Every finding on record at Providence Health Care Center

Based on record review and interview, the facility failed to ensure consents for increased dosages of psychotropic medications (medications that affect the mind, emotions, and behavior) had been obtained, for 2 of 5 residents reviewed for unnecessary medications (Residents 24 and 31). Findings include: 2. On 6/9/26 at 1:34 p.m., the medical record of Resident 31 was reviewed. The resident was admitted to the facility on [DATE]. Diagnosis included but were not limited to cerebral infarction (stroke, a medical emergency that occurs when blood flow to an area of the brain is cut off). An annual Minimum Data Set assessment dated [DATE] indicated the resident had no cognitive deficits, required assistance with daily care needs and was administered psychotropic medication during the assessment period. A care plan dated 4/16/25 indicated the resident had the potential for pain. Intervention included but was not limited to administer medication as ordered. A physician order dated 4/5/26 indicated to administer Duloxetine HCl Oral Capsule Delayed Release Sprinkle 20 mg (milligrams) Give 1 capsule by mouth daily for pain. A physician order dated 4/6/26 indicated to administer Duloxetine HCl Oral Capsule Delayed Release Sprinkle 30 mg (Duloxetine HCl) Give 1 capsule by mouth one time a day for pain. The record indicated the resident signed an informed consent for administration of psychotropic medication. The consent statement did not indicate if the resident consented to the use of the prescribed medication or did not consent at that time. On 6/26/26 at 2:57 p.m., the Administrator provided an undated document, titled, PSYCHOTROPIC MEDICATIONS POLICY, and indicated it was the policy currently being used by the facility. The policy indicated, . 10. Informed Consent Prior to initiation of a psychotropic medication, the attending practitioner and/or facility staff shall ensure that the resident or resident representative is informed of: a. The reason for the medication. b. Expected benefits c. Potential risks and adverse effects. d. Reasonable alternatives, including non-pharmacological interventions. e. The right to refuse treatment. The facility shall involve residents and/or their representatives in treatment decisions to the extent practicable. 410 Indiana Administrative Code (IAC) 3.1-3(n)(2)(3) 1. Resident 24's record was reviewed on 6/9/26 at 1:11 p.m. The profile indicated the resident's diagnoses included, but were not limited to, Alzheimer's disease with late onset (a common form of dementia [loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life] that starts after the age of 65) and unspecified anxiety disorder (anxiety that causes significant distress or functional impairment but lacks enough information for a specific diagnosis). A care plan, dated 9/10/24, and revised on 3/18/25, indicated the resident had a diagnosis of anxiety disorder. Interventions included, but were not limited to, administer medication as ordered. A quarterly Minimum Data Set (MDS) assessment, dated 4/16/26, indicated the resident had severe cognitive disorder and received an antianxiety medication. A historical review of the resident's physician's orders indicated the resident had an order, dated 2/7/26, to administer 0.25 milliliters (ml) of lorazepam (antianxiety medication) twice a day. That order was discontinued on 2/25/26. A physician's order, dated 2/25/26, indicated to administer 0.25 ml of lorazepam twice daily and 0.25 ml every 6 hours as needed. The record lacked documentation of a consent for the increase of the as needed lorazepam, ordered on 2/25/26. During an interview, on 6/10/26 at 1:33 p.m., the Director of Nursing (DON) indicated the consent with the addition of every 6 hours as needed lorazepam had just been missed. A consent should have been completed since the addition of the as needed dose was an increase in the medication dosage.

Based on record review and interview, the facility failed to ensure the receiving hospital was notified prior to the transfer of residents for evaluation and treatment, for 2 of 3 residents reviewed for hospitalization (resident 5 and 51). Findings include:1. Resident 5's record was reviewed on 6/10/26 at 2:15 p.m. The profile indicated the resident's diagnoses included, but were not limited to, partial intestinal obstruction unspecified cause (a blockage that keeps food or liquid from passing through your small intestine or large intestine). a. The census indicated that the resident had been transferred to the hospital emergency room (ER) for evaluation and treatment on 4/27/26. A health status note, dated 4/27/26 at 6:18 p.m., indicated the resident had voiced complaints of her stomach hurting very badly. The physician was contacted and gave orders to transfer the resident to the ER for evaluation and treatment. The resident was transported via ambulance to the ER. The record lacked documentation that the facility nurse had contacted the ER to provide notification and report on the resident's transfer. b. The census indicated that the resident had been transferred to the hospital emergency room (ER) for evaluation and treatment on 6/1/26. A health status note, dated 6/1/26 at 6:09 p.m., indicated the resident was vomiting and complaining of abdominal cramping. Resident was offered to go to hospital , but declined. A health status note, dated 6/1/26 at 7:28 p.m., indicated the resident was agreeable to be transferred to the ER. An order was obtained from the physician to transfer for evaluation and treatment. The resident was transferred via ambulance. The record lacked documentation that the facility nurse had contacted the ER to provide notification and report on the resident's transfer. 2. Resident 51's record was reviewed on 6/11/26 at 9:45 a.m. The profile indicated the resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD- a common lung disease causing restricted airflow and breathing problems) and chronic respiratory failure with hypercapnia (when the airways that carry air to the lungs become narrow and damaged which limits the movement of air throughout the body). The census indicated the resident had been transferred to the hospital emergency room (ER) on 5/6/26. A health status note, dated 5/6/26 at 11:05 a.m., indicated a Certified Nursing Assistant (CNA) notified the nurse that the resident was complaining of shortness of breath (SOB). Upon assessment, the resident's oxygen saturation (the amount of oxygen being carried in the red blood cells, which load up with oxygen in the lungs and then transport it to the rest of the body) was measuring in the 60's on 3 liters of supplemental oxygen (O2). The resident and her daughter were in agreement to send the resident to the ER. The physician was notified and gave an order to send the resident to the ER for evaluation and treatment. The resident was sent to the ER via ambulance. The record lacked documentation that the facility nurse had contacted the ER to provide notification and report on the resident's transfer. During an interview, on 6/11/26 at 11:20 a.m., the Director of Nursing (DON) indicated she could not find any documentation that indicated the facility nurse had contacted the ER and gave a report prior to the transfer for either of the residents' transfers. Notifying the ER was expected and was part of the transfer process, but it appeared that the nurse did not document any contact at the time of the transfer. On 6/11/26 at 2:45 p.m., the DON provided a policy, with an updated date of 1/15/26, titled, Transfer and Discharge, and indicated it was the policy currently being used by the facility. The policy indicated, .Standards: .29. A licensed nurse will contact the facility the resident is transferring to and provide an oral condition report to the nurse responsible for the resident upon admission. 410 IAC (Indiana Administrative Code) 16.2-3.1-6(A)(v)

Based on record review, interview, and observation, the facility failed to ensure a wound identified on admission had assessments, treatments ordered, and preventive measures implemented to prevent the worsening of wounds and development of new wounds for 1 of 2 residents reviewed for wound care (Resident 13). Findings include:On 6/10/26 at 2:02 p.m., the medical record of Resident 13 was reviewed. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, major joint replacement of the right hip (a surgical procedure where an orthopedic surgeon removes a damaged or diseased hip joint-which works like a ball and socket-and replaces it with artificial parts), chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high) and hypertension (high blood pressure). An admission nursing clinical assessment, dated 1/2/26, indicated Resident 13 was admitted with a wound to the right outer ankle measuring 0.3 centimeters (cm) by (x) 0.3 cm x 0.2 cm. The wound description indicated the wound was classified as a diabetic foot ulcer (an open sore or wound on the foot or lower leg of a person with diabetes) and indicated that the resident told the nurse he had previous treatment to the wound. On 1/4/26 the medical record included an advanced skin evaluation. The record lacked documentation of a wound on the right ankle. A care plan, dated 1/5/26, indicated the resident had the potential for pressure ulcer development related to requiring assistance with repositioning, decreased mobility, pressure ulcers. Intervention included, but were not limited to, administering medications as ordered, administering treatments as ordered and observing for effectiveness, follow facility policies/protocols for the prevention of skin breakdown, observe for/report to physician as needed (PRN) changes in skin status, and resident requires pressure relieving/reducing device on bed/chair. The record lacked documentation of implementation of preventive measures. The record lacked documentation of wound provider addressing the wound on the right ankle. On 1/11/26 a skin assessment indicated no skin issues. On 1/18/26 an advanced skin assessment indicated a diabetic foot ulcer right outer ankle. The assessment lacked documentation of a wound evaluation. A Wound Care Provider note, dated 2/11/26, indicated the resident was seen by the wound care provider and the following wounds, and measurements were recorded in the medical record. a. Wound 1 - Left heel, stage 2. 100% epithelial (the surface tissue (cells) that line the internal and external surfaces of the body) in the wound base. Measured at 3.2 cm x .6 cm x.1cm. Treatment recommendation. Cleanse with wound cleanser, apply skin prep (a single-use, pre-moistened wipe used to ready the skin for medical procedure) to base of the wound, leave open to air BID (two times a day) and PRN (as needed). b. Wound 2 - Right heel, stage 2. 100% epithelial in the wound base. Measured at 3.1 cm x.6 cm x .1 cm. Treatment recommendation. Cleanse with wound cleanser, apply skin prep to base of the wound, leave open to air BID and PRN c. Wound 3 - Sacrum (a triangular bone at the base of the spine that sits between the lower back and the tailbone), stage 2 (a standardized system healthcare providers use to describe and classify the depth and severity of a wound, usually a pressure injury, bedsore) (stage 2 is described as (the top layers of the skin are broken or lost, creating a shallow, open wound). 100% epithelial in the wound base. Measured at 1.3 cm x 4.3 cm x 0.16 cm. Treatment recommendation was. Cleanse with wound cleanser, apply Triad paste (a zinc oxide-based paste that manages light-to-moderate wounds and protects delicate, wet skin) to base of the wound. Leave open to the air BID and PRN. The Wound Care Provider note, lacked documentation of ankle wound. The note indicated wounds to bilateral heels and sacrum. Recommendations were ongoing pressure reduction and turning and repositioning precautions per protocol, including pressure reduction to the heels and all bony prominences.Float heels while in bed with use of heel boots (specialized medical cushions used for bedridden or immobile patients that completely lift or float the vulnerable heel off the surface of the bed). Review of the Treatment Administration Record TAR indicated wound treatments did not begin until the wounds were addressed by the wound care provider on 2/11/26. A care plan, dated 2/13/26, indicated the resident had a stage 2 pressure (a partial-thickness skin loss where the outer layer and part of the underlying layer are damaged which presents as a shallow, open sore with a pink or red wound bed, or as an intact or ruptured serum-filled blister) ulcers to his left heel, his right heel, and his sacrum. A care plan, dated 2/19/26, indicated the resident had a stage 2 pressure ulcer injury to his left heel, his right heel, and a stage 3 (a serious, full-thickness skin loss that extends into the subcutaneous fat which forms a deep crater, but underlying muscles, tendons, and bones are not exposed) ulcer to his sacrum. A Wound Care Provider note, dated 3/4/26, indicated the resident was seen by the wound care provider and the following wounds were assessed: a. Wound 1 - Left heel. Stage 2. 100% epithelial in the wound base. Measured at 2.5 cm x 1.5 cm x .1 cm. Treatment recommendations indicated. Wound 1, left heel, apply skin prep to base of wound. Secure with Leave open to air, change BID and PRN (did not indicated what was it to be secured with. b. Wound 2 - Right heel. Unstageable (a full-thickness wound, but its true depth cannot be determined because it is completely covered by dead tissue (slough or eschar). 100% eschar wound base. Measured at 2.4 cm x .6 cm x .1 cm. Treatment recommendations indicated, Wound 2, right heel, apply betadine to base of the wound, leave open to the air, BID. c. Wound 3 - Sacrum. Stage 3 (The wound goes through the top layers of skin into the underlying fat tissue) 40% epithelial (the final outer layer of skin growing over the top of the granulation tissue), 60% granulation (the new, healthy connective tissue filling the base of the wound). Measured at 1.5 cm x 2.1 cm x 1 cm. Treatment recommendations indicated Wound 3, sacrum, cleanse wound with wound cleanser and pat dry. Apply triad paste to base of the wound, leave open to air, BID. d. Wound 4 - Left outer ankle. Unstageable. Wound base 100% eschar. Measured at .8 cm x .8 cm x 0 cm. The wound provider indicated the wound was present on admission. This was not indicated on the admission clinical assessment form. Treatment recommendations for wound 4 indicated, Left outer ankle. Cleanse wound with cleanser apply betadine to base of the wound. Leave open to air. The medical record indicated the physician orders were obtained for the first time for the ankle. e. Wound 5, skin tear left anterior of the lower extremity. g. Wound 6, Right ankle. DTI (deep tissue injury, the skin may be intact but bruised, showing a dark maroon or purple discoloration, indicating severe damage to the soft tissues underneath), pressure. The wound care provider Indicated it was present on admission. Measured at 1.5 cm x 1.5 cm x 0 cm. Appearance of the wound indicated as 100% intact epithelium with evidence of deeper tissue injury (maroon or darkened purplish discoloration). The medical record lacked admission documentation of DTI to the right ankle. Treatment recommendations for wound 6 indicated, Cleanse with wound cleanser, apply skin prep to base of wound. Leave open to air, BID. A care plan, dated 3/5/26, indicated the resident had a stage 2 pressure ulcer injury to his left heel, an unstageable pressure (wound where dead tissue completely covers the base, hiding its true depth) ulcer to his left outer ankle, an unstageable pressure ulcer to his right heel, a suspected deep tissue injury (DTI, severe, rapidly progressing form of pressure ulcer that begins in the muscle layer near the bone and works its way up to the skin and are characterized by a localized area of intact or non-intact skin with persistent, non-blanchable deep red, maroon, or purple discoloration) to his right ankle, and a stage 3 to his sacrum. A Wound Care Provider note, dated 3/11/26, the record indicated the resident was seen by the wound care provider and the following was documented:a. Wound 1- Left heel. Stage 2. 100% epithelial in the wound base. Measured at 2 cm x 1.5 cm x 1 cm.b. Wound 2 - Right heel. Unstageable. 100 % eschar. Measured at 2 cm x .6 cm x .1 cm.c. Wound 3 - Sacrum. Stage 3. 40% epithelial, 60% granulation. Measured at 1.5 cm x .8 cm x .1 cm.c. Wound 4 - Left outer ankle. Unstageable. Measured at 0.8 cm x 0.8 cm x 0 cmd. Wound 5 - Skin tear lower [NAME]. Wound 6 - Right ankle, DTI. 100% intact epithelium with evidence of deeper tissue injury (maroon or darkened purplish discoloration).Treatment recommendations were unchanged from previous visit. A Wound Care Provider note, dated 3/18/26, indicated the resident was seen by the wound care provider and the following was documented:a. Wound 1 - Left heel, stage 2. 100% epithelial. Measured at 2 cm x 1.5 cm x 0.1 cmb. Wound 2 - Right heel, unstageable. 100% eschar. Measured at 2 cm x 0.6 cm x 0.1 cmc. Wound 3 - Sacrum - Wound healedd. Wound 4 - Left outer ankle. Unstageable. 100 % eschar. Measured at 0.8 cm x 0.8 cm x 0 cm e. Wound 6 - Right ankle. Wound healedTreatment orders were unchanged from previous visit. A care plan, dated 3/23/26, indicated the resident had a stage 2 pressure ulcer injury to his left heel, an unstageable pressure ulcer to his left outer ankle, and an unstageable pressure ulcer to his right heel. A Wound Care Provider note, dated 3/25/26, indicated the resident was seen by the wound care provider and the following was documented:a. Wound 1 - Left heel, stage 2. 100 % epithelium. Measured at 2 cm x 1.5 cm x 0.1 cm.b. Wound 2 - Right heel, unstageable. 100 % eschar. Measured at 2 cm x 0.6 cm x 0.1 cm.c. Wound 4 - Left outer ankle, unstageable. 100% eschar. Measured at 0.8 cm x 0.8 cm x 0 cm.Wound treatment orders unchanged. A Wound Care Provider note, dated 4/1/26, indicated the resident was seen by the wound care provider and the following was documented:a. Wound 1 - Left heel, stage 2. 100 % epithelial. Measured at 2 cm x 1.5 cm x 0.1 cm.b. Wound 2 - Right heel, Unstageable. 100 % eschar. Measured at 2 cm x 0.6 cm x 0.1 cm.c. Wound 4 - Left outer ankle, Unstageable. 100 % eschar. Measured at 0.8 cm x 0.8 cm x 0 cm.Wound treatment orders were unchanged. A Wound Care Provider note, dated 4/7/26, indicated the resident was seen by the wound care provider and the following was documented:a. Wound 1 - Left heel, stage 2. 100 % epithelial. Measured at 2 cm x 1.5 cm x 0.1 cm.b. Wound 2 - Right heel, unstageable. 100 % slough, 0 % eschar. Measured at 2 cm x 0.6 cm x 0.1 cm.c. Wound 4 - Left outer ankle, unstageable. 100 % epithelium. Measured at 0.5 cm x 0.8 cm x 0 cm.Treatment recommendations. Wound 1 and 2 cleanse with cleaner and apply calcium alginate (a seaweed-derived, highly absorbent pad or rope into a wet wound to soak up excess fluid. As it absorbs, it turns into a soft gel that keeps the wound bed moist to promote healing). Skin prep surrounding tissue. Change daily and PRN. A Wound Care Provider note, dated 4/14/26, indicated the resident was seen by the wound care provider and the following was documented:a. Wound 1 - Left heel, stage 2. 100 % epithelial. Measured at 1cm x 1.5 cm x 0.1 cm.b. Wound 2 - Right heel, unstageable. Wound base 80% granulation, 20 % slough (a layer of dead), non-viable tissue commonly found in the wound bed. 0 % eschar. Measured at 1.5 cm x 0.6 cm x 0.1 cm.c. Wound 4 - Left outer ankle, unstageable. Wound base 0 % epithelial, 100 % slough. Measured at 0.5 cm x 0.8 cm x 0.1 cm.Treatment recommendation Wound 1, added collagen with silver and bordered dressing.Wound 2 changed to add MediHoney (a medical-grade, sterilized Leptospermum (Manuka) honey primarily used for advanced wound care) secure with border dressing. A Wound Care Provider note, dated 4/21/26, indicated the resident was seen by wound care provider and the following was documented:a. Wound 1 - Left heel. Stage 2. 100 % epithelial. Measured at 1cm x 1.5 cm x 0.1 cm.b. Wound 2 - Right heel. Stage 3. 100% granulation, 0 % slough, 0 % eschar. Measured at 1cm x 0.5 cm x 0.1 cm.c. Wound 4 - Left outer ankle. Unstageable. Wound base 0 % epithelial, 100 % slough. Measured at 0.5 cm x 0.8 cm x 0.1 cm. The resident was admitted to the hospital on [DATE] and returned to the facility on 4/27/26. The hospital discharge record lacked documentation of pressure wounds or discharge treatment orders for treatment of wounds. After re-admission from the hospital the resident was seen weekly by the wound care provider. On 6/9/26 the record indicated the resident was seen by the wound care provider and a new wound was identified to the right heel and classified as DTI. On 6/11/26 at 10:00 a.m., during a routine observation and interview, observed resident sitting in wheelchair on top of a thick foam cushion with a smaller black cushion on top of it. Observed the bed did not have a low air loss mattress. The resident indicated the cushion under him was very uncomfortable but if he was not up high his hips would be out of alignment. On 6/11/26 at 10:31 a.m., during an interview, Registered Nurse (RN) 15 indicated she would call the doctor immediately for any changes in wounds. She indicated they kept the resident's heels floated and helped him turn. She indicated when the resident was first admitted he was more dependent and was on an air mattress. She indicated she did not document any preventive measures and did not know if the Certified Nurse Aides (CNA) documented preventive measures. On 6/11/26 at 10:40 a.m., during an interview, RN 16 indicated she assessed residents before and after treatment and documented it on the Electronic Medical Record (EMAR). She indicated she would notify the nurse manager of changes in a wound and she would let them notify the doctor of changes in a wound. On 6/12/26 at 1:40 p.m., during an observation and interview the resident was observed sitting in recliner. A pressure reduction device was not in the chair. Observed wounds on the right heel and the left outer ankle. No sign of infection noted. No complaint of pain. On 6/15/26at 2:38 p.m., the administrator provided an undated document titled, SKIN CONDITION AND PRESSURE ULCER ASSESSMENT and indicated it was the policy currently being used by the facility. The policy indicated, .1. A Skin Assessment and Braden Scale will be performed on admission, quarterly and as necessary. 3. All areas of each resident's skin shall be inspected by his or her nurse and documented at least every seven days. If the abnormality noted during the Weekly Skin Assessment is new, the nurse shall notify the attending physician and obtain a treatment order, if indicated. 410 Indiana Administrative Code (IAC) 3.1-37

Based on observation, record review, and interview, the facility failed to implement a brace for a resident with left hand contracture as recommended by the therapy department for 1 of 1 resident reviewed for Range of Motion (Resident 3). Findings include: During an observation on 6/9/26 at 10:56 a.m., Resident 3 was sitting in her wheelchair in the common area by the television and noted having a contracted left hand (the connective tissue beneath the palm's skin to thicken forcing one or more fingers (usually ring or pinky) to curl inward) with no brace or preventative device in place. During an observation on 6/10/26 at 9:30 a.m., Resident 3 was sitting in her wheelchair in the common area by the television, left hand was contracted and had no brace or preventative device in place. During an observation on 6/11/26 at 9:45 a.m., Resident 3 was sitting in her wheelchair in the common area by the television, left hand was contracted and had no brace or preventative device in place. During an observation on 6/11/26 at 1:13 p.m., Resident 3 was sitting in her wheelchair at the dining room table, left hand was contracted and had no brace or preventative devices in place. Resident 3's record was reviewed on 6/11/26 at 8:51 a.m. The profile indicated the resident's diagnoses included, but were not limited to, vascular dementia, moderate, with psychotic disturbance (involves a decline in cognitive function caused by restricted blood flow to the brain, combined with symptoms like hallucinations, paranoia, or delusions), presence of pacemaker (is a small, battery operated implanted device that monitors your heart rhythm and sends electrical signals to keep it beating at a regular, safe pace), and hemiplegia and hemiparesis following cerebral infarction (stroke) affecting right dominate side (resulting in one sided weakness, and destruction of red blood cells indicates systemic or localized complications that require immediate clinical evaluation and specialized management). A quarterly Minimum Data Set (MDS) assessment, dated 2/25/26, indicated the resident had severe cognitive impairment and had impairment on one side of her upper extremity. Splint or brace assistance was marked NO. A care plan, dated 1/5/21 with a revised date of 12/21/25, indicated the resident had an ADL (activities of daily living) self-care performance deficit related to. limited range of motion. Interventions included but were not limited to, black brace/sleeve to left hand, observe skin with care, and physical therapy and occupational therapy to eval and treat as per MD (medical doctor) orders. Review of restorative aid note, dated 10/2/25 at 11:23 a.m., indicated Resident 3 was being evaluated by therapy and picked up for contracture management at this time. Review of Occupational Therapy Discharge summary, dated [DATE] to 11/20/25, indicated for Resident 3 to wear the brace during the day, off at night and as needed. Recommendations upon therapy discharge: Caregivers were instructed on proper application of brace for left hand. Review of advanced skin check note, dated 12/8/25 at 10:44 p.m., indicated Resident 3 did not have an external device. Review of advanced skin check note, dated 1/21/26 at 7:31 p.m., indicated Resident 3 did not have an external device. During an interview on 6/11/26 at 10:48 a.m., Therapy Manager indicated Resident 3 had a palm protector for her left-hand contracture at one time, but it caused a sore. The resident was picked up by occupational therapy on 9/30/25 and was re-evaluated. It was our recommendation for the resident to wear the brace to her left hand during the day. She was under the assumption that the recommendation was being implemented as advised by therapy. During an interview on 6/11/26 at 11:04 a.m., Registered Nurse (RN) 6 indicated Resident 3 had not worn a brace for a long time because she thought it caused a sore, but she was not sure how long ago that was. During an interview on 6/11/26 at 11:24 a.m., the Director of Nursing indicated she was unable to find an order on the computer for a brace for Resident 3's left hand. She indicated staff must have missed the recommendation. During an interview on 6/11/26 at 1:52 p.m., Certified Nurse's Aide (CNA) 7 indicated they had never seen Resident 3 with a brace on her left hand. During an interview on 6/11/26 at 1:54 p.m., CNA 8 indicated she had remembered Resident 3 having a brace at one time, but she thought it was just being trialed by therapy and only saw it for a short time. During an interview on 6/11/26 at 1:56 p.m., the Therapy Manager indicated the nursing staff had never placed an order in Resident 3's chart for the brace. She would have to put in a new request to have the resident re-evaluated since the brace was recommended over 7 months ago and was never implemented. On 6/11/26 at 4:01 p.m., the Administrator provided an undated document, titled, Specialized Rehabilitative Services Policy, and indicated it was the current policy being used by the facility. The policy indicated, .To ensure that appropriate rehabilitative services are available to the residents and outline the responsibilities of therapy providers as well as facility staff.8. Therapists are responsible to communicate in writing to the Nursing Department recommendations.9. Nursing staff shall provide interventions with compliment, reinforce, and are consistent with specialized services and projected outcomes.11. The qualified therapist will assess the resident and develop a plan of care including the type, amount, frequency, and duration of treatment and measurement in response to the physician's order. Assessment will include quantitative measurements, as appropriate of the resident's baseline status. 12. The therapist will provide the attending physician evaluation findings and obtain specific treatment orders prior to initiating service.15. The therapists will maintain close communication with the nursing staff concerning the resident's progress and/or needs. Therapists will be notified of changes in the resident's condition as it relates to therapy. 410 IAC (Indiana Administrative Code) 16.2-3.1-42(a)(2)

Based on interview and record review the facility failed to provide a respiratory assessment prior to and after administration of respiratory treatment for 1 of 4 residents reviewed for respiratory care (Resident 47).Findings include:On 6/8/26 at 1:28 p.m., during an initial interview and observation, Resident 47 indicated the nurses did not assess her before or after nebulizer treatments. On 6/10/26 at 2:00 p.m., reviewed the medical record of Resident 47. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, asthma (a chronic lung disease that causes the airways to swell, narrow, and produce extra mucus), atrial fibrillation (an irregular heart rhythm that begins in the upper atria of your heart), hypertension (high blood pressure), and respiratory failure.A Physician order, dated 5/21/26, indicated to administer via nebulizer (a medical device that converts liquid medication into a fine mist that you breathe directly into your lungs) 1 vial of budesonide (corticosteroid used to treat asthma) inhalation suspension 0.5 mg (milligrams) per (/) 2 ml (milliliter) two times a day for shortness of breath.An admission Minimum Data Assessment (MDS), dated [DATE], indicated the resident had some cognitive deficits, was dependent upon staff for assistance with daily care needs and received respiratory therapy treatment during the assessment period.Review of the Electronic Medication Administration Record (EMAR) for June 2026 lacked documentation the resident had been assessed prior to administration of nebulizer treatment. The EMAR indicated the resident was only assessed for pain.On 6/10/26 at 2:30 p.m., during an interview the Director of Nursing (DON) indicated residents should be assessed prior to administration of breathing treatments and she did not know why it had not been completed for Resident 47.On 6/11/26 at 10:31 a.m., during an interview Registered Nurse (RN) 15, indicated she assessed residents for lung sounds heart rate and administered medication then would assess again after medication administration.On 6/11/26 at 10:40 a.m., during an interview RN 16 indicated she assessed residents before and after treatment and documented it in the EMAR.A care plan, dated 5/22/26, indicated the resident had altered respiratory status/difficulty breathing related to, asthma, chronic bronchitis, and chronic respiratory failure. Interventions included, but were not limited to, administer medication/puffers as ordered, monitor for effectiveness and side effects, and monitor for signs and symptoms of respiratory distress and report to physician and as needed.On 6/10/26 at 2:57 p.m., the Administrator provided an undated document, titled, NEBULIZED MIST INHALATION TREATMENT, dated, and indicated it was the policy currently being used by the facility. The policy indicated, . 5. Assess and document a. Lung sounds, b. Oxygen saturation, c. Heart rate. Post-Treatment 1. Reassess and document: Breath sounds, Respiratory rate, Heart rate, Oxygen saturation, and length of treatment.410 Indiana Administrative Code (IAC) 16.2-3.1-21(i)(1)

Based on record review and interview, the facility failed to ensure a pharmacy recommendation was implemented as requested and approved by physician for 1 of 5 residents reviewed for unnecessary medications (Resident 59). Findings include: Resident 59's record was reviewed on 6/9/26 at 1:10 p.m. The profile indicated the resident's diagnoses included, but were not limited to, type II diabetes mellitus with chronic diabetic kidney disease (happens when high blood sugar damages the small blood vessels in your kidneys, affecting their ability to filter waste), chronic obstructive pulmonary disease (COPD- a group of progressive lung diseases, primarily emphysema [progressive irreversible lung disease where the tiny air sacs in the lungs are destroyed] and chronic bronchitis, that block airflow and make breathing difficult), and osteoporosis (a bone disease that causes bones to become weak, brittle, and highly susceptible to fractures). Facility census information indicated Resident 59 was admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) assessment, dated 4/18/26, indicated the resident was cognitively intact. Review of pharmacy recommendation, dated 7/22/25, indicated Resident 59 received Alendronate (is a bisphosphonate [strengthens bones by flowing down bone breakdown] medication used to prevent and treat osteoporosis) 70mg (milligrams) every week. Please consider reducing the dose to 35mg every week. The physician marked the form as agreed and signed and dated the form on 7/28/25.The electronic health record indicated the resident remained on the 70mg dose until 4/13/26During an interview on 6/10/26 at 9:16 a.m., the Director of Nursing (DON) indicated she was unable to find where Resident 59's Alendronate medication had been decreased as recommended and agreed upon by the physician. The facility did not follow the pharmacy recommendation that the physician agreed upon. On 6/10/26 at 2:58 p.m., the Administrator provided an undated document, titled, Pharmacy Consultation, and indicated it was the current policy being used by the facility. The policy indicated, .4. Individual pharmacy recommendations will be delivered to appropriate physicians for review, acceptance, or revision. 5. Upon receipt of signed recommendations, orders are noted by Director of Nursing or designee for implementation.410 IAC (Indiana Administrative Code) 16.2-3.1-48(a)(1)

Based on observation and interview, the facility failed to ensure employees washed and sanitized their hands during meal services for 2 of 2 meal service observations.Findings include:On 6/8/26 at12:08 p.m., during hall tray meal service, observed Certified Nurse Aide (CNA) 4, standing in the restroom with Resident 43. CNA 4 left the door to the room open and the resident's restroom door open. The resident and CNA were visible from the door to the room and into the restroom. The CNA assisted the resident to pull down her pants. He left the restroom walked out of the room and closed the door. CNA 4 was not observed washing his hands or utilizing hand sanitizer. He came into the hall and passed a meal tray to Resident 7. Observed CNA leave the room and failed to wash or sanitize his hands before going to the next resident.On 6/8/26 at 12:13p.m., observed CNA 5, pass trays in the hall and in the rehabilitation dining room. The CNA assisted residents with clothing protector, napkins and failed to sanitize her hands after assisting the residents and before assisting the next resident. On 6/8/26 at 12:20 p.m., during an interview CNA 5, acknowledged she failed to sanitize or wash her hands between residents.On 6/8/26 at 12:25 p.m., during an interview CNA 4 indicated he washed his hands while he was in the restroom with Resident 43. He indicated normally he used wipes to clean his hands, but he had washed them instead.On 6/10/26 at 3:00 p.m., the Director of Nursing provided an undated document, titled, Hand Hygiene, dated, and indicated it was the policy currently being used by the facility. The policy indicated, . Hands will be washed with running water at a temperature of not less than 100 F and antimicrobial soap whenever there is visible soiling (these materials include but are not limited to feces, blood or other body fluids), and a. Before and after assisting a resident with meals. Taking care to not touch ready to eat foods with bare hands, b. After using the bathroom, c. Before and after assisting a resident with toileting. 410 Indiana Administrative Code (IAC)16.2- 3.1-21(i)(1)410 Indiana Administrative Code (IAC)16.2-3.1-21(i)(3)

Based on record review and interview, the facility failed to ensure medications were documented as administered as ordered, for 1 of 5 residents reviewed for unnecessary medications (Resident 24). Findings include:Resident 24's record was reviewed on 6/9/26 at 1:11 p.m. The profile indicated the resident's diagnoses included, but were not limited to, unspecified dementia with agitation (confusion or mild cognitive impairment which may include symptoms agitation or irritability, fidgeting, or other repetitive movements), essential hypertension (high blood pressure), unspecified pain, and unspecified glaucoma (an eye disease that damages the optic nerve). Review of the May 2026 Medication Administration Record (MAR), indicated the following: A physician's order, dated 12/30/24, indicated to administer two 325 milligram (mg) tablets of Tylenol (medication used to treat pain) two times daily for pain. The MAR lacked documentation that the 6:00 p.m., dose on 5/7/26, had been administered as ordered. A physician's order, dated 12/31/24, indicated to administer a 3 mg tablet of Rexulti (medication to treat dementia with agitation) every evening for dementia. The MAR lacked documentation that the 6:00 p.m., dose on 5/7/26, had been administered as ordered. A physician's order, dated 12/31/24, indicated to administer a 100 mg tablet of Seroquel (medication to treat dementia with agitation) every evening for agitation. The MAR lacked documentation that the 6:00 p.m., dose on 5/7/26, had been administered as ordered. A physician's order, dated 9/17/25, indicated to administer 1 drop of Travoprost Solution (medication to treat glaucoma symptoms) to both eyes every evening for eye pain. The MAR lacked documentation that the 6:00 p.m., dose on 5/7/26, had been administered as ordered. A physician's order, dated 4/24/26, indicated to administer a 20 mg tablet of Lisinopril (medication to treat high blood pressure) two times daily for hypertension. The MAR lacked documentation that the 6:00 p.m., dose on 5/7/26, had been administered as ordered. During an interview, on 6/10/26 at 1:33 p.m., the DON indicated she was not sure why the 6:00 p.m., medications on 5/7/26 had not been documented as administered. The expectation was that medications should be documented when given. On 6/10/26 at 2:57 p.m., the DON provided an undated document, titled, Medication Administration Policy, and indicated it was the policy currently being used by the facility. The policy indicated, .Standards: .18. Medications shall be recorded on the medication record promptly after each administration by the individual who administered the drug. 410 IAC (Indiana Administrative Code) 16.2-3.1-50(a)(2)

Based on record review and interview, the facility failed to ensure pressure ulcers (skin and tissue damage caused by prolonged pressure) were treated timely after admission for 3 of 3 residents reviewed for pressure ulcers (Residents B, C, and D). Findings include:1. Resident B's record was reviewed on 1/15/26 at 11:16 a.m. Census information indicated the resident was admitted to the facility on [DATE]. A pre-admission screening tool, dated 10/30/25, indicated the resident had a wound to the right buttock. An admission Minimum Data Set (MDS) assessment, dated 11/10/25, indicated the resident had an unhealed pressure ulcer. Hospital discharge instructions, signed 11/3/25, indicated, .Wound care-Mepilex [soft foam dressing] on coccyx [tailbone] wound, barrier cream. An admission skin assessment, dated 11/3/25, indicated the resident had a red, scabbed area on the upper mid back. The assessment lacked documentation there was a wound to the buttocks or coccyx. A wound Nurse Practitioner (NP) note, dated 11/5/25, indicated the resident had blanchable erythema (redness that turns white when pressed) with satellite lesions (small, scattered areas) to the sacrum (tailbone). The NP recommended Triad (zinc based cream for wound healing) cream and antifungal powder twice daily and leave open to air for 14 days. A physician's order, dated 11/8/25, indicated cleanse area on buttocks with soap and water, pat dry thoroughly, apply house antifungal powder, keep buttocks clean and dry and prevent skin to skin contact, prevent excessive moisture and apply barrier protection as needed, and leave the area open to air every day and night shift. The order was discontinued on 11/25/25. A physician's order, dated 11/8/25, indicated apply a thick layer of Triad cream and house antifungal powder to buttocks, keep buttocks clean and dry and prevent skin to skin contact, prevent excessive moisture, apply barrier protection as needed, leave open to air twice daily. The order was discontinued on 11/25/25. A Treatment Administration Record (TAR), dated November 2025 lacked documentation a physician's order was obtained for a treatment to the resident's buttocks or coccyx prior to 11/8/25. A skin check note, dated 11/10/25, indicated the resident had moisture associated skin damage to the right buttock that was acquired in house. A physician's order, dated 11/25/25, indicated cleanse area of buttocks with soap and water, pat dry thoroughly, apply layer of Triad (zinc based cream for wound healing) cream and house antifungal powder to buttocks, keep buttocks clean and dry and prevent skin to skin contact, prevent excessive moisture, apply barrier protection as needed, leave open to air twice daily. The order was discontinued on 12/4/25. A wound NP progress note, dated 12/3/25, indicated the facility requested the NP re-evaluate the resident's sacrum. A stage three (full-thickness tissue loss extending into the fatty layer) pressure ulcer was noted to the resident's right inner buttock. The NP recommended a treatment of medical grade honey to the wound. A physician's order, dated 12/5/25, indicated cleanse wound with wound cleanser, pat dry, apply medical grade honey to the base of the wound, secure with bordered gauze, change dressing daily and as needed. The order was discontinued on 12/18/25. A TAR, dated December 2025, lacked documentation a physician's order for a treatment to the resident's right inner buttock pressure ulcer was obtained prior to 12/5/25. 2. Resident C's record was reviewed on 1/15/26 at 3:19 p.m. Census information indicated the resident was admitted to the facility on [DATE]. An admission Minimum Data Set (MDS) assessment, dated 1/3/26, indicated the resident was cognitively intact and had an unhealed pressure ulcer. A nursing progress note, dated 12/16/25, indicated the resident had a pressure ulcer on each buttock, and the physician was notified. A nursing progress note, dated 12/17/25, indicated the resident was sent to the emergency room (ER). A nursing progress note, dated 12/27/25, indicated the resident returned to the facility. A skin check note, dated 12/27/25, indicated the resident had a wound to the buttocks but lacked documentation of an assessment of the wound or measurements. A physician's order, dated 12/29/25, indicated cleanse the wounds on bilateral buttocks with saline, pat dry, apply medihoney (treatment to promote wound healing) to wound bed, cover with bordered gauze, and change daily. A Treatment Administration Record (TAR), dated December 2025, lacked documentation a physician's order was obtained for a treatment to the pressure ulcers on the resident's bilateral buttocks prior to 12/29/25. A wound Nurse Practitioner (NP) progress note, dated 12/31/25, indicated the resident had one stage three (full-thickness tissue loss extending into the fatty layer) pressure ulcer to the left buttock and one stage three pressure ulcer to the right buttock. The wound NP recommended a treatment of Triad (zinc based cream for wound healing) paste and Nystatin powder (antifungal) for the wounds. 3. Resident D's record was reviewed on 1/16/26 at 10:27 a.m. Census information indicated the resident was admitted to the facility on [DATE]. A skin check note, dated 1/13/26, indicated the resident was admitted with moisture associated skin damage to the buttocks. A wound Nurse Practitioner (NP) note, dated 1/14/26, indicated the resident had a deep tissue injury to the sacrum (tailbone) that was present upon admission. A physician's order, dated 1/15/26, indicated cleanse wound to sacrum with wound cleanser, pat dry, apply Triad cream (zinc based cream for wound healing) and antifungal powder and leave open to air twice daily and as needed. A Treatment Administration Record (TAR), dated January 2026, lacked documentation a physician's order was obtained for the treatment of the sacral wound prior to 1/15/26. During an interview, on 1/15/26 at 9:37 a.m., the Director of Nursing (DON) indicated she was unable to find any additional documentation treatments were initiated to Resident B, C, or D's wounds at the time of admission. When a resident was admitted with a wound the nurses should have followed the hospital discharge instructions and notify the wound nurse. The facility had a wound NP that made treatment recommendations, but they had to get the orders from the medical director. Treatments should have been ordered at admission or when a wound was found. On 1/16/26 at 9:50 a.m., the DON provided an undated document titled, Skin Condition and Pressure Ulcer Assessment, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure.5. If the abnormality noted during the Weekly Skin Assessment is new, the nurse shall notify the attending physician and obtain a treatment order, if indicated. This citation relates to Intake 2689447. 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to ensure that staff assessed a resident with a pressure ulcer and implemented treatments which resulted in harm due to the pressure ulcer worsening from a stage 1 (non-blanchable red intact skin) to a stage 3 (full thickness skin loss where fat tissue may be visible) before pressure ulcer assessments and treatments were started for 1of 2 residents reviewed for pressure ulcers (Resident 16). Findings include: On 5/12/25 at 11:23 a.m., during an initial observation and interview Resident 16 indicated he had a sore area on his bottom. On 5/14/25 at 8:46 a.m., the medical record of Resident 16 was reviewed. The resident was admitted to the facility on [DATE], diagnosis included but were not limited to myocardial infarction type 2 (occurs when there's an imbalance between the heart's oxygen supply and demand, leading to injury or death of heart muscle tissue), chronic respiratory failure with hypoxia (the lungs are unable to adequately transfer oxygen into the blood over a long period, leading to low oxygen levels in the blood and tissues), chronic obstructive pulmonary disease (COPD) (a group of diseases that cause airflow blockage and breathing-related problems), and pressure ulcer of sacral region (tail bone). A warm handoff form (a form used to receive patient information including medical conditions at the time of the discharge from the hospital), from admission on 3/25/25, indicated the resident was discharged from the hospital with a stage 1 wound to the coccyx, (stage 1 wound indicated the skin was red, no broken skin). The medical record lacked evidence of an assessment of the pressure wound on the coccyx area at time of admission on 3/25/25, until the resident was seen by wound care services on 4/1/25. The record lacked evidence of a physician order to treat the wound on the coccyx from 3/25/25 to 4/1/25. The medical record indicated when the resident's wound was assessed by the wound care nurse 7 days after admission to the facility the wound had increased from a stage 1 to a stage 3. A care plan, dated 3/27/25, indicated the resident had the potential for pressure wounds. The record lacked documentation indicating a care plan was initiated for an actual pressure wound with interventions. An admission Minimum Data Set Assessment (MDS), dated [DATE], indicated the resident was cognitively intact and required assistance for daily care needs. A Physician order, dated 4/2/25, indicated to cleanse area on coccyx, apply collagen to area and cover with bordered gauze daily and PRN (as needed) every night shift for a stage 3 pressure ulcer (a full thickness ulcer that might involve subcutaneous fat). A physician order, dated 4/8/25, indicated every night shift to cleanse area on coccyx, apply Medihoney to area and cover with a ABD pad (large absorbent dressing) and do not secure with tape for stage 3 pressure ulcer. On 5/13/25 at 9:55 a.m., during an interview Registered Nurse (RN) 5 indicated the resident was admitted with a wound on the coccyx. She acknowledged the report from the hospital indicated the resident had a stage 1 pressure area on the coccyx. She indicated the resident refused to allow the nurse to assess the wound at admission. She did not know why treatment orders were not obtained on the day of admission or until 4/1/25. On 5/13/25 at 2:11 p.m., during an interview the Director of Nursing (DON) indicated if a resident was admitted with a wound it should be assessed at the time of admission. If the resident refused to allow an assessment they would continue to attempt to assess the wound. She acknowledged the nurse would call the physician and obtain wound care orders at the time of admission. She indicated the wound care provider visits weekly and assesses wounds. On 5/14/25 at 2:11 p.m., during an interview Registered Nurse (RN) 9 indicated she would look at the resident's skin at admission. If the resident refused she would pass the information onto the next shift and ask the nurse to assess the resident's skin. She indicated she would assess the resident from head to toe at admission. She would call physician if there were no treatment orders in the admission discharge hospital orders. If the resident had a pressure wound she would assess the wound but would not measure it or stage it. She would wait for the wound nurse to measure the wound. On 5/13/2025 at 1:37 p.m., the DON provided an undated document, titled, Skin condition and pressure ulcer assessment, and indicated it was the policy currently being used by the facility. The policy indicated, .1. A skin assessment and Braden Scale will be performed on admission .8. The nurse shall document in the Nurse Progress note that a skin abnormality was identified, the physician and legal representative notification and any new orders 3.1-40

A. Based on interview and record review, the facility failed to prevent a delay in treatment after a fall with fracture for 1 of 3 residents reviewed for accidents (Resident 27). B. Based on record review and interview, the facility failed to ensure a treatment order was stopped or clarified after 60 days for 1 of 5 residents reviewed for unnecessary medications (Resident 30). Findings include: A. During an interview, on 5/12/25 at 9:40 a.m., Resident 27's Health Care Representative indicated the resident fell in December 2024 and fractured her hip. They thought the resident was not injured, so she was not sent to the hospital right away. The Health Care Representative indicated she normally placed the resident's walker next to her bed before she left in the evening, but the day the resident fell she had not ensured the walker was next to the resident's bed before she left. The Health Care Representative indicated since the resident's fall she always made sure the resident's walker was next to her bed before leaving for the evening. Resident 27's record was reviewed on 5/15/25 at 9:11 a.m. A significant change Minimum Data Set (MDS) Assessment, dated 3/14/25, indicated the resident had a severe cognitive impairment and had occasional urinary incontinence. Diagnoses on the resident's profile included, but were not limited to, unspecified fracture of the left femur (thigh bone). A Progress Note, dated 12/1/24 at 4:33 a.m., indicated the nurse was called to the resident's room after the resident was found on the floor on her back. The resident was alert with confusion and had not used her walker. The resident was assessed and had no open areas or bruising. As the staff moved her to bed, the resident indicated her hip and knee hurt. The resident's leg had no shortening, swelling, or disfigurement. The staff placed the resident in bed. The note indicated, This nurse will pass on the info to [physician name] and the next shift. The record lacked documentation the physician was notified of the resident's fall or left hip pain on 12/1/24. An xray report indicated an xray of the resident's left femur and knee was completed on 12/1/24 at 6:09 p.m. The results indicated an acute fracture of the neck of the resident's left femur. The results were reported to the facility on [DATE] at 8:07 p.m. The report did not indicate how the results were communicated to the facility. A Progress Note, dated 12/2/24 at 8:09 a.m., indicated the resident complained of left leg pain during day shift on 12/1/24. The nurse assessed the resident and contacted the physician for an xray order. The xray was ordered, and results came back on night shift of 12/1/24. Upon the return of the day shift nurse, xray results were found, and the resident had a fractured left femur. The nurse contacted the physician, and the resident was sent to the emergency room (ER). Hospital Discharge Instructions, dated 12/6/24, indicated the resident was discharged back to the facility after an open reduction internal fixation (ORIF) (repair) of the left femur. A Progress Note, dated 12/6/24, indicated the resident returned to the facility. During an interview, on 5/15/24 at 10:42 a.m., the Assistant Director of Nursing (ADON) indicated the facility staff should have called the physician when the resident fell , and the conversation and physician's response should have been documented in the resident's medical record. On 5/15/25 at 11:14 a.m. the ADON provided the following documentation of the physician notification of the resident's fall and pain. a. A text message thread included an undated and untimed message to the physician which indicated, .We had three falls last night The text message indicated the resident had some pain in the left hip and knee but no shortening, and she was able to lay on it. The resident seemed weak and did not walk well. There was no response from the physician. The next text message in the thread was on 12/1/24 at 3:13 p.m., and indicated the resident was still complaining of pain in the left leg, and requested an order for an xray of the resident's femur and knee. The physician responded, Yes. b. A fall report, dated 12/1/24, indicated the resident fell . The report indicated the physician was notified on 12/1/24 at 4:32 a.m., however, the Progress Note, reviewed above, was written one minute later than the report and indicated the physician would be notified at a later time. During an interview, on 5/15/25 at 11:14 a.m., the ADON acknowledged the fall report indicated the physician was notified one minute before the Progress Note was written which stated the physician would be notified at a later time. She was unable to provide further information regarding the notification of the resident's physician of the fall or the resident's reported pain. The ADON indicated when the physician was contacted, by text message or other means, the nurse should have documented the physician notification and the response in the resident's medical record. The reported time on the resident's xray report was the date and time the facility was notified of the results. The xray company faxed results and did not call the facility. The staff should have addressed the resident's fracture immediately when the report was received. During an interview, on 5/15/24 at 11:30 a.m., Certified Nurse Aide (CNA) 14 indicated if a resident fell the CNA called for help and waited for a nurse assessment before the resident was moved. If the resident complained of pain they should have notified the nurse. During an interview, on 5/15/24 at 11:32 a.m., Registered Nurse (RN) 9 indicated if there were signs or symptoms of a fracture after a resident fell they should not have moved the resident until Emergency Medical Services (EMS) arrived. If the nurse assessed the resident and assisted the resident to move, but the resident complained of pain when moving then the staff should have stopped moving the resident and sent them to the hospital. On 5/13/24 at 2:15 p.m., the Director of Nursing (DON) provided an undated document titled, Fall Risk and Post Fall Assessment, and indicated it was the policy currently being used by the facility. The policy indicated, .4. Conduct Physical and Mental Status Assessment .d. Assess limb strength and motion by asking the resident if he/she has pain and the location .e. If you suspect any injury to bone/joints, don't move until seen by a physician or transported to an acute care setting On 5/15/24 at 11:55 a.m., the ADON provided a document titled, Diagnostic Services, updated on 2/23/18, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: To ensure that appropriate diagnostic services are available to the residents and to outline the responsibilities of provider services and facility staff .11. Licensed nurses are responsible for documenting the performance of laboratory tests and test results if performed in-house, and physician notification in the nurses's notes .14. Upon notification by the diagnostic service, the nurse in charge will notify the attending physician of abnormal lab and/or radiology results 34525 B. Resident 30's record was reviewed on 5/12/25 at 1:57 p.m. The profile indicated the resident's diagnoses included, but were not limited to, multiple sclerosis (a chronic autoimmune disease that affects the central nervous system [brain and spinal cord]). A quarterly Minimum Data Set (MDS) assessment, dated 2/11/25, indicated the resident was at risk for skin issues. A physician's order, dated 12/13/24, indicated to apply Ammonium Lactate External Cream 12 % (used to treat dry or scaly skin in adults and children) to both feet topically (on the skin) at bedtime for skin integrity protection for 60 days. The order lacked a specific stop date for the treatment. A pharmacy recommendation, dated 4/17/25, indicated to discontinue (DC) the treatment order, since it had been active for longer than 60 days. The order history lacked documentation that an order had been written to DC the treatment order. During an interview, on 5/13/25 at 11:50 a.m., the Director of Nursing (DON) indicated she had assumed that the order was an as needed (PRN) order. The pharmacy recommendation should have been addressed. The Pharmacist should have caught this around the time of the 60 days, and requested that an end date for the treatment be obtained. During an interview, on 5/13/25 at 1:44 p.m., the DON indicated the recommendation was not designated for the physician to address, but was for the nursing staff to address. The Pharmacist should have provided an specific end date for the cream when the order was originally sent to the Pharmacy, but had failed to do so. On 5/13/25 at 1:38 p.m., the DON provided an undated document, titled, Pharmacy Consultation, and indicated it was the policy currently being used by the facility. The policy indicated, .Standards .5. Upon receipt of signed recommendations, orders are noted by the Director of Nursing or designee for implementation. 3.1-37(a)

Based on interview and record review, the facility failed to ensure a root cause analysis was completed and an intervention put in place after falls for 1 of 3 residents reviewed for accidents (Resident 27). Findings include: During an interview, on 5/12/25 at 9:40 a.m., Resident 27's Health Care Representative indicated the resident fell in December 2024 and fractured her hip. They thought the resident was not injured, so she was not sent to the hospital right away. The Health Care Representative indicated she normally placed the resident's walker next to her bed before she left in the evening, but the day the resident fell she had not ensured the walker was next to the resident's bed before she left. The Health Care Representative indicated since the resident's fall she always made sure the resident's walker was next to her bed before leaving for the evening. Resident 27's record was reviewed on 5/15/25 at 9:11 a.m. A significant change Minimum Data Set (MDS) Assessment, dated 3/14/25, indicated the resident had a severe cognitive impairment and had occasional urinary incontinence. Diagnoses on the resident's profile included, but were not limited to, unspecified fracture of the left femur (thigh bone). A Progress Note, dated 12/2/24 at 4:33 a.m., indicated the nurse was called to the resident's room when the staff found the resident on the floor on her back. The resident was alert but confused and was not using her walker. The resident was assessed, and there were no open areas or bruising. When the staff moved the resident she complained of pain to the left hip and knee. There was no shortening, swelling, or disfigurement in the resident's leg. The resident was put in bed. The note lacked documentation an immediate intervention was put in place to prevent another fall. A Post Fall Evaluation Note, dated 12/2/24 at 4:54 a.m., indicated the resident had an unwitnessed fall in her room, and the reason for the fall was toileting. The note indicated there were no injuries. The note lacked documentation of why the resident had not used her walker when attempting to ambulate to the bathroom or an intervention put in place to prevent further falls. A Progress Note, dated 12/2/24 at 8:09 a.m., indicated the resident complained of left leg pain during day shift on 12/1/24. The nurse assessed the resident and requested an order for an xray from the physician. The xray results came back on night shift on 12/1/24. Upon return of day shift, on 12/2/24, the xray results showed the resident had a fractured left femur. The physician was notified, and the resident was sent to the emergency room (ER). A Progress Note, dated 12/6/24, indicated the resident returned to the facility. A care plan, initiated on 12/18/24, indicated the resident had a left femur fracture related to a fall. Interventions included anticipate and meet the resident's needs, ensure the call light is within reach and respond promptly, change surgical incision dressing as ordered and as needed, encourage deep breathing and relaxation techniques, follow the physician's orders for weight bearing status, and modify the environment as needed to meet the resident's current needs. The care plan lacked resident-specific interventions to address the root cause of the resident's fall. A Progress Note, dated 12/20/24, indicated the resident's sitter came to the nurse's station and reported the resident was on the floor. The nurse entered the room, and the resident was sitting on the floor leaning towards her right hip. The resident said she wanted to scoot to the bathroom. The resident's sitter indicated the resident did not fall, and when the sitter woke up the resident said she was going to the bathroom then lowered herself gently to the floor. The resident was assisted to the bathroom and back to bed. The note lacked documentation of an intervention put in place to prevent further falls. A care plan, last revised on 4/3/25, indicated the resident was at risk for falls related to requiring assistance with activities of daily living (ADLs), decreased mobility, unsteady balance, history of falls, cognitive deficit, behaviors, incontinence, pain, shortness of breath, and the use of multiple medications. Interventions were reviewed and were dated on, or before, 1/5/23. There were no updated or revised interventions with the falls on 12/1/24, 12/20/24, or 5/4/25, included on the fall care plan. A Post Fall Evaluation Note, dated 5/4/25 at 4:19 p.m., indicated the resident had an unwitnessed fall in her room. The resident stated she was just standing in her room. The resident was found siting on her bottom in the doorway, with no apparent injuries. The root cause analysis questions were answered, but the note lacked documentation of an intervention put in place to prevent further falls. A Progress Note, dated 5/4/25 at 4:33 p.m., indicated the resident had an unwitnessed fall, in her room, around 3:45 p.m. The resident was found sitting up on the floor in her doorway. The resident stated she went down gracefully and did not hurt herself. The note lacked documentation of an intervention put in place to prevent further falls. During an interview, on 5/15/15 at 11:14 a.m., the Assistant Director of Nursing (ADON) indicated a root cause analysis should have been completed with each fall, and an intervention should have been put in place to prevent further falls. On 5/15/25 at 1:37 p.m., the ADON provided documentation from therapy the resident was evaluated as an intervention for the resident's fall on 5/4/25. At the same time, the ADON indicated the intervention should have been documented in an interdisciplinary team (IDT) note after the fall, but a note was not completed. The ADON indicated she was unable to find an intervention put in place for the falls on 12/1/24 and 12/20/24. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident's indwelling urinary catheter (a semi-flexible plastic tube with one end inserted into the bladder) which is attached to a urinary drainage bag (a bag that collects urine) did not touch the floor for 1 of 1 residents reviewed for catheter care (Resident 52). Findings include: On 5/9/25 at 11:18 a.m., during an initial observation and interview Resident 52 indicated he was not sure why he had a catheter, but he thought it may be due to prostate cancer. Observed the resident sitting in a wheelchair in the main dining area. The catheter bag was attached to the bar under the wheelchair and was touching the floor. On 5/9/25 at 12:11 p.m., observed Resident 52 propelling self in wheelchair. Observed catheter bag dragging on the floor under the wheelchair. On 5/13/25 at 9:52 a.m., during interview with Registered Nurse (RN) 5 she indicated the catheter bag should never touch the floor and when she was positioning a drainage bag she would ensure the bag was not touching the floor. On 5/14/25 at 11:35 a.m., reviewed the medical record of Resident 52. The resident was admitted to the facility on [DATE]. Admitting diagnosis included but not limited to retention of urine (a condition in which you are unable to empty all the urine from your bladder), malignant neoplasm of prostate (a tumor within the prostate gland), and benign prostatic hyperplasia (a non-cancerous enlargement of the prostate gland, often causing urinary problems). A care plan dated 4/15/25, indicated the resident had an Indwelling Catheter related to urinary retention. Intervention included but not limited to, prevent kinks in catheter tubing. An admission Minimum Data Set Assessment (MDS) dated [DATE], indicated the resident was cognitively intact and had an indwelling catheter since admission to the facility. On 5/13/25 at 1:37 p.m., the Director of Nursing (DON) provided an undated document, titled, Urinary Catheter Care, and indicated it was the policy currently being used by the facility. The policy indicated, .Standards .7. Urinary drainage bags and tubing shall be positioned to prevent either from touching the floor 3.1-41(a)(1)

Based on observation, record review, and interview, the facility failed to ensure proper cleaning and storage of respiratory equipment for 2 of 4 residents reviewed for respiratory care (Residents 50 and 270). Findings include: 1. During an observation, on 5/15/25 at 8:53 a.m., Registered Nurse (RN) 8 administered a breathing treatment to Resident 50. The nurse removed the breathing treatment mask from the resident at 9:08 a.m., she opened the chamber (this holds the liquid medication) and dumbed out the remaining medication left in the chamber into the trash can and returned the respiratory mask and tubing to a clear plastic bag. Resident 50's record was reviewed on 5/15/25 at 11:07 a.m. The profile indicated the resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD- a lung disease characterized by airflow obstruction, making it difficult to breathe) with acute exacerbation (a period where COPD symptoms worsen significantly beyond the usual day-to-day experience) and unspecified asthma (a chronic disease in which the bronchial airways in the lungs become narrowed and swollen, making it difficult to breathe). An admission Minimum Data Set (MDS) assessment, dated 4/16/25, indicated the resident was cognitively intact and received respiratory therapy. A physician's order, dated 4/9/25, indicated ipratropium-albuterol solution (a medication that can help people with lung problems, like asthma or obstructive pulmonary disease, breathe easier) 0.5-2.5 milligrams (mg)/3 milliliters (ml) inhale orally via nebulizer four times a day for COPD. A care plan, dated 4/10/25, indicated the resident had COPD and asthma. Interventions included, but were not limited to, give aerosol or bronchodilators (a drug that causes widening of the bronchi) as ordered, give oxygen therapy as ordered by physician, and head of bed to be elevated. During an interview on 5/15/25 at 10:25 a.m., Registered Nurse (RN) 9 indicated the nebulizer mouthpiece and medication chamber was to be rinsed out after use and once dried it should be placed in a bag until used again. 48226 2. On 5/9/25 at 2:11 p.m., during initial observation the resident was sleeping in bed. Observed a clear storage bag next to the resident's bed. The storage bag was dated 5/9/25. A nebulizer unit, (a reservoir for holding the liquid for nebulization), and a tracheostomy (an opening surgically created through the neck into the trachea to allow air to fill the lungs) mask which adapts nebulizers for patients who have had a tracheostomy to receive inhalation therapy which the medication aerosol is inhaled and the nebulizer tubing was inside of the bag. The reservoir was observed to have clear liquid inside. Observed suction canister (a container used in medical procedures to collect body fluids and debris removed during treatment through suction pressure), was next to the bed. The canister was half full of green liquid. The suction tubing (suction tubing is used to remove fluids, secretions, or debris from the body, during procedures like suctioning the airway) was observed with green and white colored debris throughout the inside of the tubing. The suction tubing was placed inside of the bag with the nebulizer administration set. On 5/12/25 at 9:48 a.m., observed nebulizer equipment inside of a clear storage bag next to the resident's bed. The storage bag observed with clear fluid in the interior of the bag. The nebulizer administration set was wet and stored inside of the bag. On 5/13/25 at 9:45 a.m., observed nebulizer administration set in a clear bag next to the bed. The inside of the bag was wet, and the nebulizer administration set was wet. On 5/13/25 at 9:51 a.m., during an interview Registered Nurse (RN) 5 indicated after she completed a nebulizer treatment she rinsed the equipment and allowed it to dry and placed the equipment in the storage bag. On5/13/25 at 1:59 p.m., during an interview the Director of Nursing (DON) indicated the suction canister was a closed system and the suction tubing from the machine must be cleaned after use and stored in a clean bag separate from other equipment. She acknowledged the nebulizer equipment should be clean and dry before being placed in a clean bag. On 5/14/25 at 2:08 p.m., during interview Registered Nurse (RN) 9 indicated she would clean the nebulizer administration set and place it in the designated bag. If it was very soiled she would wash the equipment and allowed to air dry, before placing it into storage bag. On 5/14/25 2:15 p.m., the medical record of Resident 270 was reviewed. The record indicated the most recent admission to the facility was on 5/5/25. Admission diagnosis included but was not limited to acute and chronic respiratory failure (a long-term condition where the lungs are unable to adequately exchange oxygen and carbon dioxide), traumatic brain injury (a form of acquired brain injury, occurs when a sudden trauma causes damage to the brain), and quadriplegia (a condition characterized by the paralysis or loss of function in all four limbs). A physician order, dated 5/5/25, indicated to administer Ipratropium-Albuterol Solution 0.5-2.5 (3) mg (milligram) 3ML (milliliter) 1 vial via (by way of) trach (tracheostomy) every 6 hours for respiratory failure and 1 vial via trach every 4 hours as needed for congestion; shortness of breath. A care plan, dated 1/16/20, indicated that the resident had the potential for altered respiratory status/difficulty breathing related to tracheostomy status and diagnosis of acute and chronic respiratory failure. Interventions included but were not limited to, administer breathing medications as ordered and monitor for effectiveness and side effects. A quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated the resident had a tracheostomy which required suctioning and received nebulizer treatments during the review period. On 5/13/2025 at 1:37 p.m., the DON provided an undated document titled, Nebulizer inhalation device sanitizing, and indicated it was the policy currently being used by the facility. The policy indicated, .2. Respiratory equipment used with a mini nebulizer will be stored clean and covered between resident uses .4. The mouthpiece, T-piece nebulizer cup and lid will be washed with warm soapy water, rinsed thoroughly between each use with sterile water or tap water, and disinfected daily. All pieces are then rinsed thoroughly with tap water, drained, air dried in a clean location, then stored in a clean container On 5/13/2025 at 1:37 p.m., the DON provided an undated document titled, Suction machines cleaning and sanitizing, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure .4.Suction water or saline solution through tubing into collection chamber, if needed to clear tubing 3.1-47(a)

Based on observation, interview, and record review, the facility failed to ensure medication was labeled properly and the facility failed to ensure expired medication was disposed of for 2 of 2 medication storage rooms reviewed for medication storage (Resident 49). Findings include: 1. On [DATE] at 10:00 a.m., the north hall medication storage room refrigerator contained an opened and undated multi use vial of Aplisol (a clear, colorless solution for injection as an aid in the diagnosis of tuberculosis) solution. During an interview, on [DATE] at 10:02 a.m., Registered Nurse (RN) 7 indicated she was not aware of how long the Aplisol was good for once opened, but she was aware it should be dated once opened. 2. On [DATE] at 10:11 a.m., the south hall medication storage room refrigerator contained an opened bottle of Mary's Magic Mouthwash (a compounded oral rinse used to treat mouth sores and pain, often associated with cancer treatment). The bottle contained a label that indicated it was for Resident 49 and was opened on [DATE] and had an expiration date of [DATE]. During an interview, on [DATE] at 10:14 a.m., the Assistant Director of Nursing (ADON) indicated the mouthwash should have been discarded two days ago on [DATE]. She also indicated the Aplisol solution was good for 30 days once opened and should have been dated when it was opened. On [DATE] at 2:52 p.m., the Administrator provided an undated document titled, Refrigerated Products Expiration Date, and indicated it was the current policy used by the facility. The policy indicated, .Aplisol injection discard open vials after 30 days On [DATE] at 1:31 p.m., the Administrator provided a document with a revised date of [DATE], titled, Medication Storage Policy, and indicated it was the currently policy used by the facility. The policy indicated, .22. No drugs or biological shall be stored which are beyond manufacturer's expiration date or facility established expiration date 3XXX,d+[DATE](j)

Based on observation, interview, and record review, the facility failed to ensure beard restraints were worn in the kitchen serving area (on the skilled unit) and in the main kitchen food prep area for 2 of 2 kitchen observations. Findings include: 1. During an observation in the kitchen serving area (located on the skilled unit), on 3/11/24 at 11:40 a.m., the Dietary Director was placing whip cream on top of the vanilla and chocolate shakes. The Dietary Director was not wearing a beard restraint and his facial hair was exposed. 2. During an observation in the kitchen serving area, on 3/11/24 at 11:43 a.m., the Dietary Director was placing cinnamon pita chips onto 16 dessert plates from a serving pan. The Dietary Director was not wearing a beard restraint and his facial hair was exposed. During an interview, on 3/11/24 at 11:50 a.m., Dietary Director indicated he should have worn a beard restraint while prepping food that was to be served to the residents. During an interview, on 3/11/24 at 11:54 a.m., Dietary aide 5 indicated when you have facial hair it was to be covered with a beard restraint while in the food prep area. 3. During an observation in the kitchen, on 3/14/24 at 10:21 a.m., Dietary aide 9 was in the food prep area and was transferring applesauce and olives into separate containers and placed them in the refrigerator. The dietary aide was also preparing desserts for the lunch time meal, he was not wearing a beard restraint and his facial hair was exposed. On 3/11/24 at 2:20 p.m., the Dietary Director provided a document, with a revised date of 1/24, titled, Uniform Dress Code, and indicated it was the policy currently being used by the facility. The policy indicated, .Associates working with food .Restrain all facial hair with a beard net/restraint 3.1-21(i)(3)

Based on observation, record review, and interview, the facility failed to accurately assess and document impairments in skin for 1 of 1 residents reviewed for skin impairments (Resident 15). Finding includes: During an observation, on 3/12/24 at 10:21 a.m., Resident 15 was sitting in her wheelchair in her room. The resident indicated she had a sore area behind her right ear, and it had been there for a long time. The resident indicated she thought it was caused by her glasses. A couple of scabbed areas were noted behind her right ear underneath where her glasses touched her skin. Excoriated skin tissue was noted as well. The resident also had a scabbed area on her cheek and nose and indicated she was told they were skin cancer spots. Resident 15's record was reviewed on 3/15/24 at 1:36 p.m. The profile indicated the resident's diagnoses included, but were not limited to, dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgement), disorder of the skin and subcutaneous tissue (medical condition that occurs in the subcutaneous layer), and type II diabetes (a long term condition in which the body has trouble controlling blood sugar and using it for energy). A quarterly Minimum Data Set (MDS) assessment, dated 2/14/24, indicated the resident was cognitively intact and had no open lesions or pressure ulcers. The record lacked a care plan regarding the skin alteration behind the resident's right ear. A weekly skin assessment note, dated 3/12/24, indicated Resident 15 had multiple cancer areas on her face but lacked documentation of the area behind her right ear. A skin sweep progress note, dated 3/7/24, lacked documentation of the resident's skin alteration behind her right ear. During an interview, on 3/15/24 at 1:54 p.m., Resident 15 was sitting up in her wheelchair outside of her room. The resident indicated the nursing staff had not looked at the area behind her ear and had not been treating it with anything. During an interview, on 3/15/24 at 1:56 p.m., Registered Nurse (RN) 8 indicated she was not aware of the area behind Resident 15's ear, but she was aware that she would pick at the sores on her face at times. During an interview on 3/15/24 at 1:57 p.m., Certified Nurse's Assistant (CNA) 20 indicated she was aware of the area on the back of Resident 15's ear and indicated it had been there for a long time. She indicated she had made a note of the area on the shower sheet dated 3/14/24 and it was reported to the nurse. The CNA indicated she thought the area had gotten bigger. During an interview, on 3/15/24 at 2:13 p.m., Director of Nursing (DON) indicated she was not aware of an area of the resident having a skin issue behind her ear. During an interview, on 3/15/24 at 2:37 p.m., DON indicated the wound nurse had noted areas on the resident's face but not behind her ear on the skin assessments. The DON further indicated she had reviewed progress notes and was not able to find any notes regarding the area behind the resident's right ear. The DON assessed the area and noted the scabbing and a small open area behind the ear. A head to toe assessment should be completed by the wound nurse when conducting skin sweeps. On 3/15/24 at 2:32 p.m., the DON provided an undated document titled, Skin Condition and Pressure Ulcer Assessment, and indicated it was the policy currently being used by the facility. The policy indicated, .2. Resident's identified by the Braden Scale as being at risk of a skin breakdown, will have a care plan customized and initiated to address the at risk individual's skin care needs. 3. All areas of each resident's skin shall be inspected by his or her nurse and documented at least every seven days .9. The Director of Nursing will be notified of any new skin abnormality 3.1-37

Based on record review, observation, and interview, the facility failed to ensure physician orders were followed for 2 of 5 residents reviewed for unnecessary medication review (Residents 35 and 37). Findings include: 1. On 3/13/24 at 11:00 a.m., the medical record of Resident 35 was reviewed. Resident 35's diagnoses on the resident's profile included but were not limited to, type 2 Diabetes Mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high), Atherosclerosis (a thickening or hardening of the arteries caused by a buildup of plaque in the inner lining of an artery), Hyperlipidemia (high cholesterol) is an excess of lipids or fats in your blood), Atrial Fibrillation (Fibrillation an irregular heart rhythm (arrhythmia) that begins in the upper (atria) of your heart), Hypertension (HTN) (also known as high or raised blood pressure, is a condition in which the blood vessels have persistently raised pressure). Physician Orders include but are not limited to: Lisinopril Tablet 40 mg (milligrams) give 1 tablet by mouth one time a day for HTN hold for Systolic Blood Pressure (SBP) less (< ) than 100, 11/30/22. (The systolic blood pressure is the maximum blood pressure during contraction of the ventricles of the heart). Review of the medication administration records from 1/1/24 to 3/13/24 indicated the resident received Lisinopril 40 milligram (mg) by mouth once daily. Record lacked documentation of monitoring of the blood pressure. The weights and vitals summary record documentation indicated, the blood pressure had been assessed and the reading was entered into the summary report 10 days in total from January to March 2024. The most recent quarterly Minimum Data Set (MDS) assessment indicated the resident had a diagnosis of hypertension and orthostatic hypotension (a drop in blood pressure that occurs when moving from a laying down [supine] position to a standing [upright] position). The MDS indicated the resident was cognitively intact. A care plan, dated 2/19/21, indicated the resident had a diagnosis of hypertension. Intervention included but were not limited to, blood pressure readings as ordered/per protocol. Report significant abnormalities to medical doctor as needed. On, 3/15/24 at 9:03 a.m., the Director of Nursing (DON) provided an undated document, titled. Physician's Orders, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy: Facility nursing personnel will ensure clear, accurate and complete physician's orders. Procedure: .5 .Ensure any follow through is completed 34525 2. Resident 37's record was reviewed on 3/13/24 at 10:13 a.m. The profile indicated the resident's diagnoses included, but were not limited to, diabetes type 2 with diabetic chronic kidney disease (diabetes [a disease that occurs when your blood glucose, also called blood sugar, is too high] that isn't well controlled can damage blood vessels in the kidneys that filter waste from the blood). A quarterly minimum data set assessment (MDS-part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes), dated 11/23/23, indicated the resident had severe cognitive deficit and received hypoglycemic (medications that work by stimulating pancreatic insulin secretion, enhancing tissue sensitivity to insulin, or slowing the absorption of glucose in the intestines). A physician's order, dated 9/1/23, indicated glimepiride oral tablet (hypoglycemic medication) 1 milligram (mg). Give 0.5 tablet by mouth one time a day for diabetes. A care plan, dated 9/5/23, indicated the resident had a diagnosis of diabetes and received diabetes medications. A care plan, dated 9/5/23, indicated the resident had a diagnosis of chronic kidney disease. Interventions included, but were not limited to, lab/diagnostic work as ordered. A pharmacy recommendation, dated 9/15/23, indicated since the resident received glimepiride, to consider checking the resident's A1C (a simple blood test that measures the average blood sugar levels over the past 3 months) every six months. The physician agreed and signed the recommendation on 9/20/23. A copy of a physician's order, dated 9/20/23, provided by the Director of Nursing (DON), on 3/14/24 at 8:30 a.m., indicated to check the resident's A1C every 6 months. The record lacked documentation of the resident's A1C lab every being completed as ordered. During an interview, on 3/13/24 at 3:11 p.m., the DON indicated she had put the order in on 9/20/23, but the lab had never been completed as ordered. On 3/14/24 at 8:30 a.m., the DON provided an undated document, titled, Pharmacy Consultation, and indicated it was the policy currently being used by the facility. The policy indicated, .Standards: .5. Upon receipt of signed recommendations, orders are noted by the Director of Nursing or designee for implementation 3.1-48(a)(3)

Based on record review and interview, the facility failed to address a significant weight discrepancy for 1 of 2 residents reviewed for nutrition (Resident 57). Finding includes: Resident 57s record was reviewed on 3/15/24 at 9:08 a.m. The profile indicated the resident's diagnoses included, but were not limited to, unspecified protein-calorie malnutrition (a disorder caused by a lack of proper nutrition or an inability to absorb nutrients from food) and cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). An admission Minimum Data Set assessment, dated 2/21/24, indicated the resident required supervision or touching assist with eating, and had no swallowing or nutrition disorders noted. The assessment lacked documentation of weight gain or loss. A physician's order, dated 2/14/24, indicated weekly weights and to review weights and report significant changes to physician. A physician's order, dated 2/16/24, indicated the resident was to have a regular diet with mechanical soft texture (a modified diet with a texture soft for people with difficulty swallowing or chewing). Review of the resident's weights indicated he weighed 108.0 pounds (lbs) upon admission on 2/14/24. Subsequent weights included, but were not limited to the following: a. On 3/9/24 at 1:52 p.m., the resident had been weighed by Certified Nursing Aide (CNA) 18. His weight was measured at 104.8 pounds (lbs). b. On 3/9/24 at 2:54 p.m., the resident had been weighed by CNA 17. His weight was measured at 127.2 lbs. c. On 3/10/24 at 12:44 p.m., the resident had been weighed by CNA 17. His weight was measured at 127.5 lbs. d. On 3/11/24 at 5:59 p.m., the resident had been weighed by CNA 17. His weight was measured at 104.4 lbs. The record lacked documentation that the significant discrepancies in the resident's weights between 3/9/24 at 1:52 p.m., and 3/11/24 at 5:59 p.m., had been addressed by the facility. A nurse progress note, completed by Licensed Practical Nurse (LPN) 11, on 3/6/24 at 2:24 p.m., indicated the resident had been weighed on 3/5/24 at 5:56 p.m., sitting on the scale. His weight was measured at 104.2 lbs. A nutritional at risk (NAR) meeting note, dated 3/7/24, indicated the resident had lost 2 lbs. He was reported to eat 26-50% of his meals and had been provided a nutrient-rich caloric drink supplement with B-vitamins to help convert food to energy, two times daily. A nurse progress note, completed by Registered Nurse (RN) 14, on 3/8/24 at 10:36 a.m., lacked documentation of the resident's weight. A nurse progress note, completed by LPN 11, on 3/9/24 at 2:58 p.m., indicated the resident had been weighed on 3/9/24 at 2:54 p.m., sitting on the scale. His weight was measured at 127.2 lbs. A nurse progress note, completed by LPN 15, on 3/10/24 at 11:40 p.m., lacked documentation of the resident's weight. A nurse progress note, completed by RN 16, on 3/11/24 at 7:50 p.m., indicated the resident had been weighed on 3/11/24 at 5:59 p.m., sitting on the scale. His weight was measured at 104.4 lbs. A NAR meeting note, dated 3/14/24, indicated the resident consumed about 50 % of his meals, was on a regular diet, and was being weighed daily. He continued on his drink supplement and his weights had remained stable since admission. The plan was to discontinue being followed by the NAR committee at that time. The note lacked documentation of the weight discrepancies from 3/9/24 at 1:52 p.m., through 3/11/24 at 5:59 p.m. During an interview, on 3/15/24 at 9:51 a.m., the Director of Nursing (DON) indicated if a significant discrepancy of a resident's weight was discovered, the resident should be re-weighed to confirm the accuracy of the measured weight. During an interview, on 3/15/24 at 10:49 a.m., CNA 19 indicated if there was a significant weight discrepancy she would re-weigh the resident to make sure the weight was accurate. She would then inform the nurse and double check for any significant changes with the resident's health that could be causing the weight change. On 3/15/24 at 10:42 a.m., the DON provided an undated document titled, Certified Nursing Assistant (CNA) Rehab/LTC Orientation Checklist, and stated it was the orientation and annual competency checklist for the CNA's. The form lacked documentation of any competency measurement on weighing residents. On 3/15/24 at 10:42 a.m., the DON provided a document, dated 9/22/21, titled, Weighing Residents, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure: .4. A licensed nurse evaluates weight changes to determine if there is a 5% or greater weight loss/gain in one month and notifies the physician of unanticipated or undesired weight loss/gain .Rationale/Amplification: .A re-weigh should be taken with the licensed nurse present as soon as possible after an unanticipated weight reading is noted and prior to calling the physician 3.1-46(a)(1)

Based on observation, interview, and record review, the facility failed to ensure a nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) mask was stored properly when not in use and an self administration assessment was completed for 1 of 2 residents reviewed for respiratory care (Resident 113), and failed to ensure oxygen orders were in place for 1 of 2 residents reviewed for respiratory care (Resident 39). Findings include: 1. During the initial pool observation, on 3/11/24 at 11:24 a.m., Resident 113's nebulizer mask was observed un-bagged and sitting on his bedside table. At the same time, the resident indicated he had used the nebulizer earlier that morning and that it should have been placed into a bag, but the nurse had not been in since he had used the nebulizer. During a random observation, on 3/14/24 at 10:09 a.m., the resident's nebulizer mask was observed un-bagged and sitting on his bedside table. During a random observation, on 3/14/24 at 1:42 p.m., the resident's nebulizer was sitting, un-bagged on his bedside table. At the same time, the resident indicated that he had just used it right after lunch. He doubted it would not be placed in a bag by the nurse, until the next shift, if they put it in the bag at all. Resident 113's record was reviewed on 3/14/24 at 10:21 a.m. The profile indicated the resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD-a group of diseases that cause airflow blockage and breathing-related problems), unspecified respiratory failure (a condition in which the blood doesn't have enough oxygen or has too much carbon dioxide), and pleural plaque with presence of asbestos (areas of thickened tissue that form in the lining of the lungs caused by significant asbestos exposure). A baseline care plan, dated 3/11/24, indicated the resident had been admitted with a diagnosis of pneumonia (an infection of one or both of the lungs caused by bacteria, viruses, or fungi). A physician's order, dated 3/8/24, indicated albuterol sulfate inhalation solution (medicine that is used for the relief of bronchospasms [the tightening and swelling of the muscles around the airways]), 2.5 milligrams (mg)/3 milliliters (ml) 0.083%. Inhale 3 ml orally via nebulizer in the afternoon for COPD. A physician's order, dated 3/8/24, indicated ipratropium (used to prevent wheezing, shortness of breath, coughing, and chest tightness in people)-albuterol inhalation solution 0.5-2.5 (3) mg/3 ml. Inhale 3 ml orally via nebulizer every 6 hours as needed for COPD. The record lacked documentation of an assessment to determine the independent use of the nebulizer by the resident. During an interview, on 3/14/24 at 1:57 p.m., Licensed Practical Nurse (LPN) 11 indicated she would set up the resident's nebulizer, but he used it himself. She was not aware of any assessment that had been completed to determine if the resident was able to use his nebulizer independently. During an interview, on 3/14/24 at 2:16 p.m., the Director of Nursing (DON) indicated the resident should have had an assessment to use the nebulizer independently. The nebulizer masks should be placed in plastic bags when not in use. On 3/14/24 at 2:25 p.m., the DON provided a document, dated 9/25/21, titled, Licensed Nurse or Respiratory Therapist Procedure Nebulized Mist Inhalation Treatment, and indicated it was the procedural documentation on the proper use of nebulizer equipment for the facility. The document indicated, .Procedure .Disassemble the nebulizer and place in plastic bag with nebulizer tubing 35317 2. During an interview, on 3/12/24 at 9:21 a.m., Resident 39 indicated he used oxygen therapy per nasal cannula (device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help) during the nighttime. During an observation, on 3/12/24 at 9:21 a.m., an oxygen concentrator was in Resident 39's room and had a nasal cannula attached to it. The resident was not using oxygen at the time of the observation. Resident 39's record was reviewed on 3/13/24 at 10:02 a.m. The profile indicated the resident's diagnoses included, but were not limited to, multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves resulting in nerve damage), dependence on supplemental oxygen (used to keep your organs or tissues healthy), and heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). A quarterly Minimum Data Set (MDS) assessment, dated 2/20/24, indicated Resident 39 was cognitively intact and was not marked as using oxygen therapy. A care plan, dated 6/17/21, with a revised date of 11/28/23, indicated resident had oxygen therapy related to ineffective gas exchange and chronic respiratory failure (occurs when a person's blood has too much carbon dioxide and not enough oxygen) and dyspnea (shortness of breath). Interventions included but were not limited to, oxygen 2L(liters) per nasal cannula during the night. The record lacked documentation of a physician order for the oxygen therapy at night. Review of a hospice clarification fax sent to the facility, dated 3/13/24, indicated the hospice company had requested an order for Resident 39 to have Oxygen therapy 3L as needed. The order was dated 1/31/24 but was not implemented into the resident's electronic health record. The March Medication Administration Record (MAR) lacked documentation of oxygen being used at night or as needed. Review of vital signs note, dated 2/5/24 at 7:07 a.m., indicated Resident 39's oxygen saturation was 100% on oxygen via nasal cannula. Review of vital signs note, dated 2/4/24 at 7:56 p.m., indicated Resident 39's oxygen saturation was 99% on oxygen via nasal cannula. Review of vital signs note, dated 2/1/24 at 3:24 p.m., indicated Resident 39's oxygen saturation was 100% on oxygen via nasal cannula. During an interview, on 3/13/24 at 11:35 a.m., Certified Nurse's Aide (CNA) 7 indicated Resident 39 used oxygen therapy at nighttime During an interview, on 3/13/24 at 11:36 a.m., Registered Nurse (RN) 8 indicated she thought Resident 39 had an order for oxygen to be used as needed. During an interview, on 3/13/24 at 1:18 p.m., Director of Nursing (DON) indicated Resident 39 should have an order in his chart for the oxygen use but he had been in and out of the hospital, so she wasn't sure if it was missed. On 3/14/24 at 9:45 a.m., the Administrator provided an undated document, titled, Oxygen Therapy, and indicated it was the policy currently being used by the facility. The policy indicated, .It is the policy of Providence Health Care to administer oxygen in accordance with physician's order and on emergency basis .5. Initial and ongoing assessments will be documented in the nursing progress notes .18. Record oxygen therapy on the treatment or special record and nursing notes if prn (as needed), Include type of catheter and liter flow 3.1-47(a)(6)

Based on observation, record review, and interview, the facility failed to ensure communication was received post [CONDITION(S)] (filters blood to rid the body of harmful wastes) from the [CONDITION(S)] center, post [CONDITION(S)] assessments were completed, care plans were revised, and assessments of an prostatic arteriovenous graft (used for [CONDITION(S)] treatment) site and an implanted permacath (a flexible tube inserted into a vein most commonly in the neck used for [CONDITION(S)] treatment) were completed which resulted in harm when the resident developed an infection to the graft site that led to the site opening and the resident losing one to two liters of blood, being hospitalized , and requiring a new graft placement for 1 of 1 residents reviewed for [CONDITION(S)] (Resident 6). Findings include: During an observation, on 9/14/21 at 10:24, Resident 6 was observed to have sutures to the left forearm. At this time, the resident indicated she had recently had a revision to her [CONDITION(S)] graft site. The prior graft had been removed due an abscess that had burst and caused an active bleed. The resident's medical record was reviewed, on 9/15/21 at 1:26 p.m. A hospital notes, dated 7/6/20, indicated the resident had underwent creation of a non-[MEDICATION(S)] left brachial antecubital veins prostatic arteriovenous (av) graft for hemodialysis. A Medication Administration Record (MAR), dated July 2021, indicated the resident went to the [CONDITION(S)] center every Monday, Wednesday, and Friday at 10:45 a.m. The resident's medical record lacked documentation of communication post [CONDITION(S)] from the [CONDITION(S)] center. A MAR, dated July 2021, lacked documentation the left forearm prostatic av graft had been assessed every shift for bleeding, increased pain, or signs of infection. A review of progress notes, dated July 2021, lacked documentation the left forearm prostatic av graft had been assessed every shift for bleeding, increased pain, or signs of infection. A skin wound progress note, dated 7/14/21 at 9:14 a.m., indicated the resident had an infection to the left forearm av graft site. A review of skin wound progress notes, physician orders, and nursing progress notes, dated 7/15/21 through 7/20/21, lacked documentation the resident received antibiotics and any monitoring for side effects. A [CONDITION(S)] nursing home information document, dated 7/21/21, and uploaded to resident's documents in the electronic medical record on 9/16/21, indicated the resident received two antibiotics during [CONDITION(S)] treatment, [MEDICATION(S)] 750 milligrams (mg) and [MEDICATION(S)] 100 mg. A skin wound progress note, dated 7/21/21 at 8:47 a.m., indicated the resident was observed by the wound physician and the resident's left forearm prostatic av graft measured at 9.3 centimeters (cm) by 9 cm, [CONDITION(S)] was aware and following. The resident received antibiotic therapy at [CONDITION(S)]. The Certified Nursing Assistants (CNA) would observe skin with routine care notify the charge nurse of concerns. Nursing to complete any treatments and dressings and weekly skin assessments and notify the wound nurse with concerns. A physician wound note, dated 7/21/21, indicated the resident's left forearm prostatic av graft measured 15.4 cm by 4.86 cm by 4.55 cm and had new swelling. The site was being managed by physicians at the [CONDITION(S)] center. The management of care for this critical [CONDITION(S)] site would be deferred to the resident's nephrologists and surgeons and interventionalists who are monitoring the site. A review of the resident's medical record lacked documentation the resident received [MEDICATION(S)] (antibiotic) and [MEDICATION(S)] (antibiotic) at [CONDITION(S)] only a progress note that indicated the resident had received antibiotic therapy at [CONDITION(S)]. The record lacked documentation to support [MEDICATION(S)] troughs had been monitored or an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, initiated, 3/4/20, indicated the resident received [CONDITION(S)] related to [CONDITION(S)]. Interventions included but were not limited to apply ice to left arm for 20 minutes twice daily and initiated on 4/7/21; check and change dressing daily at access site; observe for and report to the physician any signs or symptoms of infection such as redness, swelling, warmth, or drainage to the access site; and observe for and report to the physician any signs or symptoms of bleeding, hemorrhage, bacteremia (infection), or septic shock. The care plan lacked documentation the resident had received antibiotic therapy for an abscess to the left forearm graft site. A health status progress note, dated 7/23/21 at 10:54 a.m., indicated the writer was called to the resident's room at approximately 7:15 a.m., The resident was observed sitting on side of the bed with staff member holding pressure to the resident's left arm. An abscess to the resident's left arm had broken open and was squirting out blood. Staff continued to hold pressure to site and monitor level of alertness while 911 was called and family was notified. Resident was transferred via stretcher by emergency medical services to the emergency room . At the time of transfer the resident was observed to be lethargic and skin color was pale. A hospital notes, dated 7/23/21, indicated the resident presented to the emergency room from a long-term care facility (LTC) with complaints of spontaneous bleeding from the left forearm av graft site. Per Emergency Medical Services (EMS) report she had lost approximately one to two liters of blood prior to their arrival to the long-term care facility with low blood pressures in the 70's. She was symptomatic with [CONDITION(S)] when sat upright by LTC facility staff. The EMS staff controlled the bleeding and no further episodes of [CONDITION(S)]. An abscess was reported to the av graft site prior to the bleeding and the resident was on unknown oral antibiotic for seven days. Last known [CONDITION(S)] treatment was Monday 7/19/21. A hospital physician diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The av graft site was noted with evidence of an abscess/ulceration and would need repaired. A chronic [CONDITION(S)] catheter would be placed today. Laboratory blood tests were completed and included, but were not limited to, hemoglobin (a protein in red blood cells that carry oxygen to organs and tissues and transports [MEDICATION(S)] from your organs and tissues back to the lungs) 8.2 (low) with no active bleeding from AV graft site. A hospital progress note, dated 7/25/21, indicated the resident's av site had evidence of an abscess/ulceration. Revision and excision were performed to the ulcerated left brachial antecubital veins and prosthetic arteriovenous graft due to bleeding and localized infection of the perforated graft segment. The resident now had a permacath placed. A general post operation note indicated the following: A fluoroscopic guided placement to the right internal jugular vein, glide path, tunneled with a chronic dual lumen hemodialysis catheter placed. And finally, a revision and excision to the ulcerated left brachial antecubital veins and prosthetic arteriovenous graft due to bleeding and localized infection of the perforated graft segment. A nurse's progress note, dated 7/25/21 at 7:05 p.m., indicated the resident returned to the facility from the hospital and the resident's physician gave an order to follow hospital discharge instructions. A wound note, dated 7/26/21 at 11:00 a.m., indicated the resident had a port placed to the right neck that measured 1.7 centimeters (cm) by 0.1 cm by 0 cm and was left open to air. A left forearm [CONDITION(S)] surgical site that measured 10.5 cm by 0.9 cm by 0.4 cm. A hospital dressing was noted in place. The CNA to observed skin with routine care and notify the charge nurse of concerns. The nursing staff would complete treatments and dressings and weekly skin assessments. The MAR, dated July and August 2021, lacked documentation the port to the right neck and the left forearm [CONDITION(S)] surgical site were assessed every shift for bleeding, increased pain, or signs of infection. During an interview, on 9/15/21 at 2:53 p.m., Registered Nurse (RN) 6 indicated Resident 6 went to the [CONDITION(S)] center on Monday, Wednesday, and Friday every week. She had a fistula to the left forearm, and it had gone bad and was recently replaced. She was unsure if the resident had an order to monitor the fistula site or what the facility policy was. During an interview, on 9/15/21 at 2:55 p.m., RN 7 indicated Resident 6 had a fistula to the left forearm that became infected and busted that required pressure to be held to the site due to heavy bleeding. The resident had to be sent to the hospital for treatment. She also indicated she checked for bruit and thrill and the fistula site for signs of infection or bleeding, but she was unsure if there was anywhere to document the assessment on the MAR and she would not typically document the assessment in the progress notes. She was unsure what the facility policy was for documentation of the assessment. During an interview, on 9/16/21 at 9:24 a.m., the Director of Nursing indicated all [CONDITION(S)] communication would be uploaded in the documents tab on the electronic record, the facility did not have a binder or any other place the communication would be kept. She was unsure if [CONDITION(S)] had sent the communication after each [CONDITION(S)] visit but she was aware the medical records staff had been behind on uploading documents into resident's medical records. The resident had an abscess to the graft site, and she indicated staff should have monitored the site for signs and symptoms per the facility policy. In July the resident had been sent to the emergency room due to a bleed that occurred at the facility when the abscess to the graft site had burst opened. The graft site was removed at the hospital and new graft site was placed. She was unsure when the permcath had been placed. The permcath site should also be monitored per the facility. During an interview, on 9/16/21 at 10:33 a.m., RN 5 from the [CONDITION(S)] center indicated the resident had an av graft site to her left forearm which was an artificial loop with a created fistula. He indicated the bruit and thrill should be monitored and was completed every Monday, Wednesday, and Friday while the resident was at [CONDITION(S)] receiving treatment. He was unsure what date the abscess had developed to the resident's graft site but the physician over [CONDITION(S)] had started [MEDICATION(S)] 100 mg and [MEDICATION(S)] 750 mg on 7/19/21. The resident received a total of 6 intravenously infused antibiotic treatments while at [CONDITION(S)]. It would have been up to the resident's physician to order any troughs to be drawn with [MEDICATION(S)] treatment and the [CONDITION(S)] facility would not have drawn labs for that, it would have been up to the facility to follow up on that. Some facilities would send a post communication form that included what care was provided to the resident during the resident's [CONDITION(S)] treatment. He was unsure if communication with Resident 6's facility had been done after each treatment but was able tell me that the facility had called the [CONDITION(S)] center earlier that day and requested all of the post communication documentation to be faxed to them at the facility. The resident's new graft site to the left forearm was currently not being used and the permcath the right side of the neck was being used for all [CONDITION(S)] treatments at this time. This site should also be monitored. On 9/13/21 at 2:00 p.m., the Administrator provided a document, undated, and titled, [CONDITION(S)], and indicated it was the policy currently being used by the facility. The policy indicated, Policy: This policy is to outline care and services for [CONDITION(S)] residents in order to prevent infections, complications, and to provide for ongoing monitoring and interventions. Procedure: .a. The [CONDITION(S)] center will be asked to provide information with regards to the residents visit, weights, and any order pertinent information .5. Fistula/shunt site will be checked every shift for bruits, bleeding, increased pain, and signs of infection. Will be documented on the TAR On 9/16/21 at 3:02 p.m., the DON provided a document, updated 2/2019, and titled, Medication Administration Policy, and indicated it was the policy currently being used the facility. The policy indicated, .Standards 28. The assessment of the effectiveness of medication is based on staff observations, resident perceptions and information from the medical record and medication profiles. On 9/16/21 at 3:03 p.m., the DON provided a document, undated, and titled, Resident Care Plan Policy and indicated it was the policy currently being used the facility. The policy indicated, Purpose: To provide an individualized plan of care for each resident .Additions and modifications will be made by each disciplinary team member to assist facility personnel in meeting the needs of the resident. Plans will be reviewed at least quarterly and revised at any time the condition of the resident changes .Nurses on each shift are responsible for revising and updating the resident care plan whenever the resident's condition changes 3.1-37(a)