Every finding on record at Pilgrim Manor

Based on observation, interview and record review, the facility failed to assess for the continued use of an indwelling urinary catheter, failed to monitor for UTI's, and failed to assess and monitor a resident's ability to urinate following removal of a urinary catheter for 1 of 1 residents reviewed (Resident E). Findings include:On 6/1/26 at 1:59 P.M., Resident E's record was reviewed. Diagnoses included but were not limited to: congestive heart failure, Alzheimer's dementia, and neuromuscular dysfunction of the bladder (nerve damage interrupts the communication between the brain and the bladder which is usually chronic). Review of Hospice progress notes, prior to admission to the facility, indicated the following: -A medical Social Service hospice note, dated 2/11/26, indicated Resident E's caregiver had reported she had started behaviors of removing her pants and pull-ups in the morning and not remembering doing so. The behavior had resulted in urinary accidents. The caregiver indicated she had spoken with the hospice nurse about the behavior. -A hospice care plan update, dated 2/13/26, indicated an indwelling catheter had been placed. -A hospice home visit progress note, dated 3/10/26, indicated during the visit, Resident E's indwelling catheter contained cloudy urine which was foul smelling. An antibiotic was started for urinary tract infection (UTI). -A Hospice Comprehensive Assessment and Plan of Care Update form, dated 3/11/26 at 4:11 p.m., indicated a list of diagnoses which had not included neurogenic bladder. The form indicated Resident E was incontinent and had an indwelling foley catheter which was draining well. An admission Minimum Data Set Assessment (MDS), dated [DATE], after the resident was admitted to the facility indicated the resident was severely cognitively impaired, had disorganized thinking, exhibited on 7-11 days of the asssessment time frame feeling down, exhibited delusions, exhbitied physical behaviors toward others, and on 1-3 days of the assessment time frame had exhibited wandering behavior in her wheelchair. in addition, Resident E required partial assistance with toilet transfers and toileting hygiene, had an indwelling urinary catheter for a diagnosis of a neurogenic bladder and was always incontinent of her bowels. The MDS assessment also indicated Resident E was receiving hospice services. The MDS had not indicated the resident had been admitted with a urinary tract infection. A Care Area Assessment for urinary incontinence and the use of the indwelling catheter, dated 3/20/26, had no documentation of Resident E's urinary tract infection, even though she had been treated with antibiotics from 3/12/26-3/17/26, and remained at risk for further UTI's related to the indwelling catheter use. A current care plan, revised on 3/20/26, indicated Resident E had an indwelling foley (urinary) catheter due to a diagnosis of a neurogenic bladder. The goal was for the resident to remain free from catheter-related trauma. Interventions were: The resident was to have an indwelling catheter which was to be positioned below the level of her bladder; staff were to check tubing for kinks each shift; monitor and document intake and output; and observe and document pain/discomfort related to the catheter. There was no plan of care to address the resident's continued risk of UTI or interventions to prevent UTIs. Intermittent observations on 6/1/26, from 10:00 A.M. to 4:00 P.M., indicated Resident E had no foley catheter or foley catheter bag attached to her wheelchair. An admission history and physical form, dated 3/12/26, indicated Resident E had been admitted from home, on hospice services due to worsening debility. She was incontinent of her bladder. The form had not indicated Resident E had a diagnosis of neurogenic bladder nor was there documentation of an indwelling catheter being present. However, a physician's order, dated 3/17/26, indicated the resident was to have a 16 Fr ( French- unit of measurement) foley (urinary) catheter with a 30cc (cubic centimeter) balloon with a drainage bag to gravity. The order included the following: May change as needed for leakage, dislodgement or as needed; Catheter care every shift; and monitor and record color and clarity of urine every shift. Nursing progress notes indicated the following: -3/16/26 at 7:06 p.m., the nurse had contacted the primary care physician to discuss the resident's foley catheter. A new order had been obtained to add the diagnosis of a neurogenic bladder. -3/21/26 at 11:18 p.m., Resident E was observed walking in her room holding onto her wheelchair. Staff intervened but during attempts to assist the resident to sit back down, she had pulled her catheter tubing out. She had mild bleeding which had subsided after a few minutes. A new catheter had been inserted. -3/29/26 at 2:31 a.m., Resident E pulled her catheter out. She had no bleeding or complaints of pain. The catheter was re-inserted which the resident tolerated well. -4/2/26 at 7:00 p.m., the resident was observed on the floor next to her bed, incontinent of urine, with her foley catheter dislodged. -4/20/26 at 3:17 a.m., the resident had removed her foley catheter, which was observed on the floor beside her bed. She was agitated and would not allow staff to replace the catheter. -At 3:29 a.m., the nurse received a call back from the on-call hospice nurse who ordered the foley catheter be left out until hospice could make an in-person visit later in the morning.-At 12:06 p.m., Resident E had urinated during the day shift. -5/16/26 at 7:19 a.m., the evening nurse had reported, the resident had not urinated on evening shift nor had she urinated on night shift. There were no assessments related to urinary continence completed after removal of Resident E's catheter on 4/20/26. There were also no changes made to her care plan or physician's order for the catheter to be discontinued. There were no interventions or plan put in place to monitor resident's ability to urinate after the removal of the catheter or a plan to restore the resident's bladder function. Treatment Administration Records (TAR), dated April 2026 and May 2026, indicated nursing staff continued to document, per initials, that catheter care had been provided as ordered on 3/17/26, even though the catheter had been left out on 4/20/2026 and there was no documentation it had been reinserted. During an interview with the Interim Director of Nursing (DON), on 6/1/26 at 4:35 p.m., she indicated she was not aware of why the urinary catheter had been placed for Resident E prior to or had been continued after admission to the facility. When asked, she indicated a physician order to discontinue the catheter should have been obtained and nurses were expected to have assessed and monitored the resident after the removal of an indwelling catheter to ensure the resident was able to urinate. Facilitation of Elimination was retrieved from the National Library of Medicine at www.ncbi.nlm.nih.gov on 6/1/26 which indicated nursing interventions related to facilitating elimination included inserting urinary catheters and preventing complications.indwelling urinary catheters should be used only for appropriate indications.catheter associated urinary tract infection (CAUTI) is a common complication caused by indwelling urinary catheters.Signs and symptoms of CAUTI should be monitored and reported to the physician.It is the nurse's responsibility to assess for continued need for an indwelling catheter daily and advocate for removal when appropriate.After removal of an indwelling catheter, patients should be encouraged to increase fluid intake, monitor ability to urinate within 4-6 hours after catheter removed, and assessed for bladder tenderness, distension, or urinating small amounts frequently. A current facility policy, titled Urinary Continence and Incontinence Assessment and Management was provided by the Administrator on 6/1/26 at 5:02 P.M. The policy indicated the facility was to provide appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible. Indwelling urinary catheters were to be used sparingly for appropriate indications only. If a resident/patient was admitted from the hospital with a newly placed indwelling catheter, the Attending Physician and staff were to evaluate the potential for removing it, depending on the current condition and the rationale for its original placement. The physician was to identify situations in which an indwelling catheter was indicated and document why other alternatives were not feasible. If an indwelling catheter was needed, staff were to monitor for and report complications such as UTI's. A policy/procedure specific to indwelling urinary catheters was requested but not provided during the survey. This Citation relates to Intake 3026032. 410 Indiana Administrative Code (IAC) 16.2-3.1-41(2)(a)

Based on observation, interview and record review, the facility failed to identify targeted behaviors and individualize interventions to clinically support the use of an antipsychotic and anti-depressant medications for 1 of 2 residents reviewed for chemical restraints (Resident E). Findings include:During intermittent observations on 6/1/26, from 10:00 A.M. to 4:00 P.M., Resident E was observed seated in her wheelchair, in the hallway across from the nurse's desk. Her face had a flat affect and she demonstrated no response to others as they passed by her. She did not seem to be sleepy or sedated but she was also unaware of her environment. The resident was not observed in any form of activity while seated in the hall. On 6/1/26 at 1:59 P.M., Resident E's record was reviewed. Diagnoses included but were not limited to: congestive heart failure, Alzheimer's dementia, neuromuscular dysfunction of the bladder, and parkinsonism (group of brain disorders which can cause tremors, slow movement, rigid muscles, and balance issues). Hospice progress notes, prior to admission, indicated the following: -Resident E had been receiving hospice services at home since 5/27/25. -On 6/16/25, the resident had been prescribed an anti-psychotic medication which was not part of her hospice plan of care. She was prescribed Olanzapine 2.5 milligram (mg)-1 tablet by mouth 2 times per day for behaviors/Alzheimer's. Per her hospice plan of care, she was prescribed Trazodone 50 mg-1 tablet by mouth for insomnia/restlessness. -A medical Social Service hospice note, dated 2/11/26, indicated Resident E's caregiver had reported since January 2026, the resident had become more confused and restless. She had behaviors of removing her clothes and incontinence products resulting in urinary accidents. An admission Minimum Data Set (MDS) assessment, dated 3/18/26, indicated the resident had severely impaired cognition, disorganized thinking, exhibited felling down in the past 7-11 days of the assessment time frame, had delusions, had exhibited physical behaviors toward others, and had exhibited 1-3 days of wandering in her wheelchair during the assessment time frame. The assessment indicated Resident E was prescribed anti-psychotic and anti-depressant medications. Review of the current care plans included the following: -Dated 3/18/26, Resident E had a behavior problem related to dementia. The goal was to not have evidence of behavior problems and have fewer episodes of physical/verbal behavior toward staff. Interventions included: administer medications as ordered and observe for/document side effects; be aware the resident does not get out of bed early except to go to the bathroom; staff should move slowly while leading her; provide activities which interested and accommodated her; and monitor behavior episodes and attempt to determine underlying cause-consider location, time of day, persons involved, and situations: document behavior and potential causes. -Dated 3/25/26, the resident used psychotropic medications related to behaviors. The goal was for the resident to not have side effects from the use of anti-psychotic medication. Interventions included: consult with pharmacy and physician to consider dosage reduction when clinically appropriate; monitor/record/report to physician, as needed, side effects of anti-psychotic medications which may include: tremors, confusion, restlessness, pacing, anxiety, dry mouth, blurred vision, constipation, low blood pressure, sedation/drowsiness, increased falls, appetite/weight changes, headache, insomnia, seizures, and urinary retention; observe for/record occurrence of target behavior symptoms and document per facility protocol. Current Physician orders, dated 3/12/26, included the following medication orders: 1. Olanzapine 2.5 mg-give 1 tablet by mouth 2 times per day for behaviors/Alzheimer's and 2. Trazodone 50 mg-give 1 tablet by mouth at bedtime for insomnia. A behavior note, dated 3/13/26 at 10:25 a.m., indicated Resident E was trying to get out of bed herself. When the Certified Nurse Aid (CNA) tried to help her, she had hit the CNA in the stomach, pulled the CNA's hair, and had thrown her orange juice at her. She had exhibited anxiety due to wanting to get out of bed and agitation because someone had attempted to help her. The note indicated Resident E was in a new setting and she had confusion due to her dementia. A Social Service Note dated 3/16/26 at 3:45 p.m., indicated during a phone discussion with the resident's Power of Attorney (POA), he had given his approval for the use of all psychotropic medications. The POA indicated Resident E was a different person without the anti-psychotic medications. He indicated she really had not had behaviors but was not cooperative (with care) when not on the medication. The Social Service note had not indicated the POA had been notified of the benefits, risks, and alternatives for the medications or possible side effects of their use. A Nursing progress note, dated 3/18/26 at 1:20 p.m., indicated an order was received for the resident to be seen by the in-house psychiatric services. A behavior progress note, dated 4/9/26 at 11:28 a.m., indicated a monthly behavior meeting had occurred with the pharmacist, psychiatric nurse practitioner (NP), unit manager and Social Services Designee (SSD). They had discussed the resident's use of antipsychotic medication and hospice services. Their recommendation was to continue the use of the antipsychotic medication, Olanzapine 2.5 mg 2 times per day and the hypnotic medication, Trazodone 50 mg at bedtime. The meeting note indicated they would re-evaluate the medication use the following month to consider a possible decrease in medication dosages. A behavior note, dated 5/10/26 at 4:33 a.m., indicated when a CNA had been attempting to change the resident, the resident had scowled at her, bared her fingernails, and said You'd better not b----. I've got talons and I can scratch your pretty face. The CNA was able to calm the resident and proceed with care. A nurse note, dated 5/10/26 at 4:15 p.m., indicated Resident E was acutely ill with a moist cough. There were no other behaviors documented in the resident's record. Medication Administration Records (MAR), dated March 2026, April 2026, and May 2026, indicated the resident was administered Olanzapine 2.5 mg 2 times per day and Trazodone 50 mg at bedtime, as ordered on 3/12/26. The MARs for March, April, and May 2026, had not shown side effects of the medications had been monitored or documented. There were no targeted behaviors documented for the use of anti-psychotic and anti-depressant medications. There were no targeted behaviors documented for the use of anti-psychotic and anti-depressant medications or side effects of the medications in the progress notes. There was no documentation completed for monitoring the resident's sleep and insomnia. There were no records indicating Resident E had been seen by the psychiatric NP since admission to the facility. During an interview with the Social Services Director, on 6/1/26 at 4:11 P.M., she indicated residents who were prescribed psychotropic medications were to have targeted behaviors and interventions on the care plan and the MAR. She was unable to find targeted behaviors with interventions on the care plan or MAR for Resident E. When asked, she indicated documentation of behaviors was completed by the nurses in the nursing progress notes or behavior progress notes. She indicated the CNA's were not responsible for documenting behaviors in their task list. She indicated Resident E's care plan included that she was on psychotropic medications and side effects were to be monitored, but the side effect monitoring was not documented on the MAR. She indicated she had not notified the psychiatric NP of the order, dated 3/18/26, which had indicated the resident was to have been seen by the NP. She indicated it was missed. A current facility policy, titled Psychotropic Medication Use was provided by the Administrator on 6/1/26 at 4:59 P.M. which indicated: Residents do not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition documented in the medical record. Psychotropic medication management is an interdisciplinary process that involves the resident, family, and/or the representative and includes: a. determining adequate indications for use; b. establishing appropriate dose (including duplicate therapy) and duration; c. adequate monitoring for efficacy and adverse consequences; d. determining appropriateness of gradual dose reduction; and e. preventing, identifying, and responding to adverse consequences. Circumstances that warrant an evaluation of the resident's underlying medical condition and medications include: admission or readmission. Behavioral and other non-pharmacological approaches are used (unless contraindicated) to minimize or eradicate the need for medications, permit the lowest possible dose if indicated, and support efforts at gradual dose reduction.Adequate indication for use refers to the identified, documented clinical rationale for administering medication that is based on: an assessment of the resident's condition and therapeutic goals; a determination that non-pharmacological interventions are clinically contraindicated; and manufacturer's recommendations, clinical practice guidelines, clinical standards of practice, medication references, clinical studies, or evidence-based review articles that support the use of the medication. Prior to initiating the use of, increasing the dose of, or switching to a different psychotropic medication, the staff and physician will review the following with the resident/representative prior to obtaining documented consent or refusal: non-pharmacological alternatives; the indications and rationale for the recommendation; the potential risks and benefits (including possible side effects, adverse consequences, and black box warnings); and the resident's/representative's right to accept or decline the treatment. Residents receiving psychotropic medication are monitored and the response to treatment is documented. Monitoring may include lab results, vital signs, progress notes, behavior flow sheets, medication administration records, and the drug regimen review from the consultant pharmacist. In addition, residents are monitored for adverse consequences associated with psychotropic medications. This Citation relates to Intake 3026032. 410 Indiana Administrative Code (IAC) 16.2-3.1-48(a)(3)(4)

Based on observation, record review and interview, the facility failed to implement preventative measures for 1 of 3 residents at risk for elopement which resulted in a resident elopement. (Resident B) Finding includes:During an observation and interview, on 4/15/2026 at 9:49 A.M., Resident B was in his room, seated in his wheelchair with his portable oxygen nasal cannula tubing in the top drawer of his bedside table. Resident B was unable to determine where his oxygen cannula tubing was located. He also had an animated dog on his bed and was speaking to the animated dog about his feelings. A record review for Resident B was completed, on 4/15/2026 at 9:54 A.M. Diagnoses included, but were not limited to: dementia and a pathological fracture in neoplastic disease of the hip An Elopement/Wander Risk Evaluation, completed on 3/11/2026, indicated Resident B had been forgetful, had a short attention span and exhibited/expressed fear/anxiety, expressed a desire to go home and packed belongings or hovered at exit doors. The note indicated, around 7:30 P.M., Resident B had wanted to go home with his kids, removed his gown and oxygen nasal cannula and attempted to move the bedside table. An admission Minimum Data Set (MDS) assessment, dated 3/16/2026, indicated Resident B had severe cognitive impairment. A Care Plan, initiated on 3/11/2026 and revised on 3/19/2026, indicated Resident B's was an elopement risk/wander as evidenced by wandering/exit seeking. Interventions included, but were not limited to: distract Resident B from wandering by offering pleasant diversions, structured activities, food, conversation, television and books and provide structured activities including toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. A Nursing Progress Note, on 3/12/2026 at 12:03 A.M., indicated Resident B stated he was going home because no one was taking care of his children. Resident B firmly believed he needed to go home. Resident B became agitated when staff provided reassurance of the children being okay and stated, I don't want you to tell me they are okay, I want to go and see them. No further behaviors observed of eloping or getting out noted. Staff continued to check on Resident B frequently. A Nursing Progress Note, on 3/12/2026 at 3:31 P.M., indicated sundowning behavior at evening shift noted with reassurance, one to one conversation with staff and safety provided at all times. A Nursing Progress Note, on 3/15/2026 at 6:36 P.M., indicated Resident had been engaging in wandering behaviors, but easily redirected. A Nursing Progress Note, on 3/23/2026 at 6:45 P.M., indicated Resident B had intermittent confusion and anxious complaints concerning the safety of his daughters. A Nursing Progress Note, on 3/24/2026 at 10:38 A.M., indicated intermittent confusion in the morning. Resident B indicated, Can you look to see if my mother is here, I believe she is in this hospital. A Nursing Progress Note, on 3/25/2026 at 1:37 A.M., indicated Resident B had been observed on the East Hall (room was on [NAME] Hall) upon arriving for the shift and had been difficult to redirect to his room. A Nursing Progress Note, on 3/26/2026 at 4:15 P.M. and 11:03 P.M., indicated Resident B had intermittent confusion and had been concerned about his car. A Nursing Progress Note, on 3/28/2026 at 9:00 P.M., indicated Resident B had been observed outside of the facility and had exhibited chronic and persistent confusion. A Nursing Progress Note, on 3/28/2026 at 10:31 P.M. as a late entry on 4/4/2026 at 6:35 P.M., indicated an Elopement Risk Assessment had been completed and a Wander guard (a wearable bracelet with a door sensor system to provide staff alerts when breaching a door) had been placed in the back pocket of Resident B's wheelchair. A Facility Reportable Incident, with a identified time of incident of 3/28/2026 at 8:50 P.M., indicated a Licensed Professional Nurse (LPN) reported to the Executive Director that Resident B had left the facility unattended. The Executive Director initiated an investigation and reviewed the facility's camera footage. Resident B had been observed exiting the facility and was outside for four minutes and 14 seconds. Prior to the elopement, Resident B had been observed, on the camera footage, self-propelling his wheelchair within sight of facility staff members and not trying to exit the building. At 8:43 P.M., Resident was observed self-propelling down the hallway. He exited the facility at 8:46 P.M. Resident B had been observed on the camera footage re entering the building at 8:51 P.M. Resident B indicated he had been looking for his daughters and his truck. An Employee Statement, dated 3/29/2026, indicated QMA 2 had brought Resident B back to his residing hallway twice prior to the elopement. She indicated the first time Resident B had tried to leave through the back doors by the dietary department, and a cook brought Resident B back around at 8:45 P.M. Education had been provided to Resident B without success. Resident B requested to call his daughter and spoke with her via the telephone. Resident B then attempted to exit the doors at the end of his residing hallway and had been redirected. QMA 2 indicated the Certified Nursing Assistant (CNA) for the hallway was at lunch and QMA 2 had been in another resident room when Resident B had eloped and a CNA from another hallway returned the resident to his hall. An Employee Statement, on 3/29/2026 at 1:09 P.M., indicated LPN 3 had been notified by a CNA that Resident B had been observed outside of the building in the parking lot. LPN 3 indicated she had been notified that Resident B had not been wearing a Wander guard at the time. LPN 3 indicated she personally observed the CNA bring Resident B back into the facility. LPN 3 indicated she had observed Resident B propelling himself up and down various hallways earlier during her shift and he had been looking for his daughters, but had been easily redirected. LPN 3 indicated she was not sure when the breach of the exit door had occurred or how long Resident B had been outside. During an interview, on 4/16/2026 at 10:04 A.M., the Executive Director indicated the door Resident B had eloped from had to be manually locked by the staff, otherwise it was unlocked. He indicated the door was usually locked by 9:00 P.M. He indicated an elopement risk assessment had been completed at admission for Resident B and the assessment had determined the basis as to the resident's elopement risk. If a resident was determined to be an elopement risk, the information was placed in the facility elopement risk binder with resident specific interventions that could include, but were not limited to a Wander guard. During an interview, on 4/16/2026 at 12:25 P.M., QMA 2 indicated she had not been aware that Resident B was an elopement risk. She indicated the dietary department had informed her that Resident B had been trying to exit the building around the dietary department. She indicated she had been questioned about his fifteen-minute checks, but there had been no paperwork indicating he was to be checked every fifteen minutes. QMA 2 indicated she was unaware that Resident B was to have been on fifteen-minutes checks. A policy was provided, on 4/16/2026 at 10:24 A.M, by the Executive Director. The policy titled, Elopement, indicted, .It is the policy of this facility to provide a safe and secure environment for our residents and to be proactive in preventing resident elopement. Residents at risk for elopement will be appropriately monitored to reduce the potential for injury. Elopement is defined as a resident leaving the premises of the facility without the knowledge and supervision of facility staff. 1. Upon admission, readmission, quarterly, and with a significant change of condition, residents will be assessed for elopement risk. 2. Residents that are identified as moderate or high risk for elopement will have an intervention implemented for their safety.4. Elopement risk will be care planned with individualized approaches to reduce the potential for elopement and/or to redirect the resident in the event that an elopement attempt is made. 5. Residents at moderate/high risk for elopement shall have their picture maintained for identification purposes. 6. Electronic monitoring systems may be implemented as possible interventions as appropriate. The past noncompliance began on 3/28/2026 at 8:43 P.M. when Resident B exited the facility unattended. The deficient practice was corrected on 4/1/2026, prior to the start of the survey, after the facility implemented a systemic plan that included the following actions: Revision of elopement assessment and elopement care plan for Resident B, which included the implementation of a Wander guard bracelet placed on his wheelchair, a full facility re-evaluation of elopement risk assessments and review of all coordinating care plans, update and revision of the elopement risk binder, staff education regarding elopement risk and binder use and audits to ensure elope risk assessments were updated as required and the facility elopement risk binder was updated.This citation relates to Intake 2967439. 410 IAC 16.2-3.1-45(a)(2)

Based on interview, observation and record review, the facility failed to assess, notify the family and provider and document the change in the medical record after a resident developed blood in her colostomy (an opening in the abdominal wall, connecting the colon to the outside of the body to divert waste and gas) bag for 1 of 1 residents reviewed for colostomy care. This deficient practice resulted in a delay of treatment for a gastrointestinal bleed (GI) and anemia (low hemoglobin) and unexpected hospitalization. (Resident J) Finding includes: During an interview on 2/9/2026 at 12:02 P.M., Resident J indicated a staff member had found blood and blood clots in her colostomy bag and that the employee had taken a picture of the blood to show the nurse. Resident J was not able to recall what staff member had taken the picture, but did recall it was around the end of second shift (2:00 - 1030 P.M.) on 2/8/2026. Resident J indicated she had not been updated with any information related to the blood in her colostomy bag. During an observation of Resident J's colostomy bag on 2/9/2026 at 12:05 P.M., the bag was empty and did not contain stool or any blood. Resident J indicated the colostomy had last been emptied the night before. During an interview on 2/10/2026 at 9:00 A.M., Resident J indicated she had not been updated on the plan of care related to the blood in colostomy and she was having increased abdominal pain that the facility was giving her pain medications to treat. Resident J's record review was completed on 2/12/2026 at 11:02 A.M. Diagnoses included, but were not limited to: thrombocytosis, colostomy, schizophrenia, major depressive disorder, generalized anxiety disorder and chronic kidney disease. A Quarterly Minimum Data Set (MDS) assessment, dated 1/8/2026, indicated Resident J had clear speech, adequate hearing, had been able to make herself understood and understands others, had been on an antiplatelet and had a colostomy present. Resident J had the following current Physician's orders:-An order, dated 12/17/2025, indicating Resident J was to have colostomy care every shift.-An order, dated 12/3/2025, indicated Resident J was to receive one 81 milligram (mg) tablet of aspirin (anti-platelet). -An order, dated 2/9/2026, indicated Resident J was to receive two 325 mg tablets of hydrocodone-acetaminophen (opioid pain reliever).A review of Resident J's pain scale indicated the resident had needed to be administered two 325 mg tablets of hydrocodone-acetaminophen for abdominal pain on 2/9/2025 at 9:30 P.M. due to a pain level of 9 (pain scale of 0-10 with 0 being no pain and 10 being the worst pain), 2/10/2026 at 2:11 A.M. due to pain level of 4 and 2/10/2026 at 5:12 P.M. due to pain level of 9. Before 2/9/2026 at 9:30 P.M., Resident J had not been administered a pain reliever since 2/6/2026 at 12:58 P.M.A current care plan, initiated on 12/10/2025 indicated Resident J had a colostomy related to a bowel resection. Interventions, initiated on 12/10/2025, indicated the staff would change the colostomy bag after each bowel episode or when full and Resident J would be educated on alerting the nurse regarding when to change the bag. A current Care Plan, initiated on 11/14/2025 indicated Resident J was on antiplatelet therapy and was at risk for bleeding. An intervention, initiated on 11/14/2025 indicated staff would observe for, document and report signs and symptoms of anticoagulant complications. Anticoagulant complications included but were not limited to dark or bright red blood in stools. Resident J's record lacked the documentation to indicate the blood and the blood clots found during ostomy care on 2/9/2025 during second shift had been assessed by a nurse, documented in the resident's medical record or that the medical provider or Resident J's family had been notified of the change in the resident's condition. A Nursing Note, dated 2/10/2026 at 5:20 P.M., indicated Resident J continued to complain of abdominal pain and rated the pain as a 9 out of 10. The resident was displaying nonverbal indicators of pain and the resident reported pain medications had been ineffective. Resident J had not had any gas or stool output in over 30 hours, although the resident had been eating a regular diet. The last time the resident had had any output, there had been a small amount of stool with a small amount of blood. Resident vitals were: blood pressure of 136/80, heart rate of 90, respirations elevated at 22, blood oxygen level was 97.A Nursing Note dated 2/10/2026 at 5:33 P.M. indicated the provider had been updated on Resident J's pain, lack of output in her colostomy, hypoactive bowel sounds and blood in her stool. The provider indicated the resident should be sent to local Emergency Department (ED) for evaluation. A review of Resident J's ED note dated 2/10/2026 at 6:26 P.M. indicated resident arrived at the ED with a hemoglobin of 6.5 (normal 12-15) and a hematocrit of 20.1 (normal 36-48) and required two units of packed red blood cells to be transfused (blood transfusion). Resident J was found to have an acute GI bleed that had caused anemia and would require being transferred to a larger hospital in a different city and county. During an interview on 2/13/2026 at 9:18 A.M., the Unit Manager indicated Employee 8 had provided colostomy care to Resident J and during the care had noticed blood and blood clots in the resident's colostomy, on 2/8/2026, towards the end of second shift. Employee 8 had taken a picture of the contents of the colostomy and had sent the image to the nurse,Employee 9, who had been assigned to the resident. Employee 9 did not notice the message until many hours later, after his shift and after he had left the facility. Employee 9 called the third shift nurse (Employee 10) who was assigned to Resident J and forwarded the picture of the contents of the colostomy to Employee 10. Employee 10 had passed the message off on report the next morning to the first shift nurse, Employee 11. None of the employees, Employee 8, 9, 10 or 11, had documented the blood and blood clots in Resident J's colostomy or entered any notes related to the blood in the colostomy bag. Employees 9, 10 and 11 had not notified a provider or the resident's POA that the resident had blood and blood clots in her colostomy bag. During an interview on 2/13/2025 at 2:05 P.M., CNA 12 indicated she had seen blood and blood clots in Resident J's colostomy bag and had reported it in a message to the nurse assigned to the resident. CNA 12 indicated she had not followed up with the nurse related to Resident J and had not known the nurse had not seen the message. On 2/12/2026 at 2:00 P.M., the Executive Director provided an undated policy titled, Change in Resident's Condition or Status, and indicated it was the policy currently used by the facility. The policy indicated, .Our facility promptly notifies the resident, hir or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status.1. The nurse will notify the resident's attending physician or physician on call when there has been a[an].i. specific instruction to notify the physician of changes in the resident's condition.On 2/13/2026 at 11:58 A.M., the DON provided an undated policy titled, Charting and Documentation and identified it as the policy currently used by the facility. The policy indicated, .All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition . 2. The following information is to be documented in the resident medical record: d. changes in the resident's condition 3.1-47(a)(3)

Based on observation, interview and record review, the facility failed to follow infection control practices related to hand hygiene procedures and wound care procedures for 1 of 1 resident reviewed for pressure ulcers. (Resident 34) In addition, the facility failed to track and complete infection surveillance during a COVID (Coronavirus) outbreak. Findings include: 1.During an interview, on 2/10/2026 at 11:26 A.M., a resident representative indicated Resident 34 had a pressure ulcer on her coccyx. During an observation, on 2/12/2026 at 12:25 P.M., Resident 34 was observed receiving wound care for the wound on her coccyx. Certified Nursing Assistant (CNA) 14 and the IP (Infection Prevention) nurse were already standing outside Resident 34's room. They had both donned gowns, masks and were wearing disposable gloves. An additional staff member, CNA 7 was observed to open the door with Resident's room door, then after she had entered Resident 34's room, CNA 7 closed the door, pulled two disposable gloves from a box stored behind the resident's door and applied the gloves to her hands without performing any hand hygiene. CNA 14, the IP Nurse and CNA 7 assisted Resident 34 to reposition to her right side and removed a slightly wet incontinence brief from the resident Resident 34 did not have any dressing over the open area on her coccyx which was approximately the size of a quarter. The IP nurse removed her gloves, applied hand sanitizer and put on clean gloves. Next, IP nurse opened a sterile 4 x 4 sized gauze squares package and moistened several gauze pads with wound cleanser from a spray bottle. She then proceeded to take one of the moistened gauze pads to wipe the coccyx wound from the direction of the southern edge nearest the tailbone towards the resident's cephalic region. The IP nurse then flipped the used gauze pad over and continued to wipe the coccyx wound in the same cephalic direction. The Infection Prevention nurse repeated this step with two additional moistened gauze pads; and was observed to flip each gauze pad over during the process to re-wipe the resident's coccyx wound. The clinical record of Resident 34 was reviewed on 2/13/2026 at 10:03 A.M. The resident's diagnoses included but were not limited to: acute on chronic systolic heart failure, diabetes mellitus, dementia, peripheral vascular disease, morbid obesity, hypertensive heart disease, acute on chronic respiratory failure, depression, paranoid schizophrenia, hypothyroidism, anxiety, and agoraphobia with panic disorder. A Significant Change Minimum Data Set (MDS) assessment, dated 12/22/2025, indicated the resident was cognitively intact. A current Physician's Order, dated 1/16/2026, indicated Resident 34 had been placed in Enhanced Barrier precautions (a guideline that requires healthcare staff to wear gowns and gloves during high-contact care activities such as dressing, bathing, transferring, changing linens/briefs, device care for residents with specific risks like chronic wounds or indwelling devices) due to her wounds. A current Physician's Order, dated 2/4/2026, indicated the resident's pressure ulcer was to be cleansed with wound cleanser, patted dry, and collagen and calcium alginate applied to the wound bed and covered with a foam dressing daily and as needed. During an interview, on 2/12/2026 at 12:48 P.M., the IP nurse indicated the gauze used on a resident's wound should not have been flipped over and used again to cleanse the resident's wound. 2. During an interview on 2/12/2026 at 2:16 P.M., the IP Nurse indicated the facility had experienced a COVID outbreak in January 2026 but the infection had not been tracked as required. There was no infection surveillance documentation of the COVID outbreak completed. On 2/9/2026 at 1:54 P.M. the ED provided a current policy, dated May 2023 and titled, Coronavirus Disease (COVID 19) - Infection Control and Prevention. The policy indicated, .The infection prevention and control measures that are implemented to address the SARS -CoV-2pandemic are incorporated into the facility infection prevention and control plan. These measures include: c. identifying and managing ill residents and staff On 2/12/2026 at 2:58 P.M., the Administrator provided a policy titled, Standard Precautions, dated 9/2022 and indicated the policy was the one currently used by the facility. The policy indicated .Standard precautions are used in the care of all residents.Hand hygiene refers to handwashing with soap or the use of alcohol-based hand rub (ABHR).Hand hygiene is performed with ABHR or soap and water: before and after contact with the resident; before performing an aseptic task . On 2/12/2026 at 2:58 P.M., the Administrator provided a policy titled, Dressings, dated 9/2013 and indicated the policy was the one currently used by the facility. The policy indicated .If using gauze, use clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area (usually, from the center outward) . 3.1-18(a) 3.1-18(b)(3)

Based on observation and interview, the facility failed to prepare and serve food under sanitary conditions related to staff hygiene in the kitchen and food temperature of hall trays for 1 of 1 kitchen areas observed. This issue had the potential to affect 62 of 62 residents who resided in the facility and received food from this dietary area.Findings include:During an interview, on 2/11/2026 at 11:20 A.M., the Dietary Manager indicated food remained on the steam table until it was plated or put on the resident meal trays.During an observation, on 2/12/2026 at 11:59 A.M. of the last hall tray, it was removed from the portable food cart and the Dietary Manager obtained the following food temperatures:Ham & scalloped potatoes:110 degrees Fahrenheit,Carrots:111 degrees Fahrenheit,Chocolate milk: 46 degrees Fahrenheit,Fruit cocktail: 60 degrees Fahrenheit. During an interview immediately following the temperature assessments, the Dietary Manager indicated the food should have been hotter (sic) than the recorded temperatures and indicated the facility had recently ordered new plate warmers.2. During an observation, on 2/11/2026 at 12:00 P.M., two maintenance staff were standing in the facility kitchen without hairnets with the kitchen door open. One of the maintenance staff was wearing a knit cap and was kneeling on the floor, the other maintenance staff was holding the kitchen door open.During an interview, on 2/11/2026 at 12:05 P.M., the Dietary Manager indicated hair nets was a requirement for all staff entering the kitchen.On 2/11/2026 at 1:40 P.M., the Administrator provided a policy titled, Employee Sanitary Practices, dated 7/2023 and indicated the policy was the one currently used by the facility. The policy indicated .Hair nets or caps, covering all of the hair, must be worn at all times.The cap must be one that is designated for kitchen use only.On 2/13/2026 at 3:56 P.M., the Administrator provided a policy titled, Temperatures, dated 7/2025 and indicated the policy was the one currently used by the facility. The policy indicated .Foods sent to the units for distribution.will be transported and delivered to maintain temperatures at or below 41 degrees F for cold foods and at or above 135 degrees F for hot foods and hot beverages.3.1 - 21(i)(3)

Based on observation, record review and interview, the facility failed to ensure 2 of 2 nursing staff (LPN 2 and LPN 3) followed standard pharmacy procedure to ensure accuracy related to documenting medication administration and administering preset medications for 1 of 1 residents observed for dignity. (Resident L)Finding includes:A record review for Resident L was completed, on 2/13/2026 at 10:06 A.M. Diagnoses included, but were not limited to: left femur fracture, diabetes mellitus type 2 and anxiety disorder.An admission Minimum Data Set (MDS) assessment, dated 1/26/2026, indicated Resident L was cognitively intact and received opioid medications for pain.During an interview, on 2/12/2026 at 9:07 A.M., Resident L notified the surveyor team of a concern she had related to her medication administration. Resident L indicated LPN 2 had been very sharp and snippy with her when she had requested her morning medications and pain medication and had not administered her morning medications yet, which included the pain medication that she had requested two hours prior. She indicated LPN 2 had told her that she needed to wait for her medication administration until she had eaten breakfast.A review of the January Medication Administration Record, on 2/12/2026 at 9:27 A.M., indicated all medications, including the as needed pain medication had been signed as administered prior to the time Resident L had notified the survey team of the concern.During an observation, on 2/12/2026 at 9:22 A.M., Resident L returned to her unit and LPN 2 was heard telling Resident L that she had pulled her medications for administration prior to Resident L complaining to the State surveyors.During an interview and observation, on 2/12/2026 at 9:22 A.M., LPN 2 initially indicated she had not signed Resident L's medications as given prior to the administration of the medications. When LPN 2 had been asked why the Medication Administration Record had Resident L's medication recorded as having already been administered, LPN 2 indicated she must have signed the medication as already given. LPN 2 then was observed to hand a souffle cup of of oral medications and two inhalers to LPN 3 to administer to Resident L. LPN 3 went to Resident L's room with the medications, did not verify the medications against the Medication Administration Record (MAR) prior to administering the medications that LPN 2 had handed to her. During an interview, on 2/12/2026 at 9:35 A.M., LPN 3 confirmed she had administered Resident L's medications to her that LPN 2 had handed off to her.During an interview, on 2/13/2026 at 1:24 P.M., QMA 4 indicated medications should not be signed as given prior to administration and another nursing staff should never administer medications prepared by other nursing staff.A policy was provided by the Executive Director, on 2/13/2026 at 2:10 P.M. The policy titled, Medication Administration General Guidelines, indicated, .Preparation or administration of medication[s] or biological completed in accordance with physician's orders; manufacturer's specifications [not recommendations]; accepted professional standards and principles that apply to professionals providing service. Accepted professional standards and principles include the various practice regulations in each State, and current commonly accepted health standards established by national organizations, boards, and councils.Preparation/Administration.c. Medication[s] prepared for on person at a time. i. Medications[s] are administered at time they are prepared. 1. Do not pre-pour or pre-set medication[s]. 2. Do not administer medication[s] prepared by someone else.3.1-25(b)(3)3.1-25(b)(4)

Based on record review and interview, the facility failed to obtain informed consent for psychotropic medication administration for 5 of 5 residents reviewed for unnecessary medications. (Res 5, 57, B, H & J)Findings include:1.A record review for Resident 5 was completed on 2/13/2026 at 8:49 A.M. Diagnoses included, but were not limited to: anxiety disorder and depression.A Quarterly Minimum Data Set (MDS) assessment, dated 12/22/2025, indicated Resident 5 was cognitively intact and received medication administration of an antianxiety and an antidepressant medication.Physician's Orders, dated 12/15/2025, indicated Resident 5 received desvenlafaxine 50 milligrams daily for depression and buspirone 10 milligrams three times daily for anxiety.A Care Plan, initiated on 9/26/2025, indicated Resident 5 used an antidepressant medication. The goal indicated Resident 5 would be free from discomfort and adverse reactions related to antidepressant therapy.A Care Plan, initiated on 1/16/2026, indicated Resident 5 used an anti-anxiety medication. The goal indicated Resident 5 would be free from discomfort and adverse reactions related to the use of anti-anxiety medication.During an interview, on 2/13/2026 at 11:10 A.M., the Social Service Director (SSD) indicated all notifications and signatures for medication consents had not been obtained until 2/13/2026 after the request for consent documentation had been requested by the survey team.2. A record review for Resident 57 was completed on 2/13/2026 at 9:40 A.M. Diagnoses included, but were not limited to: depression and dementia.A Significant Change MDS assessment, dated 12/11/2025, indicated Resident 57 was not able to be interviewed due to cognitive status and received an antidepressant medication.A Physician's Order, dated 1/16/2026, indicated Resident 57 received Lexapro 5 milligrams daily for depression.A Care Plan, initiated on 10/1/2025, indicated Resident 57 used an antidepressant related to dementia with behavioral disturbances. The goal indicated Resident 57 would be free from discomfort and adverse reactions related to antidepressant therapy.During an interview, on 2/13/2026 at 11:10 A.M., the SSD indicated all verbal notifications for medication consents had not been obtained until 2/13/2026, after the request for psychotropic notification consents had been requested by the survey team.3. A record review for Resident B was completed on 2/12/2026 at 11:15 A.M. Diagnoses included, but were not limited to: dementia, schizoaffective disorder, PTSD (post-traumatic stress disorder), psychotic disorder, generalized anxiety and bipolar disorder.A Quarterly MDS assessment, dated 1/8/2026, indicated Resident B was cognitively intact and received medications including an antipsychotic, an antianxiety, an antidepressant and a hypnotic.Physician's Orders included the following medications:-8/28/2025 Klonopin 0.5 milligrams twice daily for schizophrenia.-10/2/2025 Zyprexa 10 milligrams at bedtime for schizophrenia.-10/10/2025 Ramelteon 8 milligrams as bedtime for insomnia.-1/12/2026 Buspirone 15 milligrams twice daily for anxiety.A Care Plan, initiated on 7/16/2025, indicated Resident B used antipsychotic/antihypnotic medications related to insomnia and schizoaffective disorder. Interventions included, but were not limited to: administer medications as ordered and monitor/report to physician as needed for side effects of the antipsychotic medications.A Care Plan, initiated on 8/25/2025 and revised on 9/2/2025, indicated Resident B used an antianxiety medication. Interventions included, but were not limited to: educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of antianxiety medications.During an interview, on 2/13/2026 at 11:08 A.M., Resident B indicated the SSD had just left her room after obtaining informed consent for psychotropic medication use.During an interview, on 2/13/2026 at 11:10 A.M., the SSD indicated she had just had Resident B sign a form regarding informed consent for psychotropic medication use. 4. A record review for Resident H was completed on 2/12/2026 at 8:52 A.M. Diagnoses included, but were not limited to: dementia, major depressive disorder and mood adjustment disorder.A Significant Change MDS assessment, dated 12/29/2025, indicated Resident B had moderate cognitive impairment and received an antidepressant medication.A Physician Order, dated 12/17/2025, indicated an order for Cymbalta 20 milligrams daily for depression and an order, on 1/30/2026, indicated Ativan 0.5 milligram at bedtime and every four hours as needed for anxiety, A Care Plan, initiated 7/26/2025 and updated on 10/6/2025, indicated Resident H had the potential for depression related to loss of health and independence and a goal of: no signs or symptoms of depression.During an interview, on 2/13/2026 at 11:10 A.M., the SSD indicated all verbal notifications for medication consents had been obtained on 2/13/2026 after the request for psychotropic notification consents had been requested. 5. A record review for Resident J was completed on 2/12/2026 at 2:20 P.M. Diagnoses included, but were not limited to: schizoaffective disorder, mood disorder, major depressive disorder and anxiety disorder.A Quarterly MDS assessment, dated 1/8/2026, indicated Resident H was cognitively intact and received medication of an antipsychotic and an antidepressant.Physician's Orders, dated 12/2/2025 indicated Abilify 10 milligrams twice daily for schizophrenia, Doxepin 10 milligrams at bedtime for depression and sertraline (Zoloft) 50 milligrams 1.5 tablets for depression.A Care Plan, initiated 7/27/2024 and revised on 12/17/2025, indicated Resident H had the potential for depression with the goal of no signs or symptoms of depression.A Care Plan, initiated on 11/18/2024 and revised on 12/17/2025, indicated Resident H used psychotropic medications related to schizoaffective disorder with the goal of no effects from the use of antipsychotic medication.During an interview, on 2/12/2026 at 11:10 A.M., the SSD indicated all verbal notifications for medication consents had been obtained on 2/12/2026 after the request for psychotropic notification had been requested. The SSD indicated it had been hard to get ahold of residents and their resident representatives.A policy for informed consent for psychotropic medications was requested on 2/13/2026 at 11:15 A.M. A policy was not provided prior to the close of the survey.3.1-3(n)(2)

Based on observation and interview, the facility failed to ensure the walk-in freezer equipment was in working order for 1 of 1 kitchen reviewed. This deficient practice had the potential to affect 62 of 62 residents who received meals from the kitchen.Finding includes:During an observation of the kitchen, conducted on 2/09/2026 at 9:40 A.M. with the Dietary Manager, the walk-in freezer, located directly outside of the facility, had a large accumulation of ice buildud between the cooling unit of the freezer and the upper southern corner. On of the ice formations was the size and shape of a small watermelon and the other ice formation was the size of a cantaloupe and shaped like an upper cased L letter.During an interview, on 2/9/2026 at 10:00 A.M., the Dietary Manager indicated she had put in a work order weeks ago to get the ice buildup removed from the walk-in freezer. The Dietary Manager indicated the Maintenance Director had told her the freezer could not be fixed until it could be thawed out.During an interview, on 2/11/2026 at 9:05 A.M., the Maintenance Director indicated the ice buildup in the walk-in freezer had been present since he had been hired by the facility, which had been at least over a year. On 2/13/2026 at 3:56 P.M., the Administrator provided a policy titled, Malfunctions and Repairs, dated and 7/2023 the policy was the one currently used by the facility. The policy indicated .All malfunctions and repairs are reported to the food service manager and maintenance department.If repairs require outside help or the purchase of parts, this must be approved per facility policy .3.1 - 19 (bb)

Based on interview and record review, the facility failed to ensure a the infection control program regarding stewardship of antibiotics was promoted regarding the use of an antibiotic without adequate assessment completed for use for 1 of 1 resident reviewed for antibiotics. (Resident 2)Finding includes:During an interview on 2/12/2026 at 1:59 P.M., the Infection Prevention (IP) Nurse indicated Resident 2 was treated with an antibiotic for a urinary tract infection on 1/4/2026 for 5 days. A urinalysis and/or culture and sensitivity had been ordered on 1/4/2026 to verify the urinary tract infection but was the testing had not been completed as ordered. The IP Nurse further indicated the facility was to utilize the McGreer's criteria to determine the need for an antibiotic but Resident 2's use of an antibiotic had not met the criteria and the physician had not been notified of the issue and lack of criteria to support the use of the antibiotic treatment. On 2/12/2026 at 2:16 P.M. the IP nurse provided a current policy, dated December 2016 and titled, Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes. The policy indicated, .The IP, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics

Based on interview and record review, the facility failed to ensure hand splints to prevent bilateral hand contractures was implemented for 1 of 3 residents reviewed for range of motion. (Resident D) The clinical record for Resident D was reviewed on 2/13/2026 at 10:55 A.M. Diagnosis included, but were not limited to, rheumatoid arthritis and contracture of left and right hand.An Occupational Therapy notes, dated 8/15/2025 through 9/22/2025, provided by the Physical Therapy Director, on 02/13/2026 at 1:40 P.M., indicated current hand splints were appropriate and fit properly and should be continued to be worn at night. A second note, dated 10/08/2025, indicated the resident splints were in good functional order and appropriate for the resident to use. There was no order for the splints in the nursing charting and no documentation that nursing management staff made aware of order.A current Care Plan, initiated on 8/14/2025 with a target date of 2/23/2026, indicated Resident D, had self-care deficits related to joint pain, decreased mobility and rheumatoid arthritis. Interventions included, but were not limited to, physical therapy/occupational therapy evaluation and treatment per medical director orders and treatment plan of care.During an interview with Physical Therapy Director on 2/13/2026 at 1:40 p.m., the Nursing Management staff referred to in the above documentation was clarified to refer the Director of Nursing (DON).During an interview with the DON on 2/13/2026 at 2:34 p.m., she indicated she should have put the order in for bilateral hand splints at night. for Resident D.On 2/13/2026 at 4:10 P.M., the Director of Nursing (DON) provided a policy titled, Physician Orders, dated 3/17/2022 and indicated the policy was the one currently used by the facility. The policy indicated .The facility is obligated to follow and carry out the orders of the prescriber in accordance with all applicable state and federal guidelines.On 2/13/2026 at 4:10 P.M., the DON provided a policy titled, Functional Impairment - Clinical Protocol, dated 2/2014 and indicated the policy was the one currently used by the facility. The policy indicated .whenever a significant change of condition occurs, and periodically during a resident/patient's stay, the physician and staff will assess the resident/patient's function along with their physical condition.3.1-42(a)(1)

Based on observation, record review and interview, the facility failed to provide timely assessments related to safe and appropriate use of a bed alarm and failed to document resident/family education and consent for a bed alarm for 1 of 2 residents reviewed for restraints. (Resident 30)Finding includes:During an observation of Resident 30's room on 2/9/2026 at 3:06 P.M., a bed alarm pad could be seen laying on the empty bed with a cord coming off the bed alarm pad and plugged into an alarm near the bed. During random observations of Resident 30 from 2/10/2026-2/13/2026, Resident 30 had not been observed laying in her bed. Resident 30's record review was completed on 2/13/2026 at 1:44 P.M. Diagnoses included, but were not limited to dementia, anxiety disorder, depression, hypertension (high blood pressure) and dysphagia. A Quarterly Minimum Data Set (MDS) assessment, dated 12/11/2025, indicated Resident 30 had severely impaired cognition, had adequate hearing, clear speech, had usually been able to understand others and others usually understood her. Resident 30 had been dependent on staff for all transfers and had used a bed alarm daily. A current Physician's order, initiated on 3/18/2025 indicated Resident 30's bed alarm placement and function should be checked every shift. A current Care Plan, initiated on 10/21/2025, indicated Resident 30 used a bed alarm for enhanced safety and to prevent falls. An intervention, initiated on 10/21/2025 indicated the staff should document any side effect related to the use of the bed alarm in the nursing notes of the resident's medical record and were to check the placement and functionality of the bed alarm every shift. Resident 30's record lacked the documentation to indicate the resident had been assessed for safety related to the bed alarm use before the bed alarm was applied . A Physical Restraint Evaluation, dated 6/20/2025 had been started, but had not been completed. Physical Restraint Evaluations completed on 8/21/2025 and 10/21/2025 indicated restraints were not recommended after the evaluations had been completed. During an interview on 2/13/2025 at 2:04 P.M., Licensed Practical Nurse (LPN) 5 indicated that she had always believed bed alarms were a restraint, but the Director of Nursing had told her bed alarms were not restraints and she had not needed to follow the requirements for restraints. During an interview on 2/13/2025 at 2:10 P.M., the Unit Manager (UM) indicated that she had been educated by her DON that bed and chair alarms were not restraints and had not needed to be assessed. The UM indicated the resident did not have a diagnosis related to having a bed alarm and she believed a diagnosis of falls was not an appropriate diagnoses for which to initiate a bed alarm. The UM indicated the resident had fallen and the family had wanted her to have the alarm because the resident had been on the floor for sometime before staff had found her. However, the UM was not able to provide any documentation the family had requested the bed alarm, had been educated on the use of a bed alarm, or had been agreeable to the bed alarm usage before the exit of the survey on 2/13/2026 at 5:00 P.M. During an interview on 2/13/2025 at 2:30 P.M., the DON indicated the bed alarm was being used because it had made the family feel safer after the resident had had a previous fall at the facility. The DON indicated the bed alarm was not a restraint and they were not using the bed alarm to restrict the resident's movements, but to alert staff that the resident was out of bed. The DON indicated that she had been told by another staff member that bed alarms were not a restraint and staff did not need to complete quarterly evaluations, provide resident/family education or have family's consent documented in the resident's record. On 2/13/2026 at 4:22 P.M., the Executive Director provided an undated policy titled, Use of Restraints and indicated it was the policy currently used by the facility. The policy indicated, .Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience,or for the prevention of falls .6. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that may improve the symptoms .14. Residents and/or surrogate/sponsor shall be informed about the potential risks and benefits of all options under consideration, including the use of restraints, not using restraints, and the alternatives to restraint use.15. Should a resident not be capable of making a decision, the surrogate or sponsor may exercise the right of the use or non-use of a restraint. (Note: The surrogate/sponsor may not give permission to use restraints forthe sake of discipline or staff convenience or when the restraint is not necessary to treat the resident's medical symptoms.) 16. Restrained individuals shall be reviewed regularly (at least quarterly) to determine whether they are candidates for restraint reduction, less restrictive methods of restraints, or total restraint elimination. 17. Care plans for residents in restraints will reflect interventions that address not only the immediate medical symptom(s), but the underlying problems that may be causing the symptom(s) 3.1-3 (w)3.1-26 (a)3.1-26 (q)3.1-26 (s)

Based on interview and record review, the facility failed to consult the physician prior to administration of antihypertensives as instructed in emergency room discharge instructions for 1 of 2 residents reviewed for hospitalizations. (Resident H) This deficient practice resulted in medical-induced hypotension (unwanted low blood pressure caused by medications) and contributed to hospital readmission. In addition the facility failed to notify the physician regarding vital signs outside ordered parameters for blood pressures and blood sugars for 1 of 5 residents reviewed for unnecessary medications. (Resident H) Findings included: 1.The clinical record of Resident H was reviewed on 2/11/2026 at 1:30 P.M. The resident's diagnoses included, but were not limited to: chronic obstructive pulmonary disease, diabetes mellitus, Alzheimer's disease with late onset, depression, chronic fatigue, esophagitis, psoriasis, hypertensive heart disease, dementia, resistant hypertension, chronic diastolic congestive heart failure, atrial fibrillation, chronic kidney disease, hypotension and anxiety. A Significant Change Minimum Data Set (MDS) assessment, dated 12/29/2025, indicated the resident was moderately cognitively impaired. Current Physician orders included, but were not limited to: Torsemide (a loop diuretic water pill) prescribed to reduce excess fluid (edema) caused by heart failure, kidney disease, or liver cirrhosis, and to treat high blood pressure) Oral Tablet 20 milligrams (mg): give 20 mg by mouth one time a day, initiated on 1/6/2025. Metoprolol tartrate (a beta-blocker prescribed to treat high blood pressure) 50 mg tablet: give 3 tablets orally two times a day, initiated on 8/26/2024. A Nursing Progress Note, dated 9/26/2025, at 4:06 A.M., indicated Resident H was sent to the emergency room for an elevated blood pressure of 210/140 mmHg (millimeters of Mercury and a standard unit for measuring blood pressure). An emergency room Discharge summary, dated [DATE], at 7:26 A.M., indicated the resident's visit was for hypertension (high blood pressure or blood pressure greater than 130/80 mm/Hg) and indicated to ask your doctor about the following medications, which included, but were not limited to: Metoprolol tartrate and Torsemide. The Discharge Summary indicated Resident H had been administered Hydralazine (a direct-acting vasodilator used to treat moderate to severe high blood pressure) at 4:59 A.M. and Labetalol (a prescription beta-blocker medication used to treat high blood pressure) at 5:25 A.M. A Nursing Progress Note, dated 9/26/2025, at 8:15 A.M., indicated Resident H had returned from the emergency room and the nurse did not received a report but had noted blood pressure meds[medications].while in ER [emergency room] . A manual blood pressure was recorded as 120/70 mmHg on 9/26/2025 at 8:32 A.M. A Nursing Progress Note, dated 9/26/2025, at 12:40 P.M., indicated Resident H's blood pressure was 88/44 mmHg and the resident was difficult to arouse to a sternal rub (a painful, central nervous system stimulus used by healthcare professionals and emergency responders to assess the responsiveness of an unconscious patient). The clinical record failed to evidence any documentation of physician consultation regarding Resident H's scheduled antihypertensive medications prior to their administration. The September 2025 Medication Administration Record indicated Resident H had received her morning doses of Torsemide and Metoprolol on 9/26/2025. A Hospitalist's (a dedicated physician or nurse practitioner who manages the care of patients solely during their hospital stay) History and Physical, dated 9/26/2025, indicated Resident H had been sent back to the emergency room due to her family's concerns regarding her cognitive status. The Hospitalist indicated the patient had continued to receive routine blood pressure medications with subsequent hypotension (low blood pressure). The Hospitalist's History and Physical indicated Resident H met clinical criteria met for sepsis (a life-threatening, emergency response to infection where the immune system damages its own tissues and organs, causing rapid, widespread inflammation) but indicated sepsis was precipitated by medication-induced hypotension and had resulted in acute kidney injury in an elderly individual with chronic kidney disease. A Nurse Practitioner's Note, dated 9/30/2025, indicated Resident H was seen after a hospital stay from 9/26/2025 through 9/29/2025. The Nurse Practitioner indicated Resident H had received 100 mg of Labetalol and 25 mg of Hydralazine and when she had returned to the facility, the resident had received her routine morning medications. Resident H was later found to be somnolent and sent back to the emergency room and diagnosed with sepsis. During an interview, on 2/13/2025 at 3:03 P.M., Employee 3 indicated Resident H had transferred back to this facility from the emergency room on 9/26/2025 and, later that morning, the resident's nurse had administered Resident H's routine blood pressure medications without consulting the physician first. Employee 3 indicated Resident H's nurse had quit working at the facility during the very same shift. During an interview, on 2/13/2025 at 3:45 P.M., the Director of Nursing (DON) indicated the hospital discharge instructions were considered as physician orders and the nurse had not followed the orders when she failed to call the doctor prior to administration of Resident H's routine antihypertensives. 2. A record review for Resident H was completed on 2/12/2026 at 8:52 A.M. Diagnoses included, but were not limited to: diabetes mellitus type 2, atrial fibrillation, congestive heart failure and hypertension. A Significant Change Minimum Data Set (MDs) assessment, dated 12/29/2025, indicated Resident H had moderate cognitive impairment and received insulin. A Physician's Order, dated 12/17/2025, indicated to notify the physician for a blood pressure greater than 160/80 mmHg (millimeters of mercury). Recorded blood pressure measurements indicated the following blood pressures had not been reported to the physician according to the physician order: -12/10/2025 6:32 P.M. 220/100 mmHg -1/19/2026 6:36 P.M. 192/86 mmHg A Physician's Order, dated 11/21/2025 and discontinued on 12/8/2025, indicated Humalog Injection Solution 100 units/milliliters inject eight units subcutaneously three times a day for diabetes mellitus. The Humalog injection should have been held if Resident 19 did not eat breakfast, if the blood sugar readings were below 200 mg/dL (milligrams per deciliter) and notification of the physician of the blood sugar below 200 mg/dL. Recorded blood sugar measurements indicated the following blood sugars had not been reported to the physician according to the physician order: 1/11/21/2025 8:26 A.M. 137 mg/dL -11/21/2025 2:01 P.M. 178 mg/dL -11/25/2025 7:04 A.M. 75 mg/dL -11/27/2025 9:02 A.M. 81 mg/dL -11/28/2025 10:48 P.M. 133 mg/dL -12/2/2025 3:47 P.M. 125 mg/dL -12/3/2025 9:21 A.M. 129 mg/dL -12/4/2025 7:48 P.M. 155 mg/dL -12/5/2025 8:37 A.M. 111 mg/dL A Physician's Order, dated 12/8/2025 and discontinued on 1/6/2026, indicated Humalog Injection Solution 100 units/milliliters inject four units subcutaneously three times a day for diabetes mellitus. The Humalog injection should have been held if Resident 19 did not eat and notify the nurse practitioner if blood sugar readings were below 150 mg/dL. Recorded blood sugar measurements indicated the following blood sugars had not been reported to the nurse practitioner according to the physician order: -12/9/2025 12:26 P.M. 102 mg/dL -12/9/2025 3:30 P.M. 93 mg/dL -12/10/2025 11:17 A.M. 86 mg/dL -12/16/2025 9:32 A.M. 106 mg/dL -12/18/2025 9:11 A.M. 106 mg/dL -12/20/2025 10:06 A.M. 98 mg/dL -12/23/2025 7:43 P.M. 137 mg/dL -12/24/2025 11:00 P.M. 119 mg/dL -12/28/2025 8:33 A.M. 111 mg/dL -12/31/2025 9:36 A.M. 85 mg/dL -12/31/2025 12:44 P.M. 119 mg/dL -1/1/2026 8:34 A.M. 115 mg/dL -1/1/2026 12:27 P.M. 119 mg/dL -1/4/2026 4:16 P.M. 115 mg/dL A Care Plan, initiated on 12/19/2025 and revised on 1/6/2026, indicated Resident H had altered cardiovascular status related to atrial fibrillation, heart failure, hypertension and hyperlipidemia. Interventions included, but were not limited to: vital signs and notify the physician of any abnormal readings. A Care Plan, initiated on 7/28/2024 and revised on 1/13/2026, indicated Resident H had the potential for hypo/hyperglycemia related to type two diabetes mellitus. Interventions included, but were not limited to: Accuchecks (blood sugar assessments) as ordered, call MD for Accuchecks greater than 400 and less than 70 and to provide insulin coverage per resident's individual order. During an interview, on 2/13/2026 at 1:38 P.M., QMA 8 indicated any vital signs beyond the ordered parameters should have resulted in the nurse having been notified for physician notification. During an interview, on 2/13/2026 at 1:44 P.M., LPN 5 indicated if vitals signs were out of range from the physician's order, the physician or nurse practitioner should have been notified. A policy was provided by the Executive Director, on 2/12/2026 at 2:00 P.M. The policy titled, Change in Resident's Condition or Status, indicated, .Our facility promptly notifies the resident, hir or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status.1. The nurse will notify the resident's attending physician or physician on call when there has been a[an].i. specific instruction to notify the physician of changes in the resident's condition. On 2/13/2026 at 11:58 A.M., the DON provided an undated policy titled, Charting and Documentation and identified it as the policy currently used by the facility. The policy indicated, .All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition . 2. The following information is to be documented in the resident medical record: d. changes in the resident's condition On 2/13/2026 at 4:10 P.M., the Director of Nursing (DON) provided a policy titled, Physician Orders, dated 3/17/2022 and indicated the policy was the one currently used by the facility. The policy indicated .The facility is obligated to follow and carry out the orders of the prescriber in accordance with all applicable state and federal guidelines. On 2/13/2026 at 4:10 P.M., the DON provided a policy titled, Functional Impairment – Clinical Protocol, dated 2/2014 and indicated the policy was the one currently used by the facility. The policy indicated .whenever a significant change of condition occurs, and periodically during a resident/patient's stay, the physician and staff will assess the resident/patient's function along with their physical condition. 3.1-5(a)(3)

Based on observation, interview and record review, the facility failed to ensure a resident was treated with dignity and respect regarding her concerns with medication administration for 1 of 1 resident reviewed for resident rights. (Resident L)Finding includes:During an interview, on 2/12/2026 at 8:34 A.M., Resident L voiced a concern related to medication administration. Resident L indicated LPN 2 had been very sharp and snippy with her when she had approached the nurse about not administered her morning medications, especially her pain medication that had been requested two hours prior to the complaint . She indicated LPN 2 had told her she needed to wait for her medication administration until she had eaten breakfast.During an observation, on 2/12/2026 at 9:22 A.M., Resident L had returned to her unit and LPN 2 stated to Resident L that she had pulled her medications for administration prior to Resident L complaining to the State surveyors. LPN 2 was argumentative and unkind with Resident L and Resident L had responded with a statement to LPN 2 that she was being snarky. An Incident Report to the Indiana Department of Health was completed for an allegation of abuse, on 2/12/2026 at 10:01 A.M. The allegation indicted Resident L had gone to speak with the Indiana Department of Health Surveyors about LPN 2 refusing to administer scheduled medications and LPN 2 had responded in an unkind manner in the hallway.During an investigation, on 2/12/2026, a statement from LPN 3 indicated she could hear LPN 2 talking loudly to Resident L in the hallway. LPN 3 indicated Resident L felt LPN 2 had been snarky. LPN 3 took Resident L's prepared medications for administration and requested LPN 2 to leave the unit.A record review for Resident L was completed, on 2/13/2026 at 10:06 A.M. Diagnoses included, but were not limited to: left femur fracture, diabetes mellitus type 2 and anxiety disorder.An admission Minimum Data Set (MDS) assessment, dated 1/26/2026, indicated Resident L was cognitively intact and received opioid medications for pain.A Trauma Evaluation assessment, completed on 2/12/2026 at 10:58 A.M., indicated LPN 2 had been snarky when Resident L had requested her medications. The note indicated when Resident L returned to the unit after she had spoken with the IDOH Surveyors, LPN 2 said, I told you I was getting your pills. LPN 2 then gave Resident L's medication to LPN 3 and stated, You give them to her.During an interview, on 2/13/2026 at 1:28 P.M., the Executive Director indicated he expected staff to speak to residents in a kind manner, smile and be helpful. He indicated LPN 2 should not have been argumentative.A policy was provided by the Executive Director, on 2/13/2026 at 10:44 A.M. The policy titled, Resident Rights, indicated, .Employees shall treat all residents with kindness, respect, and dignity.1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness and dignity.This citation relates to intake 2699540. 3.1-3(t)

Based on record review and interview, the facility failed to follow bowel movement protocols. This resulted in the resident obtaining an ileus (a painful obstruction of the ileum or other part of the intestine) for 1 of 3 residents reviewed for quality of care. (Resident K) Finding includes: A record review for Resident K was completed on 11/26/2024 at 10:16 A.M. Diagnoses included, but were not limited to: Alzheimer's disease and constipation. The Quarterly Minimum Data Set (MDS) assessment, completed on 6/25/24 indicated the resident was severely cogntively impaired, was incontinent of her bladder and continent of her bowels and required some partial staff assistance for personal hygiene needs. A current Care Plan, initiated on 7/30/2024, indicated Resident K had the potential for constipation related to decreased mobility. The goal was for the resident to have a soft formed bowel movement at least every 3 days. Interventions included, but were not limited to: administer medications as ordered, check how often bowel movements occur, encourage fluid intake, give routine medications as ordered, check for bowel sounds, abdominal pain or swelling as needed, three times per week and report complaints of bowel problems to the nurse. The August 2024 physician's order recapitulation did not include orders for any as needed medications to soften stools and/or promote regular bowel movements (laxatives). The August 2024 bowel record forms indicated Resident K had a large bowel movement on 8/16/2024 during the day shift. There was no documentation of any bowel movements for Resident K in the nurse's notes or in the daily nursing bowel record form on 8/17/2024 and 8/18/2024. There was no documentation in assessments or nursing progress notes that the resident was assessed due to having gone two days without a bowel movement per the facility bowel protocol policy. On 8/19/2024 the bowel record form indicated Resident K had a small bowel movement on the evening shift. There was no documentation of any bowel movements for Resident K in the nurse's notes or in the daily nursing bowel record form from 8/20/2024 through 8/25/2024. There was no documentation in assessments or nursing progress notes that the resident was assessed due to having gone 5 days without a bowel movement. The physician was not notified and there were no PRN (as needed) medications to promote bowel movements administered to Resident K per the facility's bowel protocol policy. On 8/26/2024 during the night shift, the resident was documented as having a small bowel movement. A Physician's Progress Note, on 8/26/2024 at 10:17 P.M., indicated the family was concerned about Resident K due to abdominal swelling. An order was obtained for a 2-view abdominal x-ray. Physician Orders for Resident K, dated 8/26/2024, indicated the following medications were ordered: bisacodyl (medication to treat constipation) 5 milligrams daily, bisacodyl 10 milligram suppository (medication to treat constipation) as needed, docusate sodium (stool softener) 100 milligrams twice daily for 3 days and Milk of Magnesia (laxative) 30 milliliters as needed. A Nursing Progress Note, on 8/27/2024 at 12:29 P.M., indicated the results of the abdominal x-ray were received. The results indicated, .5.4 centimeter dilated air-filled large bowel loops within the abdomen and pelvis in keeping with ileus in the appropriate clinical setting A Nursing Progress Note, on 8/28/2024 at 12:35 A.M., indicated Resident K had no regular bowel movements after 8/16/2024. An order was received from the nurse practitioner for a bisacodyl suppository if no bowel movement after 4 hours. A Nursing Progress Note, on 8/28/2024 at 2:39 P.M., indicated new orders were obtained from the physician including: absolutely no enema, 2 doses of MiraLAX 2-3 hours apart then continue as needed for constipation, Senna Plus 50 milligrams/8.6 milligrams 2 tablets a day for 7 days then 2 tablets at night, and if no bowel movement give another suppository tonight at bedtime. The August 2024 Medication Administration Record indicated although biscodyl 5 milligram tab was ordered on 8/26/2024 to be administered twice daily until 8/29/2024, the resident did not receive any tablets until 8/29/24. Resident K was also not administered the bisacodyl suppository, docusate sodium or Milk of Magnesia from 8/26/2024 through 8/29/2024. The August bowel record indicated the resident had a small bowel movement on the evening shift of 8/26/2024 and 8/28/2024. There was no bowel movement documented on 8/27/2024 for Resident K. A Nursing Progress Note, on 8/29/2024 at 5:01 P.M., indicated Resident K has not had a bowel movement since the last orders were received and administered. A new physician's order was received to give another dose of MiraLAX if no bowel movement happened and to give MiraLAX 17 grams three times a day for 4 days. There was no bowel movement documented for Resident K on 8/29/2024 and 8/30/2024. A Nursing Progress Note, on 8/30/2024 at 11:23 A.M., indicated a physician's order was received to repeat an abdominal x-ray on 8/30/2024. A medium bowel movement on the evening shift was documented for Resident K on 8/31/2024. A Nursing Progress Note, on 9/2/2024 at 4:26 P.M., indicated Resident K's bowel sounds were present in all quadrants of the resident's abdomen. The resident's abdomen was firm and distended with discomfort noted on gentle palpation. An extra-large bowel movement was also noted. A Nursing Progress Note, on 9/2/2024 at 6:48 P.M., indicated the following results of the abdominal x-ray.dilated large bowel loops noted in the central abdomen, maximum transverse diameter of 5.5 centimeters .No significant interval change A new order was received to repeat the abdominal x-ray on 9/4/2024 and to continue with the current orders. A Nursing Progress Note, on 9/5/2024 at 1:04 P.M., indicated bowel sounds were present with slight abdominal distention noted. The resident's last bowel movement charted, on 9/5/2024, was a medium size. The physician reviewed the abdominal x-ray and gave orders to continue the currently ordered plan of care. During an interview, on 11/27/2024 at 8:53 A.M., CNA 8 indicated Resident K was a one person assist and was incontinent of bowels at times. During an interview, on 11/27/2024 at 12:53 P.M., LPN 20 indicated the facility's bowel movement regimen included the following: two days of no bowel movement to give prune juice, three days of no bowel movement to give oral laxative, four day of no bowel movement to give suppository or enema and 5 days of no bowel movement or result to call the physician. A policy was provided, on 11/27/2024 at 3:30 P.M., by the Director of Nursing. The policy titled, Bowel Protocol, indicated, .To provide effective interventions for signs and symptoms of constipation that are consistent with current standards of practice .1. Nursing staff document the resident's bowel movements each shift .2. The evening shift nurses assesses the bowel movement data daily and responds according to the protocol and/or physician orders. 3. If no bowel movement is recorded for two days: a. Assess for signs and symptoms of constipation. b. If the resident is alert and oriented, ask about any unrecorded bowel movements and assess for constipation. c. If acute abdominal symptoms are present, contact the physician immediately. 4. If no bowel movement is recorded for 3 days: a. In the absence of acute abdominal symptoms, administer a PRN [as needed] laxative or enema as ordered by the physician. b. If no PRN is ordered, contact the physician and relay the resident's status and request a laxative and/or enema. c. If acute abdominal symptoms are present, contact the physician immediately. 5. After 4 days with no bowel movement or inadequate response to previous interventions, contact the physician This citation is related to complaint investigation IN00447285. 3.1-37(a)

Based on observation, record review and interview, the facility failed to ensure food was stored and prepared in a sanitary manner for 1 of 1 kitchens observed. This deficient practice had the potential to affect 71 of 73 residents who consumed food from the kitchen. Findings include: During initial kitchen observations, on 11/21/2024 from 9:30 A.M. through 9:48 A.M. with the Dietary Manager (DM), the following was observed: - Opened cream base soup without an open date and stored unsealed. - Opened old fashioned biscuit gravy mix without an open date and stored unsealed. - Opened bag of coconut stored unsealed. - Opened pasta with no open date. - Opened chopped garlic sitting on a shelf with directions of to be refrigerate. - Spices of garlic herb seasoning, granulated garlic, granulated onion, parsley flakes and onion powder with no documented open date. - Mini freezer with heavy ice buildup. During an interview, on 11/21/2024 at 9:49 A.M., the Dietary Manager indicated the opened bags of food in the dry storage should have been sealed and/or in a baggie and have an open date documented on them, the minced garlic should have been refrigerated and the spices should have open dates on the containers. During an observation, on 11/26/2024 at10:30 A.M., the cream-based soup mix was still opened and not sealed. The mini freezer had heavy ice buildup. During an observation, on 11/26/2024 at 10:47 A.M., the sanitation bucket at the prep counter and at the dishwashing machine was tested for proper concentration. The test strip indicated a concentration of zero sanitation chemicals. During an interview, on 11/26/2024 at 10:49 A.M., the Dietary Manager indicated the concentration on the strip should have been between 200-400. During an interview, on 11/26/2024 at 2:12 P.M., the Dietary Manager indicated after changing the sanitation buckets, the buckets were tested again for concentration. The test strip indicated zero concentration. She indicated she had the maintenance department look at the automated sanitation disbursement system and the sanitation solution was not flowing through the tubing. It was unclear how long the chemical had not been mixing properly. During an interview, on 11/27/2024 10:35 A.M., the Dietary Manager indicated the mini freezer was not on a defrosting schedule, but the mini freezer was usually unplugged about every month and set outside to defrost. A policy was provided, on 11/27/2024 at 3:30 P.M., by the Director of Nursing. The policy titled, Dietary Stock Procedure, indicated, .To be sure all stock is properly put away as soon as possible after delivery .4. Bulk items must be properly dated, with date received, expiration date, open date and new expiration date if needed .5. All food needs to have open date on them once opened & expiration date, if it changes A policy was provided, on 11/27/2024 at 3:30 P.M., by the Director of Nursing. The policy titled, Freezer Cleaning, indicated, .Freezers will be defrosted as needed [when frost is 1/2 inch thick, the freezer should be defrosted], or per the manufacturer's instructions A policy was provided, on 11/27/2024 at 3:30 P.M., by the Director of Nursing. The policy titled, Cleaning cloths, Pads, Mops & Buckets, indicated, .Cleaning cloths should be kept in a container of clean sanitizing solution between use .Periodically test the sanitizing solution to assure that it maintains the correct concentration 3.1-21(h)(2) 3.1-21(h)(3)

Based on record review and interview, the facility failed to ensure a comprehensive plan of care was created for a resident with medical conditions of antiplatelet use, seizure disorder, gastroesophageal reflux disease (GERD) and glaucoma (Resident 39), a resident with splints to the wrist and fifth finger (Resident 22), and a resident with a pacemaker (Resident 29) for 3 of 19 residents reviewed for comprehensive care plans. Findings include: 1. A record review for Resident 39 was completed on 11/25/2024 at 10:19 A.M. Diagnoses included, but were not limited to: hemiplegia, seizure disorder, GERD and glaucoma. A Quarterly Minimum Data Set (MDS) assessment indicated Resident 39 received an antiplatelet medication, had range of motion limitations to one upper and lower extremity and had moderate impairment of her vision. A Physician's Order, dated 8/20/3034, indicated Resident 39 received clopidogrel (antiplatelet medication) 75 milligrams daily related to hemiplegia, levetiracetam (antiseizure medication) 750 milligrams twice daily for seizures, carbamazepine (antiseizure medication) 200 milligrams twice daily for seizures, pantoprazole (proton pump inhibitor) 40 milligrams daily for GERD and dorzolamide-timolol (topical beta blocker) 2 percent one drop in both eyes twice daily for glaucoma. A review of Resident 39's comprehensive plan of care indicated Resident 39 did not have a plan of care for antiplatelet use, seizure disorder, GERD or glaucoma. During an interview, on 11/27/2024 at 1:15 P.M., the Director of Nursing indicated Resident 39 should have had a plan of care for antiplatelet use, seizure disorder, GERD and glaucoma. 49229 2. During an observation, on 11/21/2024 at 11:39 A.M., Resident 22 had her right pinky finger splinted with two flat, wooden sticks and secured with paper tape. During an observation, on 11/25/2024 at 12:26 P.M., Resident 22 wore a firm black, cloth splint on her right wrist and 5th digit. The medical record for Resident 22 was reviewed on 11/25/2024 at 8:41 A.M. Diagnoses included, but were not limited to: resistant hypertension, Alzheimer's disease, depression, diabetes mellitus, chronic obstructive pulmonary disease, heart failure, dementia, chronic fatigue syndrome and unsteadiness on feet. A Quarterly Minimum Data Set (MDS) assessment, dated 10/24/2024, indicated the resident was mildly cognitively impaired with no hallucinations or delusions. The MDS indicated the resident had no falls since the last assessment. The current Physician's Orders included an order for an x-ray of the right wrist one time only for pain, dated and completed on 11/16/2024. An Occupational Therapy Evaluation, dated 11/21/2024, indicated Resident 22's recommendations included wearing a splint full-time with skin checks and hygiene after every meal and prior to bedtime. There was no care plan for Resident 22 regarding the use of splints. During an interview, on 11/26/2024 at 11:31 A.M., the Director of Nursing (DON) was unable to provide Resident 22's care plan for the splint use and verbalized there was not a care plan for the splint. 38845 3. The record for Resident 29 was reviewed on 11/27/2024 at 9:47 A.M. Diagnoses included, but were not limited to: obesity, chronic ischemic heart disease, pacemaker, spinal stenosis, chronic pain syndrome,and hypertension. An Admission Nursing Assessment, dated 10/31/2024, indicated the resident had a pacemaker. Under the comments section was documented: resident stated that she hasn't had her pacemaker checked since last year. The History and Physical form from the hospital dated, 10/31/2024, indicated under surgical history was documented as Pacemaker/Defibrillator 2020. The clinical record lacked a care plan for the use and care of the pacemaker. During an interview, on 11/27/2024 at 10:39 A.M., the Director of Nursing indicated there should have been a care plan for the pacemaker on the chart. On 11/27/2024 at 12:42 P.M., the Director of Nursing provided the policy titled, Care Plans, Comprehensive Person -Centered, dated 9/2022, and indicated the policy was the one currently used by the facility. The policy indicated . 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develop and implements a comprehensive, person-centered care plan for each resident . Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change 3.1-35(a)

Based on interview and record review, the facility failed to complete a self administration of medication assessment timely for 1 of 1 resident reviewed for self administration of medications. (Resident N) Finding includes: During an interview, on 11/26/2024 at 9:11 A.M., Resident N indicated the nurse left her medications in her room and she took her medications herself. During an interview, on 11/26/2024 at 9:13 A.M., QMA 16 indicted it was okay to leave Resident N's medications in her room because she was alert and oriented. A current Care Plan, initiated on 7/28/2024, indicated the resident had requested to administer his/her own medications. Interventions included: The nurse was to bring medications to her room, all medications may be left with resident to take without assistance except for narcotics. A current physician order, dated 8/18/2024, indicated the following: may leave medications at bedside every shift. A Self Administration of Medications Assessment, dated 5/28/2024, was provided by the Director of Nursing and indicated Resident N was able to self administer medications. The Director of Nursing indicated the last Self Administration of Medication Assessment was completed on 5/2024 and she was unable to provide more recent assessments for August or November. On 11/27/2024 at 12:41 P.M.,the Director of Nursing provided the policy titled, Self Administration of Medications, dated 5/20/2020, and indicated the policy was the one currently use by the facility. The policy indicated . 3. The interdisciplinary team determines the resident's ability to self-administer medications by means of a skill assessment conducted on a quarterly basis 3.1-50(a)(1)

Based on record review and interview, the facility failed to provide quarterly statements for 2 of 2 residents reviewed for personal funds. (Residents 5 & E) Findings include: 1. During an interview, on 11/22/2024 at 10:46 A.M., Resident 5 indicated she had not received quarterly statements for her personal funds account at the facility. She indicated if she needed to know her account's balance, the Business Office Manager (BOM) would verbally tell her the balance of the account. A record review for Resident 5 was completed on 11/25/2024 at 9:32 A.M. Diagnoses included, but were not limited to: dementia with psychotic disturbance, psychotic disorder with delusions, bipolar disorder, generalized anxiety disorder and depressive disorder. An Annual Minimum Data Set (MDS) assessment, dated 11/13/2024, indicated Resident 5 was cognitively intact. 2. During an interview, on 11/21/2024 at 2:38 P.M., Resident E indicated he had only received one quarterly statement since his admission to the facility, on 7/28/2023. A record review for Resident E was completed on 11/25/2024 at 10:53 A.M. Diagnoses included, but were not limited to: heart failure, atrial fibrillation, and hypertensive heart with heart failure. A Quarterly Minimum Data Set (MDS) assessment, dated 11/6/2024, indicated Resident E was cognitively intact. During an interview, on 11/27/2024 at 12:59 P.M., the BOM indicated the residents received personal fund statements whenever they asked for a statement. She indicated she tried to give the residents a statement anytime they withdrew money. The statement included the beginning and ending balances of their account. She indicated there were no specific time frames for personal fund statements to be provided to the residents. The Business Office Manager was unable to provide any documentation the residents and/or their representatives had received quarterly resident fund account statements. A policy was provided on 11/27/2024 at 3:30 P.M. by the Director of Nursing. The policy titled, Accounting and Records, indicated, .2. The individual financial record will be available through quarterly statements and on request to the resident or his or her legal representative 3.1-6(g)

Based on interview and record review, the facility failed to allow residents to exercise their rights when choosing where to eat for 3 of 3 resident reviewed for resident rights. (Resident C, D and N) Findings include: 1. During an interview on 11/22/2024 at 10:27 A.M., Resident C indicated she was not allowed to eat in her room and all meals were to be eaten in the dining room. A record review for Resident C was completed on 11/25/2024 at 8:27 A.M. Diagnosis included, but were not limited to: schizoaffective disorder (bi-polar type), depression, anxiety, extrapyramidal and movement disorder. The current diet order for Resident C indicated she was on a regular diet with thin consistency. A Quarterly Minimum Data Set (MDS) Assessment. dated 11/01/2024, indicated Resident C was cognitively intact and only required set-up assistance for eating. During an interview, on 11/26/2024 at 1:35 P.M., Resident C indicated that if you were feeling bad or just did not want to eat in the dining room, staff would not bring a tray to your room. If you were hungry, you would have to go to the dining room. She indicated she was allowed to eat in her room once, but only because staff felt she was too sick to go to the dining room. During an interview on 11/26/24 at 03:28 P.M., RN #14 indicated that the North Hall residents were more independent and could go down to the dining room and they were not allowed to get their meals in their rooms. He indicated that was the way he understood the facility's policy. RN #14 indicated he had been instructed to encourage the residents to go down to the dining room for meals, otherwise the resident would not receive a meal. During an interview on 11/27/24 at 10:58 A.M. CNA #13 indicated residents could not eat in their rooms because they were able to get up and go to the dining room. CNA #13 indicated staff were to encourage residents to go to the dining room and if they still did not want to eat in the dining room, they were not to receive a meal. 2. A record review for Resident N was completed on 11/25/2024 at 3:15 P.M. Diagnosis included, but were not limited to: vascular dementia without disturbances, depression, fibromyalgia, and anxiety. The current diet order for Resident C indicated she was on a regular diet with thin consistency. A Quarterly Minimum Data Set (MDS) Assessment, dated 11/08/2024, indicated Resident N was cognitively intact and required set-up assistance for eating. A current Care Plan, dated 7/28/2024, indicated the resident needed help with self-care related to: lack of motivation. Interventions included but were not limited to: -Eats meals in west dining room, had food in her room if she chose not to eat in the dining room. Independent with transfer, bed mobility, toileting, toileting hygiene, eating. During an interview, on 11/26/2024 at 2:50 P.M., Resident N indicated that North Hall were independent and if they did not go down to the dining room they were on their own for that meal. The resident indicated she kept food in the fridge in her room in case she did not feel like going down to the dining room because staff would not bring a tray to her room. 3. During an interview on 11/26/24 2:40 P.M., Resident D indicated that if she was not feeling good, she would have to go to the dining room for meals. She also indicated there were a couple times she did not want to go down but had to go because staff would not bring any food to her room. She indicated she was allowed to eat in her room once, but only because staff felt she was too sick to go to the dining room. A record review for Resident D was completed on 11/27/2024 at 11:20 A.M. Diagnosis included, but were not limited to: depression, anxiety, CKD, unspecified dementia without disturbances. A current care plan dated 8/9/2024 indicated the resident needed little help with self care Interventions included but were not limited to: independent in eating, eats all meals in the west dining room. The current diet order for Resident D indicated she was on a regular diet with thin consistency. A Quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated Resident C was cognitively intact and only required set-up assistance for eating. During an interview on 11/27/24 at 1:22 PM., the Dietary Manager indicated she did not recall anyone on North Hall ever receiving a room tray and she did not know if resdients were allowed to eat in their rooms. She indicated she would expect staff to have asked for a room tray if a resident stayed in their room for the meal. A current policy was provided on 11/27/2024 at 3:20 P.M. by the DON, titled, Quality of Life-Residents Self Determination and Participation. The policy included the following: Each resident is allowed to choose activities, schedules and health care that are consistent with his or her interests, values, assessments and plans of care, including: daily routine, such as sleeping and waking, eating . 3.1-3(u)(1) 3.1-3(u)(3)

Based on interview, observation and record review, the facility failed to ensure medically related social services were provided and interventions were developed and implemented for 1 resident (Resident J) with on-going aggressive behaviors affecting 4 of 5 other residents (Resident D, E, H and K). This resulted in psychosocial harm as displayed by Resident J getting into Resident H's personal space causing her to leave the dining room prior to eating when Resident J was near. Resident J laughing and mocking Resident H. Resident E felt bad after being yelled at by Resident J. Resident D avoiding Resident J. Findings include: 1. During an interview on 11/02/2016 at 8:51 A.M., Resident #22 indicated Resident J came in to the dining room in his wheelchair and began picking on Resident H. Resident #22 indicated two nurses assisted Resident J out of the dining room. Resident H then left the dining without consuming her meal. During interview on 11/2/2016 at 10:00 A,M., the administrator and social services director indicated Resident J gets into peoples personal spaces and Resident J is just Resident J. The Administrator indicated she had concerns with Resident H mental status suggesting a possible need for counseling. During an interview on 11/03/2016 at 10:56 A.M., RN (Registered Nurse) #9 indicated Resident H has left the dining room and will refuse to eat due to Resident J upsetting her. She further indicated staff will position him in the dining room as to not disturb anyone and due to his inappropriate behaviors. A clinical record review was conducted on 11/3/2016 at 10:55 A.M., and indicated Resident H was admitted on [DATE]. Her [DIAGNOSES REDACTED]. A behavior note, dated 6/02/2016, indicated Resident H was going into the dining room, Resident J was in his wheelchair and cut her off. Resident H indicated to staff He keeps cutting me off and bumping into me and asked staff Well you tell him that if he runs into me one more time I am going to ram him. Resident H further indicated to staff You know, I'm not the only person he does this to. He bumps into a lot of people and it's not right. An MDS (Minimum Data Set) assessment, dated 10/25/2016, indicated the BIMS (Brief Interview for Mental Status) score was 15, cognitively intact. A progress note, dated 11/02/2016, indicated Resident H gets uptight anytime Resident J is around her. The progress note further indicated; this writer did get Resident H to state that she would yell for staff if Resident J was making her uncomfortable. 2. Resident #J's clinical record was reviewed on 11/4/16 at 4:00 P.M. The [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment, dated 9/16/2016, indicated the Basic Interview Mental Status (BIMS) score was 11, moderately cognitively impaired. The NURSES & SOCIAL SERVICE NOTES indicated the following: * On 6/1/2016, Resident #J took a hold of the another resident's wheelchair by the handles and shoved her out of the way causing the resident to be rammed into a medication cart. * On 7/25/2016 at 2:36 P.M., the nurse was made aware of Resident #J screaming at another resident in the TV room over a movie on the TV. The resident was redirected back to his room without any further incidents. * On 7/26/2016 at 6:43 P.M., the SSD (Social Service Director) note indicated she had spoke with Resident #J regarding incident with other resident over movie. She indicated RN (Registered Nurse) #8 intervened and redirected Resident #J back to his room. * On 10/4/2016 at 1:58 P.M., UM (Unit Manager) #10 indicated Resident #J was telling nurse, I'm so mad right now! If she was a man I would of hit her! Resident #J was upset Resident #H had flipped him the bird (middle finger) and commented a nasty remark. * On 10/11/2016 at 6:11 P.M., the SSD indicated she had spoken with Resident #J regarding him being upset with Resident #H in which she instructed Resident #J to avoid Resident #H. * On 10/30/2016 at 3:35 P.M., the SSD indicated on two separate occasions that Resident #J was laughing at and mocking Resident #H. Staff redirected Resident #J. She indicated in her note she instructed him to leave Resident #H alone. During an interview on 11/3/2016 at 11:08 A.M., UM #10 indicated Resident #J had been intentionally bumping into Resident #H's wheelchair. She indicated they moved Resident H's seating spot in the dining room. During an interview on 11/4/2016 at 9:28 A.M., the SSD indicated she was not aware of the incident where Resident #J rammed another resident in her wheelchair into a medication cart. She did indicate she was aware of the incidents. 3. During an interview on 11/1/2016 at 3:34 P.M., Resident #E indicated over a month ago Resident #J offered him a piece of chicken in the hallway. When Resident #E refused the piece of chicken, Resident #J said, S---- you, (Resident #E's name). Resident #J indicated this made him feel bad. During an interview on 11/3/2016 at 9:10 A.M., Resident #E indicated RN (Registered Nurse) #8 intervened in the incident regarding the chicken. During an interview on 11/3/2016 at 10:30 A.M., the Social Service Director (SSD) and the Administrator (ADM) indicated they were not aware of the piece of chicken incident. The SSD indicated Resident #J liked to share food items and was able to differentiate between staff and residents. She also indicated staff was instructed to accept the food items and throw it away. Resident #E clinical record was reviewed on 11/2/2016 at 2:00 P.M. The [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment, dated 9/23/2016, indicated the Basic Interview Mental Status (BIMS) score was 15, cognitively intact. 4. During an interview on 11/1/2016 at 2:09 P.M., Resident #D indicated Resident #J had yelled at him in an angry manner. During an interview on 11/3/2016 at 8:50 A.M., Resident #D indicated 3 weeks ago he was outside the old administrator's office while Resident #J kept knocking on the door. When Resident #D tried to explain no one was in the office, Resident #J started yelling at him and told him it was none of his business. He indicated a staff member was present to intervene. Resident #D indicated he avoided this resident because his physical limitations. He told the SSD who instructed him to stay away from Resident #J. Resident #D also indicated he witnessed Resident #J taking the TV remote out of Resident #K's hand as if he was going to hit her. During a men's group activity on 11/3/2016 at 2:28 P.M., Resident #D was observed to change his direction as he was going to participate in the group activity to avoid Resident #J coming out of his room. During an interview on 11/3/2016 at 10:25 A.M., the SSD and the ADM indicated they were unaware of Resident #D's reported incidents. The ADM indicated Resident #D over exaggerated stories. Resident #D clinical record was reviewed on 11/2/2016 at 2:15 P.M. The [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment, dated 9/6/2016, indicated the Basic Interview Mental Status (BIMS) score was 15, cognitively intact. The NURSES & SOCIAL SERVICE NOTES indicated, on 11/1/2016 at 9:00 P.M., the SSD and Unit Manager #10 met with Resident #D. He affirmed the incident with Resident #J and confirmed to the writer, Inservice Director (INS) #11 was present to intervene. Resident #D described INS #11 as physically holding Resident #J down in his chair. This note indicated INS #11 heard the yelling, calmed Resident #J but did not physically hold him in his chair. Resident #D indicated Resident #J was glaring at him in an angry manner during the yelling episode. 5. During an interview on 11/3/2016 at 9:34 A.M., Resident #K indicated around 3 months ago while she was watching TV, Resident #J grabbed the remote out of her hand to change the TV channel. During an interview on 11/3/2016 at 10:22 A.M., the SSD and the ADM indicated they were not aware of this incident. During an interview on 11/3/2016 at 11:08 A.M., UM #10 indicated it was reported to her by Resident #K, who was in watching TV (Television) when Resident #J came in and took the remote out of her hand. Resident #K clinical record was reviewed on 11/4/2016 at 4:43 P.M., The [DIAGNOSES REDACTED]. The significant Minimum Data Set (MDS) assessment, dated 8/30/2016, indicated the Basic Interview Mental Status (BIMS) score was 15, cognitively intact. 3.1-34(a)