [MEDICATION NAME] TID (three times daily), and get culture of drainage." This was signed by RN # 3. The [DEVICE] site appearance or drainage was not documented on 7/21/13. Nurses notes continued: 7/22/13 at 2:00 A.M.: "Res. dressing change to peg tube ([DEVICE]) completed. (No) drainage present. Culture no (sic) able to obtain...." 7/22/13 at 6:30 A.M.: "Culture obtained @ this time of [DEVICE] drainage. Minimal amt (amount) of yellowish drainage obtained. Surrounding skin slightly pink...Drain sponge re-applied." The resident's Treatment Administration Record (TAR), dated July 2013, included: "Cleanse [DEVICE] site w/Normal Saline, Apply gauze drsg daily. Day." The entry was initialed as completed from July 1-July 21. On 7/29/13 at 11:50 A.M., a skin assessment of Resident B's [DEVICE] stoma site was requested. RN # 1 removed the resident's old dressing, which had a moderate amount of brownish-red drainage. RN # 1 indicated, "It looks pretty good," referring the resident's [DEVICE] site. RN # 1 was asked to raise the plastic [DEVICE] disc, which kept the [DEVICE] in place, so a closer observation could be made. The stoma site was reddened, with fresh blood oozing from the stoma site. The resident indicated the area was "sore." On 7/29/13 at 12:30 P.M., during an interview with LPN # 1, she indicated she was working on 7/20/13. She indicated she was called into Resident B's room by CNA # 1. She indicated CNA # 1 "had a weird look on her face, and said she needed me now." LPN # 1 indicated she took another nurse in with her to the resident's room. LPN # 1 indicated CNA # 1 showed her the resident's [DEVICE] dressing, which "had a lot of drainage on it." LPN # 1 indicated the old dressing had "what may have been an insect" on it. LPN # 1 indicated she could not say what type of insect it was, but that it was approximately .5 centimeters long and clear-looking. LPN # 1 indicated she did not see any type of insect on the skin, but saw the "insect-looking thing" on the dressing. She indicated the "desk nurse" notified the physician, and obtained an order to culture the area. She indicated there was no further drainage to culture at that time. On 7/29/13 at 12:45 P.M., during an interview with CNA # 1, she indicated she was working on 7/20/13, and was giving Resident B her bath. She indicated the resident's [DEVICE] dressing looked "dirty and nasty," so she removed the dressing. She indicated she saw "3 little worm things" on the resident's skin. She indicated she thought they must have fallen from the resident's dressing. CNA # 1 indicated she "immediately summoned my nurse (LPN # 1)." She indicated LPN # 1 came into the room, as well as other nurses. She indicated she questioned the supervisor if she should put the insects in a specimen cup, and was informed to "just throw the washrag and everything away." CNA # 1 indicated, "It looked like maggots to me. They were alive and wriggling." CNA # 1 indicated the dressing appeared as if "it hadn't been touched all week." CNA # 1 indicated LPN # 1 "was really distraught." CNA # 1 indicated she herself called the Director of Nursing (DON), because she wasn't sure that any of the nurses were going to call her. CNA # 1 indicated the DON was informed of the presence of insects, and "seemed nonchalant about it." On 7/29/13 at 1:20 P.M., during an interview with RN # 3, she indicated she was working on 7/20/13. RN # 3 indicated she went into Resident B's room after everything was cleaned, and did not see anything. She indicated she heard "maggots were growing under" the [DEVICE] dressing. RN # 1 indicated LPN # 1 was "extremely upset about it. She saw it." RN # 1 indicated she called the physician and informed him of the purulent drainage, but did not mention the insects. RN # 1 indicated the physician gave an order to obtain a culture and start [MEDICATION NAME]. On 7/29/13, during a confidential interview with Staff # 5, she indicated, "Someone was not doing the treatments" to Resident B's [DEVICE] site. On 7/30/13 at 9:00 A.M., during an interview with the Administrator and DON, the DON indicated the culture was not obtained from the resident's [DEVICE] site earlier than 7/22/13, due to no drainage from the site. The DON indicated she realized there was no documentation regarding the site on 7/21/13. The DON indicated she called the attending physician on 7/22/13, and informed him what she had heard regarding the presence of insects. The DON indicated she had told LPN # 1 to fill out an incident report regarding the incident, which she did, but now could not find it. The DON indicated she knows staff had changed the dressing on Friday 7/19. On 7/30/13 at 10:40 A.M., during an interview with CNA # 5, she indicated she was working on the same unit as Resident B on 7/20/13, but was not taking care of her that day. She indicated she "knew the nurse was really upset about something," but that she didn't know what it was. She indicated that she heard gossip, but did not really listen to that. On 7/30/13 at 11:15 A.M., during an interview with the Unit Manager, she indicated she knew Resident B's dressing had been changed on 7/19, because she was in the room and observed it was off. She acknowledged that she did not look under the plastic disc to observe the site. The Unit Manager indicated she hoped that staff had lifted up the plastic disc and cleansed under it when they did the dressing changes. 2. On 7/29/13 at 10:20 A.M., the ADON indicated Resident C had a feeding tube. On 7/29/13 at 12:10 P.M., Resident C's gastrostomy tube ([DEVICE]) site was observed. A dressing was not observed on the site. A slight red irritation was observed around the site. RN # 1 indicated at that time that Resident C did not have dressings applied to the site, because she "didn't like dressings on." The clinical record of Resident C was reviewed on 7/29/13 at 12:25 P.M. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Cleanse [DEVICE] stoma with normal saline (and) apply gauze dressing." A care plan, dated 7/19/13, indicated, "Focus, Alteration in Nutrition...She has a [DEVICE]..." The Interventions included, "Cleanse [DEVICE] stoma with NS (normal saline) and apply gauze dressing." A care plan which indicated the resident refused dressing changes was not documented. On 7/30/13 at 9:10 A.M., the DON provided a Treatment Administration Record (TAR), dated July 2013. The TAR indicated, "Cleanse [DEVICE] stoma with Normal Saline (and) apply gauze dressing. Day (shift)." The TAR was initialed as completed daily, including on 7/29/13. 3. On 7/30/13 at 11:45 A.M., the ADON provided the current facility policy on "Gastrostomy Tube Care," undated. The policy included: "...The purpose of [DEVICE] care is to: Prevent infection, Prevent tube complications...Provide proper skin care of the stoma site. Stoma care for [DEVICE]s should be done on a daily basis...Documentation may appear on any form used in the facility...." This Federal tag relates to Complaint IN 179. 3.1-44(a)(2)