Every finding on record at Richland Bean Blossom Health Care Center

Based on interview and record review, the facility failed to submit accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (Centers for Medicare and Medicaid) for 22 days out of a quarter (Fiscal Year Quarter 1). Findings include: On 4/6/26 at 10:45 a.m., the facility's Certification and Survey Provider Enhanced Reports (CASPER) was reviewed.The CASPER report indicated the following:- The facility failed to have Licensed Nursing Coverage 24 Hours/Day on 10/4/25; 10/18/25; 10/19/25; 10/25/25; 10/26/25; 11/1/25; 11/2/25; 11/8/25; 11/9/25; 11/15/25; 11/16/25; 11/23/25; 11/29/25; 11/30/25; 12/6/25; 12/7/25; 12/13/25; 12/14/25; 12/20/25; 12/21/25; 12/27/25; 12/28/25.- The facility had low weekend staffing.- The facility had a 1 start staffing rating. A review of the staffing sheets from the quarter indicated the facility was fully staffed and had licensed nurse on all of the days listed above. During an interview on 4/9/26 at 11:35 a.m., the Administrator indicated the payroll-based journal information had to have been a data entry error because she had verified the facility had licensed staff coverage on the timesheets. On 4/10/26 at 12:05 p.m., the Administrator provided the facility's policy, Payroll Based Journal, dated 1/1/25, and indicated it was the policy currently being used. A review of the policy indicated, . 5. The facility will ensure all staffing data entered in the Payroll-Based Journal (PBJ) system is auditable and able to be verified through either payroll, invoices, and/or tied back to a contract .

Based on interview and record review, the facility failed to ensure the written notifications required for a transfer/discharge and bed hold policy was provided to the resident and/or the resident representative for 4 of 4 residents reviewed for discharge and hospitalization. (Resident 2, Resident 7, Resident 27 and Resident 53).Findings include: 1. On 4/7/26 at 9:38 a.m., Resident 27's clinical record was reviewed. The diagnoses included, but were not limited to, generalized anxiety disorder (a mental health condition characterized by excessive, uncontrollable worry about everyday things, lasting at least six months), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), and dementia (loss of memory, language, problem-solving and other thinking abilities). Resident 27's progress notes indicated the following: - On 12/9/25 at 10:35 p.m., the resident complained chest pain, lower back pain, and shortness of breath. 911 was called and the resident was transported to the hospital. - On 12/15/25, time unknown, the resident returned to the facility. The clinical record lacked required documentation that a written Notice of Transfer/Discharge was provided to the resident and resident representative, that the bed-hold policy was provided to the resident and/or the resident respresentative, and the required information was conveyed to the receiving facility upon transfer. During an interview on 4/10/26 at 11:19 a.m., the Assistant Director of Nursing (ADON) indicated Resident 27's clinical record lacked documentation of the Notice of Transfer/Discharge and the Bed Hold policy being given to Resident 27 and documentation that required information was conveyed to the receiving facility upon transfer. During an interview 4/10/26 at 11:27 a.m., the Administrator indicated they did not have documentation that a written copy of the transfer notice and bed hold was provided to the resident representative. 2. On 4/9/26 at 3:14 p.m., Resident 53's clinical record was reviewed. The diagnoses included, but were not limited to, congestive heart failure and muscle weakness. Resident 53's progress notes indicated the following: - On 02/27/26 at 2:14 p.m., Resident 53 complained of painful urination and bloody urine. The nurse practitioner was notified and indicated to send the resident to the emergency room. The clinical record lacked documentation of the Notice of Transfer/Discharge and Bed Hold policy being given to Resident 53 or the resident representative. During an interview on 4/10/26 at 12:11 p.m., the Director of Nursing (DON) indicated Resident 53's clinical record lacked documentation of the Notice of Transfer/Discharge or the Bed Hold policy being given to Resident 53 when transferred. 3. On 4/9/26 at 3:00 p.m., Resident 2's clinical record was reviewed. The diagnoses included, but were not limited to, chronic respiratory failure and diabetes. Progress notes indicated on 3/22/26 the resident was discharged to the hospital for respiratory failure. There was no documentation that indicated a notice of transfer/discharge or bed hold policy was provided to the resident and/or the resident's representative in writing. 4. On 4/9/26 at 3:10 p.m., Resident 7 's clinical record was reviewed. The diagnoses included, but were not limited to, chronic kidney disease and dementia. Progress notes indicated on 12/23/25 the resident was discharged to the hospital. There was no documentation that indicated a notice of transfer/discharge or bed hold policy was provided to the resident and/or the resident's representative in writing. On 4/10/26 at 11:50 a.m., the Director of Nursing indicated there was no documentation that notice of transfer/discharge or bed hold policy was provided to the residents and/or the residents' representatives in writing. On 4/10/26 at 12:00 p.m., the Administrator provided the facility's policy Transfer and Discharge (including Against Medical Advice [AMA]) dated 1/15/26, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .3. The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manner in which they can understand .8. For a transfer to another provider, for any reason, the following information must be provided to the receiving provider: a. Contact information of the practitioner who was responsible for the care of the resident .c. Advance directive information .d. All other information necessary to meet the resident's needs .10. Emergency Transfers to Acute Care .f. Document assessment findings and other relevant information regarding the transfer in the medical record. g. Provide a notice of transfer and the facility's bed-hold policy to the resident and respresentative as indicated . 410 IAC (Indiana Administrative Code) 16.2-3.1-12(a)(6)(A)(i)410 IAC 16.2-3.1-12(a)(6)(A)(ii)410 IAC 16.2-3.1-12(a)(6)(A)(iii)410 IAC 16.2-3.1-12(a)(25)(A)410 IAC 16.2-3.1-12(a)(25)(B)410 IAC 16.2-3.1-12(a)(26)

Based on interview and record review, the facility failed to ensure staff electronically transmitted the MDS (Minimum Data Set) data to the CMS (Centers for Medicare and Medicaid) System within 14 days of completion for 1 of 24 residents reviewed for transmittal data. (Resident 36)Findings include:On 4/9/26 at 10:06 a.m., Resident 36's clinical record was reviewed. An Annual MDS assessment, dated 2/23/26, indicated it was over 120 days past due for submission to CMS.During an interview on 4/10/26 at 11:22 a.m., the MDS coordinator indicated she had 2 care area assessments left to complete on the annual MDS assessment, she had just completed them and had submitted the MDS to CMS.During an interview on 4/10/26 at 12:05 p.m., the Administrator indicated the facility did not have a policy in regard to MDS transmissions.

Based on interview and record review, the facility failed to ensure the MDS (Minimum Data Set) assessment accurately reflected a resident's status for 2 of 24 residents reviewed for MDS accuracy. (Resident 4, Resident 27)Findings include: 1. On 4/9/26 at 10:07 a.m., Resident 4's clinical record was reviewed. The diagnoses included, but were not limited to, bipolar disorder and anxiety. An Annual MDS assessment, dated 3/11/26, indicated the resident was not currently considered by the state Level II PASARR (Preadmission Screening and Resident Review) process to have a serious mental illness and/or intellectual disability or related condition. A Level II PASARR was completed on March 31, 2023. During an interview on 4/10/26 at 11:10 a.m., the MDS coordinator indicated she corrected the resident's MDS assessment to accurately reflect the PASARR Level II information. During an interview on 4/10/26 at 12:05 p.m., the Administrator indicated the facility did not have a policy in regard to MDS assessment coding, but followed the RAI (Resident Assessment Instrument) manual. 2. On 4/9/26 at 9:38 a.m., Resident 27's clinical record was reviewed. The diagnoses included, but were not limited to, generalized anxiety disorder (a mental health condition characterized by excessive, uncontrollable worry about everyday things, lasting at least six months), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), and dementia (loss of memory, language, problem-solving and other thinking abilities). A review of the resident's Quarterly MDS Assessment, dated 3/30/26, did not indicate anxiety as an active diagnosis. The MAR (Medication Administration Record) indicated, the resident had active orders on 2/27/26 for Lorazepam (medication used for short-term treatment of severe anxiety), 0.5 milligram (mg) twice daily and 1 mg once in the morning, for generalized anxiety disorder. A review of the Resident Assessment Instrument (RAI) 3.0, Version 1.20.1, October 2025, on 4/9/26 at 11:33 a.m., indicated for section I5700, Anxiety Disorder, . Active diagnoses are diagnoses that have a direct relationship to the resident's current functional, cognitive, or mood or behavior status, medical treatments, nursing monitoring, .during the 7-day look-back period . to identify active diagnoses: .medication sheets, doctor's orders . During an interview with the MDS coordinator on 4/10/26 at 11:09 a.m., she indicated the resident had an active diagnosis of anxiety disorder. She indicated the Quarterly MDS assessment, dated 3/30/26, was marked no for diagnosis of anxiety disorder and it should have been marked yes. The MDS coordinator and the Administrator indicated the facility did not have a MDS policy and they utilized the RAI tool to complete MDS assessments. 410 IAC (Indiana Administrative Code) 16.2-3.1-31(d)

Based on interview and record review, the facility failed to ensure narcotic pain medication was reconciled when it was delivered from the pharmacy. (Resident B) Findings include:During an interview on 12/9/25 at 8:23 a.m., the Administrator indicated, on 9/23/25, Licensed Practical Nurse (LPN) 1 reported that she was not able to locate Resident B's oxycodone-acetaminophen (narcotic pain medication) 7.5 milligrams (mg)-325 mg. When LPN 1 called the pharmacy, she was told that 30 oxycodone-acetaminophen 7.5-325 mg tablets had been delivered for Resident B on 9/21/25. LPN 2 had signed the delivery slip for the controlled medications that night but did not follow the proper procedure for reconciling the controlled medications that had been delivered with what was listed on the delivery slip before she signed for them. LPN 2 did not reconcile the narcotic medications she placed in the locked drawer on the medication cart with the narcotic disposition record. The oxycodone-acetaminophen 7.5-325mg that was delivered, on 9/21/25, was never located. LPN 2's employment had been terminated due to not following the facility policy and procedure for accepting and reconciling narcotic medications.The clinical record for Resident B was reviewed on 12/8/25 at 10:03 a.m. The diagnoses included, but were not limited to, dementia, pain disorder, and hypertension.A quarterly Minimum Data Set (MDS) assessment, dated 11/4/25, indicated Resident B was severely cognitively impaired and did not have any pain.A physician's order, initiated on 7/31/25, indicated oxycodone-acetaminophen 7.5-325 mg administer one tablet orally every 6 hours as needed for pain. The order was discontinued on 10/22/25.On 12/8/25 at 11:48 a.m., the Administrator provided a copy of a handwritten note, dated 9/29/25, and indicated this was the written statement given by LPN 2 regarding Resident B's missing oxycodone-acetaminophen. A review of the note indicated, on 9/21/25, LPN 2 signed the pharmacy delivery documents for the controlled substances but did not thoroughly review the medications that were listed on the document. LPN 2 took the medication to the medication cart but waited until the end of the shift to reconcile the controlled medications that were delivered with the narcotic medication disposition record. LPN 2 did not remember any medication that had been delivered for Resident B.On 12/8/25 at 11:48 a.m., the Administrator provided a copy of an undated policy, titled Controlled Substance Administration and Accountability, and indicated this was the current policy used by the facility. A review of the policy indicated the controlled medication being delivered are immediately recorded on the appropriate drug disposition record by the nurse accepting the delivery.This citation relates to Intake 2627048.3.1-25(e)(2)

Based on observation, interview, and record review, the facility failed to promptly respond to grievances from the resident council meetings for 5 of 5 residents interviewed. (Resident 11, Resident 31, Resident 55, Resident 45, Resident 41) Findings include: During a resident council meeting on 5/7/25 at 10:01 a.m., Resident 11, Resident 31, Resident 55, Resident 45, and Resident 41, indicated if a meal included a wet item, such as corn, their bread was often soggy and unappetizing. The resident's indicated they had told staff this was a problem multiple times and it was an ongoing problem. A review of the resident council meeting minutes indicated the following: - On 12/26/24, the residents indicated they would like separate dishware for liquid type foods, such as, cottage cheese, fruit, baked beans, etc. - On 2/27/25, the residents discussed the need of bowls for liquid foods. - On 3/27/25, the residents indicated when liquid foods were on the plate with regular food, the sandwiches, or breads would get soggy. On 5/7/25 at 12:10 p.m., a test tray was obtained from the 300 hall cart. The meal included a hamburger on a bun, fried onion rings, and whole kernel corn on a flat plate. The corn was beneath the bun and a few onion rings were on top of the corn. The bottom of the hamburger bun and the onion rings placed on top of the corn were soggy. During an interview on 5/8/25 at 11:29 a.m., the Dietary Manager indicated he was not aware of the residents' concerns related to soggy food. 3.1-3(l)

Based on observation, interview, and record review, the facility failed to implement an ongoing resident centered activities program for 13 of 13 residents who resided on the secure dementia unit. Findings include: On the following dates and times, residents of the secured dementia unit were observed walking in the hallway, and sitting in the dining area and common area with no structured activities taking place: - On 5/5/25 from 11:00 a.m. to 12:30 p.m. and from 2:00 p.m. to 3:05 p.m. - On 5/6/25 from 9:40 a.m. to 12:15 p.m. and from 1:40 p.m. to 2:55 p.m. - On 5/7/25 from 9:45 a.m. to 11:55 a.m. and from 1:20 p.m. to 3:00 p.m. - On 5/8/25 from 9:30 a.m. to 11:05 a.m. No activities schedule was observed posted or located on the closed dementia unit. During confidential interviews during the course of the survey, they indicated there had been no activities calendar or schedule posted on the unit for several months, and no scheduled activities had taken place for several months, including the survey period. On occasion, an activities assistant would come to the unit to do unscheduled activities with the residents. Activities were inconsistently provided for residents on the unit. The nursing staff would do random and unscheduled activities with the residents when not attending to resident nursing care needs. During an interview on 5/8/25 at 11:15 a.m., the Executive Director indicated there was a need for regularly scheduled activities on the secure dementia unit. On 5/09/25 at 1:21 p.m., the Executive Director provided the facility Admission Statement, undated, and indicated this was the Admission Statement currently used by the facility. A review of the statement indicated, .These services are provided under the daily basic rate for residents regardless of the payor source .an activities program, including, but not limited to, a planned schedule for recreational , motivational, social, and other activities . 3.1-33(a)

Based on observation, interview, and record review, the facility failed to provide sufficient nursing staff on the secured dementia unit for 13 of 13 residents who resided on the secure dementia unit (Resident 13, Resident 15, Resident 19, Resident 23, Resident 34, Resident 53, Resident 32, Resident 14, Resident 52, Resident 8, Resident 54, Resident 208, and Resident 48). Findings include: On 5/6/25 at 2:10 p.m., LPN 1 was observed attending to Resident 34 who was ambulating in an unsteady manner in the hallway. LPN 1 observed Resident 52 ambulating in an unsteady manner farther down the hallway and instructed Resident 34 to hold to the hallway railing in order to attend to Resident 52. During this time, QMA 1 was assisting a resident in a resident bathroom. CNA 1 was in the shower room with another resident. LPN 1 guided Resident 52 to a chair in the common area and returned to assist Resident 34. On 5/7/25 at 1:30 p.m. LPN 1 was observed assisting Resident 34 to a chair in the common area. CNA 1 was assisting a resident in a resident room. Resident 34 was resistant to sitting and was becoming agitated. At that time, Resident 32 was attempting to enter the room of another resident. LPN 1 instructed Resident 34 to hold onto the wall railing and redirected Resident 32 to the common area prior to assisting Resident 34 to a chair. No other staff were observed on the unit at that time. On 5/8/25 at 10:30 a.m., LPN 2 was observed at the far end of the unit hallway assisting Resident 52 as he ambulated in an unsteady manner. In the common area, Resident 34 was observed to begin to sit on the lap of Resident 48, who was agitated at that situation. LPN 2 assisted Resident 52 in steadying himself with the wall railing and sprinted the length of the hallway to intervene in Resident 34's attempt to sit on the lap of Resident 48. During that time, QMA 1 was in a resident room attending to a resident's toileting needs and CNA 3 was off the unit procuring supplies for the unit. Confidential interviews were conducted the course of the survey and indicated the following: - From 7:00 a.m. to 3:00 p.m., there was 1 nurse and 2 CNA's on the unit. At 3:00 p.m., one of the CNA's was pulled from the unit, either to clock out or to work in another area of the facility, which left 2 staff working on the unit from 3:00 p.m. to 7:00 p.m. At 7:00 p.m., the second shift nurse and CNA relieved the first shift staff, which left 2 staff working on the unit from 7:00 p.m. to 7:00 a.m. - Most of the residents required extensive assistance of 1 or 2 staff for transferring and toileting and were at risk of falling. - The time period between 3:00 p.m. and 11:00 p.m. was when some residents experience sundowner's syndrome (a neurological condition during which some with dementia experience increased confusion and restlessness beginning in the late afternoon and early evening), and may become agitated and more difficult to direct and redirect. If one resident displayed challenging behaviors or required 2 staff to manage, this left the other residents unattended and at risk of falling. If one staff needed a bathroom break, or was attending to another resident in a resident's room, this left only 1 staff to attend to the rest of the residents. The residents were all at risk of falling, and with only 2 staff on the unit the residents were at a higher risk of falling and not receiving care that would fully meet their physical, emotional, and psychosocial needs. On 5/7/25 at 2:05 p.m., a review of the secure dementia unit staffing schedule indicated the secure dementia unit was assigned 3 nursing staff each day from 7:00 a.m. to 3:00 p.m., and 2 nursing staff each day from 3:00 p.m. to 7:00 a.m. On 5/7/25 at 2:10 p.m., a clinical record review of the residents of the secure dementia unit indicated the following: - There were 4 residents who required extensive assistance of 1 staff member for transfers from surface to surface. - There were 4 residents who required extensive assistance of 2 staff members for transfers between different surfaces. - There were 2 residents who required total assistance for transfers between different surfaces. - There were 6 residents who required extensive assistance of 1 staff member for toileting. - There were 6 residents who required extensive assistance of 2 staff members for toileting. - Between 5/1/24 and 5/7/25 there were a total of 53 fall events amongst the 13 residents on the secure dementia unit. Of those 53 falls, 39 falls occurred between the hours of 3:00 p.m. and 7:00 a.m. On 5/8/25 at 11:20 a.m., the Director of Nursing indicated indicated there were 3 staff scheduled from 7:00 a.m. to 3:00 p.m., and 2 staff scheduled to work on the dementia unit from 3 p.m. to 7 a.m. On 5/5/25 at 11:00 a.m., the ED provided the Facility Assessment Tool, copyright date of June 2024, and indicated this was the Facility Assessment Tool currently used by the facility. A review of the Facility Assessment Tool indicated, .the facility takes into consideration all resident care needs including assist levels for ADL's [activities of daily living] and special clinical needs .the facility periodically analysis patient outcomes and negative events when determining future staffing needs .the staffing needs for each care unit are determined with consideration of the patient functional care needs . 3.1-17(a)

Based on observation, interview, and record review, the facility failed to ensure staff served food that had a palatable texture and appearance for 1 of 1 test trays observed. (Resident 11, Resident 31, Resident 55, Resident 45, Resident 41, Resident 17) Findings include: During a resident council meeting on 5/7/25 at 10:01 a.m., Resident 11, Resident 31, Resident 55, Resident 45, and Resident 41, indicated if a meal included a wet item, such as corn, their bread was often soggy and unappetizing. They indicated they had told staff this was a problem multiple times and it was an ongoing problem. On 5/7/25 at 12:10 p.m., a test tray was obtained from the 300 hall cart. The meal included a hamburger on a bun, fried onion rings, and whole kernel corn on a flat plate. The corn was beneath the bun and a few onion rings were on top of the corn. The bottom of the hamburger bun and the onion rings placed on top of the corn were soggy. During an interview on 5/7/25 at 12:15 p.m., the Administrator did not deny the hamburger bun was soggy. During an interview on 5/7/25 at 12:20 p.m., Resident 17 indicated the onion ring and hamburger buns were soggy from the corn liquid. During an interview on 5/8/25 at 11:29 a.m., the Dietary Manager indicated he was not aware of the residents' concerns related to soggy food. 1.3-21(a)(2)

Based on record review and interview, the facility failed to ensure residents and/or their representative were provided informed consent prior to initiating an antipsychotic medication for 1 of 6 residents reviewed for unnecessary medications. (Resident 13) Findings include: On 5/6/25 at 2:09 p.m., Resident 13's clinical record was reviewed. The diagnoses included, but were not limited to, myotonic muscular dystrophy (a genetic disorder characterized by progressive muscle weakness and difficulty relaxing muscles after use), psychosis (significant loss of contact with reality, often characterized by hallucinations and delusions), and senile degeneration of the brain (a decline in cognitive function). A review of physician's orders indicated the following: On 4/29/25, an order for Olanzapine (an antipsychotic medication) 2.5 mg (milligrams) once daily was prescribed for a diagnosis of psychosis. A review of Resident 13's progress notes indicated the following: On 4/29/25, the resident informed staff that she saw an accident take place that had multiple casualties. The resident was seen by her primary care doctor and psychologist, both providers recommended to start resident on Olanzapine 2.5 mg daily, due to continued hallucinations. The record indicated the family was aware. The clinical record lacked documentation that indicated informed consent was provided to the resident and the resident representative regarding treatment options, risks, and benefits of psychotropic medication. During an interview with the DON (Director of Nursing), on 5/9/25 at 11:52 a.m., she indicated there was not an informed consent prior to the start of a psychotropic medication. On 5/9/25 at 1:57 p.m., the DON indicated they did not have a policy for initiating psychotropic medication, nor did they have a policy on obtaining informed consent. 3.1-3(n)(2)

Based on interview and record review, the facility failed to ensure resident's care planning conferences were completed for 1 of 1 residents reviewed for care planning. (Resident 41) Finding includes: During an interview on 5/6/25 at 9:48 a.m., Resident 41 indicated the staff did not involve him or his family in care conferences, and he could not remember the staff ever involving him with the development of his care plan. On 5/6/25 at 11:10 a.m., the resident's clinical record was reviewed. The diagnoses included, but were not limited to hemiplegia (complete paralysis on one side) and hemiparesis (partial weakness on one side of the body) following a cerebral infarction (a condition where brain tissue dies due to a lack of blood flow) affecting left non-dominant side, need for assistance with personal care, dysphagia following cerebrovascular disease, and cerebral infarction without residual deficits. A Quarterly Minimum Data Set (MDS) assessment, dated 2/19/25, indicated the resident had moderately impaired cognition. A review of the resident's clinical record indicated his last care conference was on 6/2/24 and his Annual MDS assessment was dated 8/9/24. During an interview on 5/7/25 at 9:50 a.m., the Director of Nursing (DON) indicated the care conference documentation should appear under care planning or observations tab. She verified there were no care conferences located under in the resident's record and she would verify it on her end. During an interview on 5/9/25 at 2:00 p.m., the DON indicated the resident's last care conference was in 2024 and they should be done quarterly. On 5/9/25 at 2:20 p.m., the DON provided the facility policy, Care Planning-Resident Participation, undated, and indicated it was the policy currently being used. A review of the policy indicated, This facility supports the resident's right to be informed of, and participate in, his or her care planning and treatment (implementation of care) . 10. The facility will discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences, and allow them to see the care plan . at routine intervals . 11. If the participation of the resident and/or resident representative is determined not practicable for the development of the resident's care plan, an explanation will be documented in the resident's medical record. 3.1-35(d)(2)(B)

Based on observation, interview, and record review, the facility failed to ensure reasonable accommodation of needs for 1 of 5 residents interviewed during the resident council meeting. Call lights were not within reach. (Resident 55) Findings include: During a resident council meeting on 5/7/25 at 10:01 a.m., Resident 55 indicated she did not have access to her call light. Resident 55 indicated the staff had recently deep-cleaned their room and they did not have use of their call lights for 24 hours. Resident 55 insisted she still did not have access to her call light because it was under a stack of plastic totes in their room. On 5/7/25 at 10:45 a.m., Resident 55's call light was observed on the floor, under a plastic storage container. She would not have had prompt access to call for help. On 5/7/25 at 11:00 a.m., Resident 55's clinical record was reviewed. The diagnoses included, but were not limited to, unsteadiness on feet, difficulty in walking, need for assistance with personal care, and glaucoma. The Quarterly Minimum Data Set (MDS) assessment, dated 1/16/25, indicated the resident had moderately impaired cognition. On 5/8/25 at 9:29 a.m., Resident 55 was observed in her recliner and putting on her shoes. Her call light remained on the floor, under the plastic container. She indicated she did not have access to her call light because it was still under the plastic container. She then got up and went to activities. On 5/9/25 at 2:20 p.m., the Director of Nursing provided the facility policy, Call Lights: Accessibility and Timely Response, dated 1/22/25, and indicated it was the policy currently being used. A review of the policy indicated, . 5. Staff will ensure the call light is within reach of resident and secured as needed. 6. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room . 3.1-3(v)(1)

Based on interview and record review, the facility failed to ensure the resident representative was notified of a change in condition and treatments for 1 of 1 resident's reviewed for death. (Resident 57) Findings include: On [DATE] at 2:31 p.m., Resident 57's closed clinical record was reviewed. The diagnoses included, but were not limited to, dementia, muscle weakness, need for assistance with personal care, and stage 3 chronic kidney disease. A review of the resident's progress notes indicated the following: - On [DATE] at 10:22 p.m., the resident was ordered 2 liters (2 bags) of sodium chloride solutions for dehydration. His son and wife were notified. The note was recorded as a late entry on [DATE] at 10:24 p.m. - On [DATE] at 3:35 a.m., the sodium chloride (0.9% NaCl) solutions were completed via hypodermoclysis (the subcutaneous infusion of fluids, a hydration technique suitable for mildly to moderately dehydrated adult patients). - On [DATE] at 7:56 a.m., the resident had fatigue, a change in mental status, and dark urine. The note did not indicate the family had been notified. - On [DATE] at 9:32 p.m., the resident had congestion, fever, and a productive cough. The note did not indicate the family had been notified. - On [DATE] at 11:17 p.m., the resident was lethargic, his oxygen saturation was 94 percent on room air (normal level is typically between 95% and 100%), and his respirations were 26 (normal respiratory rate for a resting adult is typically between 12 and 20 breaths per minute). The Nurse Practitioner ordered 1 liter of dextrose and sodium chloride (D5W/NaCl, a combination of a sugar and a salt used as a source of water, electrolytes, and calories), followed by 1 liter of sodium chloride. The note did not indicate the family had been notified. - On [DATE] at 11:30 p.m., the D5W/NaCl was subcutaneously running at 75 milliliters per hour. The note did not indicate the family had been notified. - On [DATE] at 6:20 a.m., the resident was found with no pulse or respirations. A second nurse confirmed his death. On [DATE] at 2:23 p.m., LPN 2 indicated she was not working when the resident expired. She indicated he was diagnosed with COVID-19 a few days prior to death and he had recently recovered from a UTI (urinary tract infection). She was surprised to learn he passed away. On [DATE] at 3:20 p.m., the DON provided the facility policy, Notification of Changes, undated, and indicated it was the policy currently being used. A review of the policy indicated, . The facility must . notify the resident's family member . when there is a change requiring such notification. Circumstance requiring notification include: . 2. Significant change in the resident's physical, mental . condition such as deterioration in health . 3. Circumstances that require a need to alter treatment. This may include: a. New treatment. b. Discontinuation of current treatment . 3XXX,d+[DATE](a)(2) 3XXX,d+[DATE](a)(3)

Based on record review and interview, the facility failed to ensure an accurate MDS (Minimum Data Set) assessment for 2 of 2 residents reviewed for resident assessment. (Resident 31, Resident 11) Finding includes: 1. On 5/8/25 at 2:52 p.m., Resident 31's clinical record was reviewed. The diagnoses included, but were not limited to, bipolar disorder (a mental health condition causes extreme mood swings), dementia (a group of diseases that affect your thinking, memory, reasoning, personality, mood and behavior), and mood disorder (a mental health condition characterized by significant and persistent changes in mood). A review of the notice of PASARR (Preadmission Screening and Resident Review) Level II Outcome, dated 5/22/23, indicated, Final Determination By: Determination Date: 5/22/23, Level II Outcome: Long Term Approval without Specialized Services. The Annual MDS assessment, dated 6/27/24, did not indicate resident was a PASARR level II. During an interview with the Clinical Reimbursement Director on 5/9/25 at 12:15 p.m., she indicated section A1500 on MDS assessment, dated 6/27/24, was marked no in error and indicated it should have been marked yes for PASARR Level II. She indicated they did not have a MDS assessment coding policy, they followed the Resident Assessment Instrument (RAI) manual for coding the MDS assessment. On 5/9/25 at 1:30 p.m., a review of the RAI, Version 3.0 User's Manual, 10/2023, for section A1500 of MDS indicated, Code 1, yes: if PASARR Level II screening determined that the resident has a serious mental illness and/or ID (Intellectual disability)/DD (Developmental disability) or related condition . 2. On 5/8/25 at 3:04 p.m., Resident 11's clinical record was reviewed. The diagnoses included, but were not limited to, heart disease without heart failure, chronic respiratory failure with hypoxia (a condition where the lungs struggle to adequately transfer oxygen into the blood, leading to chronically low oxygen levels), and dementia. An order, dated 5/8/24, indicated hospice services were provided by the hospice provider. The Quarterly MDS assessment, dated 4/3/25, was not marked for hospice care services. During an interview with the Clinical Reimbursement Director on 5/9/25 at 12:15 p.m., she indicated that Resident 11 was receiving hospice services during the quarterly assessment period and Section O0110 on the MDS should have been marked yes. She indicated they did not have a MDS assessment coding policy, they followed the RAI manual for coding the MDS assessment. On 5/9/25 at 1:30 p.m., a review of the RAI, Version 3.0 User's Manual, 10/2023, for section O0110 of MDS indicated, .check all treatments, procedures, and programs that the resident received or performed after admission/entry or reentry to the facility and within the last 14 days .Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided . 3.1-31(d)

Based on observation, interview, and record review, the facility failed to ensure a resident received the necessary interventions to prevent the development of a pressure ulcers for 1 of 2 residents reviewed for pressure ulcers. A resident developed a Stage 3 pressure ulcer. (Resident 38) Findings include: During an observation on 5/6/25 at 2:56 p.m., Resident 38 was observed to be resting in her bed on her back and her heels were on the bed. Her heels were not observed to be floated on pillows. During an observation on 5/7/25 at 9:43 a.m., Resident 38 was observed to be resting in the bed on her back and her heels were on the bed. Her heels were not observed to be floated on pillows. During an observation on 5/7/25 at 1:57 p.m., Resident 38 was observed to be resting in the bed on her back and her heels were on the bed. Her heels were not observed to be floated on pillows. During an observation on 5/8/25 at 9:30 a.m., Resident 38 was observed to be resting in the bed on her back and her heels were on the bed. Her heels were not observed to be floated on pillows. During an observation on 5/9/25 at 9:04 a.m., Resident 38 was observed to resting in the bed on her back and her heels were on the bed. Her heels were not observed to be floated on pillows. On 5/7/25 at 11:11 a.m., Resident 38's clinical record was reviewed. The diagnoses included, but were not limited to, stage 3 pressure ulcer of the sacral (lower back) region, dementia, diabetes mellitus, and muscle weakness. The Clinical Quarterly assessment, dated 3/20/25 at 3:37 p.m., indicated Resident 38 was at a moderate risk for pressure ulcers and was dependent on staff for rolling from left to right side when lying on back in the bed. The quarterly MDS (Minimum Data Set) assessment, dated 3/25/25, indicated Resident 38 had severe cognitive impairment, required maximum assist with rolling from left to right side when lying on back in the bed, was always incontinent of bowel and bladder, was at risk for skin breakdown, and did not have any pressure ulcers. The care plan, dated 11/23/22, indicated Resident 38 was at risk for pressure related skin breakdown due to mobility deficit and incontinence. The interventions were to encourage Resident 38 to turn and reposition every 2 hours and as needed; provide thorough skin care with any incontinent episode; and to keep bony prominences from prolonged contact with surfaces. The care plan, dated 3/28/25, indicated Resident 38 was at risk for complications from a stage 3 pressure ulcer to coccyx. The interventions lacked documentation of turn and reposition or to float heels. The Wound Management Detail Report, dated 3/31/25 at 1:04 a.m., indicated the following: - On 3/31/25 at 1:22 p.m., Resident 38 was evaluated for a new stage 3 pressure ulcer to her coccyx. She was incontinent of bowel and bladder. She had poor mobility and was bed and chairfast. The pressure ulcer was 1.2 cm (centimeters) x (by) 0.5 cm x 0.1 cm. The treatment recommendations were to cleanse the coccyx with normal saline, apply collagen (wound dressing) to the base of the wound, and cover with a gauze. The preventive measures were to turn and reposition per protocol; pressure reduction to the heels and all bony prominences; and to float the heels while in the bed with the use of pillows. All prevention measures were discussed with the staff at the time of the visit. - On 4/8/25 at 8:56 p.m., Resident 38's stage 3 pressure ulcer was improving without complications. The size was 0.8 cm x 0.3 cm x 0.1 cm. The treatment recommendations were to cleanse the pressure ulcer with normal saline, apply collagen to the base of the wound, and cover with a gauze. The preventive measures were to turn and reposition per protocol; pressure reduction to the heels and all bony prominences; and to float the heels while in the bed with the use of pillows. All prevention measures were discussed with the staff at the time of the visit. - On 4/15/25 at 9:06 p.m., Resident 38's stage 3 pressure ulcer was improving without complications. The size was 0.7 cm x 0.3 cm x 0.1 cm. The treatment recommendations were to cleanse the pressure ulcer with normal saline, apply collagen to the base of the wound, and cover with a gauze. The preventive measures were to turn and reposition per protocol; pressure reduction to the heels and all bony prominences; and to float the heels while in the bed with the use of pillows. All prevention measures were discussed with the staff at the time of the visit. - On 4/23/25 at 4:12 p.m., Resident 38's stage 3 pressure ulcer was improving without complications. The size was 0.4 cm x 0.3 cm x 0.1 cm. The treatment recommendations were to cleanse the pressure ulcer with normal saline, apply collagen to the base of wound, and leave the area open to the air. The preventive measures were to turn and reposition per protocol; pressure reduction to the heels and all bony prominences; and to float the heels while in the bed with the use of pillows. All prevention measures were discussed with the staff at the time of the visit. Resident 38's progress notes indicated the following: - On 4/29/25 at 5:08 p.m., Resident 38's stage 3 pressure ulcer was improving without complications. The size was 1 cm x 0.5 cm x 0.1 cm. The treatment recommendations were to cleanse the pressure ulcer with normal saline, apply collagen to the base of the wound, and cover with a border gauze. The preventive measures were to turn and reposition per protocol; pressure reduction to the heels and all bony prominences; and to float the heels while in the bed with the use of pillows. All prevention measures were discussed with the staff at the time of the visit. - On 5/6/25 at 9:10 p.m., Resident 38's stage 3 pressure ulcer was improving without complications. The size was 0.8 cm x 0.5 cm x 0.1 cm. The treatment recommendations were to cleanse the pressure ulcer with normal saline, apply calcium alginate (wound care dressing) to the base of the wound, and cover with a border gauze. The preventive measures were to turn and reposition per protocol; pressure reduction to the heels and all bony prominences; and to float the heels while in the bed with the use of pillows. All prevention measures were discussed with the staff at the time of the visit. The clinical record lacked documentation of Resident 38 refusing to float heels or to turn and reposition. During an interview on 5/7/25 at 2:13 p.m., the Assistant Director of Nursing (ADN) indicated Resident 38 had a Stage 3 pressure ulcer to her coccyx. The root cause of the pressure ulcer was from sliding down in her wheelchair. Her interventions were to lay down after meals, turn and reposition, occupational therapy to assist with wheelchair positioning, and a wheelchair cushion to help prevent pressure ulcers. During an interview on 5/8/25 at 10:40 a.m., CAN 2 indicated Resident 38's pressure ulcer interventions were to provide incontinent care and to lay down after meals. Resident 38 did not refuse care. Resident 38 did not turn and reposition after meals or float heels when in bed. During an interview on 5/9/25 at 10:14 a.m., Qualified Medication Aide (QMA) 2 indicated Resident 38 was dependent on staff for activities of daily living (ADL). Resident 38 did not refuse care. Resident 38 was on a turn and reposition schedule. During an interview on 5/9/25 at 11:25 a.m., the Director of Nursing (DON) indicated the clinical record lacked documentation of Resident 38 refusing to turn and reposition or floating heels. On 5/9/25 at 12:14 p.m., the DON provided the facility policy, Pressure Injury Prevention and Management, dated 1/22/25, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .Basic or routine care interventions could include, but are not limited to: I. Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.) .iii. Provide appropriate, pressure-redistributing, support surfaces; . 3.1-40(a)(1)

Based on observation, interview, and record review, the facility failed to ensure a resident with limited range of motion received services to prevent further decline for 1 of 2 residents reviewed for mobility.(Resident 41) Findings include: During an interview on 5/6/25 at 9:55 a.m., Resident 41 indicated his left hand did not open and he would like to try a splint to see if that improved his left hands function and mobility. His left hand was observed to not fully open and did not have a splint in place. On 5/6/25 at 2:19 p.m., Resident 41 was observed in his room without a splint on his left hand. On 5/7/25 at 1:57 p.m., Resident 41 was observed in his bed without a splint on his left hand. He indicated staff did not do any range of motion exercises with him. On 5/6/25 at 11:10 a.m., Resident 41's clinical record was reviewed. The diagnoses included, but were not limited to hemiplegia (complete paralysis on one side) and hemiparesis (partial weakness on one side of the body) following a cerebral infarction (a condition where brain tissue dies due to a lack of blood flow) affecting left non-dominant side, need for assistance with personal care, dysphagia following cerebrovascular disease, and cerebral infarction without residual deficits. A Quarterly Minimum Data Set (MDS) assessment, dated 2/19/25, indicated the resident had moderately impaired cognition and functional limitation in range of motion with impairment on one side in his upper and lower extremities. A Occupational Therapy OT Discharge Summary, dated 4/4/25, indicated an extensor resting hand splint was ordered and once it was delivered, OT would assess for correct fit and establish and provide education regarding a wearing schedule. A care plan titled, ADLs Functional Status/Rehabilitation Potential, dated 5/23/24, indicated the resident was to put on a left hand brace in the morning and remove it in the evening. During an interview on 5/8/25 at 1:53 p.m., Certified Occupational Therapy Assistant (COTA) 1 indicated she wrote the progress note in regard to the splint. She had not verified the Business Office Manager (BOM) had placed the order. During an interview on 5/8/25 at 1:54 p.m., the BOM indicated she did not know if she had placed the order for the splint and she would look the splint's order status. During an interview on 5/8/25 at 3:17 p.m., Executive Director (ED) indicated the splint's order must have not gone through. During an interview on 5/9/25 at 11:45 a.m., the Director of Nursing (DON) indicated the facility did not have restorative aides and to talk to the clinical MDS consultant in regard to range of motion exercises and the implementation of a restorative program for residents. During an interview with the Clinical Reimbursement Director she indicated the facility did not have a restorative aide and was actively looking to hire one. She confirmed the resident was not on a restorative program which would typically happen after a resident was discharged and recommended by therapy. On 5/9/25 at 2:20 p.m., the DON provided the facility policy, Prevention of Decline in Rang of Motion, dated 1/25/25, and indicated it was the policy currently being used. A review of the policy indicated, . 4. Preventative Care . b. Staff will . iii. Encouraging resident to remain active and assisting with any exercises . iv. Assisting resident in . use of any assistive devices. v. Assisting resident with range of motion exercises, performing passive range of motion for resident unable to actively participate. c Residents will receive services from restorative aides or therapist as needed . 3.1-42(a)(2)

Based on observation, interview, and record review, the facility failed to implement infection control practices for 1 of 11 residents observed for care. Gloves were not changed, hands were not washed, and Enhanced Barrier Precautions were not implemented. (Resident 38) Findings include: During an observation of a pressure ulcer dressing change on 5/7/25 at 10:46 a.m., the Assistant Director of Nursing (ADON) went into Resident 38's room with treatment supplies to change Resident 38's pressure ulcer dressing. The ADON placed the treatment supplies on Resident 38's bed. CNA 4 performed incontinent care on Resident 38. CNA 4 removed her soiled gloves. She was observed to put on a new pair of gloves. CNA 4 was not observed to wash her hands or apply hand sanitizer prior to putting on the new gloves. The ADON removed the soiled dressing from Resident 38's coccyx. The ADON did not change her gloves after removing the old dressing and placing the new dressing on. The ADON picked up the treatment supplies and placed them back in the treatment cart. The ADON and CNA 4 were not observed to be wearing a gown during the dressing change. On 5/7/25 at 11:11 a.m., Resident 38's clinical record was reviewed. The diagnoses included, but were not limited to, stage 3 pressure ulcer of the sacral (lower back) region, dementia, diabetes mellitus, and muscle weakness. The physician orders, dated 4/8/25 through 5/8/25, lacked an order for enhanced barrier precautions (an infection control strategy that used gloves and gowns during high-contact resident care to reduce the spread of resistant organisms). The ADL (activities of daily living) Functional care plan, dated 5/13/24, indicated Resident 38 had no isolation. The care plan, dated 3/28/25, indicated Resident 38 was at risk for complications from a stage 3 pressure ulcer to coccyx. The interventions lacked documentation of enhanced barrier precautions. During an interview on 5/7/25 at 2:13 p.m., the ADON indicated Resident 38 had a stage 3 ulcer to her coccyx. Resident 38 should of been on enhanced barrier precautions during her pressure ulcer dressing change. When a dirty dressing is removed, they need to wash hands and change gloves. On 5/8/25 at 1:51 p.m., the Executive Director (ED) provided the facility policy, Clean Dressing Change, dated 4/1/25, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .5. Set up clean field on the overbed table with needed supplies for wound cleansing and dressing application: .10. Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. 11. Wash hands and put on clean gloves . On 5/8/25 at 1:51 p.m., the Executive Director (ED) provided the facility policy, Enhanced Barrier Precautions, dated 1/22/25, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .Enhanced barrier precautions .employs targeted gown and gloves use during high contact resident care activities .b. An order for enhanced barrier precautions will be obtained for residents with any of the following: 1. Wounds (e.g. chronic wounds such as pressure ulcers .) .4. High-contact resident care activities include: .h. Wound care: any skin opening requiring a dressing . 3.1-18(b)(1)

Based on observation, interview, and record review, the facility failed to ensure residents were informed of the state and local advocacy organization and contact information for filing complaints. This had to potential to affect 58 out of 58 residents residing in the facility. Findings include: During a resident council meeting on 5/7/25 at 10:36 a.m., residents indicated they did not know where the State Survey Agency (SSA) or the State Long-Term Care Ombudsman information was posted. They further indicated they did not know how to file a complaint with the State Survey Agency. During an observation on 5/7/25 at 10:49 a.m., the local advocacy information was observed posted up by the front entrance approximately 4 and one half feet from the floor. The posting was located amongst other papers and was not easily identifiable nor within eyesight of a wheelchair bound resident. On 5/7/25 at 3:20 p.m., the resident council meeting minutes were reviewed. The resident council meeting minutes did not indicate the SSA or ombudsman posting information was discussed during meetings. During an interview on 5/9/25 at 2:05 p.m., the Clinical Nurse Consultant indicated a staff member should go over the local advocacy posting information during resident council meetings and the residents were provided a copy at admission. She further indicated the facility did not have a specific policy in regard to the posting of local advocacy agencies. 3.1-4(j)(3)(A) 3.1-4(j)(3)(C)

Based on interview and record review, the facility failed to ensure accurate acquiring and accounting of controlled substances for 1 of 3 residents reviewed for pharmacy services. (Resident E) Findings include: Resident E's clinical record was reviewed on 9/24/24 at 11:00 a.m. The diagnoses included, but were not limited to, end stage renal disease and pain. Physician Orders, dated 8/24/24 through 9/24/24, indicated Resident E's medications included, but were not limited to, hydrocodone-acetaminophen (a pain medication) Schedule II (drugs with high potential for abuse) tablet 7.5-325 mg (milligram) one every six hours as needed for pain. The medication start date was 4/17/24. The pharmacy document titled, Packing Slip was reviewed on 9/25/24 at 11:45 a.m., for Resident E and indicated 60 hydrocodone-acetaminophen tablets 7.5-325 mg were delivered to the facility on [DATE]. The medication was received and signed for by LPN 1. The facility document titled, Controlled Substance Acceptance Log was reviewed on 9/25/24 at 11:50 a.m., for Resident E. The document was observed to be blank for the acceptance of the 60 hydrocodone-acetaminophen tablets delivered by the pharmacy on 8/28/24. The pharmacy document titled, Controlled Drug Record was reviewed on 9/25/24 at 11:52 a.m., for Resident E. The document indicated only 30 hydrocodone-acetaminophen tablets were left instead of the 60 as indicated on the pharmacy Packing Slip. During an interview on 9/24/24 at 9:40 a.m., the Administrator indicated the pharmacy would deliver medications in the evening and the facility evening nurse would accept the medications from the pharmacy technician. The accepting nurse was supposed to fill out the document titled, Controlled Substance Acceptance Log, for all incoming narcotic medications. This document was not filled out for Resident E on 8/28/24, for the delivery of the hydrocodone-acetaminophen tablets. The pharmacy document titled, Packing Slip indicated 60 tablets were left in 2 separate medication cards of 30 each, however, the facility was showing only 1 card of 30 medications was delivered to facility. During a second interview on 9/24/24 at 12:13 p.m., the Administrator indicated the pharmacy would bring narcotic medications with a manifest titled, Packing Slip. The packing slip would indicate how many medications were being delivered. Resident E's Packing Slip for 8/28/24, indicated 60 hydrocodone-acetaminophen 7.5-325 mg tablets were delivered and accepted by the facility nurse LPN 1. LPN 1 failed to fill out the Controlled Substance Acceptance Log for the narcotics. The medication comes 30 in a card therefore, two cards would have been delivered by the pharmacy. The pharmacy only brought 1 document titled, Controlled Drug Record which indicated to the facility on ly one card was left with 30 narcotic tablets. The facility was unsure what happened to the second card of narcotics, however it was unable to be located. On 9/24/24 at 1:15 p.m., the Administrator provided the facility policy, Controlled Substances Policies with a revision date of 3/30/22, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . All Controlled Substances: Controlled Substance Records: All CII-CV [schedule II] controlled substances ordered from [pharmacy name] are delivered with a Controlled Substance Record . each controlled substance prescription will have its own record, even if there are multiple controlled substances prescribed to a single patient . On 9/24/24 at 1:15 p.m., the Administrator provided the facility policy, Courier Deliveries with a revision date of 12/28/21, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . 2. Courier will hand the totes/bags to the . nurse . 3. Courier will have the . nurse sign and date one manifest to verify its deliver . 4. Courier will leave one copy of the manifest with the package . This deficient practice was corrected on 9/11/24 after the facility implemented a systemic plan of correction that included the following actions: staff was inserviced on receiving and acquiring controlled substances from the pharmacy with ongoing monitoring and audits. This citation relates to Complaint IN00443589. 3.1-25(e)(2) 3.1-25(e)(3)

Based on interview and record review, the facility failed to ensure the resident's representative was informed of the baseline care plan for 1 of 1 residents reviewed for mood and behavior. (Resident 56) Finding include: On 7/11/24 at 10:15 a.m., Resident 56' clinical record was reviewed. The diagnoses included, but were not limited to, Alzheimer's disease, anxiety, and insomnia. His admitted was 6/6/24. Resident 56's Interim 48 hour baseline care plan was started on 6/6/24. The clinical record lacked documentation of the resident's representative being informed of the baseline care plan. During an interview on 7/12/24 at 10:24 a.m., the Social Service Designee (SSD) indicated when a new admission was admitted , the facility would have a 72 hour care plan with the family to go over the baseline care plan. During an interview on 7/12/24 at 11:44 a.m., the SSD indicated the clinical record lacked documentation of the 72 hour care plan meeting with family. On 7/12/24 at 11:59 a.m., the Regional Operational Support provided the the facility policy, Resident/Family Participation - Assessment/Person Centered Care Plans, revision date of 4/2017, and indicated it was the policy currently being used. A review of the policy indicated, .5. After baseline care plan is developed a care conference will be held with the resident/representative within 72 hours of admission .

Based on observation, interview, and record review, the facility failed to provide services to prevent the development of a pressure sore for 1 of 3 residents reviewed for pressure sores. This deficient practice resulted in Resident 73 acquiring a Stage 3 (full thickness skin loss) pressure area. Findings Include: Resident 73's clinical record was reviewed on 7/9/17 at 3:15 p.m. On 3/1/17, Resident 73 was admitted to the facility with [DIAGNOSES REDACTED]. An Admission Braden Scale (for predication of Pressure Sore Risk), dated 3/1/17, was observed with a score of 18, indicated at risk. Admission skin assessment, dated 3/1/17, indicated no obvious problems. No pressure or open areas on the skin were noted. On 07/11/2017 at 1:51:42 p.m., the Registered Nurse (RN) wound nurse was observed performing the treatment and dressing change on the plantar (sole) area on the bottom of the left foot. The wound nurse indicated the area began as a blister that was caused by rubbing of his splints, decreased feeling in the lower extremities, and the area not being caught until it popped. Progress notes dated 3/1/17 through 5/6/17, indicated a Physician's Progress note, dated 3/1/17, Neuro RLE (right lower extremity) foot drop b/l (bi-lateral) [MEDICAL CONDITION] wearing splints limited motor There were no documented nurse's notes to indicate nursing staff were aware of the resident wearing splints nor assessment of the skin due to splint usage. On 7/12/17 at 10:40 a.m., the DON provided a document titled Treatment Administration History, dated 5/1/17 - 5/31/17. Documentation indicated, skin on 5/4/17 intact, signed by LPN 1. A nursing progress note, dated 5/5/17, indicated .resident has an open blister to the ball of his left foot. He states that he thinks it's from his shoe rubbing. A Pressure Wound Observation Report, dated 5/5/17 indicated, Stage 3 wound, measurements of 3.0 cm x 2.4 cm x 0.2 cm, open blister to the bottom of the foot; serosanguinous (thin, watery, pale red or pink) drainage, redness to the surrounding tissue. A physician's orders [REDACTED]. [REDACTED]. The Minimum Data Set (MDS) Quarterly Assessment, dated 6/8/17, indicated; Brief Interview for Mental Status (BIMS) score 15 (indicating cognitively intact) and independent for self-performance of locomotion with no support required. Functional Status: required supervision for bed mobility, transfers, dressing, toileting, and personal hygiene; all with one person physical support. Skin Condition: Risk of Pressure Ulcers: (1) indicating Yes the resident is at risk of developing pressure ulcers. 1 Stage 2 (partial thickness skin loss) pressure ulcer, 1 Stage 3 (full thickness tissue loss) pressure ulcer measuring 1.2 cm x 0.5 cm x 0.1 cm. A care plan, dated 3/14/17 and last reviewed/revised 7/12/17, indicated Problem: Res (resident) is at risk for pressure ulcers due to decreased mobility. Goal: Resident will not develop pressure ulcers thru next review. Interventions: Notify MD (medical doctor) of any skin issues when they arise. PDR (pressure reducing devise) to bed. Treatment per order. Turn and reposition every 2 hours and prn (as needed or when necessary). Weekly skin assessment by licensed nurse. A care plan, dated 5/8/17 and last revised 7/6/17, indicated Problem: Res (resident) has an open area on the pad of his left foot. Goal: Open area to pad on left foot will be resolved within the next 30 days. Interventions: Encourage res to elevate foot as much as possible. Encourage to not wear shoe on left foot as he has metal inserts which caused open area. Notify MD as needed. Treatment as ordered. Weekly assessments with documentation. A care plan, dated 5/9/17 and last revised 7/6/17, indicated Problem: Resident has Stage 3 on left plantar part of foot proximal to great toe. Goal: Pressure Ulcer will be healed without complications through the next review date. Interventions: Assist with turning and repositioning. Notify MD if ulcer worsens or does not improve. Obtain labs per MD order and report findings to MD. Pericare after each incontinent episode. PRD (pressure reduction device) to bed and chair. Treatment per MD order. Weekly skin assessments by licensed staff member and document on appropriate wound observation. On 7/7/17 at 10:33 a.m., the DON indicated the resident had an in-house acquired Stage 3 pressure ulcer on the plantar side of the left foot. The pressure ulcer was a result of his brace rubbing when he walks. On 7/12/17 at 8:37 a.m., Resident 73 indicated he had a full body check when he first arrived for admission to the facility, and staff had not done another one until after the wound was found on his foot. It was a visitor who noticed blood on his sock on the bottom of his foot and this is how the wound was found. On 7/12/19 at 10:06 a.m., the Regional Support Nurse provided a policy titled Skin Care and Wound Management Program, dated 6/17/17, and indicated the policy was the one currently being used by the facility. The policy indicated, Assessment: Identifying Residents at Risk for Skin Breakdown. Pre-Admission: Attempt to collect key information that may indicate a person is at risk for developing pressure ulcers . Planning: Care Planning. Develop an Individualized Skin Care Plan: Based on the resident's assessment, the Interdisciplinary Team develops an individualized care plan to prevent or treat skin breakdown. Include mobility, activity, moisture, nutrition, sensation, and friction On 7/12/17 at 11:19 a.m., MDS nurse indicated she was not sure what the resident utilized to support his foot, although she thought it was a special shoe. Her review of the records for Resident 73 and her own documentation, she could find no documentation regarding a brace or shoe splints. Review of Resident 73's care plan per the MDS nurse indicated the shoe splints/AFO had not been care planned. On 07/12/2017 at 11:28 a.m., the Regional Director/Occupational Therapist indicated the resident was admitted to the facility with 2 Ankle Foot Orthosis (AFO) orthotics for both of his feet. During therapy the resident was ordered new carbon based orthotics as his older AFO orthotics were worn and the new would help his toes and foot to clear better when ambulating. The therapist indicated he did not keep manufacture's information on the orthotics as the information was usually tossed as the therapy staff know how to use them. On 7/12/17 at 12:14 p.m. the Regional Support Nurse indicated it is not standard to have a physician's orders [REDACTED]. She indicated typically the resident would have an order to check the skin so the nurse would know, and the physician knew of the splint as it was documented in the physician's progress notes, however he did not write an order to check the skin for Resident 73. Ankle Foot Orthosis (AFO) Instructions, as provided by the manufacture Infinite Technologies orthotics and prosthetics, indicated Useful Notes: A clean sock must be worn under your orthosis . Cotton socks are recommended .Low top, lace-up athletic style shoes with a flat bottom work best. Remove the insole when possible to create more room for the orthosis. Skin Checks: Carefully check the foot and leg for pressure areas after each wear period. Remove the orthosis and sock. Note any redness or irritation, particularly over bony prominences. The redness should disappear after 30-40 minutes. If redness persists, or is accompanied by skin breakdown, fluid discharge or swelling, call the office for instructions and a follow-up appointment 3.1-40(a)(1)

Based on observation, interview, and record review, the facility failed to ensure a resident could alter the temperature of his room for his comfort as the facility's resident rights policy indicated in that a metal bar was screwed into the control panel of the heating/air conditioning unit covering the thermostat and the resident could not change the temperature of his room which resulted in mental anguish due to the resident always being cold for 1 of 40 observed residents during Stage 1. (Resident #29). Findings include: On 4/27/2015 at 11:36 a.m., during the Stage 1 interview with Resident #29, he indicated he had difficulty with the temperature in the building in that he was always cold in his bedroom. Resident #29 became upset and indicated the facility had placed a metal bar across his room thermostat, because he used to much heat which forced his room mates out. Resident #29 could not recall the name of the person who ordered the metal bar, but indicated the current maintenance man put the metal bar in place 2 months ago. On 4/27/2015 at 11:36 a.m., an observation of Resident #29's thermostat revealed a metal bar screwed into the heating/air conditioning unit which prevented Resident #29 from adjusting his room's temperature by himself. The metal bar was placed at an angle which, if on a clock, would be approximately 10:00 p.m. to 5:00 p.m. The clinical record was reviewed for Resident #29 on 4/30/2015 at 11:05 a.m. [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment, completed on 4/6/2015, indicated a Brief Interview for Mental Status (BIMS) score of 9 (when 8-15 was interviewable and cognitively intact), and assessed Resident #29's functional status as being independent when walking in room. On 4/29/2015 at 2:22 p.m., during an interview with the Maintenance Director (MD), the question was asked why a metal bar was across the thermostat in Resident #29's room. The MD walked into Resident #29's room and was observed to immediately kneel down on his knees, obtained a screwdriver from his pocket and remove the metal bar. The MD denied any knowledge of putting the metal bar over the thermostat during which Resident #29 became upset and indicated to the MD that he had been the one who did put the bar there. On 4/29/2015 at 3:05 p.m., with the Administrator present, Resident #29's thermostat was observed with two screw holes where the metal bar had previously been. The Administrator denied knowledge of the metal bar. Resident #29 indicated to the Administrator that he is comfortable now and is happy to be able to change the temperature himself. The Administrator indicated the thermostat should not have been like that and he cannot believe anyone would do that. On 4/30/2015 at 10:40 a.m., an interview with Certified Nursing Assistant (CNA #2) indicated Resident #29 is constantly cold. CNA #2 indicated she is constantly bringing the resident extra blankets and he always wears his coat. Sometimes she brings him a heating pad. CNA #2 denied knowledge of the metal bar across the thermostat. On 4/30/2015 at 11:04 a.m., License Practical Nurse (LPN #2) indicated Resident #29 always complains of being cold and wears his coat a lot. LPN #2 indicated she brings him more blankets and turns up his heat when he complains of being cold. When asked how Resident #29's heat can be turned up with a metal bar in place, LPN #2 denied knowledge of the metal bar. On 4/30/2015 at 10:55 a.m., during a follow up interview with Resident #29, he indicated the metal bar across his thermostat made him feel like a slave. He indicated he had no power and has been cold 95 percent of the time since he was admitted to the facility on [DATE]. Resident #29 also indicated he believed being cold had affected his body and had caused his health to deteriorate. On 5/01/2015 at 10:22 a.m., the Social Service Director (SSD) indicated the metal bar was put on by the current MD sometime in March. The metal bar was ordered by the former Administrator, because the room would get so hot it could be felt out in the hallway. The SSD indicated she was told by the current MD the temperature could still be adjusted to between 84 and 72 degrees however, Resident #29 could not see the thermostat and was not able to move freely around in his room in order to turn the heat up. Based on observation and record review Resident #29 was observed to propel freely in a wheelchair up and down hallway and the quarterly MDS completed on 4//6/2015, assessed Resident #29's functional status as being independent when walking in room. On 5/1/2015 at 10:38 a.m., a second interview with the MD indicated he had no knowledge of the metal bar being put across the thermostat and if he placed it there he doesn't remember doing so. He indicated no work order had been initiated for the placement of the metal bar and he did not have temperature logs of where the room temperature had been measured in Resident #29's room. On 5/1/2015 at 2:27 p.m., the Administrator provided "Resident Rights" policy, undated, and indicated it was the policy currently used by the facility. The policy indicated, " ... A resident has the right to ... 3. make choices about aspects of his or her life in the facility that are significant to the resident. ..." 3.1-3(u)(3)

Based on interview and record review, the facility failed to ensure residents at risk of falls were provided with supervision to prevent falls, in that Resident G's alarm did not ring when she stood from the bed, resulting in a fall and hip fracture, Resident W had repeated falls without an increase in supervision, resulting in a fall with aleft fhumeral head (shoulder) fracture, for 2 of 3 residents reviewed for falls in the sample of 4. Resident G and W Findings include 1. The clinical record for Resident G was reviewed on 5/5/11 at 9:45 A.M. The record indicated Resident G had [DIAGNOSES REDACTED]. The MDS (minimum data set) assessment, dated 1/3/11, indicated Resident G had severe cognitive impairement. Resident G required extensive assistance of one with bed mobility and extensive assistance of two with transfers and toilet use. Resident G had no falls since the prior assessment. A care plan, dated 6/22/10, reviewed 3/31/11 and 4/6/11, 4/7/11, indicated a problem of "I am at risk for falls r/t (related to) poor safety awareness. I have been known to roll or climb out of bed and crawl on the floor. I have osteopenia, osteoarthritis and osteoporosis." The interventions were "I have a fall risk assessment, upon admission, quarterly and PRN (as needed) thereafter. I have assist of 2 for transfers with hoyer (lift) from surface to surface. Pharmacy may review my medications that increase potential for falls. I have a bed and chair alarm in place. I have been instructed to call for help if I need assitance. I have a high-low bed. I have a mat on the floor. 1-21-11 I have a perimeter mattress." The Fall Risk Assessment, dated 1/3/11, indicated a score of 11. The form indicated "Total Score above 10 represents HIGH RISK." The Nurses Notes, dated 3/8/11 at 12:45 A.M., indicated "Alarm sounded CNA ran to residents room and found her laying on Rt (right) side on her mat next to bed. When ask what she was doing stated I don't know...Able to move all extremities normal for herself. Hematoma (raised) over Rt brow area. Neuro checks started..." The Nurses Notes, dated 3/8/11 at 1:00 A.M., indicated "Returned to bed for further assessment. No c/o (complaints of) discomfort voiced..." The Nurses Notes, dated 3/8/11 at 3:00 A.M., indicated "...Intervention of placing foam over bed frame added to care plan. DON (Director of Nursing) aware of intervention." The 6/20/10 fall care plan was updated on 3/8/11 to include the intervention of "My bed frame is covered with foam." The Nurses Notes, dated 3/31/11 at 12:45 A.M., indicated "Writer called to res (resident) rm (room) by CNA. Res laying on R (right) side on blue mat. Res holding L (left) thigh area with bil (bilateral) hands. Writer noted L upper leg to be visibly out of proper alignment with inner rotation noted. No visible s/s (signs or symptoms) trauma to L left noted...Res moving L leg staff propped L leg with pillows et (and) staff member holding leg in proper alignment...Res alert et (and) confused as per res usual. Res c/o(complained of) mod (moderate) pain to L leg. No further injuries. Writer asked res what she was doing res states I was trying to get something to drink. Writer noted res water cup et juice cup tipped over et spilled on top of bedside cabinet. Writer explained to res that she will remain on blue mat with L leg being stabilized by staff pending transport to ER (emergency room )..." The facility lacked evidence to indicate the alarm was intact and functioning at the time of the fall. The Nurses Notes, dated 3/31/11 at 5:30 A.M., indicated "(Name) Hosp (hospital) called to report L femur fx (fracture) just below old hip fx. Will splint and place in traction..." In an interview with the Director of Nursing, on 5/5/11 at 12:25 P.M., she indicated Resident G had been on hourly checks for about a year. She indicated it was not documented to check Resident G hourly in the record, the staff just knew to do it. In an interview with the Director of Nursing and Administrator, on 5/5/11 at 1:30 P.M., they indicated Resident G's bed alarm did not sound prior to the fall on 3/31/11. 2. The clinical record for Resident W was reviewed on 5/5/11 at 10:45 A.M. The record indicated Resident W had [DIAGNOSES REDACTED]. The MDS (minimum data set) assessment, dated 4/11/11, indicated Resident W had severe cognitive impairment. Resident W required limited assistance of one with bed mobility and transfers, and extensive assistance of one with ambulation and toilet use. The MDS indicated Resident W had fallen since admission to the facility. The resident was documented to have entered the facility on 4/4/11. A fall risk assessment, dated 4/4/11, indicated a score of 11. The form indicated "Total score above 10 represents HIGH RISK." The Nurses Notes, dated 4/5/11 at 3:50 A.M., indicated "Alarm sounded in Resident's room upon entering his room this nurse saw res sitting on the side of his bed attempted to get up et (and) slid down from bed to floor. This nurse ran et(and) helped res down to dry floor. No injuries noted upon assessment...Blue mat next to bed. Res requested to get out of his room. Res was helped to his chair and is in nurses station with staff member keeping him company. Alarm is in place et activated..." A fall risk assessment, dated 4/9/11, indicated a score of 11. The form indicated "Total score above 10 represents HIGH RISK." A Care plan, dated 4/13/11, indicated a problem of "I am at risk for falls due to my medications and lack of safety awareness." The interventions were "I have a fall risk assessment upon admission, quarterly and PRN (as needed) thereafter. I am assist with ADLs (activities of daily living) and transfers. Staff uses a gait belt to enhance safety during transfers. Please keep walkways and paths free from clutter and obstructions. Please offer frequent rest periods during care and activities to lessen fatigue. Pharmacy may review my medications which may increase potential for falls. I have been instructed to call for help if I need assistance. I have a bed and chair alarm to alert staff when I am attempting to transfer myself." A fall risk assessment, dated 4/14/11, indicated a score of 12. The form indicated "Total score above 10 represents HIGH RISK." The Nurses Notes, dated 4/21/11 at 5:30 A.M., indicated "Alarm sounding, CNA entered rm (room) Resident was sitting on toilet then raising up stubbed toe on floor and fell to right side. Summoned nurse. This nurse entered rm. Active ROM (range of motion) done to all extremities. No bruising noted but c/o (complains of) R (right) side hurting when assisted up...Resident assisted back to bed x (times) 1. Resident was assisted off floor x 2." The Nurses Notes, dated 4/21/11 at 6:50 A.M., indicated "New interventions: Empty cath (catheter) bag Q (every) 4 hours (minimum); toileting when awake, mat on floor by bed, CXR (chest x-ray)..." The fall care plan, dated 4/13/11, was updated on 4/21/11 to include the intervention of "Take to BR Q 2 hours when awake. Floor mat." The Nurses Notes, dated 4/22/11 at 11:30 P.M., indicated "C/T (continues to) toilet res Q (every) 2 has sounded bed alarm x 1 staff immediately entered room res standing beside bed. Staff assisted to BR (bath room) then back to bed res states I'm tired." The Nurses Notes, dated 4/23/11 at 12:30 A.M., indicated "res sounded bed alarm res standing unassisted by bed staff assisted to BR redirected use of call light states understanding but C/T (continues to) not utilize call light. Confused denies c/o's pain. Medicated with routine Tylenol at this time, fluids offered et accepted." The Nurses Notes, dated 4/23/11 at 3:15 A.M., indicated "Bed alarm sounding this nurse entered res room et observed res lying on floor mat beside bed on stomach states I fell going to the bathroom...c/o's L (left) shoulder pain. Decreased ROM et unable to raise L arm up. ii (two) person assist to stand per waist et assisted to bed slight swelling noted at L shoulder..." The Nurses Notes, dated 4/23/11 at 3:30 A.M., indicated "Notified Dr (name) with new order received to send to (name) ED (emergency department) via ambulance to eval (evaluate) et tx (treat) L shoulder pain." The Emergency Department Chart, dated 4/23/11, indicated "...X ray of the left humeral head shows an acute fracture..." The 4/13/11 fall care plan was updated on 4/23/11 to include the intervention of "I have 1/2 hour checks." The 4/13/11 fall care plan was updated on 4/27/11 to include the intervention of "My room has been moved closer to nurses station." This federal tag relates to complaint IN 776. 3.1-45(a)(2)