Every finding on record at Retreat at the Stratford, The

Based on interview and record review, the facility failed to ensure the physician was notified of daily weight gains as ordered by the physician for 1 of 1 resident reviewed for notification of change. (Resident 3)Findings include:The clinical record for Resident 3 was reviewed on 2/10/26 at 11:11 a.m. The diagnoses included, but were not limited to, congestive heart failure, chronic kidney disease, chronic obstructive pulmonary disease, mild persistent asthma with acute exacerbation, and shortness of breath.A care plan, dated 10/3/25, indicated Resident 3 was at risk for complications related to chronic kidney disease. An intervention indicated to monitor the weight and notify the physician of a significant weight change.A physician's order, dated 10/8/25, indicated to weigh the resident daily at 6:00 a.m. and to notify the physician if there was a weight gain of 2 pounds or more over night.Resident 3 had a recorded weight gain of 2 pounds or more on the following dates:On 1/4/26, the weight went to 161 pounds from 157 pounds on 1/3/26.On 1/6/26, the weight went to 162 pounds from 157.8 pounds on 1/5/26.On 1/10/26, the weight went to 161 pounds from 158 pounds on 1/9/26.On 1/13/26, the weight went to 161.12 pounds from 156 pounds on 1/12/26.On 1/18/26, the weight went to 157 pounds from 155 pounds on 1/17/26.On 1/19/26, the weight went to 159 pounds from 157 pounds on 1/18/26.On 1/22/26, the weight went to 161 pounds from 157 pounds on 1/21/26.On 1/28/26, the weight went to 160 pounds from 158 pounds on 1/27/26.On 2/3/26, the weight went to 160 pounds from 158 pounds on 2/2/26.On 2/6/26, the weight went to 161 pounds from 156 pounds on 2/5/26.On 2/8/26, the weight went to 160 pounds from 158 pounds on 2/7/26.On 2/11/26, the weight went to 163.12 pounds from 159 pounds on 2/10/26.During an interview, on 2/11/26 at 10:05 a.m., the Clinical Support Nurse indicated he could not find documentation of the notifications for the weight gains of 2 pounds or more since January. The nurses indicated they were supposed to call the physician with any updates or needs but did not indicate they had called regarding the multiple weight gains.A current facility policy, titled Change in a Resident's Condition or Status, dated 2/2021 and provided by the Clinical Support Nurse on 2/12/26 at 10:25 a.m., indicated .The nurse will notify the resident's attending physician or physician on call when there has been a .specific instruction to notify the physician of changes 3.1-5(a)(3)

Based on observation, interview and record review, the facility failed to ensure the interdisciplinary team (IDT) assessed to determine a resident was safe to self-administer medications for 1 of 1 resident reviewed for self-medication administration. (Resident D) Findings include: During an observation and interview, on 6/2/25 8:46 a.m., Resident D had a clear plastic medication cup, with pills, on her bedside table next to her meal tray. The resident indicated the staff left her medications in her room. She would take the pills. The clinical record for Resident D was reviewed on 6/2/25 at 10:29 a.m. The diagnoses included, but were not limited to, a fracture of the lower end of the left humerus (upper arm bone) and cirrhosis of the liver. An assessment for self-administration of medication completed by the interdisciplinary team (IDT), a physician's order and a comprehensive care plan for the self-administration of medications was not located in the clinical record. During an observation and interview, on 6/2/25 at 8:52 a.m., LPN 1 indicated the resident's medications were on her bedside table. The resident had wanted to eat before she took her medications. She did not know if Resident D had been assessed for self-administration of medications. She was supposed to stay with the residents while they took their medications. During an interview, on 6/2/25 at 12:51 p.m., the Care Services Administrator indicated the resident did not have an assessment, a physician's order or a care plan to self-administer medications. A current facility policy, titled Medication Self-Administration, undated and received from the Care Services Administrator on 6/2/25 at 3:00 p.m., indicated .A Medication Self-Administration Evaluation shall be completed for each resident who desires to self-administer medications .The Director of Health Services or designee will notify the attending physician of the evaluation results, and will obtain an order for the resident to self-administer medications 3.1-11(a)

Based on observation, interview and record review, the facility failed to ensure residents were free from verbal abuse and intimidation for 2 of 4 residents reviewed for abuse. (Resident B and C) The deficient practice was corrected on 5/25/25, prior to the start of the survey, and therefore was past noncompliance. Findings include: 1. During an interview, on 6/2/25 at 8:56 a.m., Resident B indicated a staff member had been cross and impatient. She was unable to give the staff member's name (CNA 3). Resident B indicated she had slid down in her bed and CNA 3 accused her of doing it on purpose. She indicated she did not like the accusation. 2. During an interview, on 6/2/25 at 9:00 a.m., Resident C indicated CNA 3 had been verbally rude to her and she filed a complaint. Her remote control had fallen between the wall and the bed. The bed needed to be moved to get the remote. CNA 3 threw her hands up and looked at me like I was crazy and said she don't move beds. Resident C indicated she then asked for some milk. CNA 3 went and got the milk, returned, opened the milk, slammed it down, and stormed out. Later in the evening, at 10-10:30 p.m., her roommate (Resident B) turned on the call light. CNA 3 had raised her voice and sounded belligerent toward Resident B. Resident C indicated she was afraid of CNA 3. She went to talk to Resident B to see if she was okay. Resident B told her she slid down in bed, needed help, and CNA 3 had started screaming. As Resident C was talking to Resident B, CNA 3 walked into their room. Resident C indicated she started walking to the door and had her hands on her walker when CNA 3 grabbed both of her wrists hard and pushed her back into her room. Resident C sat on her bed, picked up her phone to call her son, and CNA 3 grabbed her phone from her, put it on the chest of drawers, and stormed out. Resident C indicated she was shaking. Resident C contacted RN 4, and he informed her CNA 3 was gone for the night and the incident would be taken care of the next day. She indicated she was afraid CNA 3 would return with a gun, but RN 4 assured her she was safe, and CNA 3 could not get into the facility. The resident indicated she did feel safe now. The clinical record for Resident C was reviewed on 6/2/25 at 10:59 a.m. The diagnoses included, but were not limited to, left bundle branch block (electrical signals to the heart are blocked), atrioventricular block (electrical signal block from the upper chamber to the lower chamber of the heart) and atherosclerotic heart disease. A Basic Interview for Mental Status (BIMS) assessment, dated 5/26/25, indicated she was cognitively intact. A nursing progress note, charted late on 5/27/25 at 2:13 p.m., for the date of 5/23/25, indicated the nurse was called to Resident C's room. Resident C indicated she had been in an altercation with CNA 3. CNA 3 had taken the resident's phone away from her. The resident was upset and shaken but no injury was observed. RN 4 spoke with Resident C and her son and informed them CNA 3 was no longer in the facility. Resident C was asked to write down the details of what happened. RN 4 then spoke with Resident B, and she informed him CNA 3 was .gruff and was yelling at her . CNA 3 reported Resident C scratched her. There were no witnesses to the altercation. Resident C was assessed for injury and none were found. A facility document, titled Coaching & Counseling Form, received from the Care Service Administrator on 6/2/25 at 3:48 p.m., indicated, CNA 3 was terminated. The document failed to state a reason for the termination. A facility letter addressed to CNA 3 indicated effective 5/23/25 the CNA's position had been terminated due to committing resident abuse. During an interview, on 6/2/25 at 9:46 a.m., the Care Services Administrator indicated CNA 3 had been terminated from the facility. According to Resident C, CNA 3 grabbed her wrist. Resident C grabbed her phone and told CNA 3 she was going to report her. CNA 3 grabbed the phone, put it on the dresser, and left. RN 4 sent the CNA home and the next working day she was terminated. He indicated she was terminated for abuse. She had put her hands on a resident, snatched a phone from her, and the facility had a zero-tolerance policy. During a telephone interview, on 6/2/25 at 12:29 p.m., CNA 3 indicated when she entered the residents' room, Resident C was attempting to pull Resident B up in the bed. CNA 3 told Resident C it was not safe. Resident C was screaming and yelling. Resident C then grabbed the staff member, spat on her, and scratched her. RN 4 came to the room about five minutes after it happened. CNA 3 denied all allegations made and indicated she was going to leave the facility anyway. During an interview, on 6/2/25 at 1:20 p.m., RN 4 indicated he was called to Resident B and C's room by CNA 3. When he arrived at the room, Resident C was crying and upset. Resident C indicated CNA 3 had taken her phone. RN 4 indicated he asked CNA 3 to leave the room, and he reported the incident to the Care Service Administrator. A current facility policy, titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated April 2021 and received from the Care Service Administrator on 6/2/25 at 3:00 p.m., indicated .Residents have the right to be free from abuse, neglect .This includes but is not limited to .verbal, mental .or physical abuse A current facility policy, titled Resident Rights, dated February of 2021 and received from the Care Service Administrator on 6/2/25 at 3:00 p.m., indicated .Federal and state laws guarantee certain basic rights to all residents of this facility .These rights include the resident's right to .be free from abuse The deficient practice was corrected by 5/25/25 after the facility implemented a systemic plan which included an investigation of the incident, education to the staff on resident abuse and reporting, residents were interviewed related to abuse, and CNA 3 was terminated. This citation relates to Complaint IN00460150. 3.1-27(a)(1) 3.1-27(b)

Based on interview and record review, the facility failed to ensure the physician was notified of the residents' advanced directives and an order was documented in the residents' medical record for 3 of 3 residents reviewed for advanced directives. (Resident 8, 63 and 68) Findings include: 1. The clinical record for Resident 8 was reviewed on 3/4/25 at 9:51 a.m. The diagnoses included, but were not limited to, hypertension, senile degeneration of the brain, and muscle weakness. An Indiana Physicians Orders for Scope of Treatment (POST) form was completed and signed on 11/12/24 and indicated the resident wished to be a Do Not Resuscitate (DNR). Resident 8 was admitted to the facility on [DATE]. A physician's order, dated 3/4/25, indicated the resident was a DNR. The physician's order was not in place until 3.5 months after the resident was admitted to the facility. 2. The clinical record for Resident 63 was reviewed on 3/4/25 at 2:04 p.m. The diagnoses included, but were not limited to, heart failure, stage 3 chronic kidney disease, and adult failure to thrive. An Indiana Physicians Orders for Scope of Treatment (POST) form was completed and signed on 2/21/25 and indicated the resident wished to be a DNR. Resident 63 was admitted to the facility on [DATE]. The physician's order, dated 3/4/25, indicated the resident was a DNR. The physician's order was not in place until 15 days after the resident was admitted to the facility. 38872 3. The clinical record for Resident 68 was reviewed on 3/3/25 at 11:38 a.m. The diagnoses included, but were not limited to, morbid obesity, fracture of the right femur, and hypertension. Resident 68 was admitted to the facility on [DATE]. Resident 68 did not have an order for the resident's code status entered into the record. During an interview, on 3/4/25 at 9:43 a.m., the Director of Nursing indicated the residents should have had a physician's order. During an interview, on 3/7/25 at 1:11 p.m., the Corporate Support Nurse indicated the facility followed state and federal regulations and had no other information to present. A current facility policy, dated as revised April 2009 and received from the Clinical Support Nurse on 3/7/25 at 1:00 p.m., indicated .The director of nursing services (DNS) or designee notifies the attending physician of advanced directives (or changes in advanced directives) so that appropriate orders can be documented in the residents medical record and plan of care 3.1-4(f)(5) 3.1-4(f)(7)

Based on interview and record review, the facility failed to ensure person-centered comprehensive care plan interventions were developed for a resident who had a significant weight loss for 1 of 1 resident reviewed for nutrition. (Resident 6) Findings include: The clinical record for Resident 6 was reviewed on 3/4/25 at 12:52 p.m. The diagnoses included, but were not limited to, heart failure, vitamin deficiency, dysphagia, and anorexia. A physician's order, dated 5/1/23, indicated the resident was to be weighed monthly. A vitals tab indicated the following: On 1/1/25, the resident weighed 107.12 pounds. On 2/1/25, the resident weighed 101 pounds. On 2/10/25, the resident weighed 96 pounds. Resident 6 had a significant weight loss of 5.7% in 30 days and then continued to lose more weight on 2/10/25. A Registered Dietician (RD) note, dated 2/18/25, indicated the resident triggered for a significant weight loss. The current body weight was 96 pounds and recommended Ensure Plus (nutritional supplement) twice per day to help with weight stability. A current care plan, effective 4/6/23, indicated the resident was at risk for altered nutrition and hydration related to heart failure. During an interview, on 3/6/25 at 3:02 p.m., the Clinical Support nurse indicated the facility should have updated the resident's care plan within 14 days after a significant weight loss. During an interview, on 3/7/25 at 12:05 p.m., the Director of Nursing indicated the care plan should have been updated within 14 days after significant weight loss. During an interview, on 3/7/25 at 1:11 p.m., the Corporate Support Nurse indicated the facility followed state and federal regulations and had no other information to present. A current facility policy, titled Goals and Objectives, Care Plans, dated as revised April 2009 and received from the Clinical Support Nurse on 3/7/25 at 1:00 p.m., indicated .When goals and objectives are not achieved, the resident's clinical record will be documented as to why the results were not achieved and what new goals and objectives have been established. Care plans will be modified accordingly 3.1-35(a) 3.1-35(b)(1)

Based on observation, interview and record review, the facility failed to assess and document skin issues for 1 of 2 residents reviewed for quality of care. (Resident 5) Findings include: During an observation, on 3/3/25 at 10:15 a.m., Resident 5 was noted to have multiple bruises on both her arms. The clinical record for Resident 5 was reviewed on 3/4/25 at 11:10 a.m. The diagnoses included, but were not limited to, diabetes mellitus, hypertension, hyperlipidemia, and a history of a stroke. A care plan, initiated on 4/17/24, indicated the resident was at risk for skin alterations and to perform and record complete skin assessments. A physician's order, initiated on 4/18/24, indicated to give aspirin (a medication used to prevent platelets from sticking together and causing clots) 81 milligrams once a day. The only documented bruise found in Resident 5's record was an area on the right lateral elbow. No other skin concerns had been found in the record. During an interview, on 3/3/25 at 10:36 a.m., LPN 2 indicated the resident had lots of bruises. During an interview, on 3/7/25 at 10:06 a.m., the Corporate Support Nurse indicated the bruising on both arms should have been documented on skin sheets and monitored. During an interview, on 3/7/25 at 11:31 a.m., the Corporate Support Nurse indicated weekly assessments of the skin were to be completed and should note any discolorations, rashes, wounds, open areas and dryness. The documentation was to include the characteristics of the areas such as color and size. During an interview, on 3/7/25 at 1:11 p.m., the Corporate Support Nurse indicated the facility followed state and federal regulations and had no other information to present. A current facility policy, titled Resident Examination and Assessment, dated as last revised in 2/14 and received from the Corporate Support Nurse on 3/7/25 at 1:07 p.m., indicated Physical Exam .Skin .presence of bruises .Documentation .All assessment data obtained during the procedure 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure narcotic count sheets were signed off by the on-coming and off-going nurses to ensure an accurate reconciliation was completed for 1 of 1 narcotic book reviewed for reconciliation. Findings include: During an observation, on 3/3/25 at 5:27 a.m., with RN 1 in attendance, the narcotic book was found to be missing entries to show the on-coming and off-going nurses had reconciled the narcotic count and signed the narcotic book to indicate the count had been reviewed. During an interview, on 3/3/25 at 5:27 a.m., RN 1 indicated staff were supposed to sign the narcotic count sheets each shift. A facility document, titled Narcotic Count January 2025 Skilled, was provided by the Director of Nursing on 3/3/25 at 5:29 a.m., and indicated the following: On 1/4/25, there were no signatures for the on-coming and off-going day and evening shifts. On 1/5/25, there were no signatures for the on-coming and off-going day and evening shifts. On 1/11/25, there was no signature for the off-going evening shift. On 1/12/25, there was no signature for the off-going evening shift. On 1/13/25, there were no signatures for the on-coming or off-going evening shift. On 1/16/25, there were no signatures for the on-coming or off-going evening shift. On 1/18/25, there was no signature for the off-going evening shift. On 1/19/25, there was no signature for the off-going evening shift. There were five (5) other blank signature boxes on the form. A facility document, titled Narcotic Count February 2025 Skilled, was provided by the Director of Nursing on 3/3/25 at 5:29 a.m., and indicated there were 24 of 84 missed opportunities to sign off on the narcotic count sheet. During an interview, on 3/6/25 at 3:43 p.m., the Director of Nursing indicated the narcotic count sheet was to be signed by the on-coming and off-going staff. A facility document located in the narcotic book and received from RN 1 on 3/3/25 at 5:29 a.m., indicated .ATTENTION!!! Nurses and QMA's .Please Make Sure That You Are SIGNING ON/OFF IN The NARC BOOK Each Shift!!! A current facility policy, titled Controlled Substances, dated as last revised 11/22 and received from the Clinical Support Nurse on 3/6/25 at 3:25 p.m., indicated .Nursing staff count controlled medication inventory at the end of each shift .The nurse coming on duty and the nurse going off duty make the count together 3.1-25(e)(3)

Based on observation, interview and record review, the facility failed to ensure medications were stored in their original packaging, failed to label an open vial with a date, and failed to monitor and document medication refrigerator temperatures for 1 of 1 medication cart and 1 of 1 medication refrigerator reviewed for medication storage. Findings include: 1. During an observation of medication storage, on 3/3/25 at 5:21 a.m., with RN 1 in attendance, the following pills were found outside of their packaging and loose in the cart: One round white oval tablet with imprint C-2. Three small round white tablets. Three oval white tables. One medium round white tablet and one rectangular white tablet. During an interview, on 3/3/25 at 5:21 a.m., RN 1 indicated another nurse last cleaned the cart. 2. During an observation of the medication refrigerator, on 3/3/25 at 5:30 a.m., with RN 1 in attendance, a bottle of Aplisol (tuberculosis testing serum) was found opened and without an open date. During the observation the medication refrigerator temperature logs were reviewed. The refrigerator temperatures had not been documented on January 3, 5, 6, 10, 12, 13, 17, 19, 20, 24, 26, 27, 29, 30 and January 31st, 2025. The February refrigerator temperature log was also found to be missing 13 of 28 temperatures. During an interview, on 3/3/25 at 5:33 a.m., RN 1 indicated the vial of Aplisol should have been labeled with a date when it was opened, and the refrigerator temperatures were to be checked and logged on the sheet every night. During an interview, on 3/6/25 at 3:25 p.m., the Corporate Support Nurse indicated the refrigerator temperatures were to be monitored daily. A current facility policy, titled MEDICATION STORAGE, dated as last reviewed in 7/12 and received from the Clinical Support Nurse on 3/6/25 at 3:25 p.m., indicated .Medication storage areas are kept clean .Medication storage conditions are monitored on a regular basis 3.1-25(j) 3.1-25(m)

Based on observation, interview and record review, the facility failed to ensure a recipe was available and followed for puree foods to ensure nutritive value and flavor was conserved for 2 of 2 residents reviewed for a pureed diet. (Resident 1 and 4) Findings include: During a continuous observation, on 3/4/25 at 10:34 a.m., Dietary Manager (DM) 5 was pureeing tuna melt sandwiches for the residents who required a puree diet. As she was pureeing the sandwich, there was no recipe out and she was using an unmeasured amount of cold milk to thin the food out. During an interview, on 3/4/25 at 10:44 a.m., DM 5 indicated they did not have recipes for how to puree food. They did not have recipes for portion sizes or for what thickeners and thinners to use for each meal. They thinned the meal with the appropriate liquids, and they trained staff in orientation about what liquids to use. During an interview, on 3/4/25 at 11:01 a.m., DM 5 indicated she was not sure how someone would know what liquids to use for the puree if someone had to fill in for absent staff members. They trained staff during orientation on what liquids to use but they did not have a recipe. During an interview, on 3/5/25 at 11:47 a.m., DM 5 indicated she made a recipe book yesterday. The recipe was not in place on the day of the observation and indicated to use hot milk and DM 5 used cold milk when completing the puree. A Dining Manager recipe, titled Pureed Tuna Melt, dated 2025 and received from DM 5 on 3/5/25 at 3:15 p.m., indicated .Ingredients: Tuna Melt .Milk, hot A current facility policy, titled Pureed Diet, dated 2022 and received from DM 5 on 3/5/25 at 3:15 p.m., indicated .Gather the equipment needed: scale, measuring cups, measuring spoons, spatulas, recipes .Add measured amounts of hot liquid for cooked foods and cold liquid (if required) for cold foods and process until a smooth consistency is achieved 3.1-21(a)(1)

Based on observation, interview, and record review, the facility failed to ensure food was distributed under safe sanitary conditions for 14 of 14 residents who resided in the nursing home area of the facility. Findings include: During the lunch meal service observation on 4/3/24 from 11:54 a.m. to 12:38 p.m., the following concerns were identified: a. At 11:58 a.m., three meal trays were placed in the food service cart. During an interview on 4/3/24 at 11:59 a.m., Cook 3 indicated she had not taken the temperatures of the food prior to placing the three trays in the meal service cart. She was aware the temperature of all foods should be taken prior to placing any meal in the food service cart. b. At 12:03 p.m., Cook 3 was taking the temperatures of the food items on the steam table. She dropped the wrapper off of the alcohol wipe on the floor. She bent over an picked the wrapper up with her gloved hands. With the same soiled gloved hands, she continued to take temperatures of the food the steam table. c. At 12:19 p.m., Cook 3 was serving meals using her gloved hands to serve meals. With her gloved hands she touched, meal tickets, dishes, utensils counter tops, the bag containing hot dog buns, drawer handles, and other kitchen services. With the soiled gloved hands Cook 3 took a bun out of the bun bag. She opened the bun with the same gloves. While holding the bun in the palm of her same soiled gloved hand, she placed a sausage in the bun. d. At 12:21 p.m., she changed her gloves without washing her hands between doffing her soiled gloves and donning her new gloves. She then repeated the process of touching counter tops, meal tickets, utensils, counter tops, bun bags, drawer handles, and multiple other surfaces. Using her soiled gloved hands she opened a hot dog bun and held it in the palm of her hand while placing a sausage in the bun. At 12:25 p.m., she changed her gloves again without washing her hands between doffing and donning. She once again began the process of touching multiple surfaces and serving sausages in the bun. At 12:38 she changed gloves without washing her hands between doffing and donning new gloves. She again touched multiple surfaces with her gloved hands. She then used her soiled gloves to open a bun, holding it in her soiled palm, and serve a sausage in the bun. A current, 10/2017, facility policy, titled Preventing Forborne Illness Employee Hygiene and Sanitary Practice, which was provided by the Administrator on 4/4/24 at 10;00 a.m., indicated the following: .6. Employees must wash their hands . d, Before coming in contact with any food surface . f. After handling soiled equipment or utensils; g. During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination . 9. Food services employees will be trained in the proper use of utensils such as tongs, gloves, deli paper, and spatulas as tools to prevent forborne illness. 10. Gloves are considered single -use items and must be discarded after completing the task This citation relates to complaint IN00417225.

Based on interview and record review, the facility failed to ensure ordered wound treatments were completed as ordered for 1 of 4 residents reviewed for wound treatment (Resident B). Findings include: Resident B's closed clinical record was reviewed on 4/02/24 at 12:02 p.m. Discharge diagnoses included, chronic atrial fibrillation, heart failure, and pacemaker placement. The resident had a 12/22/23 care plan need regarding the placement of a cardiac pacemaker. Review of the resident's Clinical Notes indicated the following: 12/22/23- The resident was admitted to the facility following the placement of a pacemaker. 12/28/23-The resident was admitted after a recent pacemaker implantation. The resident had an incision on her left upper chest. No redness was present at the wound site. 1/2/24-The resident returned from a follow-up visit with the cardiologist. The resident had a new order to clean incision daily with soap and water, no lotions, creams or powders to the incision site. Review of the Clinical Notes indicated the entries were identical on four days, and included the same typo and same wording. The identical notes were entered on the following dates and times: 12/27/23 at 8:59 a.m., 12/28/23 at 1:22 p.m., 12/29/23 at 2:16 p.m., 1/1/24 at 2:42 p.m. The entries read as follows, Res. here after hospital stay fro (sic) bradycardia with pacemaker implantation. Res. has incision on left upper chest steri strips in place dry intact some bruising noted no redness warmth or drainage noted. The typo was corrected on 1/2/24. Following the correction of the typo the identical entry was made on the following dates and times: 1/2/24 at 1:49 p.m., 1/3/24 at 7:35 p.m., 1/8/24 at 9:17 p.m. Following the 14 day period of identical documentation, a 1/9/24 at 11:15 a.m., Addendum Note indicated the resident was having some redness around the left chest incision where the steri strips (wound closure strips) were present. The resident complained of pain and had a fever. The Medical Director was in the facility and assessed the area and indicated the resident needed to see her cardiologist as soon as possible. The resident went to the Cardiologist were she was placed on antibiotics for an infection at the pacemaker site. The resident had a 1/2/24, cardiology Ambulatory Visit Summary which contained an order to wash the pacemaker incision site with soap and water and pat dry, one time each day. The clinical record lacked documentation that the pacemaker incision site was washed and patted dry from 1/2/24, when the order was received, until 1/9/24, when the site was red and the resident had a fever. The resident had a 1/9/24 order for doxycycline hyclate 100 mg tablet (an antibiotic) - take one tablet two times a day for 10 days. A 1/11/24 at 3:34 p.m. Clinical Note indicated the resident had returned from a cardiology appointment and would need to go to the hospital for a pacemaker replacement. A 1/16/24 at 12:37 p.m., Clinical Note indicated RISK MEETING. The resident was started on antibiotics for an infection to the pacemaker site. A grievance was received. During an interview, on 4/2/24 at 2:47 p.m. Resident B's family indicated the following: The family took the resident to a cardiology appointment on 1/2/24. The doctor changed an oral medication and order the pacemaker site be washed with soap and water and patted dry each day. On 1/9/24 the facility called the family and said the Medical Director wanted the resident to see the cardiologist that day or go to the hospital. The family took the resident to the cardiologist that day. When the incision was observed at the cardiologist, the site was red all around the incision and down the arm. The wound was draining a green liquid. The cardiologist ordered a very strong antibiotic and wanted them to return in a couple days. When they returned to the cardiologist on 1/11/24, the decision was made to remove and replace the pace maker because the infection was not healing quick enough. The family spoke with the DON, who could not show any proof that the facility had routinely monitored the site nor washed the wound with soap as ordered. The resident did not return to the facility following the pacemaker replacement. During an interview on 4/3/24 at 9:45 a.m., the Administrator indicated the facility had developed a plan of correction to address the concerns expressed in the grievance made by Resident B's family regarding monitoring wounds and providing wound care as ordered. The Administrator provided paperwork regarding the concern and the facilities actions. The paperwork included a Grievance Form: and the corresponding documentation. A 1/10/24, Grievance Form indicated during a care conference Resident B's family expressed concern due to the resident's pacemaker site not being cleaned. The form indicated the Action taken and Date for this concern was as follows: 1/12/24-Nursing Inservice on charting and documentation for medication and treatment orders related to wound care, 1/13/24 Audit of all residents in house, 1/15/24 Resident Incident Reporting Form, (No date listed) QA review, 2/21/24 Nursing education on second (2nd) checks of orders. A current, 10/2010, facility policy titled, Wound Care, which was provided by the DON on 4/5/24 at 10:34 a.m., indicated the following: .Documentation The following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given. . 6. All assessment data (i.e., wound bed color, size, drainage, etc) obtained when inspecting the wound The deficient practice was corrected by February 21, 2024, prior to the start of the survey, and was therefore past noncompliance. The facility had completed Nursing Inservices/education, completed audits, and taken the concern to the Quality Assurance Committee. This citation relates to complaint IN00426019. 3.1-37

Based on observation, interview, and record review, the facility failed to ensure ongoing communication for continuation of care with the dialysis center for 1 of 1 resident reviewed for dialysis services (Resident 6) Findings include: During an interview on 4/02/24 at 1:54 p.m., Resident 6 was sitting in bed in her room watching TV. She indicated she went to dialysis and had a port to her left chest. Resident 6's clinical record was reviewed on 4/2/24 at 3:18 p.m. Current diagnoses included end stage renal disease (ESRD), dependence on dialysis, and congestive heart failure. The resident had a current April 2024 order for dialysis. The resident had a current care plan problem/need regarding a diagnosis of ESRD and receiving hemodialysis. The goal for this problem was Fluid balance will be maintained and resident will have no complications with hemodialysis through the next review. Approaches/interventions included: Interventions: monitor for complications from dialysis such as: hypoglycemia, hypotension, irritation to access site, and muscle cramps and Dialysis is at ( dialysis facility name) on Tuesday, Thursday, and Saturday The clinical record for dialysis communication indicated, from January 2024 to April 2024, communication notes were not down loaded into the electronic medical record. The dialysis communication binder was reviewed on 4/3/24 at 10:02 a.m. Each Nurses Dialysis Communication Record: contained three (3) sections as follows: a. PRE- DIALYSIS ASSESSMENT b. DIALYSIS CENTER c. [NAME] POST DIALYSIS ASSESSMENT Review of communication records from 4/1/24 to 3/1/24 identified the following incomplete records: 4/1/24- Pre dialysis vitals only, 3/29, 3/27, 3/25, 3/22, 3/20, and 3/18 did not have any communication logs completed, 3/18/24- Pre dialysis vitals, dialysis vitals only, 3/15 and 3/13 did not have any communication log completed, 3/11/24- Pre dialysis vitals only. 3/8 and 3/6 did not have communication logs completed, 3/4/24- Pre dialysis vitals, dialysis vitals. January and February 2024 also had missing log pages and or missing information. During an interview on 4/03/24 at 2:32 p.m., both the DON and Administrator indicated this was an ongoing problem with the dialysis center not wanting to fill this form out. The DON had many calls with the dialysis center administrator and this issue never resolved. This company is the most local one to the facility, and that's why they were still utilized. These points of contact happen by phone and there were not records of the conversation. The Administrator and DON indicated the facility sent this form with the resident for every visit. A current facility contract titled Long Term Care Facility Outpatient Dialysis Services Coordination Agreement, which was provided by the facility following the entrance conference on 4/1//24, indicated the following: .Interchange of Information: The Long Term Care Facility shall provide for the interchange of information necessary for the care of ESRD Residents, including a contact person at the Long Term Care Facility whose responsibilities included assisting with the coordination of Renal Dialysis Services for ESRD residents 3.1-37(a)

Based on observation, interview and record review, the facility failed to maintain sanitary conditions in the kitchen resulting in the potential for food borne illness for all residents who consume food from the kitchen. Findings include: 1. During an initial kitchen tour, on 03/09/23 at 9:48 a.m., with the Director of Dining Services (DDS) the following were observed: a) a large bin of yellow cornmeal like substance was noted with no open date on the bin. b) a large bin of bread crumb like substance was noted with no open date on the bin. c) a large bin of white sugar like substance was noted with no open date on bin. During an interview, on 03/09/23 at 9:48 a.m., the DDS indicated he did not know when the food was placed in the large bins without an open date on the bins. 2. A review of the Dish Machine Temperature Log, dated March 2023, indicated there was no documentation of dishwasher temperatures after 3/9/23 at dinner through 3/13/23. During an interview, on 03/13/23 at 11:02 a.m., the Executive Chef (EC) reviewed the dish machine temperature log and indicated nobody documented the dishwasher temperatures. It was not known if the dishwasher was at the proper temperature to know if the dishes were sanitized without the documentation on the dishwasher log. 3. A review of the sanitizing logs indicated there was no documented sanitizer concentration checks after 3/9/23 at 11:30 a.m., through 3/13/23. During an interview, on 03/13/23 at 11:30 a.m., the EC indicated there was no sanitizing log documentation for the sanitizer concentration after 3/9/23 at 11:30 a.m., until the present day and time. 4. During an observation of the 3 (three) compartment sink, on 03/13/23 at 11:33 a.m., the quaternary ammonium compound (QAC) solution was checked for concentration by the EC. The observed result of the QAC was 300 ppm (parts per million). 5. During an observation and interview with EC, on 03/13/23, the following was observed: a) 11:10 a.m., a plastic wrapped open bag of crispy onions was noted. The EC indicated it was an open food item without an open date. b) 11:12 a.m., an open 5-pound bag of long grain rice was noted. The EC indicated it was not dated and it was open. c) 11:14 a.m., an open 10-pound bag of spaghetti noodles was noted with no date. The EC indicated there was no date on the open bag of spaghetti noodles. d) 11:16 a.m., an open 1 liter of club soda was noted with no open date on the bottle. The EC indicated the soda was open, but no date was on the bottle. e) 11:22 a.m., a large open bag of mixed greens was noted with no date. The EC indicated the open bag of mixed greens was supposed to be dated when opened. f) 11:23 a.m., a bag of broccoli was noted without an open date. The EC indicated there was no open date on the broccoli. g) 11:25 a.m., an open bag of quinoa (edible seeds) was wrapped in plastic with no open date. The EC indicated it was open without a date. h) 11:25 a.m., multiple pieces of corn bread were noted with a missing piece of corn bread covered in plastic with no open date on the cornbread. The EC indicated the open cornbread was not dated. A current policy, titled Dishwashing Machine Use, received from the Executive Director (ED) on 3/13/23 at 1:15 p.m., indicated .The operator will check temperatures using the machine gauge with each dishwashing machine cycle, and will record the results in a facility approved log A current policy, titled Sanitization, received from the ED on 3/13/23 at 1:15 p.m., indicated .The food service area shall be maintained in a clean and sanitary manner .Sanitizing of environmental surfaces must be performed with one of the following solutions: 150 - 200 ppm (parts per million) of quaternary ammonium compound (QAC) A current policy, titled Food Receiving and Storage, received from the ED on 3/13/23 at 1:15 p.m., indicated .Food shall be received and stored in a manner that complies with safe food handling practices .Dry foods that are stored in bins will be removed from original packaging, labeled, and dated (use by date) .Other opened containers must be dated and sealed or covered during storage 3.1-21(i)(3)

Based on interview and record review, the facility failed to update advanced directives upon admission for 1 of 4 residents reviewed for advanced directives. (Resident 13) Finding includes: The Face Sheet for Resident 13 indicated the resident was a Full Code for advance directive status. A care plan indicated Resident 13 had a Full code status on admission to the facility. An Internal Medicine Progress Note, dated 10/26/22 at 12:06 p.m., indicated Resident 13's code status was DNR (do not resuscitate), and DNI (do not intubate). During an interview, on 03/14/23 at 11:05 a.m., the Executive Director (ED) indicated upon admission normally the social worker would update the code status. During an interview, on 03/14/23 at 11:19 a.m., the Social Worker indicated the facility did not have the updated code status in the record. The family and Resident 13 had changed Resident 13's code status during the last hospital visit. During an interview, on 03/14/23 at 1:34 p.m., the ED indicated upon admission to the skilled nursing center Resident 13's code status was not addressed. A current policy, titled Advance Directives, received from the ED on 3/14/23 at 2:34 p.m., indicated .The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment .Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his legal representative, about the existence of any written advance directives 3.1-4(f)(5)

Based on interview and record review, the facility failed to provide documentation to show the bed-hold policy was provided to 1 of 1 resident reviewed for bed-hold policy notification. (Resident 11) Finding includes: The record for Resident 11 was reviewed on 03/09/23 at 12:00 p.m. Diagnoses included, but were not limited to, heart failure, anemia, and hypertension. A nursing note, dated 12/21/22, indicated Resident 11 was sent to the hospital for intravenous therapy (IV fluids). There was no note or assessment found in the record indicating the resident or responsible party was provided a bed hold policy at the time of transfer or within 24 hours of the transfer. A nursing note, dated 01/24/23, indicated Resident 11 was sent to the emergency room for the evaluation and treatment of a low hemoglobin (a protein in the red blood cells which carries oxygen to the organs and tissues of the body). There was no note or assessment found in the record indicating the resident or responsible party was provided a bed hold policy at the time of transfer or within 24 hours of the transfer. During an interview, on 03/09/23 at 9:18 a.m., LPN 2 indicated when a resident was sent out of the facility, they were to be provided with the bed hold policy. A facility policy, titled Bed-Holds and Returns, dated as revised in October 2022 and provided by the Executive Director on 03/14/23 at 1:30 p.m., indicated .All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence .Residents regardless of payer source, are provided written notice about these policies .notice .well in advance of any transfer (e.g., in the admission packet); and .notice .at the time of transfer (or, if the transfer was an emergency, within 24 hours) 3.1-12(a)(25)(A) 3.1-12(a)(25)(B)

Based on interview and record review, the facility failed to develop a comprehensive care plan related discharge planning and the use of psychoactive medications for 2 of 6 residents reviewed for comprehensive care plans. (Resident 9 and 11) Findings include: 1. The record for Resident 9 was reviewed on 03/10/23 at 3:36 p.m. Diagnoses included, but were not limited to, impaired mobility, and Parkinson's disease. The resident did not have a discharge goal care planned as part of the comprehensive care. During an interview, on 03/14/23 at 10:37 a.m., the Executive Director indicated Resident 9 discharged to another facility due to financial reasons, initially Resident 9 was to be long term care. During an interview, on 03/14/23 at 3:27 p.m., the [NAME] President of Clinical (VPC) indicated a care plan should have been developed anticipating the resident's needs after a Medicare Part A (care in a skilled nursing facility, hospice care, and some home health care) stay was completed. 2. The record for Resident 11 was reviewed on 03/10/23 at 1:25 p.m. Diagnosis included, but were not limited to, mild protein malnutrition, cognitive communication deficit, and dysphagia (difficulty swallowing). A physician's order, initiated on 02/24/23, indicated to give mirtazapine (an antidepressant) 30 milligrams (mg) once a day for anorexia (an abnormal loss of the appetite for food). There was no care plan addressing the use of the antidepressant mirtazapine off label use for anorexia, or the side effects to monitor for during the use of the medication. During an interview, on 03/14/23 at 3:33 p.m., the VPC indicated a care plan should have been developed for the use of an antidepressant for anorexia. A facility policy, titled Care Plans, Comprehensive Person-Centered, dated as revised March 2022 and provided by the Executive Director on 03/14/23 at 3:32 p.m., indicated .The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .The comprehensive, person-centered care plan .describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial wellbeing .includes the resident's state goals upon admission and desired outcomes .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change 3.1-35(a)

Based on observation, interview and record review, the facility failed to maintain and store oxygen equipment for 1 of 3 residents reviewed for oxygen use. (Resident 10) Finding includes: During an observation, on 03/09/23 at 10:18 a.m., Resident 10's nasal cannula (device for putting oxygen into the nasal passage) and tubing was lying on top of the oxygen concentrator in Resident 10's room and dated 3/3. During an observation, on 03/10/23 at 8:24 a.m., Resident 10's nasal cannula and tubing was lying on top of the oxygen concentrator in Resident 10's room and dated 3/3. During an observation, on 03/10/23 at 2:37 p.m., Resident 10's nasal cannula and tubing was lying on top of the oxygen concentrator in Resident 10's room and dated 3/3. During an observation, on 03/13/23 at 8:33 a.m., Resident 10's nasal cannula and tubing was lying on top of the oxygen concentrator in Resident 10's room and dated 3/3. During an observation and interview, on 03/13/23 at 8:39 a.m., Licensed Practical Nurse (LPN) 1 observed Resident 10's oxygen tubing and nasal cannula lying on the oxygen concentrator and indicated it was just sitting on the oxygen concentrator. The oxygen tubing and nasal cannula had not been changed and the date on the tubing was 3/3 and it was greater than 1 week after date. The oxygen tubing and cannula should be changed weekly. The record for Resident 10 was reviewed. Diagnoses included, but were not limited to, respiratory failure unspecified with hypoxia (low oxygen level in blood). A physician's order, dated 2/25/23, indicated oxygen (O2) at 1 L/min (liter per minute) per nasal cannula 3 times daily. A care plan, dated 2/26/23, indicated Resident 10 was unable to maintain O2 (oxygen) saturation, and received oxygen at 1 L/min. During an interview, on 03/13/23 at 2:11 p.m., the [NAME] President of Clinical indicated the oxygen tubing and cannula needed to be dated, bagged, and changed weekly. A current policy, titled Department (Respiratory Therapy)- Prevention of Infection, received from the Executive Director (ED) on 3/13/23 at 3:42 p.m., indicated .The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff .Change the oxygen cannula and tubing every seven (7) days, or as needed .Keep the oxygen cannula and tubing used PRN (as needed) in a plastic bag when not in use 3.1-47(a)(6)

Based on interview, record review and observation, the facility failed to develop a comprehensive and person centered plan of care which included measurable objectives and time frames to meet the resident's nursing, medical and psychological needs for 5 of 8 residents reviewed for care plans. (Residents 7, 63, 4, 1 and 5). Findings include: 1. The record for Resident 7 was reviewed on 02/23/2022 at 2:32 p.m. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During observations, in the dining room, on 02/21/2022 at 12:41 p.m., and 02/24/2022 at 12:31 p.m., Resident 7 was seated in a wheelchair and fed herself without difficulty. The resident was observed to be in bed, with eyes closed, on 02/22/2022 at 2:21 p.m., 02/23/2022 at 10:32 a.m., and 02/24/2022 at 3:42 p.m. Nursing documentation, for the period of 12/02/2021 through 02/24/2022, described the resident as being pleasant and cooperative with staff with no behaviors of yelling out observed with the exception of two events. One event on 12/23/2021 at 9:06 a.m., Resident 7 was documented as refusing medication, kicking at staff and wanted to throw herself on the floor. Another event, documented on 01/23/2022 at 12:32 a.m., indicated Resident 7 was upset due to decreased visitation of her family, indicated her family didn't want her anymore and if she was gone, her family wouldn't miss her. During a review of the resident's plan of care, on 02/25/2022 at 4:01 p.m., the current plan of care identified an undated problem of .consistently shows signs of agitation, anxiety, fear or frustration, non-purposeful wandering, agitation and .non compliant with care with a goal of .will receive assistance to minimize consistent signs of agitation, anxiety, fear or frustration, non-purposeful wandering Interventions included, redirecting and engaging in appropriate activities, ensure location and inform the nurse of behavioral cognitive intervention. The plan of care also included an undated problem of alteration of urinary function related to urinary incontinence related to impaired mobility. Interventions to this problem included, safety measures, keep the path to bathroom clear and well lit, remind the resident to empty bladder before meals, at bedtime, and before activities and dress in clothing which was easily removed for toileting. During an interview, with LPN 7 and CNA 8, on 02/25/2022 at 3:22 p.m., both staff indicated the resident was continent during waking hours and incontinent if sleeping. CNA 8 indicated Resident 7 was able to bear weight, but unable to ambulate to the bathroom, requiring assist of 1 with the use of a gait belt. LPN 7 indicated the resident was seated in a wheelchair when not in bed and, although able to mobilize the wheelchair, she was extremely slow and easily monitored. LPN 7 denied the resident displayed wandering behaviors. 2. The record for Resident 63 was reviewed on 02/21/2022 at 3:26 p.m. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview, on 02/24/2022 at 1:32 p.m., Resident 63 indicated he had previously lived alone in an apartment prior to his admission to the facility. At home, he had fallen forward into a counter and hit his face at the bridge of his nose, requiring sutures and admission to the hospital. The resident indicated he really didn't know how it happened. He was at the facility to receive therapy in hopes he could return to his apartment soon. A wheelchair was observed in the resident's room with a pressure reducing cushion in the seat. When asked, Resident 63 indicated it was the wheelchair he was using while a resident in the facility. A skin assessment, dated 02/09/2022, indicated the resident had a 4 cm x 3 cm (centimeter) abrasion to the left buttocks, located at the top of the coccyx and was described to be shearing. A wound assessment, dated 02/15/2022, documented a stage 2 pressure area measuring 1 cm x 1.2 cm, with 0.1 cm depth on the left buttock. The resident's 5-day admission MDS (minimum data set) assessment tool, indicated the resident was occasionally incontinent of bowel and bladder. The resident's plan of care identified an undated problem of .at risk for alteration in skin integrity related to immobility with a goal of skin will remain intact . Documentation was lacking of a current plan of care for the existing stage 2 pressure area on the left buttock. During an interview, on 02/22/2022 at 9:14 a.m., LPN 6 verified the resident had a pressure area on the left buttock. She indicated the area began as a blister and then opened up but was unable to relay the exact date this occurred. 3. The record for Resident 4 was reviewed on 02/22/2022 at 3:53 p.m. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's current MDS assessment, dated 12/19/2021, indicated the resident had a BIMS (Brief Interview for Mental Status) score of 3, indicating the resident was cognitively severely impaired. Documentation at the beginning of the plan of care, and highlighted in yellow, indicated .Resident is a long term resident with long history of dementia. Also, she is alert and confused. She is not able to make needs known. Staff meets all her needs. She is total dependent on staff for all her ADL's (activities of daily living) .She is total dependent on staff for toileting and is incontinent of bowel and bladder The resident's plan of care included, but were not limited to, a problem of a risk for dehydration due to receiving diuretics with interventions to include respond promptly to calls for assist to the toilet and staff to assist to select clothing which was easily removed to reduce the risk of wetting accidents. Another problem was at risk for falls with interventions which included to remind the resident to call for assistance before moving from bed to chair and chair to bed. 4. The record for Resident 1 was reviewed on 02/23/22 at 11:25 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual MDS (Minimum Data Set) assessment, dated 2/21/22, indicated the resident was severely cognitively impaired and was totally dependent of the staff for transfers. A fall risk screening, dated 11/26/21, indicated a score of 11 (high risk for falls). A nursing note, dated 11/22/22 at 10:40 a.m., indicated the resident was found on her left side in front of her wheelchair. A Morning Meeting note, dated 11/24/21, indicated the resident had a fall and was found in the television room by her wheelchair. A current care plan, dated 01/22/21, indicated the resident was at risk for falls related to weakness. Interventions included, but were not limited to, Use alarm to monitor attempts to rise This care plan did not indicate any dated revisions or reviews. The resident's current physician's orders did not indicate she was to have an alarm in place to monitor her attempt to stand up. During an interview, on 03/25/22 at 3:00 p.m., the Director of Nursing (DON) indicated the facility did not use any form of pressure sensitive alarms. 5. The record for Resident 5 was reviewed on 2/22/22 at 3:00 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's order, dated 05/22/21, indicated the resident was receiving [MEDICATION(S)] (a medication used to help treat depression) daily. A current, undated, care plan indicated the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included, but were not limited to, assess changes in mental status, assess and record behaviors. The care plan did not indicate the resident's specific depressive behaviors, or changes in mental status which should have been assessed. During an interview, on 02/24/22 at 3:36 p.m., the MDS Coordinator indicated she had never seen the resident and documented fall interventions from reviewing, but not limited to, nurses notes and physician orders. She could not find a current order for the use of [MEDICAL RECORD OR PHYSICIAN ORDER] . She indicated care plans should be person-centered and should include specific targeted symptoms as well as what medication side effects to monitor for. Resident care plans should be reviewed quarterly, annually and with a significant change. There were no documented dates on the resident's plan of care to indicated this was being completed as indicated in the facilities policy. A current facility policy, titled Care Plans. Comprehensive Person-Centered, dated 12/2016 and provided by the ED (Executive Director) on 02/25/22 at 10:30 a.m., indicated .A comprehensive, person-centered care plan .includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs .for each resident .developing interventions that are targeted .to the resident .The interdisciplinary team must review and update the care plan .at least quarterly 3.1-35(a)

Based on observation, record review and interview, the facility failed to ensure a resident who experienced a significant change in status was comprehensively evaluated utilizing the Resident Assessment Instrument (RAI) process for 1 of 3 residents reviewed for nutritional status who experienced a significant weight loss greater than 5% in 30 days. (Resident 4) Finding includes: Resident 4 was observed in the dining room, during the noon meal service, on 02/21/2022 at 12:18 p.m. The resident appeared thin and frail and answered all questions shaking her head yes and saying Yes, ma'am. Resident 4 was served a regular meal tray containing a chicken casserole dish and fruit cup. Resident 4 was observed to use her fingers to eat the fruit in the cup but made no attempt to eat the chicken casserole and pushed the plate away. Staff in the dining area replaced the meal with finger foods of French fries and chopped breaded chicken. The resident was observed to pick at the finger foods, but ultimately ate less than 25% of the meal. Resident 4 was again observed, on 02/23/2022 at 8:58 a.m., to be in the dining room for the morning meal. A regular diet of scrambled eggs, dry raisin toast, dry cheerios and mandarin orange pieces was served to the resident. The resident pushed the plate of food away but ate 75% of the dry cheerios and drank 100% of the fluids offered. The record for Resident 4 was reviewed on 02/22/2022 at 3:53 p.m. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Weights for the resident were documented as follows: On December 1, 2021, the weight was 112.92 pounds. On December 6, 2021, the weight was 110.8 pounds. On January 4, 2022, the weight was 112.10 pounds. On February 1, 2022, the weight was 103.40 pounds with a reweight of 105.96 pounds on the same date. This indicated the resident had a weight loss, from January to February 2022 of 5.48%. The resident's most current MDS (Minimum Data Set) assessment observed in the clinical record, when reviewed on 02/25/2022 at 11:26 a.m., was an annual assessment dated [DATE]. Section K of this assessment indicated the resident's weight was 111 pounds and indicated the resident had experienced no weight loss. During an interview, on 02/22/2022 at 2:41 p.m., the Dietary Manager indicated Resident 4 was receiving a regular diet which was replaced with a diet of finger foods if the resident was unable to eat the regular diet tray. The dietary manager indicated Resident 4's food consumptions had been poor and the resident had been receiving supplemental ensure three times a day and at night for several months. During a phone interview, on 02/25/2022 at 4:50 p.m., the MDS Coordinator indicated she worked off-site and lived in Alabama. She stated she had never been to the facility and denied having personally seen or assessed Resident 4. The MDS Coordinator indicated she based her assessment of Resident 4, and all other residents in the facility, from information she received from the Director of Nursing (DON) during phone conversations and team meetings via the internet, review of the clinical record and faxed information received from the facility. The MDS Coordinator indicated she was unaware the resident had a recent weight loss. The resident should have had a significant change MDS assessment completed due to the weight loss. She added the dietitian usually lets her know when a resident had a weight loss. A current facility policy, titled Nutritional Assessment and Care Planning, dated as revised April 2009 and received from the facility on 02/25/2022 at 12:49 p.m., indicated .The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission .and as indicated by a change in condition that places the resident at risk for impaired nutrition 3.1-31(d)(1)

Based on interview and record review, the facility failed to follow physician's orders for the use of a blood pressure medication for 3 of 5 residents reviewed for unnecessary medications. (Resident 5, 113 and 12) Findings include: 1. The record for Resident 5 was reviewed on 02/22/22 at 3:00 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A current physician's order, dated 09/03/21, indicated [MEDICATION(S)] tablet (a medication used to treat high blood pressure) 2.5 milligrams, give one tablet daily, hold for systolic blood pressure (the top number on a blood pressure equation) of less than 120. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 02/01/22, when the BP was 116/62. b. On 02/02/22, when the BP was 108/62. c. On 02/03/22, when the BP was 113/60. d. On 02/08/22, when the BP was 109/62. e. On 02/09/22, when the BP was 108/66. f. On 02/10/22, when the BP was 108/66. g. On 02/14/22, when the BP was 106/72. h. On 02/16/22, when the BP was 106/72. i. On 02/18/22, when the BP was 118/54. j. On 02/21/22, when the BP was 118/68. k. On 02/22/22, when the BP was 108/68. l. On 02/23/22, when the BP was 116/66. m. On 02/24/22, when the BP was 108/88, An undated care plan indicated the resident was at risk for hypertension. Interventions included, but were not limited to, give medications as ordered. 2. The record for Resident 113 was reviewed on 02/22/22 at 12:17 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A current physician's order, dated 02/15/2022, indicated [MEDICATION(S)] tablet (a medication used to lower blood pressure) 6.25 milligrams, give one tablet two times daily, hold for systolic blood pressure of less than 130. The MAR, for February 2022, indicated [MEDICATION(S)] was administered to Resident 113 on the following days: a. On 02/17/22, when the BP was 110/52. b. On 02/23/22, when the BP was 112/68. A current care plan, dated 02/15/22, indicated the resident was at risk for acute chest pain and [CONDITION(S)] (stroke) related to hypertension. Interventions included, but were not limited to, administer medications per MD orders. 3. The record for Resident 12 was reviewed on 02/22/22 at 12:16 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A current physician's order, dated 09/21/21, indicated [MEDICATION(S)] 2.5 milligram tablet, give 1 tablet daily, hold for systolic blood pressure less than 120. The MAR, for February 2022, indicated [MEDICATION(S)] was administered to Resident 12 on the following days: a. On 02/03/22, when the BP was 110/71. b. On 02/05/22, when the BP was 105/64. c. On 02/13/22, when the BP was 104/63. d. On 02/20/22, when the BP was 112/61. A current care plan, dated 02/15/22, indicated the resident was at risk for acute chest pain and [CONDITION(S)] related to hypertension and to .Administer medications per MD orders During an interview, on 2/23/22 at 3:45 p.m., the Director of Nursing (DON) indicated the residents should not have received the medication because the resident's blood pressure was not in range to administer the medications. She could not provide a policy but it was her expectation for nursing to follow physician orders. 3.1-48(a)(1) 3.1-48(a)(3)

Based on record review and interview, the facility failed to initiate Cardiopulmonary Resuscitation (CPR) for a resident who was found unresponsive with no respirations or pulse. This resident had chosen no advanced directive and would have been a full code. This deficient practice affected 1 of 2 residents reviewed for death. (Resident #B). This deficient practice resulted in Immediate Jeopardy. This Immediate Jeopardy began on [DATE] when facility staff failed to identify a resident as being a full code at the time of her death and failed to initiate cardiopulmonary resuscitation. The Administrator and Director of Nursing (DON) were notified of the immediate jeopardy on [DATE]. The Immediate Jeopardy was removed on [DATE] and the deficient practice corrected on [DATE], prior to the start of the survey and was therefore Past Noncompliance. Findings include: The clinical record for Resident #B was reviewed on [DATE] at 2:15 p.m. [DIAGNOSES REDACTED].An Advanced Directive Checklist, dated [DATE], indicated Resident #B had not executed an advanced directive and did not wish to discuss advanced directives at that time. During an interview on [DATE] at 3:48 p.m., the Social Services Director indicated a resident who had not chosen an advanced directive was to be treated as a full code.A nursing note entry, completed by LPN #1, dated [DATE] at 6:34 a.m., indicated "...During bed check at 0545 (5:45 a.m.) CNA (Certified Nursing Assistant) staff notified writer (LPN #1) to immediately come to resident room...Resident (Resident #B) RHC (respirations have ceased) at 0545...pupils pinpoint and non-reactive no palpable pulses resident cold to touch...AHA (Advanced Healthcare Associates) notified new orders received and written, message left with family to contact facility ASAP (as soon as possible)...." A nursing note entry, completed by LPN #1, dated [DATE] at 7:31 a.m., indicated "...CPR initiated until emergency services arrived. Emergency services stated she (Resident #B) was non-transportable and there was nothing they could do at (that) time...." A physician's orders [REDACTED]. The Director of Nursing was interviewed on [DATE] at 3:58 p.m. Additional information was requested related to the lack of performing CPR on Resident #B who was found without respirations or a pulse on [DATE]. The DON indicated the oncoming nurse, LPN #2, called the interim DON at approximately 7:00 a.m. and advised her of Resident #B's death. The interim DON advised that CPR needed to commence and 911 needed to be called per policy. LPN #1 then commenced CPR at that time. The DON indicated LPN #1 did not follow policy and did not perform CPR on a full code resident. The DON indicated LPN #1 was no longer an employee at the facility. LPN #1 had been terminated by the facility after the event and was not available for an interview. The DON and the Administrator were interviewed on [DATE] at 11:15 a.m. They both indicated LPN #1 failed to initiate CPR for Resident #B, who had chosen no advanced directive and would have been a full code. They indicated all staff were inserviced regarding policy " 6.6 Cardiac and/or Respiratory arrest." A Policy received from the Administrator on [DATE] at 10:30 a.m., titled "6.6 Cardiac and/or Respiratory Arrest," indicated "...6. Upon discovery of a patient in cardiopulmonary arrest (e.g., no apparent pulse, blood pressure, or respiration), staff will immediately: 6.1. Call for help 6.2. Alert the licensed nurse for immediate response 6.3. Prepare the patient for CPR/AED while determining the presence of a Do Not Resuscitate order (DNR) 7. If there is no visual identification of DNR status or no DNR order on the patient's medical record 7.1. Regardless of patient's condition, CPR/AED certified staff will initiate CPR/AED application 7.2. Call 911 and notify the primary physician...." A review of staff CPR licenses on [DATE] at 3:00 p.m., indicated LPN #1 held a current CPR certificate. The past noncompliance immediate jeopardy began on [DATE]. The immediate jeopardy was removed on [DATE] and the deficient practice corrected by [DATE] after the facility implemented a systemic plan that included the following practices: An audit of all charts for DNR status and any concerns corrected, all staff were inserviced on Code status and policy, all new admission charts were audited daily for DNR forms and advance directives, new POST (Indiana Physician order [REDACTED]. Staff interviewed were aware of the policy and procedure for code status and all records were reviewed for code status. This federal tag relates to Complaint IN 634. 3XXX,[DATE](a)

Based on record review and interview, the facility failed to ensure nurses were educated on peripherally inserted central catheters (PICC) line care and failed to ensure daily PICC line care was completed for 1 of 1 resident reviewed for PICC line care resulting in a [MEDICAL CONDITION] (blood clot) of the left brachial (arm) vein. (Resident B). Findings include: A current facility policy, dated 1/15/14 and revised 7/1/12, titled "Peripheral Catheter Flushing" and provided by the Director of Nursing (DON) on 11/26/12 at 2:35 P.M., indicated: "To be Performed By: Licensed nurses according to state law and facility policy. The nurse shall be competent in the safe delivery of infusion therapy with her or his scope of practice. The nurse shall be accountable for attaining and maintaining competence with infusion therapy within her or his scope of practice. Considerations: 1. Specific flush orders must be documented ... ... 3. Flushing is performed to ensure and maintain catheter patency ... The record for Resident B was reviewed on 11/26/12 at 10:20 A.M. [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE] with a left upper arm PICC line. Discharge instructions from the hospital on [DATE] indicated additional instructions, routine PICC line care. Resident B had MEDICATION ORDERS FOR [REDACTED]. Discontinue the use of [MEDICATION NAME] after the 9/21/12 dose. Review of the resident medical record lacked any specific orders for flushing the resident's PICC line when not in use. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. The resident received a one time order for [MEDICATION NAME] on 9/27/12 and the medications and flushes administered as ordered. The resident received a one time order of [MEDICATION NAME] on 9/28/12 and the medications and flushes administered as ordered. The MAR indicated [REDACTED]. Blood draws were ordered on [DATE] and 10/1/12 and the PICC line was flushed at that time. A nurses note, dated 10/5/12 at 4:00 A.M., indicated the resident was NPO (nothing by mouth) for his appointment this A.M. A hospital critical care consult note, dated 10/5/12 at 13:46 (1:46 p.m.) indicated "... the PICC line has been difficult to dislodge ..." A hospital emergency room note, dated 10/5/12 at 14:59 (2:59 p.m.), indicated "when they attempted to remove the PICC line the resident became symptomatic ..." A hospital Staff Initial Consult, dated 10/5/12 at 23:59 (11:59 p.m.), indicated "... A Doppler (determine blood flow through arteries and veins) of the area shows a totally occluding acute [MEDICAL CONDITION] ([MEDICAL CONDITION] of the left brachial vein." During an interview with MD #1 on 11/26/12 at 10:05 A.M., he indicated the discharge instructions from the hospital would be routine PICC line care and would not be specific. They would leave that up to the facility physician to specify what that would be. He also indicated routine PICC line care would include proper dressing change technique, flushes and when it would be appropriate to discontinue use of the PICC line. During an interview with the DON on 11/27/12 at 10:30 A.M., she indicated there was no documentation of any education or inservicing the nurses for residents who require PICC line care. She also indicated some of the nurses were not IV certified and the nurses could not remember if there was an order to flush the PICC when not being used. During an interview with the Administrator on 11/27/12 at 3:00 P.M., she indicated no residents with PICC lines would be admitted to the facility until all the nurses had gone to IV training. During an interview with the facility's MD on 11/27/12 at 3:16 P.M., he indicated the PICC line should be flushed at least 2 or 3 times a day when not being used. If the discharge instructions from the hospital did not include specific flush orders then it would be up to the nurse to call and get clarification. "If I were writing the order it would be a minimum of 2 times a day if the PICC line is not in use." He also indicated during the interview that he had been called by the emergency department at the hospital and was informed the PICC line was clotted off (not patent). This Federal Tag relates to Complaint IN 354. 3.1-37(a)