Every finding on record at Oak Grove Christian Retirement Village

Based on record review and interview, the facility failed to ensure a care planned intervention for bed mobility was followed related to lack of adequate staff supervision during care which resulted in a fall from the bed, for 1 of 4 residents reviewed for accidents. (Resident C)The deficient practice was corrected on 4/3/26, prior to the start of the survey, and was therefore past noncompliance. The facility identified the concern on 3/23/26, completed a house wide education to the nursing department and agency staff who provided care to utilize and follow the Care Plan/Kardex (information for caring for the resident) for all residents. Audits were completed to ensure the Care Plans/Kardexs were all correct and updated for resident care. Eight facility staff and agency staff were interviewed and indicated the Kardex was used as a reference for completion of resident care.Finding includes:Resident C's record was reviewed on 4/13/26 at 10:27 a.m. The diagnoses included, but were not limited to, dementia and osteoporosisThe resident's Kardexes, dated 7/7/25 and 3/22/26, indicated the resident required two staff members for bed mobility assistance.A Significant Change Minimum Data Set assessment, dated 1/21/26, indicated a moderately impaired cognitive status, an impairment to one side of the lower extremities, was dependent for bed mobility, and utilized a pressure reducing device for the bed.A Care Plan, revised on 1/28/26, indicated assistance for transfers was required. The interventions indicated two staff members were to be utilized for bed mobility.A Post Fall Evaluation, dated 3/22/26 at 1:34 a.m., indicated a fall occurred on 3/22/26 at 12:10 a.m. Agency CNA 1 had rolled the resident in bed while performing care without assistance and the resident fell from the bed. The resident was assessed and there were no injuries.The Investigation of the fall, dated 3/22/26, indicated Agency CNA 1 had been completing incontinence care without assistance. She had rolled the resident toward her and the resident's arm stretched out to the right side of the bed and caused her to start sliding from the bed. Agency CNA 1 ran to the side of the the bed and was able to break the fall. Agency CNA 1 indicated she was unaware the resident required two staff for bed mobility.During an interview on 4/13/26 at 10:49 a.m., the Director of Nursing (DON) indicated Agency CNA 1 had worked at the facility prior to 3/22/26. The Aide indicated she was on the right side of the bed and attempted to roll the resident toward her when her right arm flung out of the left side of the bed and she started to slip out the left side of the bed. She ran around the bed and was able to lower the resident to the floor. The DON had attempted to call the Aide to come in for a re-enactment to be completed and has had not return response from the aide. The resident was a two-person assist for bed mobility and this was on the Kardex.This citation relates to Intake 2977396.410 IAC (Indiana Administrative Code) 16.2-3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure a resident was provided with medically-related social services related to follow up care for an allegation of abuse for 1 of 3 residents reviewed for abuse. (Resident D)Finding includes:Resident D's record was reviewed on 4/14/26 at 11:02 a.m. The diagnoses included, but were not limited to, dementia and Alzheimer's disease.A Significant Change Minimum Data Set assessment, dated 12/5/25, indicated a moderately impaired cognitive status, had other behaviors for one to three days and the behavior symptoms were worse.A Care Plan, dated 8/29/25, indicated anxiety was present and the resident would fixate on different things in regards to staff. The interventions included the staff would assist the resident to develop more appropriate methods of coping and interacting.An Indiana Department of Health reported incident, dated 2/3/26 at 10:30 a.m., indicated Resident D reported a CNA had shoved her in the chair and threw her walker. There were no injuries observed.A Care Plan, dated 2/4/26, indicated a history of making false allegations and exaggerations of the truth. The intervention included Social Service would be involved with the resident.There was no Social Service follow up after the allegation that monitored the resident psychosocial status.During an interview on 4/14/26 at 11:58 a.m., the Executive Director indicated at the time of the allegation, they had a staff member filling in for the Social Service Director. There was no policy that indicated the procedure for post abuse allegation care.The facility abuse policy, dated 7/15/25 and received per email from the Director of Nursing as current, indicated after an allegation was voiced, the resident would have increased monitoring and support.This citation relates to Intake 2961414.410 IAC (Indiana Administrative Code) 16.2-3.1-34(a)

Based on record review and interview, the facility failed to ensure laboratory (lab) services were only completed when ordered by a Physician/Nurse Practitioner (NP), related to a urinalysis (UA) completed on a resident without a Physician's Order, for 1 of 1 resident reviewed for lab tests. (Resident B)Finding includes:Resident B's record was reviewed on 4/14/26 at 8:21 a.m. The diagnoses included, but were not limited to, stroke and vascular dementia.A Progress Note, dated 3/23/26 at 11:35 a.m. and written by RN 1, indicated a urine specimen had been collected and the lab company was notified.There was no Physician/NP order for the urine specimen.During an interview on 4/14/26 at 10:06 a.m., RN 1 indicated the Director of Nursing (DON) requested the UA and she notified the NP. The resident had been catheterized for the urine collection.During an interview on 4/14/26 at 10:16 a.m., the DON indicated she had verbalized, we may want to get a UA, she had not directed RN 1 to get one and had assumed she would notify the NP for an order.410 IAC (Indiana Administrative Code) 16.2-3.1-49(f)(1)

Based on record review and interview, the facility failed to ensure a resident's record was complete and accurate related to documentation of an allegation of abuse for 1 of 3 residents reviewed for abuse. (Resident D)Finding includes:Finding includes:Resident D's record was reviewed on 4/14/26 at 11:02 a.m. The diagnoses included, but were not limited to, dementia and Alzheimer's disease.An Indiana Department of Health reported incident, dated 2/3/26 at 10:30 a.m., indicated Resident D reported a CNA had shoved her in the chair and threw her walker. There were no injuries observed.There was no documentation of the allegation of abuse in the resident's record. During an interview on 4/14/26 at 11:58 a.m., the Executive Director indicated at the time of the allegation they had a staff member filling in for the Social Service Director. The facility abuse policy, dated 7/15/25, and received per email from the Director of Nursing as current, indicated actions taken would be documented.This citation relates to Intake 2961414.410 IAC (Indiana Administrative Code) 16.2-3.1-50(a)(1)410 IAC 16.2-3.1-50(a)(2)

Based on record review and interview, the facility failed to ensure a resident's representative was informed when a resident had a change in condition and required an order for breathing treatment medication for 1 of 3 residents reviewed for change in condition. (Resident B) Finding includes: Closed record review for Resident B was completed on 2/5/26 at 10:24 a.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), heart failure, hypertension, dementia, atrial fibrillation, and depression.The Quarterly Minimum Data Set (MDS) assessment, dated 10/31/25, indicated the resident was cognitively impaired. The resident received oxygen therapy.A Progress Note, dated 12/21/25 at 6:22 a.m., indicated the resident appeared to sleep well overnight. The staff indicated they had noticed a cough. The resident's lungs were clear.A Progress Note, dated 12/21/25 at 10:07 p.m., indicated a physician's order to administer albuterol sulfate inhalation nebulization solution (medication for breathing problems) via nebulizer two times a day for cough until 12/27/25.There was a lack of documentation to indicate the resident's representative was informed the resident had a change in condition and a new order for breathing medication was completed.During an interview on 2/5/26 at 1:43 p.m., LPN 1 indicated she did not document that she spoke with the resident's representative and inform them of the resident's change in condition and a new medication had been ordered. During an interview on 2/5/26 at 3:03 p.m., the Director of Nursing (DON) indicated the nurse should have documented that she spoke with the family related to the change in condition and medication change. This citation relates to Intake 2730697.3.1-3(n)(2)

Based on record review and interview, the facility failed to ensure a resident received the necessary care and treatment related to completing a respiratory assessment when a resident had a change of condition and completing pre-and-post assessments with breathing treatment medication for 1 of 3 residents reviewed for change of condition. (Resident B) Finding includes: Closed record review for Resident B was completed on 2/5/26 at 10:24 a.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), heart failure, hypertension, dementia, atrial fibrillation, and depression.The Quarterly Minimum Data Set (MDS) assessment, dated 10/31/25, indicated the resident was cognitively impaired. The resident received oxygen therapy.A Progress Note, dated 12/21/25 at 6:22 a.m., indicated the resident appeared to sleep well overnight. The staff indicated they had noticed a cough. The resident's lungs were clear.A Progress Note, dated 12/21/25 at 10:07 p.m., indicated a physician's order to administer albuterol sulfate inhalation nebulization solution (medication for breathing problems) via nebulizer two times a day for cough until 12/27/25.The December 2025 Medication Administration Record (MAR) indicated the resident had received the albuterol sulfate via nebulizer twice a day.There was a lack of documentation a respiratory assessment had been completed on the resident which indicated why the resident needed a new breathing treatment medication. The record also lacked any documentation pre-and-post respiratory assessments had been completed each time the albuterol sulfate nebulizer was administered. During an interview on 2/5/26 at 1:43 p.m., LPN 1 indicated a CNA had informed her the resident had a cough. She completed a respiratory assessment and contacted the physician, who then ordered the albuterol sulfate nebulizer medication. She did not document her assessment and she should have. She was unsure why there were no pre-and-post assessments each time the resident received the medication, but they should have been completed. During an interview on 2/5/26 at 3:03 p.m., the Director of Nursing (DON) indicated the nurse should have documented that a respiratory assessment was completed which indicated why the nebulizer medication was started. The staff should have completed pre-and-post assessments with each nebulizer treatment and she was unable to find any documentation they were completed.A facility policy, titled Nebulizer and received as current from the Administrator on 2/5/26, indicated, .6. Obtain resident's vital signs, and perform respiratory assessments to establish a baseline.This citation relates to Intake 2730697.3.1-47(a)(6)

Based on observation, record review, and interview, the facility failed to serve food under sanitary conditions related to dishes stored upright above and below the steam table, on a cart across from the 3-compartment sink and transporting uncovered food on room trays down the hallway. This had the potential to affect all 62 residents who received food from the Kitchen and 6 residents who received room trays on Oak Branch 2 unit. (Kitchen, Oak Branch 2) Findings include:1. The initial Kitchen tour was completed on 9/15/25 at 9:12 a.m., with the Dietary Manager (DM). The following was observed.a. Plates and bowls were stored upright above the steam table.b. Pans were stored upright on a shelf below the steam table.c. Plates and bowls were stored upright on a cart at the end of the steam table across from the 3-compartment sink.During an interview at the time of the tour, the DM indicated the dishes and pans should have been stored inverted and not upright.2. On 9/16/25 at 12:24 p.m., the staff were observed serving residents lunch on the Oak Branch 2 Unit. CNA 1 was observed placing plates of food and drinks for 6 residents onto a cart. The plates and drinks were covered. She then proceeded to place 6 plates each with a piece of cake onto the cart. The cakes were not covered. She then proceeded down the hallway to the end of Oak Branch 2 to deliver the room trays.During an interview on 9/16/25 at 12:31 p.m., CNA 2 indicated she did not have anything to cover the plates of cake with before she transported them down the hallway.During an interview on 9/16/25 at 12:34 p.m., [NAME] 1 indicated another dietary staff member had prepped the cakes and should have covered them. Staff should not have taken them down the hallway uncovered.A policy titled, Food Safety Requirements and received as current from the Dietary Manager on 9/19/25, indicated, .5. Foods and beverages shall be distributed and served to residents in a manner to prevent contamination and maintain food at the proper temperature and out of the Danger Zone. Strategies include, but are not limited to: a. Covering all foods when traveling a distance (i.e., down a hallway, to a different unit or floor).3.1-21(i)(3)

Based on observation, record review, and interview, the facility failed to ensure residents were assessed for self-administration of medications and had a physician's order to self-administer medications, for 2 of 2 residents reviewed for self-administration of medication. (Residents 14 and 65)Findings include: 1. On 9/16/25 at 9:16 a.m., Resident 14 was observed seated in her wheelchair in her room. The nebulizer machine was on, and she had the mouthpiece in place to her mouth. There were no staff present in the room or near the room. LPN 2 was observed at the Nurse's Station, down the hall. The resident's record was reviewed on 9/17/25 at 9:34 a.m. Diagnoses included, but were not limited to, dementia, hypertension, and osteoarthritis. The Quarterly Minimum Data Set (MDS) assessment, dated 6/6/25, indicated the resident was cognitively intact. A Physician's Order, dated 4/1/25, indicated ipratropium-albuterol solution 0.5 mg (milligrams)-3 mg/3 ml (milliliters) two times a day. There was a lack of any physician's order for self-administration of the medication or any self-administration of medication assessment. During an interview on 9/18/25 at 10:03 a.m., the Director of Nursing (DON) was made aware of the resident self-administering the nebulizer treatment. The nebulizer policy was requested. A facility policy, titled, Nebulizer, received from the DON as current, indicated .14. Observe resident during the procedure for any change in condition. 2. During a random observation on 9/16/25 at 9:49 a.m., Resident 65 was observed in his bed watching television. On the bedside table, there was a bottle of fluticasone nasal spray (allergy nasal spray) with no medication label or instructions for use. Resident 65 indicated that it was an over-the-counter medication that he took himself whenever he needed it for his allergies. Resident 65's record was reviewed on 9/16/25 at 3:33 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD) and dementia. The Quarterly Minimum Data Set (MDS) assessment, dated 8/20/25, indicated the resident was cognitively intact for daily decision making. The current September 2025 Physician's Order Summary indicated there was no order for the fluticasone nasal spray. The record lacked a completed self-administration of medication assessment. During an interview on 9/16/25 at 3:49 p.m., the Director of Nursing indicated she had no further information to provide. A facility policy titled, Resident Self Administration of Medications, indicated, .A resident may only self-administer medications after the campus's interdisciplinary team has determined which medications may be self-administered safely .4. The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment Form .8. All nurses and aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage . 3.1-11(a)

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) comprehensive assessments were accurately completed related to antiplatelet and antianxiety medications for 1 of 16 MDS assessments reviewed. (Resident 6) Finding includes:Resident 6's record was reviewed on 9/18/25 at 2:42 p.m. Diagnoses included, but were not limited to, history of traumatic brain injury, anemia, anxiety disorder, and cognitive communication deficit. The Quarterly Minimum Data Set (MDS) assessment, dated 6/12/25, indicated the resident was severely cognitively impaired. In the 7-day look-back period, the resident received antianxiety, antidepressant, anticoagulant, antibiotic, diuretic, and opioid medications. A Physician's Order, dated 5/31/25, indicated clopidogrel (antiplatelet medication) 75 milligrams 1 tablet once daily. There was no order for an antianxiety or anticoagulant medication in the June 2025 Physician's Order Summary. During an interview on 9/19/25 at 10:36 a.m., the Director of Nursing indicated the MDS assessment needed to be modified. The resident had not taken an antianxiety or anticoagulant medication. The clopidogrel should have been coded as an antiplatelet medication. 3.1-31(i)

Based on record review and interview, the facility failed to ensure a comprehensive care plan was developed and in place for residents with significant weight loss, diuretics, and opioid medications for 2 of 16 care plans reviewed. (Resident 6 and 44) Findings include: 1. Resident 6's record was reviewed on 9/18/25 at 2:42 p.m. Diagnoses included, but were not limited to, history of traumatic brain injury, anemia, anxiety disorder, and cognitive communication deficit. The Quarterly Minimum Data Set (MDS) assessment, dated 6/12/25, indicated the resident was severely cognitively impaired. The resident had weight loss of 5% or more in the last month or loss of 10% or more in last 6 months and was not a prescribed weight-loss regimen. In the 7-day look-back period, the resident received antianxiety, antidepressant, anticoagulant, antibiotic, diuretic, and opioid medications. The resident's weight on 6/6/25 was 120.2 pounds and on 12/2/24 was 134.0 pounds. The September 2025 Physician's Order Summary indicated the resident was receiving Lasix (diuretic medication) 20 milligram (mg), 1 tablet daily, hydrocodone/acetaminophen (opioid medication) 5-325 mg 0.5 tablet every 12 hours as needed, mirtazapine (antidepressant medication) 15 mg tablet give 7.5 mg every evening for appetite stimulant, Med Pass (supplement) 120 milliliters three times a day, fortified potatoes every afternoon for supplement, and Health shake twice a day for supplement. There were no person-centered comprehensive care plans and interventions initiated for the diuretic medications, opioid medications, and nutritional status. During an interview on 9/19/25 at 10:36 a.m., the Director of Nursing indicated the care plans needed to be updated. 2. Resident 44's record was reviewed on 9/17/25 at 11:03 a.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus, heart failure, and chronic kidney disease. The admission Minimum Data Set (MDS) assessment, dated 7/24/25, indicated the resident was cognitively intact. On 08/04/2025, the resident weighed 292 pounds. On 09/09/2025, the resident weighed 266.6 pounds which was an 8.7% weight loss. The September 2025 Physician's Order Summary indicated the resident received Pro-Stat (dietary supplement) 30 milliliters in the morning. A Nutrition/Dietary Note, dated 9/11/25 at 10:46 p.m., indicated the resident had weight fluctuation with significant 9% loss over 30 days related to diuresis. The resident was on a diuretic and received a nutritional supplement. There were no new recommendations, and the resident would continue to be seen in NAR (nutrition-at-risk). There were no person-centered comprehensive care plans and interventions initiated for nutrition, weight loss, or diuretic medication use. During an interview on 9/18/25 at 10:03 a.m., the Director of Nursing indicated the care plans needed to be updated for the resident. 3.1-35(a)

Based on record review and interview, the facility failed to provide twice weekly showers/bathing for a resident who was dependent on staff for activities of daily living (ADLs) for 1 of 1 resident reviewed for ADLs. (Resident 3)During an interview on 9/15/25 at 10:53 a.m., Resident 3 indicated he was not receiving showers as he should. Resident 3's record was reviewed on 9/18/25 at 11:52 a.m. Diagnoses included, but were not limited to, hemiplegia and hemiparesis (paralysis and weakness) following a stroke affecting the left non-dominant side. The Quarterly Minimum Data Set (MDS) assessment, dated 6/30/25, indicated the resident was cognitively intact. The resident required maximal assistance for showering/bathing. The Resident Preferences document, dated 5/13/25, indicated the resident preferred a shower on Monday and Thursday evenings. The previous 60 days of shower sheets were requested. There were documented showers or bed baths on 6/21, 7/3, 7/7, 7/10, 7/17, 7/21, 7/24, 7/28, 8/4, 8/18, 8/21, 8/25, and 9/4/25. There were no documented showers received after 9/4/25. During an interview on 9/19/25 at 3:20 p.m., the Director of Nursing indicated she was unable to find any more shower sheets. The resident had a history of refusals; however, the staff were not documenting a shower refusal. 3.1-38(b)(2)

Based on observation, record review, and interview, the facility failed to ensure signs and symptoms of constipation were addressed for 1 of 1 resident reviewed for constipation, skin treatments were completed as ordered and compression stockings were applied as ordered for 2 of 3 residents reviewed for non-pressure related skin conditions. (Residents 10, 16, and 13) Findings include:1. On 9/16/25 at 9:08 a.m., Resident 10 was observed lying in bed. The resident indicated she would sometimes go for 4-5 days without having a bowel movement. Sometimes the nurses would give her a laxative, and she still would not always have a bowel movement for days. Record review for Resident 10 was completed on 9/18/25 at 10:38 a.m. Diagnoses included, but were not limited to, multiple sclerosis, anemia, hypertension, neurogenic bladder, anxiety, and depression. The Quarterly Minimum Data Set (MDS) assessment, dated 6/30/25, indicated the resident was cognitively intact. The resident had an impairment on both sides of her upper and lower extremities for a functional limitation in range of motion. The resident was dependent on staff for toileting hygiene and transferring. The resident was always incontinent with bowels and received scheduled pain medication. A Care Plan, dated 3/23/25, indicated the resident had a self-care performance deficit related to decreased mobility, multiple sclerosis, anxiety, depression, and neurogenic bladder. An intervention included for staff to provide assistance as needed for toileting. The September 2025 Physician's Order Summary (POS) indicated the resident had the following orders:- hydrocodone/apap (opioid pain medication) 10-325 mg (milligrams) at bedtime- Milk of Magnesia (laxative) 30 ml (milliliters) every 24 hours as needed for bowel management The Bowel and Bladder Elimination Task for the past 30 days indicated the resident did not have a bowel movement from 8/27-9/1/25 and again 9/8-9/11/25. The record lacked any indication the resident had received the as needed laxative on the above dates when there was no bowel movement. During an interview on 9/18/25 at 3:23 p.m., the Director of Nursing (DON) indicated she was unable to provide any documentation the resident had received any as needed laxative when she went multiple days without having a bowel movement. A policy titled, Bowel Elimination Management and received as current from the Administrator on 9/22/25, indicated, .3. Licensed nurses will review bowel movement charting each shift. 4. If the resident does not have a bowel movement in 3 days, the resident will be assessed and a bowel protocol initiated. 2. Resident 16's record was reviewed on 9/17/25 at 10:40 a.m. Diagnoses included, but were not limited to, hypertension, anxiety disorder, and Alzheimer's disease. The Annual Minimum Data Set (MDS) assessment, dated 8/23/25, indicated the resident was cognitively impaired, required substantial/maximal assist with bathing and partial/moderate assist with personal hygiene and dressing. A Nurse's Note, dated 8/20/25 at 10:11 p.m., indicated the resident was noted to have a small red non-blanchable area to the left inner buttock. The Wound Nurse was made aware. A Nurse's Note, dated 8/21/35 at 6:51 p.m., indicated there was a non-blanchable area to the left inner buttocks and wound care evaluated the area on 8/20/25. A Nurse's Note, dated 8/22/25 at 1:01 p.m., indicated the Nurse Practitioner was notified of the resident's skin issue and a new order for antifungal cream twice daily was received. The record lacked any wound assessments for the left buttock area. The Medication and Treatment Administration Records, dated 8/2025, lacked any documentation the antifungal cream had been ordered or administered. During an interview on 9/18/25 at 1:11 p.m., the DON indicated the resident did not have any current wounds. The antifungal treatment had not been completed as ordered. 3. During observations on 9/18/25 at 9:47a.m. and on 9/19/25 at 11:39 a.m., Resident 13's feet and legs were visibly red and swollen and she was not wearing compression stockings to her lower legs. Record review for Resident 13 was completed on 9/16/25 at 3:48p.m. Diagnoses included, but were not limited to, hypertension, Alzheimer's disease, dementia, anxiety, depression, and congestive heart failure. The Quarterly Minimum Data Set (MDS) assessment, dated 6/3/25, indicated the resident was moderately cognitively impaired. The resident required substantial maximal assistance for dressing and transfers. A Care Plan, dated 3/28/25, indicated the resident had hypertension. An intervention included to monitor for and document any edema (swelling) and to notify the physician. A Physician's order, dated 9/7/25, indicated to apply knee high compression stockings to both legs. The resident was to have them applied during the day and removed in the evening. During an interview on 9/18/25 at 9:47 a.m., CNA 1 indicated midnight shift was responsible for applying the resident's compression stockings. The resident's compression stockings were too tight sometimes so they would apply geri-sleeves (a protective sleeve for the arms or legs) on the resident instead. She was unaware the resident did not currently have her compression stockings in place. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure residents with pressure ulcers received the necessary treatment and services to promote healing related to a physician's order for wound care not followed during a wound care observation for 1 of 4 residents reviewed for pressure ulcers. (Resident 44) Finding includes: Resident 44's record was reviewed on 9/17/25 at 11:03 a.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus, heart failure, and chronic kidney disease. The admission Minimum Data Set (MDS) assessment, dated 7/24/25, indicated the resident was cognitively intact. The resident had an unstageable wound. A Physician's Order, dated 7/19/25, indicated cleanse the right heel with wound cleanser, pat dry, apply betadine, cover with ABD (abdominal) pad, and wrap with Kerlix (bandage wrap) every evening shift. During an observation of wound care on 9/19/25 at 1:39 p.m., Agency LPN 3 was observed performing wound care to Resident 44's right heel. Agency LPN 3 performed hand hygiene and donned a gown and gloves. She removed the old dressing, which was a bordered gauze (adhesive dressing) with no date. There was no ABD or Kerlix wrap covering the wound. The nurse performed hand hygiene and donned new gloves. She cleansed the area with wound cleanser and gauze, removed her gloves, donned new gloves, and patted the wound dry with clean gauze. She then applied the ABD pad and wrapped with Kerlix. The nurse did not apply the betadine to the wound. During an interview on 9/19/25 at 1:48 p.m., Agency LPN 3 indicated the old dressing did not have the ABD pad or Kerlix. During the wound care, she should have applied betadine. During an interview on 9/18/25 at 1:11 p.m., the Director of Nursing indicated she had no further information to provide. 3.1-40(a)(2)

Based on observation, record review, and interview, the facility failed to ensure a resident who required nebulizer breathing treatments was assessed prior to, during, and/or after the treatment for effectiveness of the treatment for 1 of 1 resident reviewed for respiratory care. (Resident 14)Finding includes:On 9/16/25 at 9:16 a.m., Resident 14 was observed seated in her wheelchair in her room. The nebulizer machine was on, and she had the mouthpiece in place to her mouth. There were no staff present in the room or near the room. LPN 2 was observed at the Nurse's Station, down the hall.The resident's record was reviewed on 9/17/25 at 9:34 a.m. Diagnoses included, but were not limited to, dementia, hypertension, and osteoarthritis.The Quarterly Minimum Data Set (MDS) assessment, dated 6/6/25, indicated the resident was cognitively intact.A Physician's Order, dated 4/1/25, indicated ipratropium-albuterol solution 0.5 mg (milligrams)-3 mg/3 ml (milliliters) two times a day. There were no orders for a pre or post nebulizer treatment assessment.There was lack of documentation any respiratory assessment had been completed prior to or after the administration of the nebulizer treatment.During an interview on 9/18/25 at 10:03 a.m., the Director of Nursing (DON) was made aware there were no documented pre or post nebulizer treatment assessments. She was unable to provide any further documentation.A facility policy, titled, Nebulizer, received from the DON as current, indicated .6. Obtain resident's vital signs, and perform respiratory assessment to establish a baseline.Documentation.4. Resident vital signs and respiratory assessment.3.1- 47(a)(6)

Based on observation, record review, and interview, the facility failed to ensure residents with dementia received appropriate treatment and services related to lack of care planning with individualized interventions and activity assessments not completed for 2 of 3 residents reviewed for dementia care. (Residents 7 and 16) Findings include:1. On 9/18/25 at 11:41 a.m., Resident 7 was observed up ambulating in the hallway near the Nurse's Station. She stopped to ask LPN 2 what was for lunch. LPN 2 invited the resident to participate in the current activity that was going on, the resident agreed and went to the activity area.Resident 7's record was reviewed on 9/18/25 at 11:23 a.m. Diagnoses included, but were not limited to, dementia with behavioral disturbance, general anxiety disorder, and multiple sclerosis.The Annual Minimum Data Set (MDS) assessment, dated 8/30/25, indicated the resident was cognitively impaired. She had received antipsychotic and antidepressant medications.A Care Plan, updated 5/28/25, indicated the resident had impaired cognitive function or impaired thought processes related to dementia. The interventions included, to communicate with the resident, family, and caregivers regarding the resident's capabilities. There was lack of documentation to indicate the care plan was individualized, person centered, and included resident specific interventions.A Care Plan, updated 9/7/25, indicated the resident was appropriate for the secured dementia unit. The interventions included, encourage family to provide items that are familiar to the resident and provide activities of interest to the resident. There was lack of documentation to indicate the care plan was individualized, person centered, and included resident specific interventions.There was no activity assessment completed for the resident.During an interview on 9/19/25 at 3:40 p.m., the Director of Nursing indicated an activity assessment had not been completed for the resident. 2. On 9/16/25 at 10:00 a.m., Resident 16 was observed lying in bed with her eyes closed.Resident 16's record was reviewed on 9/17/25 at 10:40 a.m. Diagnoses included, but were not limited to, dementia with behavioral disturbance, psychotic disorder, and anxiety disorder.The Annual Minimum Data Set (MDS) assessment, dated 8/23/25, indicated the resident was cognitively impaired. She had delusions and verbal behaviors 1-3 days during the assessment period. She had received antipsychotic, antianxiety, and antidepressant medications.A Care Plan, updated 9/15/25, indicated the resident had behaviors of believing the past was the present and believing the boys were playing jokes and or tricks on her. The interventions included to provide a program of activities that is of interest and accommodated the resident's status. There was lack of documentation to indicate the care plan was individualized, person centered, and included resident specific interventions.A Care Plan, updated 3/31/25, indicated the resident had impaired cognitive function and impaired thought processes related to dementia. The interventions included the use of antianxiety medication. There was lack of documentation to indicate the care plan was individualized, person centered, and included resident specific interventions.A Care Plan, updated 9/6/25, indicated the resident was appropriate for the secured dementia unit. The interventions included, encourage family to provide items that are familiar to the resident and provide activities of interest to the resident. There was lack of documentation to indicate the care plan was individualized, person centered, and included resident specific interventionsThere was no activity assessment completed for the resident.During an interview on 9/18/25 at 1:11 p.m., the Director of Nursing indicated an activity assessment had not been completed for the resident. The Activity Director thought she just had to complete the MDS activity section and not a full assessment.3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure infection control guidelines were in place and implemented related to lack of hand hygiene with glove changes during wound care and improper personal protective equipment (PPE) worn in an Enhanced Barrier Precaution (EBP) room while accessing a peripheral intravenous central catheter (PICC) line. (Residents 44 and 1) Findings include: 1. During an observation of wound care on 9/19/25 at 1:39 p.m., Agency LPN 3 was observed performing wound care to Resident 44's right heel. Agency LPN 3 performed hand hygiene and donned a gown and gloves. She removed the old dressing, performed hand hygiene, and donned clean gloves. She cleansed the area with wound cleanser and gauze, removed her gloves, and then donned new gloves without performing hand hygiene. She continued to pat the area dry with clean gauze and then applied the ABD pad and wrapped with Kerlix. During an interview on 9/19/25 at 1:48 p.m., Agency LPN 3 indicated she should have performed hand hygiene with every glove change. During an interview on 9/18/25 at 1:11 p.m., the Director of Nursing indicated she had no further information to provide. A facility policy titled, Hand Hygiene Policy, indicated, .6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves . 2. On 9/17/2025 at 3:54 p.m., LPN 1 was observed preparing to administer an antibiotic to Resident 1 via a PICC (peripherally inserted central catheter) line. The LPN gathered her supplies and walked to the resident's room. There was a sign outside the resident's room that indicated the resident was on EBP (enhanced barrier precautions). There was a bin outside the room that contained PPE (personal protective equipment) which included gowns. The LPN applied gloves and then primed the tubing attached to the medicine ball with the antibiotic. She cleaned the PICC line port with an alcohol wipe and flushed the tubing with 10 cc (cubic centimeter) of normal saline. The nurse then attached the tubing from the medication ball to the PICC line port. The nurse did not apply a gown when she hooked up the medication via the PICC line. Record review for Resident 1 was completed on 9/17/25 at 3:56 p.m. The September 2025 Physician's Order Summary (POS) indicated an order for cefazolin (antibiotic) 2000 mg (milligrams) intravenously three times a day for an infection. There was also an order for EBP which indicated staff were to wear gloves and a gown when providing care with high-risk activities. During an interview on 9/17/25 at 4:00 p.m., LPN 1 indicated the only time she was told to wear a gown was when she was completing wound care. A policy titled, Enhanced Barrier Precautions and received as a current from the Administrator on 9/22/25, indicated, .EBP refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities.4. High-contact resident care activities include.g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy / ventilator tubes, hemodialysis catheters, PICC lines, midline catheters. 3.1-18(b)

Based on record review and interview, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy to reduce antibiotic resistance related to antibiotics started without indication for use for 2 of 2 residents reviewed for urinary tract infections. (Resident 44 and 3) Findings include: 1. Resident 44's record was reviewed on 9/17/25 at 11:03 a.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus, heart failure, and chronic kidney disease. The admission Minimum Data Set (MDS) assessment, dated 7/24/25, indicated the resident was cognitively intact. A Progress Note, dated 9/4/25 at 1:33 p.m., indicated the nurse practitioner was notified of the resident's high blood sugar and new orders were received for a urinalysis (urine test) with culture and sensitivity. A urinalysis result, dated 9/5/25 at 4:05 p.m. and reported on 9/8/25 at 7:01 a.m., indicated the resident's urine was positive for enterococcus faecium (bacteria) vancomycin-resistant strain (VRE) 50-100,000 colonies per milliliter. The bacteria had resistance to ciprofloxacin and was susceptible to nitrofurantoin. A Physician's Order, dated 9/5/25, indicated ciprofloxacin (antibiotic) 250 milligram tablet twice daily for 10 days. A Physician's Order, dated 9/8/25, indicated nitrofurantoin (antibiotic) 100 milligram capsule twice daily for 7 days. There were no documented signs or symptoms of a urinary tract infection. During an interview on 9/19/25 at 9:47 a.m., the Director of Nursing indicated she was unable to find documentation of the resident's signs or symptoms of a urinary tract infection. 2. During an interview on 9/15/25 at 10:53 a.m., Resident 3 indicated he had been having some signs and symptoms of a urinary tract infection and he had them previously. There was a urine sample cup observed on a table in the resident's room. Resident 3's record was reviewed on 9/18/25 at 11:52 a.m. Diagnoses included, but were not limited to, hemiplegia and hemiparesis (paralysis and weakness) following a stroke affecting the left non-dominant side. The Quarterly Minimum Data Set (MDS) assessment, dated 6/30/25, indicated the resident was cognitively intact. The resident required maximal assistance for showering/bathing. A Progress Note, dated 8/27/25 at 6:51 a.m., indicated a urinalysis sample was collected via a clean urinal. The urine was malodorous, clear, yellow, and free of sediment. The urinalysis with culture and sensitivity, dated 8/26/25 at 5:00 a.m. and reported on 8/29/25 at 8:37 a.m., indicated the urine was positive for proteus mirabilis (bacteria) 10-50,000 colonies/milliliter. A Physician's Order, dated 9/1/25, indicated cephalexin (antibiotic) 500 milligram tablet three times a day. A Physician's Order, dated 9/3/25, indicated cephalexin 500 mg tablet three times a day for 5 days. A Physician's Order, dated 9/12/25, indicated urinalysis with culture and sensitivity. There were no documented signs or symptoms of a urinary tract infection. During an interview on 9/19/25 at 9:47 a.m., the Director of Nursing indicated with each infection a document was to be filled out to show that the resident's infection met criteria for antibiotic use. The resident did have an outstanding order for another urinalysis that was not completed. A facility policy titled, Antibiotic Stewardship Policy, indicated, .a. Antibiotic use protocols: i. Nursing team members shall assess residents who are suspected to have an infection and notify the physician .iii. The community uses the CDC's NHSN Surveillance Definitions, updated McGeer criteria, or other surveillance tool to define infections .

Based on observation and interview, the facility failed to post in a timely manner the daily staffing sheet which indicated how many staff were working in the facility and the facility census. This had the potential to affect the 62 residents who resided in the facility. Finding includes: On 9/16/25 at 9:32 a.m., the daily staffing sheet located at the Oak Branch Nurses' station was dated 9/14/25. On 9/16/25 at 12:30 p.m., the daily staffing sheet was at the Oak Branch Nurses' station was dated 9/15/25. During an interview on 9/16/25 at 3:50 p.m., the Director of Nursing indicated the Staff Coordinator thought the previous day's staffing levels were supposed to be posted daily.

Based on record review and interview, the facility failed to ensure medications were administered as ordered for 1 of 3 residents reviewed for medication administration. (Resident C) Finding includes: Resident C's record was reviewed on 8/13/25 at 9:04 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, heart failure, and hypertensive chronic kidney disease. The Annual Minimum Data Set assessment, dated 7/18/25, indicated the resident was moderately impaired for daily decision making. A Care Plan, dated 3/31/25, indicated the resident had an altered cardiovascular status related to congestive heart failure, hypertension (high blood pressure), and hyperlipidemia (high levels of fat/lipids in the blood). Interventions included, but were not limited to, administer medications as ordered. A Physician's Order, dated 4/1/25, indicated metoprolol tartrate (blood pressure medication) 25 milligrams, 1 tablet by mouth twice a day. Check blood pressure (bp) prior to administering the medication. Hold the medication if bp is less than 100/50 or heart rate is less than 60. The June 2025 Medication Administration Record (MAR) indicated the medication was held on the following dates and times: - Morning dose: 6/13/25 bp 101/55 and 6/19/25 no vital signs recorded - Bedtime dose: 6/14/25 bp 104/50 The July 2025 Medication Administration Record (MAR) indicated the medication was held on the following dates and times: - Bedtime dose: 7/2/25 bp 108/58 and 7/31/25 bp 106/68 The August 2025 Medication Administration Record (MAR) indicated the medication was held on the following dates and times: - Morning dose: 8/5/25 no vital signs recorded - Bedtime dose: 8/2/25 bp 117/50 During an interview on 8/13/25 at 2:15 p.m., the Director of Nursing indicated she had no further information to provide related to the medications being held when the vital signs were within the parameters to administer. This citation relates to Complaint 2587154. 3.1-37(a)

Based on observation, record review and interview, the facility failed to ensure residents received the necessary care and treatment related to oxygen administration, lack of respiratory assessments, and oxygen saturation monitoring for 2 of 4 residents reviewed for respiratory care. (Residents B and D)Findings include:1. Record review for Resident B was completed on 8/12/25 at 1:39 p.m. Diagnoses included, but were not limited to, heart failure, chronic pulmonary edema (excess fluid in the lungs), and hypertension. The Quarterly Minimum Data Set (MDS) assessment, dated 7/9/25, indicated the resident was moderately cognitively impaired. The resident required partial moderate assistance with bed mobility and dressing. The resident received oxygen therapy. A Care Plan, dated 7/3/25, indicated the resident required oxygen therapy related to ineffective gas exchange. An intervention included to check the oxygen tank every 4 hours to make sure the resident had sufficient supply. The August 2025 Physician’s Order Summary (POS) indicated an order for oxygen at 4 liters per nasal cannula continuously. A Resident Experience Form, dated 6/29/25, indicated that the resident’s daughter had a grievance that her mother’s portable oxygen tank was empty at approximately 10:00 a.m. on 6/29/25. The investigation included that CNA 1 reported the night shift did not fill the tanks before leaving. CNA 2 indicated the tank was not empty when she put it out, it felt “heavy”. The Teachable Moment on the grievance for CNA 1 and CNA 2 was the oxygen tanks must be checked at the start of a shift and before changing a resident from room concentrator to a portable tank to be certain the tank contained enough oxygen to last until the resident returned to the room. The record lacked any documentation a respiratory assessment had been completed on Resident B after the resident’s oxygen tank was found to be empty on the morning of 6/29/25. A Progress Note, dated 7/20/25 at 8:52 p.m., indicated the resident had a decrease in appetite that morning, afternoon and evening. The resident only ate bites for meals, sipped on fluids and did not take her morning medications. The resident kept falling asleep. The resident’s oxygen tank that evening “malfunctioned” at dinner time. The resident’s oxygen saturation was at 78%. The oxygen tank was refilled, and the resident was placed on 3 liters of oxygen. The resident’s oxygen saturation was then at 92% after applying the oxygen. The doctor and family were made aware and the doctor ordered laboratory testing to be completed the next morning. A Progress Note, dated 7/20/25 at 9:55 p.m., indicated that during rounds, the resident was observed to have difficulty breathing. The resident’s oxygen saturation was at 76% on 3 liters of oxygen. The doctor was called, and an order was received to increase the oxygen to 4-5 liters and monitor. The resident’s oxygen saturation was 84% on 5 liters. The family was made aware and asked that the resident be sent out the hospital. The resident was sent to the hospital by ambulance. During an interview on 8/12/25 at 3:45 p.m., the Assistant Director of Nursing (ADON) indicated on the morning of 7/20/25, the resident’s oxygen tank had to be filled due to it being empty. The resident was out and about in the facility all day in her wheelchair on her portable oxygen. The resident was on her portable oxygen tank all day. At dinner time, the resident appeared to have trouble breathing. The resident’s oxygen tank was empty. The nurse filled the tank up and the resident’s oxygen saturation increased and was not having any difficulty breathing. Later in the evening after dinner, the resident’s oxygen saturation had decreased again, and she was transported to the hospital. During an interview on 8/13/25 at 1:00 p.m., the Administrator indicated she had only in-serviced the 2 CNAs after the incident on 6/29/25 due to it being an isolated incident. On 7/20/25, the resident’s oxygen tank was found to be empty that morning and then again at dinner and had to be filled both times. At dinner the resident started having respiratory distress and after the tank was filled her oxygen saturation got better. Then approximately an hour later, she started having respiratory distress and the resident was sent out to the hospital. They then completed education and in-serviced all staff related to filling the oxygen tanks. During the education they found that a lot of the CNAs did not know how to check to see if the portable oxygen tanks were full or not. They completed an in-service with the oxygen supplier. 2. On 8/12/25 at 2:40 p.m., Resident D was observed lying in bed with her eyes closed. She had oxygen on per nasal cannula which was connected to a concentrator that was set at 2 liters per minute. On 8/13/25 at 1:16 p.m., Resident D was observed sitting up in the chair in her room. She had oxygen on per nasal cannula which was connected to a concentrator that was set at 2 liters per minute. Resident D’s record was reviewed on 8/13/25 at 1:45 p.m. Diagnoses included, but were not limited to, heart failure and atrial fibrillation (irregular heartbeat). The Quarterly Minimum Data Set assessment, dated 6/19/25, indicated the resident was moderately cognitively impaired. She was not on oxygen therapy. A Physician’s Order, dated 7/7/25, indicated oxygen at 2 liters per minute via nasal cannula to keep oxygen saturation above 90% as needed for shortness of breath. The August 2025 Medication Administration Record indicated the as needed order for oxygen at 2 liters per minute was not marked as administered during the month of August. The last documented oxygen saturation for Resident D was on 8/7/25 at 3:47 p.m. which indicated her oxygen saturation was 95% on room air. During an interview on 8/13/25 at 2:18 p.m., the Director of Nursing indicated there should have been an order for oxygen saturation monitoring. A policy titled, “Oxygen Administration,” indicated “…1. Oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control…3. Team members shall document the initial and ongoing assessment of the resident’s condition warranting oxygen and the response to oxygen therapy…13. When changing from a concentrator to a portable tank, team members shall observe portable oxygen tanks gauge to ensure sufficient oxygen is available. A. If the gauge reads below 500 psi, it is recommended to refill or replace the tank. B. The tank should be checked regularly while in use to ensure adequate oxygen is available…” This citation relates to Complaint 2567618. 3.1-47(a)(6)

Based on observation, record review, and interview, the facility failed to ensure a resident received proper assistance to prevent accidents, related to a CNA (Agency CNA 1) transferring a dependent resident (Resident B) from the bed to a chair without following the plan of care, causing pain and fractures to the resident's right leg and left ribs. The facility also failed to ensure Resident D, who was a high risk for falls and had a history of falls, was adequately supervised to prevent a fall which resulted in a head laceration requiring staples for healing for 2 of 3 residents reviewed for accidents/supervision. Findings include: 1. During an observation on 5/6/25 at 9:25 a.m., Resident B was sitting in a high back reclining chair. A mechanical lift pad was underneath the resident. She indicated the staff used a mechanical lift to transfer her. There was an immobilizer on her right lower leg. Resident B's record was reviewed on 5/6/25 at 10:26 a.m. The diagnoses included, but were not limited to, a spiral fracture of the right tibia, peripheral vascular disease, history of traumatic brain injury, and cognitive deficit. A Care Plan, dated 11/1/23 and reviewed on 1/13/25, indicated assistance was required for activities of daily living. The interventions included a mechanical lift was to be used for all transfers with the assistance of two staff members. A Quarterly Minimum Data Set (MDS) assessment, dated 2/8/25, indicated the resident had moderate cognitive impairment, had no behaviors, no impairment of movement of the upper and lower extremities, was dependent for all activities of daily living (ADL's) except eating, had no falls, and received an antiplatelet medication. A Physical Therapy Evaluation and Plan of Treatment, dated 2/28/25, indicated the resident was dependent for bed mobility and transfers, had decreased balance, and a mechanical lift and a high back wheelchair with elevating legs were to be utilized for the resident. The CNA Care Card, dated 3/7/25, indicated the resident required a mechanical lift for transfers and was dependent for care. The night shift staff were to assist the resident out of bed in the morning. A Nurse's Progress Note, dated 3/10/25 at 7:20 a.m., indicated the day shift CNA (CNA 3) reported to the nurse that there was bruising to the resident's right shin. The resident denied pain and winced when touched. The night shift CNA (Agency CNA 1) indicated the resident's legs were hanging out of the bed when he entered the room that morning. Pain medication was administered as ordered and the Nurse Practitioner (NP) was notified. Orders were received for a STAT x-ray of the right shin and the resident's family was notified. The NP Progress Note, dated 3/10/25, indicated there were complaints of pain and swelling in the right lower extremity. There was localized redness, swelling, and pain to her right tibia a couple inches below her knee. There was pain with palpation. There was no obvious deformity but a large amount of swelling. The resident was grimacing and appeared to be in distress. There was no respiratory distress, and the breath sounds were clear. After the visit the x-ray result was received and indicated a right proximal tibia fracture, she was transferred to the emergency room for further evaluation. A mobile x-ray report, dated 3/10/25 at 2:36 p.m., indicated there was an acute appearing proximal right tibia fracture. The emergency room Physician's Progress Note, dated 3/10/25 at at 1:53 p.m., indicated right lower leg injury, normal breath sounds and no respiratory distress. She had intact distal pulses, no edema, tenderness, or major deformities of the extremities. The hospital x-ray of the right tibia and fibula indicated a nondisplaced spiral fracture of the proximal tibia. There was no abnormal soft tissue calcification, and bone mineralization was normal. The chest x-ray indicated there were multiple left lower rib fractures. The family opted for conservative treatment. A knee immobilizer was applied, and the resident was transferred back to the facility. A Hospital emergency room Note, dated 3/10/25 at 7:00 p.m., indicated the resident had no acute distress and was transferred back to the facility. A Nurse's Progress Note, dated 3/10/25 at 10:29 p.m., indicated the resident returned to the facility per ambulance. She was assisted to bed by two people. There was an immobilizer on the right lower leg. She complained of pain to the area. An NP Progress Note, dated 3/12/25 at 9:51 a.m., indicated an immobilizer had been placed on the right lower leg due to a tibia fracture. Tylenol was not effective for the pain and an order for Norco (narcotic pain medication) was given and effective. She appeared to be in distress and pain. She was grimacing any time the leg was moved. Pain medication was increased to twice a day. A Physician's Order, dated 3/12/25, indicated Norco 5 - 325 milligrams, give one tablet twice a day. An Indiana Department of Health (IDOH) reported incident, dated 3/10/25 with follow up on 3/24/25, indicated on 3/10/25 at 6:30 a.m., a CNA observed a large bruise on the resident's left shin (sic) (right shin) and notified the nurse. An x-ray was obtained and an acute proximal tibia fracture was found on the left (sic) leg. The resident was then transferred to the Hospital emergency room for a further evaluation. The investigation of the incident included the following: A handwritten statement by LPN 4, dated and signed on 3/10/25 and no time documented, indicated CNA 3 asked her to assess the resident's swollen area on the right leg. There was a 2 centimeter (cm) by 2 cm raised hematoma on the right shin. The resident was asked what happened and she stated she was skipping and fell . She denied pain. She drew her leg back with light palpitation. An as needed Tylenol was administered. Agency CNA 1 was interviewed. He indicated when he entered the room, the resident's legs were hanging out of the bed. LPN 4 clarified the statement and asked if the resident had been falling out of the bed and Agency CNA 1 stated, no. He indicated he dressed her and transferred her into the wheelchair. The NP was notified, and an x-ray was ordered. A skin assessment was completed, and no other bruises or injuries were observed. A handwritten statement by CNA 3, dated and signed on 3/10/25 and no time documented, indicated she came into work at 6:00 a.m. She was receiving a walking rounds report from Agency CNA 1. Resident B was sitting in her room in a wheelchair with the mechanical lift pad positioned under the resident. She checked the positioning of the resident and made sure her feet were on the foot pedals. When she started to adjust the right leg, she observed a large swollen bruise under the right knee and the resident called out in pain. The nurse was immediately notified. A text message from the Administrator to Agency CNA 1, dated 3/10/25 at 12:27 p.m., asked the CNA for a written statement. Agency CNA 1 responded on 3/10/25 at 9:21 p.m. and indicated a statement would be emailed. An e-mailed statement from Agency CNA 1, dated 3/11/25 at 1:09 a.m., indicated the resident had been obvert (sic) with her left and right legs hanging off the left side of the bed. The legs were lifted back onto the bed and she was placed in the wheelchair. The day shift CNA came into the room and noticed the resident grimacing with pain when she attempted to place her legs on the leg rests, and she alerted the nurse. An e-mailed statement from Agency CNA 1, dated 3/11/25 at 11:47 a.m., indicated he had not used the mechanical lift to transfer the resident. He had placed an arm under both her legs and the other arm under her back and lifted her into the wheelchair. He had sent a picture with e-mail that had a man cradling a woman in his arms, with one arm around her back and one arm supporting the knees. The typed statement under the picture was, Like this into her wheelchair. The Facility Investigation of the incident, dated 3/10/25, indicated several staff who had worked with the resident one to two days prior to the incident had been interviewed and no injury had been observed. The conclusion of the investigation indicated the injury likely occurred when the resident was transferred from the bed to the chair without the use of the mechanical lift. Agency CNA 1 had signed an orientation acknowledgement for the facility on 11/26/24. During an interview on 5/7/25 at 8:30 a.m., the Administrator indicated the orientation of the residents and their care for the agency staff was completed by the nursing staff when the Agency Staff were working. They received report from the nurses and the CNAs, and they were given the CNA Care Card. Agency CNA 1 knew the mechanical lift was to be utilized for the resident's transfer, he placed the lift pad on the wheelchair before he lifted the resident into the wheelchair. She indicated that he had worked at the facility numerous times. A facility mechanical lift policy, dated 6/2024 and received from the Administrator as current, indicated the interdisciplinary team evaluated and assessed each resident's individual mobility needs and the mechanical lift would be utilized based on the resident's needs. Staff were expected to maintain compliance with safe handling/transfer practices. Resident transfers were to be performed according to the individual plan of care. 2. During an observation on 5/7/25 at 2:12 p.m., Resident D was sitting outside in a wheelchair during an activity. She was smiling and had no signs or symptoms of pain. There was a bruise and five staples located on the left front forehead. Resident D's record was reviewed on 5/7/25 at 2:07 p.m. The diagnoses included, but were not limited to, stroke and osteoporosis. A Care Plan, dated 3/11/25, indicated there was a risk for falls. The intervention, dated 11/26/24, indicated the resident would be assisted to the bathroom. A Fall Assessment, dated 1/11/25, indicated the resident was disoriented to person, place, and time, had a fall in the past three months, was chair bound, was unable to perform the gait balancing assessment, received medications that could cause falls, and was high risk for falls. A Quarterly MDS assessment, dated 2/28/25, indicated a severely impaired cognition status, no behaviors, no impairment of the upper and lower extremities, required moderate assistance for toilet transfers and hygiene and maximum assistance for transfers. She required a wheelchair for mobility. An undated CNA Care Card indicated the resident was a one person assist with the gait belt, a wheelchair was used, and in capital red letters it stated the resident was a fall risk. A Nurse's Progress Note, dated 4/28/25 at 6:28 a.m., indicated the staff had alerted the nurse at approximately 5:10 a.m. that the resident had fallen. The resident was observed lying on the bathroom floor on her right side. There was blood on the floor and the CNA was holding pressure to the resident's head. There was a laceration on the left side of the resident's head. The Emergency Medical System was notified for the resident to be transferred to the hospital. A Written Statement, signed and dated by CNA 2 on 4/28/25 at 5:15 a.m., indicated the resident was in the bathroom on the toilet. The CNA, turned her back for a couple of seconds to obtain a pair of socks and heard the resident fall. The nurse was notified, and pressure was applied to the wound until the medics arrived. A Nurse's Progress Note, dated 4/28/25 at 11 a.m., indicated the resident returned from the hospital. The forehead laceration measured 3 cm by 0.1 cm and there were five staples placed that closed the wound. The resident was placed on every 15-minute checks. A Post Fall Assessment, dated 4/28/25 at 1:30 p.m., indicated the fall had not been witnessed. The fall occurred in the bathroom and the resident attempted to self-toilet at the time of the fall. The resident stood up from the toilet and fell . An Interdisciplinary Team Note, dated 4/28/25, indicated the CNA had left the resident alone in the bathroom while she retrieved her clothing for the day and the resident fell . An IDOH reported incident, dated 4/28/25, indicated on 4/28/25 at 5:10 a.m., CNA 2 had alerted the nurse the resident had fallen in the bathroom. The resident was found lying on the bathroom floor on her right side. CNA 2 was holding pressure to the left side of the resident's head due to a laceration. CNA 2 had indicated she turned around to retrieve a pair of socks, and the resident attempted to perform self-toilet hygiene and fell . The resident was immediately transferred to the emergency room . The interventions that were put into place included the resident would not be left unattended while in the bathroom and clothing needed was to be placed in reach while care was provided. During an interview on 5/7/25 at 2:30 p.m., the Director of Nursing (DON) indicated CNA 2 was not in the bathroom at the time of the fall. Residents who were at high risk for falls were not to be left alone in the bathroom. During an interview on 5/7/25 at 2:35 p.m., the Administrator indicated CNA 2 was in the bathroom at the time of the fall. Her written statement indicated she had just turned her back to the resident for a few seconds. During an interview on 5/7/25 at 2:37 p.m., CNA 2 indicated the resident had never tried to stand on her own before. The resident was on the toilet. She had forgotten to get the resident's socks when she assisted her into the bathroom. She went out of the bathroom to the dresser to get the socks. The resident was always in her sight, until she turned for a second to get the socks and then she heard the resident fall. This citation relates to Complaint IN00455274. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure a resident received adequate assistance to prevent accidents, related to a resident who was dependent on two staff members for transfers, was transferred by one staff member. The resident was lowered to the floor, which resulted in a fracture of the left leg and severe pain for 1 of 3 residents reviewed for accidents. (Resident B) Finding includes: Resident B's record was reviewed on 10/14/21 at 11:55 a.m. The diagnoses included, but were not limited to, stroke, post COVID-19, and polyneuropathy. A Quarterly Minimum Data Set assessment, dated 8/12/21, indicated an intact cognitive status, required extensive assistance of two staff for bed mobility and transfers, required staff for stabilization with balancing, and had no falls. A Care Plan, dated 2/8/21, indicated an alteration in activity of daily living self performance. The interventions included, limited to extensive assistance would be provided for bed mobility and transfers. A Care Plan, dated 2/8/21, indicated a risk for falls. The interventions indicated a gait belt would be used for transfers. The Physician's Orders indicated: On 9/13/21, [MEDICATION(S)] (narcotic pain medications) 5 milligrams (mg) every hour as needed for pain. On 9/17/21, [MEDICATION(S)], 10 mg, every hour as needed for pain. On 9/24/21, [MEDICATION(S)] patch (narcotic pain medication), 25 micrograms (mcg) every 72 hours. On 9/30/21, add [MEDICATION(S)] patch 12 mcg to the 25 mcg every 72 hours. The Nurses' Progress Notes indicated: On 9/2/21 at 7:04 p.m., she tested positive for COVID-19. A cough with congestion was present. On 9/6/21 at 9:13 a.m., she required assistance of two staff for transfers. On 9/6/21 at 3:01 p.m., she was diagnosed with pulmonary [CONDITION(S)]. On 9/13/21 at 3:19 p.m., she was admitted to Hospice services. The Hospice Admission Note, dated 9/14/21 at 9:40 a.m., indicated the resident was bed bound, weak, and required two staff to assist with the transfers to the wheelchair. The Nurses' Progress notes indicated: On 9/15/21 at 1:26 p.m., she was very weak and needed assistance to eat and drink. On 9/16/21 at 10:10 p.m., she complained of weakness. On 9/17/21 at 9:37 p.m., she complained of severe pain to the left knee and leg. The left knee was swollen. [MEDICATION(S)] 5 mg was administered at 6:30 p.m. The Nurse Practitioner was notified of the pain and orders were obtained to increase the [MEDICATION(S)] to 10 mg every hour for pain. On 9/18/21 at 8:26 a.m. and 8:45 p.m., knee pain continued and [MEDICATION(S)] 10 mg was administered and ice packs were applied to the left knee. A late entry note, dated 9/19/21 at 3:11 p.m. for 9/17/21, indicated at approximately 7:30 a.m. Employee 1 indicated the resident had been lowered to the floor during a transfer from the bed to the wheelchair. Employee 1 indicated the resident's knees buckled and she was lowered to the floor. Employee 1 repositioned the resident off of her knees after she lowered her to the floor. The Hospice Nurse was at the facility and offered the resident's family to have a knee x-ray completed and the x-ray was refused. On 9/20/21 at 9:47 p.m., she was frequently repositioned for comfort and [MEDICATION(S)] 10 mg was administered at 6:30 p.m. for pain with effective results. On 9/24/21 at 1:47 p.m., the Hospice Nurse received an order for [MEDICATION(S)] 25 mcg patch every 72 hours for bilateral lower extremity pain. On 9/27/21 at 10:19 p.m., she received three doses of the the [MEDICATION(S)] 10 mg during the evening shift for left leg pain. Was resting and was in no distress. On 9/29/21 at 10:18 a.m., a Physician's Order for a x-ray to the left knee was obtained. The x-ray report, dated 9/29/21, indicated a displaced fracture at the distal femoral shaft, located above the left knee. A Nurse Practitioner's Progress Note, dated 9/29/21, indicated per the Hospice Nurse, the pain was a little better with the [MEDICATION(S)] Patch. The resident reported the pain was a little better. The knee was palpated without her yelling out in pain. She reported the pain was moderate to severe with movement though she was comfortable at this time. She refused to be transferred to the hospital. An immobilizer would be placed for pain management and stability. A Nurse's Progress Note, dated 10/1/21 at 12:31 p.m., indicated a left leg brace was placed on the resident's leg for stabilization. The Fall investigation, dated 9/17/21 at 7:30 a.m., indicated the root cause for the fall was not enough staff assistance with the transfer of the resident from the bed to the chair. During an interview on 10/14/21 at 2:44 p.m., Employee 1 indicated she had sat the resident on the side of the bed after dressing her, placed a gait belt on her, counted to three, and assisted her to a standing position. Her knees buckled and she was softly lowered to the floor. She had not taken care of the resident during the past weekend. No one had communicated the resident had a change in status and required extensive assistance of two staff members for transfers. This Federal tag relates to Complaint IN 842. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure a resident was free from avoidable pain, related to pain assessments not completed, effectiveness of pain medications not assessed, lack of follow up physician notification, and altered interventions for care not provided, resulting in a resident crying out in pain for more than 10 hours after a fall for 1 of 3 residents reviewed for pain management after a fall. (Resident C) Findings include: Resident C's record was reviewed on 1/8/2020 at 9:54 a.m. The [DIAGNOSES REDACTED]. An Admission Minimum Data Set assessment, dated 12/14/19, indicated a severely impaired cognition status, required extensive assistance of one for bed mobility, transfers, and toilet use, required limited assistance of one for ambulation, and had no pain. A physician's orders [REDACTED]. A Fall Investigation, dated 12/21/19, indicated a fall occurred on 12/21/19 at 10:35 p.m. A Nurse's Progress Note, dated 12/22/19 at 12:23 a.m., indicated the resident had fallen, complained of pain to the right hip, and Tylenol was administered. The Medication Administration Record, [REDACTED]. The pain was not assessed for intensity at the time the resident made the complaint post fall. There was no follow up on the effectiveness of the Tylenol. A Nurse's Progress Note, dated 12/22/19 at 9:46 a.m., indicated at 7 a.m., the resident complained of severe pain to both hips and legs. Tylenol was administered at 5 a.m. with no relief. The resident was crying out in pain when her legs were touched and required two staff member to assist with transfers. The Nurse Practitioner was notified and [MEDICATION NAME] (pain medication) 5/325 milligrams, one tablet, one time and transfer the resident to the emergency room was ordered and the resident was transported to the Hospital. The Medication Administration Record, [REDACTED] During an interview on 1/8/2020 at 11:19 a.m., the Director of Nursing (DON) indicated there had been no assessments of the pain after the fall. The Tylenol was documented as given at 5:30 a.m. without an assessment and location of the pain. The staff continued to transfer the resident after the fall and complaints of hip pain. During an interview on 1/8/2020 at 11:39 a.m., Employee 1 indicated, when the resident was being transferred to the wheelchair and the recliner, she complained of hip pain. She would touch her hip and said it hurt. She stayed in the recliner and when attempts were made to transfer her she was unable to unable to put weight on the leg. She attempted to get up once and due to the pain she was unable to get up. She would cry out with pain. An attempt was made to assist her to the bathroom she was crying out in pain. The Nurse was informed of the crying out in pain, and the Nurse suggested the wheelchair leg needed elevated to help the pain. When this was attempted, she cried out more. The attempt to toilet the resident was between 12 a.m. and 4:30 a.m. She was then left in the recliner due to the crying out. During an interview on 1/8/2020 at 11:53 a.m., Employee 2 indicated the resident was asked if she was in pain and she indicated she was. She was offered the pain medication and refused it. Employee 2 stated, honestly, (I am) not a 100% sure of the events the night of the fall. During an interview on 1/8/2020 at 12:11 p.m., Employee 4 indicated her shift started at 5:30 a.m. She was informed during report the resident had fallen, was in a lot of pain, and had stayed in the recliner all night. Employee 4 and another employee assisted the resident to get dressed and ready for the day. During the care the resident showed signs of pain and had to be lifted. She would make noises when we moved and/or transferred her. She was transferred from the recliner to the wheelchair, then to the toilet and back to the wheelchair. She was unable to walk or put weight on her legs. She was brought out into the hallway so she could be observed. The Night Shift Nurse was informed of the pain. The Resident was assisted to the Dining Room for breakfast and after breakfast she was transferred from the wheelchair to the toilet and back to the wheelchair again. During an interview on 1/8/2020 at 1:39 p.m., Employee 5 indicated, after the fall the resident was assisted into the wheelchair. She was complaining of pain and had not wanted to go to bed. The Tylenol was administered for the pain. She had facial grimacing, which Employee 5 indicated maybe a 4 or 5, (out of 10) on the pain scale. Around 5 a.m., another dose of Tylenol was administered due to pain. The resident was confused and was unable to tell her how severe the pain was. From the time of the fall on 12/21/19 at 10:35 p.m. to 12/22/19 at 7 a.m., the pain and the effectiveness of the pain medication had not been assessed. had not been assessed. The Physician had not been notified of the increase in pain and the crying out in pain until approximately 9 a.m. on 12/22/19 . The pain had not been assessed when reported to the Nurse throughout the night. The staff had not altered care related to transfers and movement of the resident to assist in decreasing the pain. An emergency room right hip x-ray, dated 12/22/19, indicated a [MEDICAL CONDITION] hip. A facility policy, dated 10/2019, titled, Pain Management, received from the DON as current, indicated, .Recognize when the resident is experiencing pain .Evaluate the resident for pain .with change in condition or status (e.g., after a fall .). Manager or prevent pain .Pain Assessment .Asking the patient to rate the intensity .or visual descriptor that is appropriate .Determining factors that make the pain better or worse .Impact of pain on quality of life .Reassess patients with pain regularly . A facility policy, dated 10/2019, titled, Physician Notification, received from the DON as current, indicated the Physician was to be notified by telephone with all conditions that required an immediate response and change in conditions that a change in treatment plan may be required. This Federal tag relates to Complaint IN 844. 3.1-37(a)