Every finding on record at Pulaski Health Care Center

Based on record review and interview, the facility failed to file a grievance from a resident's family who voiced concerns about not wanting a staff member to administer a resident's medications for 1 of 1 resident reviewed for grievances. (Resident B)Finding includes:A closed record review for Resident B was completed on 8/13/26 at 11:58 a.m. Diagnoses included, but were not limited to, dementia, congestive heart failure, diabetes mellitus, and tremors.An Employee Communication Form, completed by the Director of Nursing (DON) on 6/10/26, indicated QMA 1 was instructed to not go into a resident's room because the family did not want her to provide care for the resident. She was given the directive on 6/9/26. The next day, QMA 1 was called into the DON's office because she entered the same resident's room and tried to give medication. She was given a verbal warning to stay out of the same resident's room and understood if she went into the resident's room again, she would be terminated.A Grievance Form, dated 6/13/26, indicated the resident's wife had a concern that on 6/3/26 at approximately 12:00 p.m., QMA 1 brought in Resident B's meal tray. She noticed his mashed potatoes were blue, so she called the QMA back over and asked her what was wrong with them. The QMA whispered to her and said, I put his medications in it. The resident's wife shoved the plate aside and went and notified LPN 1. The follow up was completed on 6/15/26. The Assistant Director of Nursing (ADON) completed one on one education with the QMA regarding the administration of medications.An Employee Communication Form, completed by the ADON on 6/15/26, indicated the QMA violated medication administration policy on 6/3/26. The employee was previously told in May not to enter the resident's room. On 6/3/26, the resident was given a bowl of mashed potatoes with crushed up pills in it. The employee (QMA 1) told the resident's wife that she crushed his pills up and put them in the mashed potatoes. The resident's wife then requested again that the QMA did not enter the resident's room. The QMA indicated she did not stay near the resident to ensure he consumed the bowl of mashed potatoes which contained his medications. The QMA received a verbal warning.The June 2026 Medication Administration Record indicated QMA 1 administered the following medications to the resident before and after the 6/3/26 incident and the Employee Communication Form completed 6/10/26.-allopurinol (lowers high uric acid levels in blood) 300 milligrams (mg) on 6/1, 6/2, 6/3, 6/6, and 6/7/26 at 6:00 a.m., - 10:00 a.m. -Ativan (anxiety medication) 1 mg on 6/1, 6/2, 6/3, 6/6, 6/7, 6/9, and 6/10/26, at 8:00 a.m.-benzonatate (cough medicine) 100 mg on 6/6, and 6/7/26, at 6:00 a.m., - 10:00 a.m. -benzonatate 100 mg on 6/6, 6/7, 6/9, and 6/10/26 at 1:00 p.m., - 3:00 p.m. -bumetanide (diuretic) 2 mg on 6/1, 6/2, 6/3, 6/6, and 6/7/26 at 6:00 a.m., - 10:00 a.m.-carbidopa-levodopa (treats tremors) 25-250 mg on 6/1, 6/2, 6/3, 6/6, and 6/7/26 at 6:00 a.m., -10:00 a.m. -carbidopa-levodopa 25-250 mg on 6/1, 6/2, 6/3, 6/6, 6/7, 6/9, 6/10, and 6/12/26, at 1:00 p.m., - 3:00 p.m. -gabapentin (control seizures and nerve pain) 300 mg on 6/1, 6/2, 6/3, 6/6, and 6/7/26, at 6:00 a.m., -10:00 a.m. -gabapentin 300 mg on 6/1, 6/2, 6/3, 6/6, 6/7, 6/9, 6/10, and 6/12/26, at 1:00 p.m., - 3:00 p.m. -glipizide xl (treats high blood sugar levels) 2.5 mg on 6/1, 6/2, 6/3, 6/6, and 6/7/26, at 6:00 a.m., -10:00 a.m. -hydrocodone-acetaminophen (pain medication) 7.5-325 mg on 6/1, 6/2, 6/3, 6/6, 6/7, 6/9, and 6/10/26, at 6:00 a.m., -10:00 a.m.-hydroxyzine (antihistamine) 10 mg on 6/1, 6/2, 6/3, 6/6, 6/7, and 6/9/26, at 6:00 a.m., -10:00 a.m. -metolazone (diuretic) 2.5 mg on 6/1 and 6/3/26, at 6:00 a.m., -10:00 a.m.-MiraLAX (laxative) 17 gram (gm) on 6/1, 6/2, 6/3, 6/6, and 6/7/26, at 6:00 a.m., -10:00 a.m. -primidone (anticonvulsant) 150 mg on 6/1, 6/2, 6/3, 6/6, and 6/7/26, at 6:00 a.m., -10:00 a.m.-primidone 150 mg on 6/1, 6/2, 6/3, 6/6, 6/7, 6/9, 6/10, and 6/12/26, at 1:00 p.m., - 3:00 p.m. -spironolactone (diuretic) 50 mg on 6/1, 6/2, 6/3, 6/6, and 6/7/26, at 6:00 a.m., -10:00 a.m.-topiramate (anticonvulsant) 25 mg on 6/1, 6/2, 6/3, 6/6, and 6/7/26, at 6:00 a.m., -10:00 a.m.During an interview on 8/13/26 at 4:37 p.m., the ADON indicated the resident's wife requested again that the QMA not come into the resident's room for care. She asked the QMA if she was aware she could not go into the resident's room and the QMA answered yes, she was aware since May. The ADON was not aware the QMA wasn't supposed to take care of the resident until the QMA had told her that day. The QMA did not give any reason why she put the medication in the mashed potatoes. No grievance had been filed in May for the initial problem and request from the resident's wife.During an interview on 8/13/26 at 4:50 p.m., the DON indicated she was made aware after the incident occurred on 6/3/26. The QMA was not supposed to administer any medications to the resident after that. She was not aware the wife had requested for the QMA not to administer his medications prior to the incident on 6/3/26. The QMA no longer worked at the facility and quit a few days after being written up. There should have been a grievance filed when the wife first voiced her concerns with the QMA in May.During an interview on 8/13/26 at 4:55 p.m., LPN 1 indicated the resident's wife had told her before the 6/3/26 incident that she did not want the QMA to administer the resident's medications again. The LPN was unsure when the wife told her that. She spoke to the QMA and told her she was not allowed to administer his medications and all staff were aware the QMA was not supposed to be administering his medications. She was unsure why a grievance had never been filed.A facility policy titled, Grievances Policy And Procedures, and received as current from the DON on 8/13/26, indicated, .The resident has the right to file grievances, and the facility must make prompt efforts to resolve those grievances the resident may have .3. Grievances will be investigated and documented on Grievance forms by appropriate staff and overseen by Grievance Official and resolved within 72 business hours .This citation relates to Intake 3041912. 410 IAC (Indiana Administrative Code) 3.1-7(a)(2)

Based on record review, observation, and interview, the facility failed to ensure a resident with a pressure ulcer received the necessary treatment and services to promote healing related to a lack of treatment change or new interventions implemented timely after the pressure ulcer had worsened for 1 of 3 residents reviewed for pressure ulcers. (Resident C)Finding includes: Record review for Resident C was completed on 11/12/25 at 2:13 p.m. Diagnoses included, but were not limited to, anemia, diabetes mellitus, and end stage renal disease.The Quarterly Minimum Data Set (MDS) assessment, dated 10/13/25, indicated the resident was cognitively intact. The resident was dependent on staff for bed mobility and transfers. The resident was admitted to the facility with two stage 2 pressure ulcers. A Care Plan, dated 1/22/25 and revised 8/25/25, indicated the resident had a pressure wound to the left ischium (curved bone forming the base of each half of the pelvis). On 7/23/25 the pressure wound healed. On 8/22/25 the resident returned from the hospital with the left ischium open again as a stage 2. The Goal indicated the resident would not experience any worsening of the pressure wound by the next review date. An intervention included to measure and record description of the pressure wound with included size, color, and drainage, and then to notify the physician with any changes or worsening of the wound. A Wound Management Assessment, dated 8/25/25, indicated the resident returned from the hospital on 8/22/25 with a stage 2 to the left ischium. The wound was noted to have a superficial opening that measured 8 cm (centimeters) in length x 6 cm wide with a 0.1 cm depth. A Physician's Order, dated 8/23/25 and discontinued on 11/11/25, indicated to cleanse the left ischium with wound cleanser and apply Puracol (collagen wound dressing) to the wound bed and cover with a gauze dressing.A Wound Management Assessment, dated 10/1/25, indicated the resident had a stage 2 ulcer to the left ischium that measured 4.1 cm in length x 4 cm wide with a 0.1 cm depth. The wound was noted to have 10% slough (dead, non-viable tissue only in wounds stage 3 or higher) in the wound bed. The physician was aware of the wound status.There was a lack of documentation to indicate that when the pressure ulcer had worsened on 10/1/25, the facility changed the wound treatment or new interventions were implemented.A Wound Management Assessment, dated 10/28/25, indicated the resident had a stage 2 to the left ischium that measured 3.6 cm in length x 3.5 cm wide with a 0.1 cm depth. The wound was noted to have 10% slough in the wound bed. The physician was aware of the wound status.A Physician's Order, dated 11/3/25, indicated to cleanse the left ischium with wound cleanser and apply silver alginate (antimicrobial wound dressing) to the wound bed and cover with gauze dressing.The wound had worsened from stage 2 on 10/1/25. There was a lack of documentation to indicate any new treatment orders or new interventions were attempted until 11/3/25 or any physician documentation related to the wound status worsening. On 11/12/25 at 2:27 p.m., a wound treatment was observed with the DON (Director of Nursing) and QMA 1. The wound to the left ischium was reddened, shallow, and about the size of a nickel. There were no odors or drainage observed to the wound. During an interview on 11/13/25 at 2:50 p.m., the DON indicated she could not provide any documentation that any interventions were changed when the resident's pressure had worsened to a stage 3. The wound should have been classified as a stage 3 with slough and not a stage 2. They did put in a new treatment order for the wound, but it was a month later. The wound had not worsened during that time, but they should have attempted a new treatment timely after the wound had worsened.A facility policy, titled Pressure Ulcers/Skin Breakdown - Clinical Protocol and received as current from the DON on 11/13/25, indicated, .Monitoring 1. During resident visits, the physician will evaluate and document the progress of wound healing - especially for those with complicated, extensive, or poorly-healing wounds. 2. The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. a. Healing may be delayed or may not occur, or additional ulcers may occur because of other factors which cannot be modified. b. Current approaches should be reviewed for whether they remain pertinent to the resident/patient's medical conditions, are affected by factors influencing wound development or healing, and the impact of specific treatment choices made by the resident/patient or a substitute decision-maker.This citation relates to Intake 2659878. 3.1-40(a)(2)

Based on observation, record review, and interview, the facility failed to serve food under sanitary conditions related to touching food with gloved hands after touching other items for 1 of 1 kitchen observed. (The Main Kitchen). This had the potential to affect 44 residents who received food from the kitchen. Finding includes: During the follow-up tour of the kitchen on 8/20/25 at 10:01 a.m., [NAME] 1 was observed preparing pureed enchiladas. The cook had donned clean gloves. She had an enchilada prepared in a mixing bowl. Using her gloved hands, she scooped out the enchilada into the blender. She removed a set of gloves, as she had another pair of gloves on underneath. The Dietary Food Manager brought [NAME] 1 a container of broth mix from the cooler. [NAME] 1 opened the container, scooped out a small amount using a measuring spoon, and used her gloved finger to remove the broth mix into another container. She mixed the broth mix with water to create the beef broth mixture to add to the enchilada in the blender. She changed her gloves and did not perform hand hygiene before donning a new pair of gloves. She opened a drawer, with her gloved hands, to retrieve a measuring cup, then opened the shredded cheese container and scooped the shredded cheese with her gloved hands. She then put the cheese into the blender. She added a small amount of beef broth and continued to blend until the appropriate consistency was achieved. During an interview at the time, [NAME] 1 indicated she usually always washed her hands between glove changes and understood she should not touch food directly after touching other items/surfaces in the kitchen. She had no further information to provide. A policy titled, Handwashing/Hand Hygiene, indicated .Use an alcohol-based hand rub .or soap and water for the following situations .m. after removing gloves .o. before and after eating or handling food . 3.1-21(i)(3)

Based on observation, record review and interview, the facility failed to provide a safe, comfortable environment related to elevated hot water temperatures in 2 of 5 units observed for water temperatures. (North and Northeast Units)Finding includes:During the initial facility tour on 8/18/25 at 2:45 p.m., observations by hand of the water temperature were felt to be elevated in resident bathrooms on the North and Northeast Units. The Maintenance Assistant checked the water temperature in Rooms NE4, N2 and N3 and indicated it was 130 degrees Fahrenheit.During an interview at that time, the Maintenace Assistant indicated that was hottest he had seen the water temperature. He indicated rooms were checked randomly once a week. During an interview on 8/18/25 at 2:55 p.m., the Maintenance Director indicated water temperature should be around 111 degrees.The current policy, Weekly Water Temperatures, indicated, .if a water temperature is below or above the set temperature of 100-120, the maintenance supervisor or designee will adjust the mixing valve to bring water to the proper temperature

Based on record review and interview, the facility failed to ensure a speech therapy evaluation was completed as ordered for 1 of 4 residents reviewed for nutrition and also failed to ensure there was documentation and interventions in place for bowel management for 1 of 5 residents reviewed for unnecessary medications. (Residents B and D)Findings include: 1. The closed record for Resident B was reviewed on 8/19/25 at 3:48 p.m. Diagnoses included, but were not limited to, myasthenia gravis, cyclical vomiting syndrome and pervasive developmental disorder. The resident was admitted on [DATE] for a respite stay. The Quarterly Minimum Data Set (MDS) assessment, dated 5/6/25, indicated the resident had severe cognitive deficits and required moderate assistance with eating and substantial assistance with bed mobility and transfers. A Progress Note, dated 4/28/25, indicated the resident had arrived at the facility accompanied by family. The family indicated he was only to drink from a slow flow sippy cut, could not have milk and should have medications crushed and given in applesauce. The Baseline Care Plan, dated 4/28/25, indicated food should be provided in bite size pieces. A Care Plan Summary, dated 4/30/25, indicated the resident needed weighted silverware and a plate guard. A Progress Note, dated 5/2/25, indicated the Physician gave verbal orders to obtain a Speech Therapy evaluation due to special diet recommendations from the family. The record lacked documentation that a Speech Therapy evaluation had been completed. During an interview on 8/20/25 at 4:25 p.m., the Speech Therapist indicated she had never evaluated the resident. During an interview on 8/21/25 at 3:25 p.m., the Administrator indicated she had no information why the evaluation had not been completed, and it may have been entered by error. 2. Resident D's record was reviewed on 8/19/25 at 10:37 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, developmental disorder, cognitive communication deficit, and iron deficiency anemia. The Quarterly Minimum Data Set assessment, dated 7/30/25, indicated the resident was severely cognitively impaired. In the 7-day look-back period, the resident received an antipsychotic, antianxiety, opioid, and hypoglycemic medication. The resident was frequently incontinent of bowel and bladder and required substantial to maximal assistance with toileting hygiene. The August 2025 Physician Order Summary indicated the resident received hydrocodone-acetaminophen 5-325 milligram tablet twice daily and iron tablet 325 milligrams daily. A Care Plan, dated 11/12/24, indicated the resident was at risk for low hemoglobin (protein in red blood cells) and hematocrit (percentage of red blood cells) related to iron deficiency anemia. Interventions included, but were not limited to, administer medications as ordered and monitor effectiveness. A Care Plan, dated 11/12/24, indicated the resident was at risk for pain related to a history of right humerus fracture and chronic pain which the resident received routine pain management to address. Interventions included, but were not limited to, analgesics as ordered and observe for effectiveness of medications. The Output: Bowel Movement documentation was reviewed from 7/1/25 thru 8/19/25. Bowel movements were documented on 7/15/25, 7/19/25, 7/22/25, 7/27/25, 8/2/25, 8/4/25, 8/5/25, 8/8/25, 8/11/25, and 8/17/25. There was no documentation related to acquiring orders for treatment or intervention attempts related to the lack of bowel movements. During an interview on 8/22/25 at 1:00 p.m., the Director of Nursing and Regional Nurse Consultant were notified of the concern and provided no further information. A policy related to bowel protocols and monitoring was requested and was not received. This citation relates to Intake 1759620. 3.1-37(a)

Based on record review and interview, the facility failed to ensure a comprehensive care plan was developed and in place for resident receiving an antidepressant medication for 1 of 13 care plans reviewed. (Resident 2) Finding includes: Resident 2's record was reviewed on 8/19/25 at 3:03 p.m. Diagnoses included, but were not limited to, paraplegia, schizoaffective disorder, and chronic pain. The Significant Change in Status Minimum Data Set assessment, dated 7/15/25, indicated the resident was cognitively intact for daily decision making. In the 7-day look-back period, he had received injections, antipsychotic, antidepressant, antibiotic, opioid, and hypoglycemic medications. The August 2025 Physician Order Summary indicated the resident received amitriptyline (an antidepressant medication) 50 milligram tablet twice daily since 7/12/25. There was no care plan related to antidepressant medication use. During an interview on 8/22/25 at 1:00 p.m., the Director of Nursing and Regional Nurse Consultant indicated there was no care plan initiated for the antidepressant use because the resident was actually taking that medication for pain. There should have been a care plan related to the antidepressant use. 3.1-35(a)

Based on record review and interview, the facility failed to ensure residents that received antibiotics met the criteria of a true infection or provide a rationale for use if infection criteria were not met for 2 of 2 residents reviewed for antibiotic stewardship. (Residents 51 and 2)Findings include:1.The record for Resident 51 was reviewed on 8/19/25 at 3:00 p.m. Diagnoses included, but were not limited to, acute kidney failure, unspecified dementia and congestive heart failure. The resident was admitted on [DATE]. A Physician's Order, dated 8/15/25, indicated to obtain a urinalysis with reflex culture and sensitivity if indicated for mental status changes. The urinalysis results, dated 8/16/25, indicated there were moderate bacteria present, and a culture and sensitivity had not been done with a note, Recollect? An Observation McGeer's Criteria (tool used to determine true infections), dated 8/17/25, indicated the resident had no catheter, no dysuria, no fever and no pain. The resident's urinalysis results indicated there was at least 100,000 bacteria present. The indicators did not meet McGeer's criteria of a urine infection. A Physician's Order, dated 8/18/25, indicated to give cephalexin (an antibiotic), 500 milligrams every 12 hours x 8. There was no rationale documented in the resident's notes as to why the antibiotic was given. During an interview on 8/21/25 at 12:21 p.m., the Infection Preventionist (IP) Nurse indicated if an antibiotic was prescribed without meeting infection criteria, the physician should be notified to see if they wanted to continue or discontinue the medication. The IP Nurse indicated she had not been asking the physicians to provide a rationale to continue the antibiotics if criteria was not met but was now aware it should be documented. 2.Resident 2's record was reviewed on 8/19/25 at 3:03 p.m. Diagnoses included, but were not limited to, paraplegia, schizoaffective disorder, and neuromuscular dysfunction of the bladder. The Significant Change in Status Minimum Data Set assessment, dated 7/15/25, indicated the resident was cognitively intact for daily decision making. The resident had an indwelling catheter. A Progress Note, dated 6/24/25 at 5:32 p.m., indicated the hospice nurse returned a call to the facility and gave new order for ciprofloxacin (antibiotic) 250 milligrams twice daily for 7 days due to abnormal urine complaints by the resident. The June 2025 Medication Administration Record indicated the resident received the ciprofloxacin antibiotic as ordered. There were no physician's orders for a urinalysis culture and sensitivity or further information related to a urinary tract infection available for review in the record. During an interview on 8/22/25 at 1:00 p.m., the Director of Nursing and Regional Nurse Consultant indicated there was no further testing completed for the resident. The hospice company had started the antibiotic medication due to the reported symptoms given by the resident and did not order any urinalysis culture and sensitivity to be completed. The reported infection did not meet criteria for antibiotic use. A policy titled, Antibiotic Stewardship, indicated .11. When a culture and sensitivity is ordered lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued.

Based on record review and interview, the facility failed to ensure documentation for residents' transfer to the hospital was complete and accurate related to lack of documentation of preparation for transfer or discharge, assessment of the resident at the time of transfer, and notification to the physician at the time of transfer for 2 of 3 residents reviewed for hospitalization. (Residents 8 and 45) Findings include: 1. Resident 8's record was reviewed on 8/20/25 at 3:44 p.m. Diagnosis included, but were not limited to, intellectual disabilities, aphasia, and type 2 diabetes mellitus. The Quarterly Minimum Data Set assessment, dated 7/9/25, indicated the resident was severely cognitively impaired. A Progress Note, dated 3/19/25 at 12:49 p.m., indicated the resident was in the main dining room and was observed to be shivering, hands cyanotic (blue) from proximal knuckle to the tips of his fingers. The physician was notified, and new orders were received for labs. He had elevated finger sticks into the 300s and new orders were placed for glucose monitoring twice daily. A Progress Note, dated 3/19/25 at 11:27 p.m., indicated results were received for a CT scan and chest x-ray from the hospital. The resident was still in the emergency department. There was no documentation of the resident and or representative being prepared for transfer to the hospital. There was no documentation of an evaluation of the resident at the time of the transfer. There was no documentation of communication to the physician related to the hospital transfer. During an interview on 8/22/25 at 1:00 p.m., the Director of Nursing and Regional Nurse Consultant indicated they were unable to find any further information related to the hospital transfer. 2. Resident 45's closed record was reviewed on 8/20/25 at 4:04 p.m. Diagnoses included, but were not limited to, chronic respiratory failure, type 2 diabetes mellitus, and major depressive disorder. The Discharge Return Anticipated Minimum Data Set assessment, dated 6/5/25, indicated the resident was moderately cognitively impaired. She was dependent on staff for toileting hygiene, showering, bed mobility, and transfers. She had 1 stage 2 pressure ulcer, 2 stage 3 pressure ulcers, 1 stage 4 pressure ulcer, and 1 unstageable pressure ulcer all present on admission. A Progress Note, dated 6/4/25, indicated the resident was receiving antibiotics at the time. She had her catheter changed/placed due to low output and leakage which was tolerated well. 30 milliliters of dark yellow urine was observed for return. The physician was updated on the lab results, catheter replacement, and treatments for wounds. A Progress Note, dated 6/5/25 at 12:57 p.m., indicated the resident was mouth breathing. Vital signs were 18 breaths per minute, blood pressure 51/29, pulse 61, and temperature 96.8. She was pale, diaphoretic, appetite poor, and had to give medications with applesauce to help with her swallowing. Urinary output was less than 200 milliliters during the shift. The resident was unable to follow directions, held food and pills in her mouth. Lab results were faxed to the physician, and she continued to receive antibiotics for infection. A Progress Note, dated 6/5/25 at 3:30 p.m., indicated new orders were received and noted to send the resident to the emergency department for hypotension and altered mental status. Resident was transferred to the hospital and report was called. The resident was accompanied by her son. The record lacked documentation of a current assessment of the resident and documentation the resident and/or representative were oriented and prepared for the resident to transfer out of the facility. During an interview on 8/22/25 at 1:00 p.m., the Director of Nursing and Regional Nurse Consultant indicated there was no further documentation in the record related to the resident's transfer.

Based on record review and interview, the facility failed to ensure medical records were accurate and complete related to incomplete meal intakes, snack intakes and fluid intakes for 3 of 13 resident records reviewed. (Residents B, E, and C)Findings include: 1. The closed record for Resident B was reviewed on 8/19/25 at 3:48 p.m. Diagnoses included, but were not limited to, myasthenia gravis, cyclical vomiting syndrome and pervasive developmental disorder. The resident was admitted on [DATE] for a respite stay. The Quarterly Minimum Data Set (MDS) assessment, dated 5/6/25, indicated the resident had severe cognitive deficits and required moderate assistance with eating and substantial assistance with bed mobility and transfers. The Nutrition Care Plan, dated 5/7/25, indicated the resident was at nutritional risk due to dysphagia, feeding problems and vomiting syndrome. Interventions included, but were not limited to, monitor oral intakes. The Task Meal Consumption Logs were documented with percentage of meals eaten. The May 2025 log lacked documentation for the following meals: Breakfast: 5/1, 5/2, 5/5, 5/7, 5/8, 5/9, 5/12, 5/13, 5/15, 5/16, 5/19, 5/20, 5/21, 5/22, 5/23, 5/24, 5/25, 5/27, 5/28, 5/29, 5/30 Lunch: 5/1, 5/2, 5/4, 5/5, 5/6, 5/7, 5/8, 5/9, 5/13, 5/14, 5/15, 5/16, 5/18, 5/19, 5/20, 5/21, 5/22, 5/23, 5/24, 5/25, 5/26, 5/27, 5/28, 5/29, 5/30 Dinner: 5/1, 5/2, 5/3, 5/4, 5/5, 5/7, 5/8, 5/9, 5/10, 5/11, 5/12, 5/13, 5/14, 5/15, 5/17, 5/18, 5/19, 5/20, 5/21, 5/23, 5/24, 5/25, 5/26, 5/27, 5/28, 5/29, 5/30During an interview on 8/21/25 at 3:25 p.m., the Administrator was made aware of the missing documentation, there was no additional information provided. 2. Resident E's record was reviewed on 8/19/25 at 12:08 p.m. Diagnoses included, but were not limited to, diabetes mellitus, dementia and end stage renal disease dependent on dialysis. The Significant Change MDS assessment, dated 6/11/25, indicated the resident was cognitively intact and required set up assistance for eating and toileting. A Physician's Order, dated 7/6/23, indicated the resident was on a 1200 milliliters (ml) daily fluid restriction. Nursing was to provide a total of 480 ml, and dietary was to provide 720 ml divided by 240 ml for breakfast, 240 ml for lunch and 240 ml for dinner. A Dialysis Care Plan, dated 7/19/23, indicated the resident required dialysis related to end stage kidney disease. Interventions included, but were not limited to, monitor fluid intake (fluid restriction) and ensure that resident understands importance of dietary and fluid restrictions. The August 2025 Vitals Report lacked fluid documentation for the following meals: Breakfast: 8/2, 8/3, 8/4, 8/5, 8/6, 8/8, 8/10, 8/11, 8/12, 8/15, 8/17. Lunch: 8/3, 8/4, 8/6, 8/8, 8/9, 8/10, 8/11, 8/15, 8/18, 8/21. Dinner: 8/1, 8/2, 8/3, 8/4, 8/5, 8/6, 8/7, 8/8, 8/9, 8/10, 8/12, 8/14, 8/17, 8/18, 8/20, 8/21. During an interview on 8/21/25 at 3:25 p.m., the Administrator was made aware of the missing documentation, there was no additional information provided. 3. Record review for Resident C was completed on 8/19/25 at 12:33 p.m. Diagnoses included, but were not limited to, Parkinson’s disease, Lewy body dementia, and anxiety. The Quarterly Minimum Data Set (MDS) assessment, dated 6/5/25, indicated the resident was severely cognitively impaired. The resident was dependent on staff for eating and drinking. A Care Plan, dated 3/20/25 and revised 8/18/25, indicated the resident was on a mechanically altered diet texture related to Lewy body dementia. An intervention included to monitor and record intakes. The August 2025 Physician’s Order Summary (POS) indicated orders for the following:-Chart morning snack intake daily-Chart afternoon snack intake daily-Chart evening snack daily at bedtime -Chart breakfast intake daily-Chart lunch intake daily-Chart dinner intake daily The Task Meal Consumption Logs were documented with percentage of snacks and meals eaten. The last 30 days lacked documentation for the following snacks and meals:-Morning snack: 7/22, 7/24, 7/25, 7/27, 7/31, 8/3, 8/4, 8/6, 8/7, 8/8, 8/13, and 8/17/25-Afternoon snack: 7/19, 7/20, 7/22, 7/23, 7/24, 7/26, 7/27, 7/29, 7/30, 8/2, 8/3, 8/4, 8/5, 8/7, 8/8, 8/9, 8/10, 8/12, 8/14, 8/15, 8/16, 8/17, 8/18, and 8/19/25-Evening snack: 8/7/25-Breakfast: 7/22, 7/24, and 8/8/25-Lunch: 7/25, 8/8, and 8/10/25-Dinner: 7/19, 7/20, 7/23, and 8/18/25 During an interview on 8/20/25 at 3:59 p.m., the Director of Nursing (DON) indicated she was unable to provide any documentation the resident's meal consumption logs were completed on the above dates. This citation relates to Intake 1759620. 3.1-50(a)(1)

Based on observation, record review, and interview, the facility failed to ensure a splinting device was in place as ordered for a resident with a limited range of motion for 1 of 1 resident reviewed for range of motion. (Resident 13) Finding includes:During random observations on 8/18/25 at 2:52 p.m., 8/19/25 at 12:45 p.m., 8/21/25 at 10:01 a.m. and 4:01 p.m., Resident 13 was observed sitting in his wheelchair. At that time, his right arm was in his lap with no splinting devices observed on the right hand. Resident 13's record was reviewed on 8/21/25 at 10:07 a.m. Diagnoses included, but were not limited to, hemiplegia and hemiparesis (weakness and paralysis) following a stroke affecting the right dominant side, vascular dementia, and cognitive communication deficit. The Annual Minimum Data Set assessment, dated 6/18/25, indicated the resident was rarely or never understood. The resident had limited range of motion impairment to one side for the upper and lower extremity. He was dependent on staff for toileting, showering, personal hygiene, bed mobility, and transfers. A Care Plan, dated 12/16/23, indicated the resident required substantial/maximal up to total assistance with mostly all activities of daily living related to hemiplegia and hemiparesis following a stroke affecting the right side. The approaches were for the resident to use a right hand splint while up in the wheelchair. A Physician's Order, dated 7/31/25, indicated the resident was to wear a right hand splint when up in the wheelchair. The August 2025 Medication Administration Records (MAR) indicated the right hand splint was checked off as administered every shift (3 times a day) for every shift from 8/1/25 thru the morning of 8/21/25. There were no documented refusals of the right hand splint. During an interview on 8/21/25 at 3:59 p.m., the Director of Nursing and Regional Nurse Consultant indicated the resident has been refusing to wear the splint lately. No further information was provided at the time. A policy titled, Assistive Devices and Equipment, indicated, 1. Devices and equipment that assist with resident mobility, safety, and independence are provided for residents. These include .splints. 2. Recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the resident's plan of care . 3.1-42(a)(2)

Based on record review and interview, the facility failed to ensure to send the facility's bed-hold and reserve bed payment policy before and upon transfer to the hospital and transfer or discharge form to the resident and/or representative. The facility also failed to ensure appropriate information was conveyed to the receiving provider for 3 of 3 residents reviewed for hospitalization. (Resident 3, 8, and 45)1. Resident 3's record was reviewed on 8/21/25 at 12:28 p.m. Diagnoses included, but were not limited to, chronic respiratory failure, chronic obstructive pulmonary disease, heart failure, and high blood pressure. The Quarterly Minimum Data Set assessment, dated 7/7/25, indicated the resident was cognitively intact. She was dependent on staff for toileting, showering, bed mobility, and transfers. A Progress Note, dated 6/24/25 at 12:20 a.m., indicated the resident did not respond per normal when trying to wake the resident to take scheduled medications. She would open her eyes but not keep them open for long when rubbing her chest. She was slow to respond verbally. The physician was called and gave orders to send the resident to the hospital. She was coughing frequently. Resident was alert and oriented to person and place. Vital signs were blood pressure of 136/64, temperature 98.4, heart rate 68, respirations 20, and oxygen at 92% at 5 liters per nasal cannula. Report was called to the receiving hospital, and papers went with the EMTs to the hospital. The emergency contact was called but did not answer. The record lacked documentation of the notice of transfer or discharge form, and bed hold was sent to the resident and/or representative. There was no documentation of the information provided to the receiving provider, including but not limited to contact information for the resident's practitioner, resident representative information, advance directive information, ongoing treatments, and medications that the resident received at the facility. During an interview on 8/22/25 at 1:00 p.m., the Director of Nursing and Regional Nurse Consultant indicated they had no further information to provide. 2. Resident 8's record was reviewed on 8/20/25 at 3:44 p.m. Diagnosis included, but were not limited to, intellectual disabilities, aphasia, and type 2 diabetes mellitus. The Quarterly Minimum Data Set assessment, dated 7/9/25, indicated the resident was severely cognitively impaired. A Progress Note, dated 3/19/25 at 12:49 p.m., indicated the resident was in the main dining room and was observed to be shivering, hands cyanotic (blue) from proximal knuckle to the tips of his fingers. The physician was notified, and new orders were received for labs. He had elevated finger sticks into the 300s and new orders were placed for glucose monitoring twice daily. A Progress Note, dated 3/19/25 at 11:27 p.m., indicated results were received for a CT scan and chest x-ray from the hospital. The resident was still in the emergency department. The record lacked documentation of the notice of transfer or discharge form, and bed hold was sent to the resident and/or representative. There was no documentation of the information provided to the receiving provider, including but not limited to contact information for the resident's practitioner, resident representative information, advance directive information, ongoing treatments, and medications that the resident received at the facility. During an interview on 8/22/25 at 1:00 p.m., the Director of Nursing and Regional Nurse Consultant indicated they were unable to find any further information related to the hospital transfer. 3. Resident 45's closed record was reviewed on 8/20/25 at 4:04 p.m. Diagnoses included, but were not limited to, chronic respiratory failure, type 2 diabetes mellitus, and major depressive disorder. The Discharge Return Anticipated Minimum Data Set assessment, dated 6/5/25, indicated the resident was moderately cognitively impaired. She was dependent on staff for toileting hygiene, showering, bed mobility, and transfers. She had 1 stage 2 pressure ulcer, 2 stage 3 pressure ulcers, 1 stage 4 pressure ulcer, and 1 unstageable pressure ulcer all present on admission. A Progress Note, dated 6/4/25, indicated the resident was receiving antibiotics at the time. She had her catheter changed/placed due to low output and leakage which was tolerated well. 30 milliliters of dark yellow urine was observed for return. The physician was updated on the lab results, catheter replacement, and treatments for wounds. A Progress Note, dated 6/5/25 at 12:57 p.m., indicated the resident was mouth breathing. Vital signs were 18 breaths per minute, blood pressure 51/29, pulse 61, and temperature 96.8. She was pale, diaphoretic, appetite poor, and had to give medications with applesauce to help with her swallowing. Urinary output was less than 200 milliliters during the shift. The resident was unable to follow directions, held food and pills in her mouth. Lab results were faxed to the physician, and she continued to receive antibiotics for infection. A Progress Note, dated 6/5/25 at 3:30 p.m., indicated new orders were received and noted to send the resident to the emergency department for hypotension and altered mental status. Resident was transferred to the hospital and report was called. The resident was accompanied by her son. The record lacked documentation of the notice of transfer or discharge form, and bed hold was sent to the resident and/or representative. There was no documentation of the information provided to the receiving provider, including but not limited to contact information for the resident's practitioner, resident representative information, advance directive information, ongoing treatments, and medications that the resident received at the facility. During an interview on 8/22/25 at 1:00 p.m., the Director of Nursing and Regional Nurse Consultant indicated there was no further documentation in the record related to the resident's transfer. A policy titled, Transfer or Discharge, Emergency, indicated .4. should it be necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: a. Notify the attending physician; b. Notify the receiving facility that the transfer is being made; c. Prepare the resident for transfer; d. Prepare a transfer form to send with the resident e. Notify the representative or other family member .

Based on observation, interview, and record review, the facility failed to ensure correct Personal Protective Equipment (PPE) was used by staff members (CNA 1 and CNA 2) when providing care to residents (Resident G and Resident D) who were in Enhanced Barrier Precautions (EBP), for two random observation for infection control. Finding includes: 1. During an observation and interview on 2/23/25 at 1:45 p.m., CNA 1 and CNA 2 had transferred Resident G from the chair to the bed. A mechanical lift had been utilized. The resident had a urinary catheter. There was a sign on the room door that indicated EBP was to be used. CNA 1 and CNA 2 were observed with gloves on. Gowns were not being worn. CNA 2 indicated gowns were only needed if they were providing urinary catheter care. Resident G's record was reviewed on 2/4/25 at 3:42 p.m. The diagnoses included, but were not limited to, obstructive reflux uropathy. A Physician's Order, dated 8/10/24, indicated EBP was to be implemented for all high contact resident care activities due to the indwelling urinary catheter. A Minimum Data Set assessment, dated 12/10/24, indicated an intact cognitive status, a urinary catheter was present, and there was one stage two (partial thickness) pressure area present. A Care Plan, dated 1/22/25, indicated a pressure area was present on the left ischium and EBP was to be utilized during care. 2. During an observation and interview on 2/3/25 at 1:55 p.m., CNA 1 and CNA 2 entered Resident D's room to provide incontinent care. The CNAs washed their hands and applied gloves. They started to provide care and were stopped. CNA 2 indicated a gown only had to be used if they were providing catheter care or wound care. The CNAs then utilized the PPE indicated for EBP. Resident D's record was reviewed on 2/4/25 at 1:30 p.m. The diagnoses included, but were not limited to, transverse myelitis and diabetes mellitus. A Physician's Order, dated 6/27/24, indicated EBP was to be implemented for all high contact resident care activities due to the indwelling urinary catheter. A Care Plan, dated 10/23/24, indicated a pressure ulcer to the right posterior thigh. The interventions included Enhanced Barrier Precautions were to be used with care. An Annual Minimum Data Set assessment, dated 11/7/24, indicated an intact cognitive status, was dependent for bed mobility and toileting, had a urinary catheter, was always incontinent of bowels, had one stage two (partial thickness of skin/shallow open ulcer) and one stage three (full thickness tissue loss) pressure ulcer present. A Care Plan, dated 11/20/24, indicated a pressure ulcer was present on the the left posterior thigh. The interventions included EBP was to be used with care. During an interview on 2/3/25 at 2:10 p.m. the Director of Nursing (DON) indicated the staff have been educated on the use of EBP. A facility policy, dated 2024, and received from the DON as current, indicated EBP (gowns and gloves) were to be used during high-contact resident care activities, which included dressing, bathing/showering, transferring, hygiene, linen changes, brief changes, bathroom assistance, device care or use (central line, urinary catheter, feeding tube) and wound care. 3.1-18(b)

Based on observation, record review, and interview, the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services to promote healing, related to treatments not completed as ordered for 1 of 3 residents reviewed for pressure ulcers. (Resident D) Finding includes: During an observation and interview on 2/3/25 at 1:55 p.m., CNA 1 and CNA 2 entered Resident D's room to provide incontinence care. The CNA's assisted the resident to turn onto her left side. Resident D had a urinary catheter and the pad underneath the resident was soiled with urine. The resident indicated her urine would sometimes leak around the catheter. CNA 2 indicated the resident had pressure ulcers on the right and left upper back thigh. The areas on the posterior thighs were observed to be open and not covered with dressings. CNA 2 observed the soiled pad that was being removed and indicated the dressings were not found on the soiled pad. During an observation and interview on 2/3/25 at 2:05 p.m., the Director of Nursing (DON) indicated there were no dressings covering the pressure areas on the bilateral posterior thighs. CNA 2 indicated when she had provided care earlier, she had not paid attention and was unsure if the dressings were on the pressure areas at the time of the earlier care. CNA 2 indicated she was unsure how long the dressings had not been on the open areas. Resident D's record was reviewed on 2/4/25 at 1:30 p.m. The diagnoses included, but were not limited to, transverse myelitis and diabetes mellitus. A Care Plan, dated 10/23/24, indicated a pressure ulcer to the right posterior thigh. The interventions included the treatment and dressing would be completed to the wound as ordered. An Annual Minimum Data Set assessment, dated 11/7/24, indicated an intact cognitive status, was dependent for bed mobility and toileting, had a urinary catheter, was always incontinent of bowel, had one stage two (partial thickness of skin/shallow open ulcer) and one stage three (full thickness tissue loss) pressure ulcer. A Care Plan, dated 11/20/24, indicated a pressure ulcer was present on the the left posterior thigh. The interventions included the treatment and dressing would be completed to the wound as ordered. The Physician's Orders, dated 1/22/25, indicated the right and left posterior thighs were to be cleansed with normal saline, collagen (wound dressing) was to be applied to the wound beds and a bordered gauze was to be applied to cover the wound. The treatments were scheduled every evening at bedtime. This citation relates to Complaints IN00449796 and IN00451233. 3.1-40(a)

Based on observation, interview, and record review, the facility failed to ensure a resident's privacy was respected, related to Terminated Employee 1 using her private cell phone to take a video of a resident (Resident C), without the approval of the resident or the resident's representative, for 1 of 1 resident reviewed for privacy. The deficient practice was corrected by 8/1/24, prior to the start of the survey, and was therefore past noncompliance. The facility thoroughly investigated the recording and posting of the video. CNA 1 was terminated. CNA 2 was disciplined. Staff were re-educated on the cell-phone and confidentiality policy of the facility and staff re-signed acknowledgement of the policies. Finding includes: During an interview on 8/20/24 at 9:52 a.m., the Social Service Director indicated she was aware of a CNA who took a picture of Resident C. She indicated Resident C's cognition status varied. During an observation and interview on 8/20/24 at 10:10 a.m., Resident C was lying in bed. He was unsure why he was at the facility and was unsure of the date and the season. He indicated he knew where he used to work, but could not remember more current things. He was unable to remember if a picture/video had been taken of him. During an interview with the Administrator on 8/20/24 at 10:43 a.m., she indicated there was a full investigation of the incident. The CNA who had taken the video had been terminated. CNA 3 had notified her that Terminated CNA 1 had posted a video of the resident. The CNA's at the facility had a group page they could send messages to communicate with each other. The video had not been posted to a social media feed. The video had shown the resident from the shoulders up. It was taken in the bathroom, but someone could not tell it was a bathroom unless they worked at the facility and knew what the bathroom looked like. Terminated Employee 1 had indicated the resident was having a good day and she just thought it was cute. The employee had been suspended immediately and during the investigation, it had been determined CNA 2 had also been in the room while the video was being taken, so she was also suspended and a written warning was given. The video post had been deleted. The resident's responsible party had been notified of the incident. The video was provided by the Administrator on 8/20/24 at 10:05 a.m. The video lasted approximately three seconds and the resident was dressed in a shirt and could be seen from the mid-chest up. There was no sound on the video. During an interview on 8/20/24 at 1:19 p.m., CNA 2 indicated she was in the resident's room and Terminated Employee 1 was in the bathroom with Resident C. Terminated Employee 1 was overheard asking the resident to say something about his past employment. The resident had made a statement. CNA 2 indicated she did not know Terminated Employee 1 was going to send the video to anyone else. During an interview on 8/20/24 at 1:31 p.m., CNA 3 indicated she had seen the video on another CNA's cell phone. The video was posted on a social media messenger page and she was not a member of group. The resident's verbalization on the video was difficult to understand. The Administrator was notified of the video. Resident C's record was reviewed on 8/20/24 at 11:30 a.m. The diagnoses included, but were not limited to, diabetes mellitus and repeated falls. An Admission Minimum Data Set assessment, dated 7/24/24, indicated an intact cognition, no behaviors, and maximum assistance was required for toileting, bathing, hygiene, transfers, and wheelchair mobility. A Consent Form, signed and dated by the resident on 7/18/24, indicated he had given permission for the facility to take photographs for the medication book, charts, and wound care documentation as needed. Photos could also be taken during outing activities and he acknowledged the pictures may be used for promotional purposes. Terminated Employee 1 had signed an acknowledgement of receipt of the Employee Handbook which included resident rights and confidentiality on 1/28/16. The Employee Handbook, dated 9/10/2007, indicated all internal information was to be kept strictly confidential and was not to be discussed with any person inside or outside the facility. Terminated Employee 1 had had signed acknowledgement of the facility cell phone policy on 10/18/19. The facility cell phone policy, dated 4/9/2009 and received from the Administrator as current, indicated cell phones were not to be carried on the job. The use of camera phones or other audio or video recording devices was an invasion of the resident's personal privacy and were prohibited from use. The current facility confidentiality statement, received from the Administrator as current on 8/20/24 at 9:57 a.m., indicated the violation of any resident's rights to privacy or confidentiality of health information may result in punitive action and possible immediate dismissal from employment. The employee was not to sent photos/videos or protected health information via un encrypted email or texting. Photographs or videos with any personal mobile device were prohibited. Posting the resident's photo/video or protected health information on any social networking website/platform was prohibited. This citation relates to Complaint IN00440025. 3.1-3(o)

Based on record review and interview, the facility failed to ensure adequate monitoring was in place for a resident receiving scheduled opioid medication (pain medication) for 1 of 5 residents reviewed for unnecessary medications. (Resident 24) Finding includes: Resident 24's record was reviewed on 7/23/24 at 12:21 p.m. Diagnoses included, but were not limited to, fracture of the left femur, dementia, and osteoarthritis. The Significant Change in Status Minimum Data Set (MDS) assessment, dated 6/10/24, indicated the resident was severely cognitively impaired for daily decision making. The resident received scheduled pain medication in the last 5 days and received an opioid medication. A Physician's Order, dated 5/30/24, indicated to give hydrocodone-acetaminophen (an opioid pain medication) 5-325 milligram tablet twice a day. The June 2024 Medication Administration Record indicated the resident received the hydrocodone-acetaminophen tablet as ordered. A Care Plan, dated 5/1/24, indicated the resident was at risk for pain related to osteoarthritis, decreased mobility, and recent left hip fracture with surgical repair. Interventions included, but were not limited to analgesics as ordered and attempt non-pharmacological interventions as needed. There were no orders or a care plan related to opioid side effect monitoring. During an interview on 7/26/24 at 10:10 a.m., the Director of Nursing indicated there should be a care plan or order for side effect monitoring for an opioid medication. She was unable to provide any further information. A Policy titled, Pain - Clinical Protocol, indicated .Monitoring .4. The staff and physician will monitor for adverse effects of pain medications such as gastrointestinal bleeding from nonsteroidal anti-inflammatory drugs (NSAIDs), and anorexia, confusion, lethargy, severe constipation related to opioids. a. The physician will adjust or discontinue medications accordingly, based on effectiveness and side effects . 3.1-48(a)(3)

Based on observation, record review, and interview, the facility failed to ensure residents received the necessary treatment to prevent contractures (a fixed shortening or hardening of muscles or tendons) or decreased range of motion, related to passive range of motion not completed as recommended and a splinting device not in place as ordered for 2 of 2 residents reviewed for range of motion (ROM). (Residents 14 and 12) Findings include: 1. On 7/22/24 at 1:59 p.m., Resident 14 was observed in her bed. She indicated she was paralyzed from the waist down. She was afraid of her legs becoming contracted because she was not getting any type of range of motion (ROM) exercises. The resident's record was reviewed on 7/23/24 at 2:42 p.m. Diagnoses included, but were not limited to, acute transverse myelitis disease of the central nervous system, Diabetes Mellitus and chronic pain. The Quarterly Minimum Data Set assessment, dated 6/22/24, indicated the resident was cognitively intact and dependent on staff for toileting and transfers, and required substantial/ maximum assist for bed mobility. The resident received Physical Therapy (PT) services from 3/14/24-5/29/24. The PT Discharge Summary indicated skilled interventions provided were addressing core strength and seated balance, bed mobility, trunk ROM and LE (lower extremities) ROM and training of caregivers with LE ROM program. Discharge recommendations were 24-hour care and home exercise program with upper extremities and lower extremities ROM with assist of CNAs. During an interview on 7/24/24 at 2:20 p.m., QMA 1 indicated some residents received ROM, but Resident 14 did not, she was only on the turning and repositioning program. During an interview on 7/26/24 at 9:00 a.m., PT Aide 1 indicated recommendations for Resident 14 made at discharge were to do ROM to the lower extremities and splinting was not recommended at that time. Recommendations were either made verbally or by communication sheets to nursing staff. During an interview on 7/26/24 at 9:10 a.m., the Director of Nursing indicated ROM should be documented in the Point of Care tasks in the computer and there was nothing documented for Resident 14. During an interview on 7/25/24 at 1:30 p.m., the Administrator indicated the resident would be re-evaluated by PT. 45666 2. During an interview on 7/22/24 at 1:15 p.m., Resident 12 indicated he usually had a carrot (splinting device for contractures) in his left hand, however he was unable to find it so he was not holding the carrot at the time. His left hand was noted to be contracted. On 7/23/24 at 11:27 a.m., Resident 12 was observed in a wheelchair at a table in the dining room. His left hand was contracted and there was no carrot or washcloth observed in his hand. On 7/24/24 at 10:57 a.m., Resident 12 was observed in a wheelchair self-propelling in the hallway. His left hand was contracted and there was no carrot or washcloth observed in his hand. On 7/26/24 at 10:17 a.m., Resident 12 was observed in a wheelchair self-propelling in the hallway. His left hand was contracted and there was no carrot or washcloth observed in his hand. He indicated at the time, if a washcloth was used instead of the carrot, the washcloth would occasionally fall out of his hand. Resident 12's record was reviewed on 7/24/24 at 2:40 p.m. Diagnoses included, but were not limited to, hemiplegia (weakness or paralysis of one side of the body) of the left nondominant side and contracture of the left hand, wrist, and elbow. The Annual MDS assessment, dated 7/2/24, indicated the resident was cognitively intact for daily decision making and had impairment and limited range of motion to one side on both the upper and lower extremities. A Physician's Order, dated 10/12/23, indicated the resident wore a carrot, palm protector, or rolled washcloth to the left hand every shift. A Care Plan, dated 7/11/23, indicated the resident had a contracture to the left hand, arm, and foot. Interventions included, but were not limited to, apply carrot to the left hand or rolled wash cloth removing for meals, range of motion, or washing, and allow to refuse and vent feelings. During an interview on 7/24/24 at 2:52 p.m., CNA 1 indicated the resident had a contracture to the left hand and wore some type of splinting device to that hand at all times. During an interview on 7/26/24 at 10:10 a.m., the Director of Nursing indicated sometimes the resident did remove the splinting devices on his own, however that was not care planned at the time and would be added to his care plan. 3.1-42(a)(2)

Based on record review and interview, the facility failed to ensure a comprehensive care plan was developed and in place for anticoagulant and antiplatelet medication use for 1 of 18 resident care plans reviewed. (Resident 7) Finding includes: The record for Resident 7 was reviewed on 7/24/24 at 10:54 a.m. Diagnoses included, but were not limited to, hypertension, congestive heart failure, and venous insufficiency. The Admission Minimum Data Set (MDS) assessment, dated 5/13/24, indicated the resident had received an anticoagulant medication in the past seven days. The resident had not received any antiplatelet medications in the past seven days. A Physician's Order, dated 5/7/24, indicated to give aspirin (an antiplatelet medication) 81 milligram tablet daily. A Physician's Order, dated 5/7/24, indicated to give apixaban (an anticoagulant medication) 5 milligrams twice daily. The Medication Administration Record (MAR), dated 7/2024, indicated the resident had received the aspirin and apixaban as ordered. During an interview on 7/25/24 at 4:15 p.m., the Director of Nursing indicated there should have been a care plan in place for anticoagulant and antiplatelet medications, including monitoring for side effects of the medications. 3.1-35(a)

Based on record review and interview, the facility failed to report an allegation of abuse to the State Agency for 1 or 1 residents reviewed for abuse (Resident B) Finding includes: Resident B's record was reviewed on 1/17/24 at 10:33 a.m. The resident admitted to the facility on [DATE] and discharged on [DATE]. Diagnoses included, but were not limited to, fracture of the left femur and left fibula. The Discharge Minimum Data Set (MDS) assessment, dated 11/22/23, indicated the resident was moderately impaired for daily decision making. In an email to the facility, dated 1/2/24 at 1:19 p.m., Resident B's family member indicated the resident had complained that a nurse aide was rough with her. She was impatient with the resident while she was in the shower. The resident was evidently not moving fast enough and the aide grabbed her hips and twisted and roughly put her in the shower chair. The resident was in a lot of pain. It happened every time the aide was responsible for showering the resident. A Grievance Form, dated 1/8/24, indicated Resident B's family member emailed the Director of Nursing (DON) regarding her mother's stay at the facility. The resident was receiving skilled therapy and discharged on [DATE] with home health care. The issues noted in the email indicated the nurse aide was impatient and moving fast during shower care with no dates noted. The Investigation Timeline indicated the email from Resident B's family member was received on 1/8/24 and the investigation began with reviewing grievances with social services. There were no grievances filed in regards to Resident B. On 1/10/24, the Administrator spoke to all alert and oriented residents currently residing in the facility to ask if they felt safe or had any negative experiences while receiving care in the shower, in their rooms, or at any time in the facility. All residents stated that they felt safe with no concerns. On 1/16/24, the Administrator requested the DON and Unit Manager provide education with nursing personnel in regards to approach and not rushing. During an interview on 1/17/24 at 1:00 p.m., the Administrator indicated that they had received the email from the family member after Resident B had been discharged from the facility. She immediately started an investigation upon receiving the email and did not substantiate the allegations, so she did not report it. She indicated if the resident was still residing in the facility, she would have reported it. The policy, [NAME] Health Care Center Abuse Prohibition Policy, indicated .19. All reports of alleged or suspected or known abuse shall be reported to the Indiana State Department of Health within 2 hours by the Administrator or their designee .20. The administrator must send a follow up investigative report within 5 working days of the reported incident .Reporting requirements: A. Each covered individual shall report to the State Department of Health and local or State law enforcement agencies. B. Timing - any allegations must be reported immediately to the Administrator or their designee and within 2 hours to the State Department of Health and local or state law enforcement agencies (if applicable) . This citation relates to Complaint IN00425189. 3.1-28(c)

Based on observation, record review, and interview, the facility failed to ensure a resident's protective arm sleeves were applied as ordered by the physician, and discolorations were assessed and monitored for 2 of 3 residents reviewed for non-pressure skin condition. The facility also failed to ensure neurological checks were initiated following a fall for 1 of 2 residents reviewed for falls. (Residents 24, 42, and 7) Findings include: 1. On 8/21/23 at 2:40 p.m., Resident 24 was observed lying in bed in a hospital gown. The resident did not have any protective sleeves on either arm. There were multiple dark purple discolorations observed to both arms. On 8/22/23 at 10:12 a.m., Resident 24 was observed lying in bed in a hospital gown. The resident did not have any protective sleeves on either arm. The dark purple discolorations were still observed. On 8/23/23 at 2:18 p.m., Resident 24 was sitting up in a recliner in her room. The resident was wearing a short sleeve shirt. There were no protective sleeves observed on either arm and the discolorations were still observed. Record review for Resident 24 was completed on 8/23/23 at 2:21 p.m. Diagnoses included, but were not limited to, hypertension, diabetes mellitus, and dementia. The Admission Minimum Data Set (MDS) assessment, dated 8/19/23, indicated the resident was cognitively impaired. The resident required an extensive 2+ person assist with dressing. The resident had received an anticoagulant (blood thinning) medication. A Care Plan, dated 5/2/23 and revised 7/14/23, indicated the resident required assistance with ADLs (activities of daily living) due to a decline. An intervention included to observe skin condition with daily care. The August 2023 Physician's Order Summary (POS) indicated the following: - Eliquis (blood thinning medication) 2.5 mg (milligrams) twice a day - Tubi grips (protective sleeves) to both arms as tolerated every shift The August 2023 Treatment Administration Record (TAR) indicated, for the above dates of observation, the Tubi grips were checked off that they were applied. The record lacked any documentation the resident had refused or would not tolerate to wear them on the above dates of observation. Interview with CNA 2 on 8/23/23 at 2:53 p.m., indicated she had never applied Tubi grips on the resident and she was unaware the resident was supposed to wear them. Interview with LPN 1 on 8/23/23 at 2:55 p.m., indicated the resident had recently readmitted to the facility from a hospital stay. The resident had received multiple discolorations to both her arms and hands while in the hospital due to needle sticks from blood draws and IV's. The resident was supposed to wear the Tubi grips on both her arms. The CNAs were responsible for putting the resident's Tubi grips on. If the resident refused them then they should let the nurse know. She indicated she should not have documented they were on when the resident was not wearing them. Interview with the Director of Nursing (DON) on 8/23/23 at 2:58 p.m., indicated nursing should be documenting if the resident was refusing or not able to tolerate the Tubi grips. 45666 2. Resident 42's record was reviewed on 8/23/23 at 3:56 p.m. Diagnoses included, but were not limited to, vascular dementia with anxiety, adult failure to thrive, and cervical disc degeneration. The Significant Change MDS assessment, dated 8/17/23, indicated the resident was moderately cognitively impaired for daily decision making. The resident required extensive assistance for bed mobility, transfer, toilet use, personal hygiene, and dressing. She had a history of falls without injury since admission or prior assessment. A Care Plan, dated 4/13/23, indicated the resident was at risk for falls. Interventions included, but were not limited to, remind and encourage call light use, proper footwear as indicated, observe for safety, and remind to call for assistance with mobility/transfers as needed. A Fall Event, dated 8/4/23 at 11:48 a.m., indicated the resident had an unwitnessed fall. The Physician and the resident representative were notified of the fall. A set of vital signs, including temperature, respirations, heart rate, blood pressure, and oxygen saturation, were obtained at the time of the fall. A Progress Note, dated 8/5/23 at 12:02 a.m., indicated the resident was observed laying on the floor beside her bed with blankets and pillows underneath her. A head to toe assessment was completed with no redness or injuries observed. The resident indicated she was sleeping and rolled out of the bed. The Physician and resident representative were updated and neurochecks were initiated. The record lacked documentation of completed neurochecks following the fall on 8/4/23. Interview with the Director of Nursing on 8/24/23 at 3:30 p.m., indicated the neurochecks should have been completed after an unwitnessed fall, but the staff were unable to locate the documentation. 48383 3. Resident 7 was observed in her room on 8/21/23 at 10:18 a.m., there was bruising noted to the right forearm. The resident was unable to indicate how or when she acquired the bruise. On 8/23/23 at 10:18 a.m., the resident was observed sleeping in her recliner. The right forearm bruise remained and was darker in coloration. The resident's record was reviewed on 8/21/23 at 10:11 a.m. Diagnoses included, but were not limited to, hypertension (high blood pressure), non-Alzheimer's dementia, heart failure, atrial fibrillation (abnormal heart rhythm), arthritis, diabetes mellitus, muscle weakness, chronic obstructive pulmonary disease (COPD), and anemia (low iron). The Annual MDS (Minimum Data Set) assessment, dated 8/2/23, indicated the resident was impaired with decision making, received oxygen therapy, and was at risk for pressure ulcers and injuries. The resident required extensive assistance with one physical assist with bed mobility, transfers, dressing, toileting and personal hygiene. A Care Plan, with a revised date of 8/4/23, indicated the resident was at risk for bleeding and/or bruising related to taking an anticoagulant for atrial fibrillation. Interventions included, but were not limited to, administer medication as ordered, assess environment for needed changes, and provide gentle handling during care to avoid bruises/bleeding. A Physician's Order, dated 7/10/23, indicated to check for unusual bleeding and/or bruising. A Physician's Order, dated 7/26/23, indicated eliquis (blood thinner) 2.5 mg to be administered twice a day. Skin Assessments, completed weekly for July and August 2023, did not notate any right forearm bruise. Interview with the Director of Nursing (DON) on 8/24/23 at 1:48 p.m., indicated there was no documentation on the right forearm bruising. She measured the bruise and started an event note. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure oxygen was being administered at the correct flow rate for 1 of 1 residents reviewed for oxygen. (Resident 7) Finding includes: On 8/21/23 at 10:17 a.m., Resident 7 was observed. The resident was wearing oxygen via a nasal cannula with a flow rate set at 2.5 liters. On 8/23/23 at 10:18 a.m., Resident 7 was observed sleeping in her recliner. The resident was wearing oxygen via a nasal cannula with a flow rate set at 2.5 liters. On 8/23/23 at 11:25 a.m., Resident 7 was observed in her room wearing oxygen via nasal cannula with a flow rate set at 2.5 liters. On 8/23/23 at 3:10 p.m., Resident 7 was observed sitting in her recliner wearing oxygen via nasal cannula with a flow rate set at 2.5 liters. Resident 7's record was reviewed on 8/21/23 at 10:11 a.m. Diagnoses included, but were not limited to, hypertension (high blood pressure), non-Alzheimer's dementia, heart failure, atrial fibrillation (abnormal heart rhythm), arthritis, diabetes mellitus, muscle weakness, chronic obstructive pulmonary disease (COPD), and anemia (low iron). The Annual Minimum Data Set (MDS) assessment, dated 8/2/23, indicated the resident was impaired with decision making, and received oxygen therapy. The resident required extensive assistance with one physical assist with bed mobility, transfers, dressing, toileting and personal hygiene. A Care Plan, with revised date 8/4/23, indicated the resident had COPD. Interventions included, but were not limited to, administer oxygen per the physician's order. A Physician's Order, dated 7/14/23, indicated oxygen at 2 liters per nasal cannula continuous every shift as needed to maintain oxygenation greater than 90%. Interview with LPN 1 on 8/23/23 at 3:12 p.m., indicated the resident should be on 2 liters of oxygen and would go change the oxygen setting now. The Director of Nursing (DON) reviewed and changed the oxygen setting to 2 liters. 3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure a resident received adequate supervision and assistance to prevent accidents related to 1 (#42) resident being left unsupervised in the bathroom twice which resulted in a fracture and a laceration and failed to ensure interventions were in place for 1 (#13) resident which resulted in a fall for 2 of 7 residents reviewed with falls in a sample of 14. Findings include: 1. Resident #42's record was reviewed on 3/21/11 at 12:35 p.m. Resident #42's [DIAGNOSES REDACTED]. A Significant MDS (Minimum Data Set) assessment, dated 2/11/11, indicated Resident #42's cognition status was severely impaired, required extensive assist of two staff for transfer, limited assistance of two staff for ambulation, and had prior falls. A fall risk assessment, dated 7/24/10, indicated a score of 17, placing the resident at a high risk for falls. A Nurses' Note, dated 9/1/10 at 11:20 a.m., indicated "Found res (resident) lying on floor on stomach in room next to bathroom door. Res transferring self from toilet s/ (without) assist. Noted golf ball size bump to L (left) side of forehead et (and) abrasion to L eyebrow et to L wrist. C/O (complaint of) pain to hip/pelvic area. Res noted guarding hip/pelvic area. O/ (no) bleeding or further injury noted. O/ external rotation or shortening of (arrow down) (lower) extremities...." A History and Physical from the hospital, dated 9/3/10, indicated the resident was diagnosed with [REDACTED]. A Post Fall assessment, dated 9/1/10, indicated the resident fell when attempting to transfer self from the restroom. The Post Fall assessment indicated the CNA had been suspended. During an interview on 3/23/11 at 1:10 p.m., the DoN (Director of Nursing) indicated a CNA had left the resident unsupervised in the bathroom. The DoN indicated the CNAs know if the residents are at risk for falls, not to leave the residents unattended in the bathroom. The DoN indicated the CNA left the room and the resident fell and fractured her hip. The DoN indicated the CNA was disciplined for leaving the resident alone in the bathroom. A Nurses' Note, dated 3/8/11 at 7:30 p.m., indicated "CNA reported resident found lying on floor in her room. Resident lying in supine position on the floor. Resident yelling 'Oh my head' blood noted (arrow down) (under) resident's head. Resident reported 'on her way to bed.' Resident noted to have dry heaves et gently rolled to side c/ (with) pillow placed (arrow down) (under) head for alignment. Pressure applied c/ cold compress to back of resident's head...." A Nurses' Note, dated 3/8/11 at 10:00 p.m., indicated "Resident received staples x (times) 4...." A Fall Risk assessment, dated 3/8/11, indicated "...staff/CNA left resident unattended on toilet...." A care plan for at risk for falls, dated 6/24/10, lacked the intervention of not leaving the resident unsupervised while in the bathroom. A CNA Assignment Sheet, received from the DoN as current on 3/23/11 at 1:38 p.m., lacked documentation of not leaving the resident unattended while in the bathroom. During an interview on 3/23/11 at 1:10 p.m., the DoN indicated the CNA was suspended for leaving the resident unattended on the toilet. The DoN indicated the resident should not have been left alone on the toilet. The DoN indicated everybody had been educated in September not to leave the resident unattended in the bathroom. 2. Resident #13's record was reviewed on 3/21/11 at 12:35 p.m. Resident #13's [DIAGNOSES REDACTED]. An annual MDS assessment, with an assessment reference date of 1/25/11, indicated the resident was severely impaired with cognition, required limited assistance of one staff member for transfers, ambulation, and toilet use. The resident had fallen since the last assessment and had minor injuries. The resident's fall risk assessments, dated 1/13/11, indicated a total score of 13. The form indicated a total score above 10 represents high risk for falls. A care plan, dated 6/24/10, indicated "Resident is at risk for falls r/t (related to) dementia...1/13/11 Resident states 'feet came out from under her' Res (resident) confused at times...Encouraged to call for assist prn (as needed). Alarms added at this time...1/14/11 Resident removing personal alarm and getting up w/out (without) assist. Educated resident on risk and she acknowledged, still removes alarms r/t cognitive level..." The CNA assignment sheet, received from the DoN on 3/23/11 as current, lacked documentation to indicate the resident was at risk for falls or of any alarms used by the resident. The nurses' notes, dated 1/13/11 at 6:30 a.m., "Called into res room. Res sitting on bed stating she fell ...Swollen area 9 cm (centimeters) x 8 cm x 2.5 cm c (with) purple discoloration to rt (right) outer forehead/rt outer eyebrow area. Just below a swollen area measuring 3 cm x 2 cm x 0.2 cm skin colored. Reports some rt hip discomfort c walking..." The social service notes, dated 1/25/11 at 4:00 p.m., indicated "...Writer observed res walking down the hall later and she had her alarm in hand instead of attached..." The nurses' notes, dated 1/30/11 at 9 p.m., indicated "Res yelled 'Help!' Res found on her buttock on the floor of her room. She stated 'My feet slipped from underneath me.' Personal alarm did not alarm due to res removing alarm frequently..." During an interview on 3/22/11 at 4:45 p.m., the ADoN (Assistant Director of Nurses) indicated she was aware the resident had been taking off her alarms before the fall on 1/30/11. She indicated with the resident's cognition level they could educate but it did not do any good. She indicated if the resident was going to get up she was going to get up. She indicated after the second fall they changed the resident to a pressure alarm. During an interview on 3/23/11 at 1:35 p.m., the DoN indicated the CNA assignment sheets were not being updated. 3.1-45(a)(1) 3.1-45(a)(2)