Every finding on record at Robin Run Health Center

Based on observation, interview, and record review, the facility failed to maintain a clean, comfortable, homelike environment for 3 of 3 hallways observed for environment. Findings include:On 8/12/26 at 10:10 a.m., a general tour of the building was conducted and the following was observed: A dead beetle on the handrail outside of room [ROOM NUMBER]. A dead beetle on the handrail outside of room [ROOM NUMBER]. A dead beetle on the handrail outside of room [ROOM NUMBER]. Active cobwebs on the push handles of all three main exit doors at the end of each three residential hallways. A hand sanitizer dispenser near the nurses station was observed with no catch tray, so that drippings fell onto the floor. A dark dried puddle of sanitizer was observed on the floor which was sticky and had debris stuck in it. Multiple ceiling tiles on all three residents' hallways were observed to be mismatched, displaced in the metal brackets causing gaps in the ceiling and many showed signs of water damage. Those included, but were not limited to: A ceiling tile outside of room [ROOM NUMBER], which had large brown stains and some small back dots. A ceiling tile, just inside room [ROOM NUMBER] showed evidence of brown water rings, and several ceiling tiles between rooms 22-25 showed evidence of water damage. Handrails throughout all three residents' hallways were observed to have cobwebs in corners angles, sanitizer drip stains, and various debris and dead bugs caught on the skirt boards. The privacy curtain in room [ROOM NUMBER] had a large brown stain on it. The walls throughout each residents' hallways were observed with scratched, splash stains, drip stains, and ring stains from plate covers being left on handrails. The spa/shower room was observed. There was a large puddle of standing water near a platform wheelchair scale. There were black stains and wheelchair tracks on the floor. The scale was scratched, stained and had stains/debris on it. There was a caution wet floor sign, but it had collapsed and fallen into the puddle of water. There was a toilet that appeared to have been badly scratched and was covered in black streaks with dust and debris. There was a reclining shower commode chair which had been left in a shower stall, with evidence of uncleaned fecal matter around the seat. The threshold covering for one of the shower room entrance doors was missing showing the old glue and other unidentified dirt/debris. The main dining room was observed. There were countless dead bugs, cobwebs, old food crumbs/debris on all the windowsills. There were dead and live weeds growing in-between the glass panel of the windows and screens. The dining room exit door was observed to have large cobwebs on the door push handle as well as in the bottom corner with large quantities of debris stuck in them. During a confidential interview with a Resident, it was indicated, sometimes they did not want to take a shower because the shower room was so filthy and it was probably where most of the gnats were coming from. During a confidential interview, a resident was observed eating breakfast in the main dining room, near a window. They indicated they did not like seeing all the cobwebs and dead bugs and weeds in the windowsills, especially while trying to eat.During a confidential interview, a visiting family member indicated, there were a lot of gnats and flies in the facility, even more so than would be considered normal for this time of year. On 8/12/26 at 1:00 p.m., an environmental tour was conducted with the Housekeeping Supervisor. The above identified areas of concern were observed with the Housekeeping Supervisor. He indicated these were all issues that needed to be addressed and he would discuss them with his staff. On 8/13/26 at 7:42 a.m., the Administrator provided a copy of current but undated facility policy titled, Environment: Clean, Comfortable, and Homelike Policy. The policy indicated, The facility will maintain a physical environment that is sanitary, safe, comfortable, functional, and as homelike as possible. Residents will be afforded opportunities to personalize their living spaces and participate in decisions affecting their environment. Cleanliness and Sanitation: Resident rooms, bathrooms, common areas, and dining areas will be cleaned routinely according to facility schedules. Equipment and furnishings will be maintained in a clean and sanitary condition. Housekeeping staff will promptly address spills, odors, and environmental concerns. Safety: Hallways, resident rooms, and common areas will remain free from clutter and hazards. Environmental rounds will be conducted routinely to identify and correct safety concerns. 410 IAC (Indiana Administrative Code) 16.2-3.1-19(f)

Based on observation, interview, and record review, the facility failed to ensure a resident (Resident D) who had a history of recent falls and was a high fall risk, received person-centered and individualized interventions to prevent repeated falls after her admission for 1 of 1 resident reviewed for accidents. Findings include:On 8/12/26 at 10:00 a.m., Resident D was observed in the main T.V. lounge near the nurses' station with a group of her peers. On 8/12/26 at 11:34 a.m., during a follow up environmental observation, Resident D was observed laying on the floor in her room. She was positioned on her right side with her left leg pulled to her chest, and a blanket balled up as a pillow placed under her head. Her eyes were closed, and she breathed slow and steady. She appeared to be asleep. Her wheelchair was positioned out of reach from her bed and the call light was wrapped around the mobility bar on the far side of the bed, out of site and out of reach. There were no staff present on the hallway, and after three calls, Nurse, to a staff member who was seated down the hall at the nurses' station, Qualified Medication Aide (QMA) 4 walked down to Resident D's room. Registered Nurse (RN) 3 and Certified Nursing Aide (CNA) 5 arrived to the room and RN 3 immediately began to assess the resident. Her vital signs were checked and within normal limits, she gave short yes/no answers or nodded and pointed to indicate what she wanted. After it was determined safe to move Resident D, a gait belt was placed around her waist, and the three nursing staff assisted her off the floor and made her comfortable in bed. As Resident D was being assessed and assisted back to bed, several members of her family arrived and also observed her on the floor. During a confidential interview, her family indicated they had just completed a care plan meeting where concerns about her recent falls had been discussed, so they were very upset and disappointed to find her on the floor. The family indicated this was at least the 4th fall she had sustained in the short time she had been at the facility. The family indicated they had been assured Resident D would be moved closer to the nurses' station, or perhaps be transferred to the secured memory care unit for more routine and closer supervision. The family indicated she was not supposed to be alone in her room because her room was so far away from the nurses' station, she did not have a roommate to help look out for her, and she had dementia and was unable to understand how to use the call light. During an interview on 8/12/26 at 12:20 p.m., RN 3 indicated the Nurse Practitioner (NP) had conducted virtual rounds earlier that morning with the assistance of a Medical Assistant. The facility staff requested that the MA bring Resident D back to the nurses' station after her NP visit because she required very close supervision. The MA had not brought her back to the nurses' station, but staff had also not gone back to her room to check on her. During an interview on 8/12/26 at 12:25 p.m., CNA 5 indicated Resident D should never be left in her room alone, because she always tried to stand up, but couldn't so she would slip down to the floor or fall. On 8/12/26 at 12:30 p.m., Resident D's record was reviewed. She admitted to the facility on [DATE] and had diagnoses which included, but were not limited to, repeated falls, dementia, and muscle weakness. She admitted after a recent hospital stay, and a corresponding hospital Discharge summary, dated [DATE] which indicated, .concern for recent falls. patient was found by her sister next to her couch. this is the third time and as many days following. She never knows how she falls. She even fell down the stairs a few days ago. A nursing progress note dated 8/3/26 at 6:34 a.m., indicated Resident D was found on the floor of her room and reported that she slid off the bed, but had sustained no injuries. An interdisciplinary team (IDT) progress note, dated 8/3/26 at 8:07 a.m., attributed the fall to a recent lab result and indication for a urinary tract infection for which antibiotics had already been started. No new non-pharmacological interventions were discussed/implemented. An IDT progress note, dated 8/9/26 at 4:24 p.m., indicated Resident D experienced a fall. She appeared to have slid from the recliner rather than experienced a true loss of balance during ambulation. Current interventions will focus on increased supervision. A nursing progress note, dated 8/11/26 at 5:43 p.m., Resident D was found on the floor beside her bed as she had tried to get up and slid to the floor. No apparent injuries were noted. A nursing progress note, dated 8/12/26 at 8:51 a.m., indicated, .resident had another fall trying to self-transfer. The record lacked documentation fall follow up for the 8/11/26 fall and no fall follow up of the first a.m. fall on 8/12/26 leading up to the unwitnessed fall observed as indicated above. Resident D had an admission Fall Risk Assessment, dated 8/3/26, which indicated she was a high risk for falls. Resident D's comprehensive care plans were reviewed. A care plan initiated on 8/3/26 indicated she was at risk for falls related to her diagnoses. There were nine general interventions all dated 8/3/26, and one interventions dated 8/9/26 which included but were not limited to, keep call light within reach. The care plan lacked revision to include person-centered interventions to address the family's preference/discussion to move her to a room closer to the nurses' station. The care plan lacked revision to detail who/how/when increased supervision was to take place as indicated in the IDT note from 8/9/26. The care plan lacked revision to ensure Resident D was not left alone in her room. On 8/13/26 at 7:40 a.m., the Administrator provided a copy of current, but undated facility policy titled, Fall Management. The policy indicated, The facility is committed to identifying residents at risk for falls, implementing individualized interventions, responding appropriately to fall incidents, and continually evaluating the effectiveness of fall prevention strategies. Conduct a Root Cause Analysis Within 24 Hours. Review: Fall location, Activity at time of fall, Footwear, Environment, Medications, Acute illness, Orthostatic hypotension, Toileting needs, Equipment use, Staffing factors. The goal is to determine why the fall occurred so interventions can be targeted appropriately. Update the Care Plan: Avoid generic interventions such as monitor for falls, Instead implement specific interventions such as: Scheduled toileting, Therapy referral, Medication review, Low bed, Sensor devices, Mobility program, Environmental modifications, Increased supervision during high-risk periods. Care plan revisions should reflect findings from the post-fall investigation. 410 IAC (Indiana Administrative Code) 16.2-3.1-45(a)

Based on observation and interview, the facility failed to ensure a resident with a full code and a change in condition was closely monitored and treated timely; and failed to ensure effective communication with hospice resulting in the resident having a delay in treatment and death for 1 of 3 residents reviewed for death (Resident B). The Immediate Jeopardy began [DATE], when a resident with a full code who had been alert and participating in her care, had an overall change of condition, the staff were unable to obtain labs, and the family had requested the resident be sent to the ER. The facility called Hospice and Hospice convinced the family to not send the resident to the ER. No Hospice assessment, admission, or contract had been obtained at that time. On [DATE] Hospice admitted the resident as a full code and ordered comfort medications. Comfort medications were not administered as ordered. On [DATE] the resident had a hard extended abdomen. The family was at bedside and concerned about the resident's condition. On [DATE] at 4:33 a.m., the resident had increased respirations, secretions, gurgling, and continued extended abdomen with no bowel movement since [DATE]. On [DATE] at 7:41 a.m., the facility called Hospice and indicated the resident was actively dying and a Hospice nurse was requested. On [DATE] at 9 a.m., the resident was found without respirations or pulse. The family was not notified of the resident's decline overnight on [DATE] to [DATE]. Vital signs were not obtained every 4 hours or on [DATE]. The Administrator (ADM), [NAME] President of Clinical Service (VPCS) via phone, and Regional Nurse were notified of the Immediate Jeopardy on [DATE] at 12:36 p.m. The Immediate Jeopardy was removed on [DATE], but noncompliance remained at a lower scope and severity of isolated, no actual harm, with potential for more than minimal harm that was not Immediate Jeopardy. Findings include: An anonymous concern during the survey process indicated Resident B died on [DATE] when staff failed to initiate cardiopulmonary resuscitation (CPR) on her, even though she was a resident with full code orders. Resident B's clinical record was reviewed on [DATE] at 11:15 a.m. Resident B was admitted from an acute care hospital to the facility on [DATE] with diagnoses that included, but not limited to, schizoaffective disorder of the bipolar type (altered cognitive status with symptoms that included delirium, hallucinations, and behavioral symptoms), malignant neoplasm (cancer) of the pancreas, secondary malignant neoplasms of the liver and intrahepatic bile duct (the network of small, branching tubes located inside the liver), and constipation. A physician's order, dated [DATE], indicated the resident was full code (if your heart stops beating or you stop breathing, the medical team will attempt all possible life-saving interventions). The order was discontinued on [DATE], after the resident died. A physician's order, dated [DATE], indicated Glycolax Powder give 15 grams in 8 ounces of fluid by mouth every 24 hours as needed for constipation. An Indiana Physician Orders for Scope of Treatment (POST) form for Resident B, dated [DATE], indicated if the resident had no pulse and was not breathing, she wanted someone to attempt resuscitation/CPR. The treatment goal indicated the resident wanted full interventions including life support measures in the intensive care unit. In addition to care described in the Comfort Measures and Limited Additional Interventions sections, the resident wanted to use intubation, advanced airway interventions, and mechanical ventilation as needed. She wanted to transfer to the hospital and/or intensive care unit if indicated to meet medical needs. She wanted to use antibiotics consistent with treatment goals. Artificially administered nutrition would be decided at time of need. There was no documentation of optional additional orders. A clinical admission note, dated [DATE], indicated Resident B was alert and oriented to person, place, and time. The skin was warm and pink, and no edema was present. The abdomen was flat, non-tender, bowel sounds were present in all 4 quadrants, and the resident denied nausea, vomiting, diarrhea, constipation or bowel incontinence. A Dehydration Risk Evaluation, dated [DATE], indicated Resident B was not at risk for dehydration with a score of 2 on the evaluation. An admission Minimum Data Set (MDS) assessment, completed on [DATE], indicated Resident B had moderately impaired cognition. She required supervision or touch assistance for eating, dressing her upper body, toileting hygiene, and propelling her manual wheelchair (WC) up to 50 feet. The resident was independent with bed mobility and partial/moderate assistance for transfers. The resident was occasionally incontinent of bladder, frequently incontinent of bowel, and had no constipation present. The resident had no symptoms of swallowing difficulties and had a weight gain of 5% or more in the past 6 months. Resident B and a family member participated in the assessment and goal setting. A care plan, dated [DATE], indicated Resident B had a full code status and the goal was to honor the resident's wishes of having a full code status. Interventions included administering CPR and following instructions on the POST form. A progress note, dated [DATE] at 4:14 p.m., indicated Resident B was admitted to the facility on [DATE] and resided on the secure memory care unit. The resident's oral intakes were documented as 75 to100 percent (%), and she required 1-person for the completion of activities of daily living (ADL's - bathing, dressing, eating, toilet use) and transfers. A Care Plan Conference Summary, dated [DATE], indicated Resident B participated in activities, consumed a regular diet, had no changes in her skin, and she had no medication issues. The resident made a special request to include fruits and salad at lunch and dinner. The advanced directives/code status was full code. The family stated they would like to transfer the resident to another facility with a private room. Resident B, the resident's guardian, a family member, and 4 staff members were documented/signed as being present. A late entry Risk Meeting Notes, effective, date [DATE] at 6:30 p.m., indicated Resident B continued to receive a no added salt (NAS) regular texture diet with thin liquids. She had bilateral lower extremity (BLE) edema unchanged from her admission status. The legal guardian/family member noted slight yellowing of the resident's eyes on [DATE]. Nurse Practitioner (NP) 4 was made aware of the guardian's concerns with the yellowing of the eyes and LE edema. NP 4 spoke with the guardian about care goals and options, and if the guardian did not want chemotherapy or radiation there was little that could be done beyond supportive care to ensure comfort. The nurse and NP 4 both spoke to the guardian about hospice as a goal of care for comfort and supportive care. NP 4 would continue to follow Resident B weekly. A progress notes by NP 4, dated [DATE], indicated she had discussed oncology with the guardian, who decided she did not want to pursue aggressive treatment. NP 4 discussed referring hospice and providing comfort measures only, and the guardian indicated she was willing to consider and discuss with the family. The resident was currently full code. Labs were attempted times 2 without success. Family discussed going to the ER for evaluation versus hospice. The plan included, cancel labs and KUB secondary to undergoing hospice and unable to get labs x 2 secondary to probable dehydration. Signed by NP 4 on [DATE] at 2:57 p.m. A late entry progress by Registered Nurse (RN) 13, created on [DATE] 6:51 a.m., effective date [DATE] at 4:00 p.m., indicated Resident B was observed to be weak on initial assessment, but her vital signs were within normal limits. The physician was notified and gave instructions to obtain labs and monitor her vital signs every 4 hours. The resident was observed with improved strength later in the shift. A progress note, dated [DATE] at 6:27 p.m., indicated Resident B's guardian requested that the resident be sent to the emergency room (ER) for evaluation and treatment related to the guardian's concerns for dehydration. The resident had an overall change of condition since her admission and was displaying a new baseline. The nurse called the hospice provider to inform them of the sister's wishes. A hospice representative provided education including pros/cons of sending the resident to the ER, and the guardian was in agreeance with not sending her to the ER at this time. NP 4 was informed of the situation. A progress notes by NP 4, dated [DATE], indicated the NP was informed by nursing that hospice was coming this date to evaluate the resident for admission to comfort care. Resident 4's code status was currently full code. Signed by NP 4 on [DATE] at 3:06 p.m. A progress note, dated [DATE] at 12:36 p.m., indicated Resident B was admitted to a local hospice with a diagnosis of colon cancer. New orders were received to give lorazepam (an antianxiety) 0.5 milligrams (mg) one tab every 4 hours as needed or wanted (prn), morphine (opioid) 100 mg/5 milliliters (ml) give 0.25 ml every 4 hours prn for pain and dyspnea (shortness of breath), bisacodyl (laxative) 10 mg suppository one a day prn for constipation, acetaminophen (pain reliever) 650 mg suppository one every 6 hours for pain or fever, and hyoscyamine (a medication or substance used to relax muscles) 0.125 mg sublingual every 4 hours prn. The resident's guardian was present during the hospice admission. A progress note, dated [DATE] at 9:33 p.m., indicated Resident B's abdomen remained hard and distended and she still had not had a bowel movement. The family was at the bedside and concerned about the ineffectiveness of the last medication given to help with the bowel. Hospice was notified of the situation. A progress note, dated [DATE] at 10:41 p.m., indicated hospice responded to prior message and gave an order for a Fleet enema (saline laxative) times 1. A progress note, dated [DATE] at 4:43 a.m., indicated a change in condition was observed overnight with increased respirations and secretions, and the resident's abdomen remained distended without having a bowel movement during the shift. Hospice was notified and indicated they would be sending a nurse to the facility to evaluate the resident. A Medication Administration Note, dated [DATE] at 6:16 a.m., indicated Fleet Naturals Cleansing Enema 1 unit was ordered to be inserted until [DATE] at 11:59 p.m., was unavailable for administration. A progress note, dated [DATE] at 7:50 a.m., indicated Licensed Practical Nurse (LPN) 7 called the pharmacy for an update on morphine arrival. A pharmacy tech stated they had not received a script for the medication, and to follow up with hospice. A progress note, dated [DATE] at 8:07 a.m., indicated LPN 7 called the hospice group and requested a hospice nurse visit Resident B for further evaluation due to the resident's change in respirations. LPN 7 was told an on-call nurse would be sent to visit the resident. A progress note, dated [DATE] at 9:00 a.m., indicated LPN 7 was called to Resident B's room by Qualified Nursing Assistant (QMA) 10. Resident B's respirations and pulse had ceased. LPN 7 called and notified hospice and received a response that a nurse would be coming to the facility as soon as possible. A progress note, dated [DATE] at 9:30 a.m., indicated a hospice nurse arrived at the facility at 9:20 a.m., and stated she had notified the family of Resident B's passing and had called the funeral home to pick up the remains as ordered. The family was on the way to view the body. During the record review on [DATE], Resident B's clinical record lacked hospice documentation to include a hospice admission consent, hospice assessment, or a hospice plan of care. Resident B's clinical record lacked documentation that comfort medications ordered by hospice that included lorazepam, morphine, acetaminophen suppository or hyoscyamine were received by the facility or administered to the resident as ordered. The record lacked nursing documentation, from [DATE] - [DATE], to support a change in the resident's mental status, oral intake, bowel sounds were assessed, or nursing measures to help prevent dehydration or constipation. There was no documentation to indicate the primary MD/NP or Resident B's guardian had been notified of the resident's change in condition prior to death. Resident B's clinical record lacked documentation that vital signs were monitored every 4 hours per MD instructions. The last documented vital signs included on [DATE] at 7:52 a.m., respirations of 18 per minute and a temperature of 97.4 degrees Fahrenheit. On [DATE] at 7:44 p.m., a pulse of 90 beats per minute and a blood pressure of 92/65. On [DATE] at 7:40 a.m., oxygen saturations were 90% on room air. An Incident/Event form by the ADM, discovery date [DATE] at 11:45 a.m., indicated the alleged occurrence/incident requiring investigation included death of a resident who was a full code status and staff did not perform CPR. Resident had change in condition and hospice was notified and asked to come in to see resident at around 4:43 a.m. Hospice to send nurse to evaluate. At 8:07 a.m., hospice renotified and asked hospice to evaluate resident due to change in respiratory rate. At 9:00 a.m., called to room by CNA no respirations or pulse called hospice, they stated nurse would be there as soon as possible. Hospice nurse arrived at 9:20 a.m., called family, and she called funeral home.Final disposition, resident is deceased and staff will return to work. An Incident/Event Employee Incident/Event Investigation Statement by RN 9, dated [DATE], indicated on [DATE] the nurse came for her shift at 3:00 p.m. and was assigned to the memory care unit. When given report by the 1st shift nurse, she was told the resident had not had a bowel movement [BM] and her abdomen was distended. The 1st shift nurse reported that she had given the resident an ordered suppository. Family stated they were concerned about the resident not having a BM since Saturday. RN 9 contacted hospice regarding the patient's situation. Hospice called back after an hour and gave a verbal order for a Fleet enema. The nurse put the order into the computer but was unable to find a Fleet enema in the pyxis (an automated medication dispensing system). RN 9 passed on the information to night nurse about the patient's situation. An Incident/Event Employee Incident/Event Investigation Statement by QMA 11, dated [DATE], indicated she had checked on the resident about 8:15 a.m. when breakfast came. An Incident/Event Employee Incident/Event Investigation Statement by QMA 10, dated [DATE], indicated she was on her way back from giving another resident her breakfast and when she checked on Resident B realized the resident was not breathing. QMA 10 called the resident's name and she did not respond. QMA 10 immediately ran and called for LPN 7. An Incident/Event Employee Incident/Event Investigation Statement by LPN 7, dated [DATE], indicated she walked into Resident B's room at 7:40 a.m. and the resident's breathing was shallow, her pulse was 50, and 02 sats were 90% on room air. LPN 7 was able to give a scheduled atropine as ordered. LPN 7 called hospice to notify them of the resident's condition. She then called the pharmacy to get an update on when morphine would be delivered and was told they never received a script. LPN 7 called hospice back and notified them of pharmacy not receiving a script. At 8:55 a.m., QMA 10 called her to the resident's room, and the resident was not breathing and no pulse was found. LPN 7 called hospice and the MD to notify them. The resident's record lacked documentation of the vital signs referenced on the incident investigation. A Witness Statement sent via email by LPN 8, dated [DATE], indicated during shift report last night, RN 9 informed her that it was reported that the day nurse noticed Resident B had abdominal distention and the resident had been given a suppository by day shift nurse per hospice orders. RN 9 then stated to LPN 8 that sometime during her shift she was notified the resident had still not had a BM, the abdominal distention was still present, and RN 9 notified hospice who gave orders to give a Fleet enema and monitor. RN 9 stated she couldn't find the Fleet enema, and it was not in emergency drug kit (EDK). LPN 8 stated that it may come with pharmacy when they came around 3:30 - 4:00 a.m., and she would monitor. Resident B was resting. Pharmacy arrived around 4:00 a.m. and did not deliver the resident's medication. LPN 8 noted a change in condition and gave a prn medication for secretions. Around 4:30 a.m., LPN 8 notified hospice that there was no Fleet enema on hand that was previously ordered, of the change in condition, and to get further instructions. Hospice said monitor and a nurse from the company would come to assess the patient's condition further. LPN 8 indicated she followed as ordered made a progress note, by shift change nurse reported to next nurse about patient condition and to be expecting the hospice nurse to come out because she hadn't come before I left. Followed hospice procedures and at no time were orders given for patient to be sent out! An Employee Suspension Pending Investigation Notice for LPN 7, dated [DATE]. The notice indicated the suspension was a result of an alleged or suspected violation or matter regarding misconduct or performance. Details of the current situation indicated Resident B was a full code on hospice. CPR was not performed when she was found expired. LPN 7 had been certified to perform CPR on [DATE]. An Employee Suspension Pending Investigation Notice for LPN 8, dated [DATE]. The notice indicated the suspension was a result of an alleged or suspected violation or matter regarding misconduct or performance. Details of the current situation indicated Resident B had a change of condition. Hospice was notified but had not arrived to the facility. The resident was not sent to the hospital. A typed interview with QMA 10, dated [DATE] at 1:15 p.m., indicated the interview was conducted by the Administrator and [NAME] President of Clinical Services 12 via phone. When the employee was asked what was the appearance of resident upon the employee noting resident without respirations, the QMA stated the resident was cool to touch and noted grayish color around her lips/mouth. Her lips were open, but her teeth were clenched. QMA 10 then notified the nurse on dayshift. A typed interview with RN 7, dated [DATE] at 1:28 p.m., indicated the interview was conducted by the Administrator and [NAME] President of Clinical Services 12 via phone. When asked if the resident showed significant signs of rigor, RN 7 stated the resident's lips were parted but teeth/jaw appeared clenched. Noted gray pallor peri-oral. Resident was cool to touch. At that time, RN 7 notified hospice services. During an interview, on [DATE] at 10:30 a.m., Resident B's guardian indicated she had concerns regarding care for the resident during her stay and questions surrounding her death. The guardian indicated she had requested the facility assist in seeking alternative placement so the resident could have a private room, and although the family had agreed to admit the resident for hospice services, there was no expectation of imminent death, and the resident had remained a full code status. During an interview on [DATE] at 10:45 a.m., the Medical Record Supervisor indicated all medical records were scanned into the electronic medical record system versus being kept in paper-form. There had been no hospice documentation for Resident B available before he called with a request for copies on [DATE]. An admission Hospice Consent document for Resident B indicated, visit date [DATE]. There was no documentation of the resident having been visited by a hospice representative after the initial intake until after she died on [DATE]. The admission note indicated Resident B did not have a DNR order. The POA/Guardian verbalized agreement and understanding of patient rights and responsibilities. Patient code status is a full code with limited interventions. During an interview on [DATE] at 11:40 a.m., the Regional Director for a local hospice indicated, on [DATE], Hospice RN 17 had completed the hospice admission process with Resident B's guardian. Orders given for comfort medications should have been sent directly to the hospice Medical Director who should have given approval and signed off immediately. The orders were then sent to the facility pharmacy who were responsible for timely delivery. Residents were generally seen by a hospice nurse the day following admission to hospice and then scheduled bi-weekly routine visits. If a resident was deemed to be actively dying or imminent death, a nurse was scheduled to visit daily. A facility call after-hours would generate a follow-up by the on-call team for a prn visit, and the expectation was a 3-hour turn-around time. Resident B's hospice consents were signed electronically by the guardian and then a copy should have been sent to the guardian and facility electronically by the following business day. Hospice triage had been called on [DATE] at 7:00 p.m., to report a distended stomach and no relief/bowel movement after having been given a suppository, and responded at 8:30 p.m., with an order for a Fleet enema. Triage was called again on [DATE] at 1:30 a.m., to report Resident B had still not passed stool. On [DATE] at 5:00 a.m., triage logged a call from the facility requesting a nurse visit as the resident was experiencing an increased respiratory rate and gurgling, and Hospice RN 18 was assigned to go for a prn visit. On [DATE] at 7:41 a.m., triage logged a call from the facility stating Resident B was actively dying. Hospice documentation indicated Resident B had passed away around 9:15 a.m. before Hospice RN 18 arrived at the facility. The Regional Director indicated review of Resident B's hospice clinical record and the triage log for hospice indicated, there was no documentation a hospice visit was done from [DATE] when the admission process was completed, until after the resident's death on [DATE]. During an interview on [DATE] at 3:20 p.m., the ADM indicated on [DATE] she had received a call at home to inform her of Resident B's death. An investigation of the resident's death was initiated related to the resident being a full code and CPR was not performed. LPN 7 indicated she had not initiated CPR due to the resident being on hospice services, and her mouth showed the beginning signs of rigor to include her lips were parted, lips were discolored, she had grayish color around her mouth, and her skin was cool. Documentation indicated Resident B had not been observed by staff for approximately 2 hours before she was found dead. LPN 7 and RN 8 had been suspended pending investigation and had not yet returned to the schedule. Resident B's clinical record lacked documentation to support the ADM's statements. During an interview with NP 4 on [DATE] at 8:43 p.m., she indicated Resident B had been admitted to the facility on [DATE] with diagnoses of liver cancer but had been doing fairly-well. There was no expectation that the resident would have died within a month due to how she was presenting. NP 4 had visited Resident B on Friday [DATE], and the resident had been alert, sitting in a dining chair at a dining table in her room, and she was not having behaviors. The NP and Assistant Director of Nursing (ADON) met with the guardian who verbalized she did not want aggressive treatment for the resident, and the NP suggested hospice services. The guardian indicated she wanted to have a discussion with the family before deciding on hospice. NP 4 ordered repeat labs to be done on [DATE]. On Monday [DATE], the NP asked about lab results and was informed staff had been unable to get lab samples after 2 attempts. Resident B's condition was observed to be declining, and lab orders and a KUB order were discontinued by the NP after nursing staff indicated hospice services were being initiated that night. NP 4 indicated that was the last time she had a visit with the resident. On [DATE] at 8:15 a.m., facility staff had called NP 4 to request a morphine order, and NP 4 asked that they call hospice as she was enroute to another facility. NP 4 indicated neither she nor the primary MD had been made aware of the resident's change in status or rapidly declining condition after the visit on [DATE], and they had not been contacted with information regarding the facility not being able to get the resident's comfort medications or Fleet enema that had been ordered by hospice. During an interview on [DATE] at 7:27 a.m., QMA 11 indicated on Sunday [DATE], she had observed Resident B up in chair and she was alert. The resident was due to have more blood work. On Tuesday [DATE] when she worked again, the resident was actively dying, and staff did not get her out of bed. On Wednesday [DATE], she had gotten to work around 7:00 a.m. for her shift and had been assigned to work the floor as an aide. QMA 11 indicated the last time she saw Resident B was around 8:15 a.m. from the hallway as she was taking other resident to dining room for breakfast, and the resident had been breathing at that time. QMA 10, who was also working as an aide, had found Resident B unresponsive and went and got LPN 7. To her knowledge, vital signs had not been taken yet on the shift. QMA 11 and QMA 10 had been asked by the nurse to wash up the resident for presentation for the family. During an interview on [DATE] at 12:21 p.m., Unit Manager (UM) 20 indicated, on [DATE], there had been an order placed in Resident B's chart to admit her to hospice. UM 20 had spoken with a hospice representative who was in the facility and informed him that Resident B's guardian wanted the resident sent to the hospital. The hospice representative then spoke with the sister who was in the facility and called UM 20 back at 6:25 p.m. that evening and informed her that he had spoken to the guardian, and she agreed to leave the resident at the facility. The hospice representative indicated that the resident was in the works to admit to hospice, and to UM 20 that meant they would be coming on that date to sign the admission agreement with the family. LPN 7 and LPN 8 were unable to be reached for interview during the survey process. On [DATE] at 1:18 p.m., the ADM provided an Emergency Procedure-Cardiopulmonary Resuscitation, revised February 2018, and indicated the policy was the one currently being used by the facility. The policy indicated, General Guidelines.6. If an individual [resident, visitor, or staff member] is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. It is known that a Do Not Resuscitate [DNR] order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. There are obvious signs of irreversible death [e.g. rigor mortis]. The American Red Cross website, dated 2026, indicated Cardiopulmonary Resuscitation (CPR) can help save a life during cardiac arrest. When giving CPR, 1. If the person appears unresponsive, check for responsiveness, breathing, life-threatening bleeding or other life-threatening conditions using shout-tap-shout. 2. If the person does not respond and is not breathing or only gasping, call 911 and get equipment, or tell someone to do so. 3. Kneel beside the person. Place the person on their back on a firm, flat surface. 4. The American Red Cross CPR Guidelines recommends 100 to 120 chest compressions per minute, 30 at a time. Remember these 5 points: Hand position: two hands centered on the chest. Body position: shoulders directly over hands with elbows locked. Compression depth: at least 2 inches. Rate of compressions: 100 to 120 per minute. Allow chest to return to normal position after each compression. 5. Give 2 breaths. Open the airway to a past-neutral position using the head-tilt/chin-lift technique. Pinch the nose shut, take a normal breath, and make complete seal over the person's mouth with your mouth. Ensure each breath lasts about 1 second and make the chest rise, allow air to exit before giving the next breath. 6. Continue to give sets of 30 chest compressions and 2 breaths. Use an AED as soon as one is available. Minimize interruptions to chest compressions to less than 10 seconds. On [DATE] at 1:18 p.m., the ADM provided a Guidelines for Notifying Physicians of Clinical Problems, revised [DATE], and indicated the policy was the one currently being used by the facility. The policy indicated, These guidelines are intended to help ensure that 1) medical care problems are communicated to the medical staff in a timely, efficient and effective manner and that 2) all significant changes in resident/patient status are assessed and documented in the medical record.The following symptoms, signs and laboratory values [which are not all-inclusive] should prompt immediate notification of the physician, after an appropriate nursing evaluation. Immediate implies that the physician should be notified as soon as possible, either by phone, pager, text messaging, or other means. These situations include.2. Rapid decline or continued instability [for example, markedly fluctuating vital signs], unless the individual is receiving palliative care and has declined workup or treatment. 3. The following symptoms: a. Sudden in onset or a marked change [for example much more severe or frequent] compared to usual [baseline] status and are b. Unrelieved by measures which have already been prescribed and/or attempted. For example.abdominal pain with distension or fever.new or worsening confusion.4f. New and/or severe gastrointestinal signs, including prolonged and/or aggressive nausea and vomiting. Painful, persistent abdominal distention. A Hospice Program policy, dated [DATE], indicated, Hospice services are available to residents at the end of life.6. The agreement with the hospice provider will be signed by the facility representative and a representative from the hospice agency before hospice services are furnished to any resident. 7. A copy of the agreement is available through the facility business office and the hospice agency.9. In general, it is the responsibility of the hospice to manage the resident's care as it relates to the terminal illness and related conditions, including: a. Determining the appropriate hospice plan of care; b. Changing the level of services provided when it is deemed appropriate; c. Providing medical direction, nursing and clinical management of the terminal illness.e. Providing medical supplies, durable medical equipment, and medications necessary for the palliation of pain and symptoms. 10. In general, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual's needs. These include.c. Notifying the hospice about the following: [1] A significant change in the resident's physical, mental, social, or emotional status. [2] Clinical complications that suggest a need to alter the plan of care. [3] A need to transfer the resident from the facility for any condition. [4] The resident's death.12. Our facility has designated [blank space] to coordinate care provided to the resident by our facility staff and hospice staff.b. Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the resident and family. c. Ensuring that the LTC facility communicates with the hospice medical director, the resident's attending physician, and other practitioners participating in the provision of care to the resident as needed to coordinate the hospice care with the medical care provided by other physicians The immediate jeopardy that began on [DATE] was removed on [DATE] when the facility had conducted a facility wide audit of all residents for POST forms, orders for code statuses, for documentation related to change of co

Based on record review and interview, the facility failed to protect a resident's right to be free from physical abuse and mental abuse by a staff member when the staff member roughly provided resident care and left the resident exposed without clothes while a non-caregiver observed via a video phone call without the resident's knowledge for 1 of 3 residents reviewed for abuse (Resident E). Using the reasonable person concept, it is likely the deficient practice would lead to psychosocial distress, anxiety, and/or fear. The deficient practice was corrected by 5/15/26 after the facility implemented a systemic plan and was therefore Past Noncompliance Findings include:On 5/29/26 at 11:00 a.m., the Administrator indicated the facility received a recording of a video call between Certified Nursing Aide (CNA) 22 and an unknown individual not employed by the facility. The facility received the video on 5/12/26 at 1:30 p.m. The investigation determined the recording occurred during the evening shift on 4/4/26. The video had no sound and was 2 minutes and 54 seconds in length. The Administrator provided a copy of the video call recording for review. The following events were observed on the video: At 00:01, CNA 22 positioned her phone on a surface directed at Resident E's bed. A small inset image in the lower left corner showed an unidentified person participating in the video call. At 00:07, CNA 22 moved the resident's legs from the footrest and grabbed the resident's left wrist, pulling her forward abruptly while placing her other hand behind the resident's neck and jerking the resident forward in her seat. At 00:16, CNA 22 placed her arms under the resident's arms and pulled her up from the wheelchair to a standing position. She used her left hand, while holding the resident up with her right arm, to pull down the resident's pants to her thighs. At 00:26 CNA 22 turned the resident to the right and seated her upright on the side of the standard height bed. She immediately turned away from the resident and moved forward to retrieve her phone. CNA 22 moved to the resident's bathroom with her back to the resident, leaving the resident out of CNA 22's sight and sitting upright on the side of the bed. At 00:36 CNA 22 placed her phone down, stepped back a few steps and turned her body to the side. She pulled her scrub top tightly to her abdomen at the bottom of her back and raised her other arm above her head. She could be seen speaking. She then turned her body, facing the other direction with her scrub top remaining tightened against her abdomen and her arm raised above her head and appeared to be speaking. At 00:42 CNA 22 picked up her phone and returned to the room, placing her phone down again. The resident could be seen sitting upright on the side of her bed. At 00:49 CNA 22 approached the resident and placed her right hand on the resident's back and her left arm to the back of the resident's knees and forcefully pivoted her to a lying position in bed. She removed the resident's pants. From 01:03 to 1:29, CNA 22's actions were mostly obstructed due to her position relative to the phone. She appeared to remove the resident's gown and unfasten her brief, and she tossed the gown to the floor. At 01:32, CNA 22 returned to her phone and looked at it. She then moved out of view, leaving resident in full view, lying in bed, with her breast exposed. She was completely unclothed except for her socks. Her knees were bent and partially obscured her lower abdomen/pelvis. The resident was observed moving her legs up and rubbing the back of her thighs with her hands. At 01:45, CNA 22 returned with a brief and gown. She pushed the resident to her right side abruptly and pulled her brief off the bed from under her right hip, exposing her buttock. She threw the brief onto the floor. At 02:01, CNA 22 rolled the resident onto her back and secured a clean brief without performing peri-care. At 02:17, Resident E raised her left arm and touched the CNA's arm as the CNA continued to secure the brief on the resident. At 02:22, CNA 22 rolled the resident to her left side at the edge of the bed, with the resident supported against the CNA's thighs, and she repositioned something behind the resident. At 02:27, CNA 22 rolled the resident on to her back and pulled a gown over the resident's head abruptly. At 02:53, the video ends. A clinical record review for Resident E was completed 5/29/26 at 11:04 a.m. Diagnoses included Alzheimer's disease, anxiety disorder, and malnutrition. A Lift/Transfer Evaluation, dated 4/28/26, indicated the resident was non-weight bearing and was not cooperative with transfers or repositioning. She was not able or partially able to assist with transfers from bed to chair. A health care plan, revised on 10/23/24, indicated Resident E had an activities of daily living (ADL) self-care deficit related to Alzheimer's disease. She was at risk for fluctuations day to day in ability to participate in her ADLs. Interventions included for her bed to be in low position when in bed, for assistance of two staff using a mechanical lift for transfers, and for two staff to assist with bed mobility. During a telephone interview on 6/1/26 at 2:13 p.m., Resident E's son indicated his mother had been a very private person and socially conservative. This exposure of her to anyone other than a caregiver would have devastated her. He chose not to review the video due to her exposure and was told there had been an investigation and CNA 22 was no longer employed by the facility. A current facility policy, revised April 2021, titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, provided by the Assistant Director of Nursing on 6/1/26 at 1:22 p.m., included the following: Policy Statement Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.Policy Interpretation and Implementation The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff. The deficient practice was corrected by 5/15/26 after the facility implemented a systemic plan and was therefore Past Noncompliance. The plan included the following actions: all interviewable residents were interviewed, non-interviewable residents had skin checks completed, and in-service training to staff on abuse, neglect, and resident rights was completed. Ongoing monitoring by Quality Assurance and Performance Improvement (QAPI) was implemented. This citation relates to Intake 3011816. 410 IAC (Indiana Administrative Code) 16.2-3.1-27(a)(1)

Based on observations, interviews, and record reviews, the facility failed to implement timely interventions and treatments for residents who had pressure ulcers resulting in harm when those pressure ulcers worsened as a result of the lack of implementing interventions and treatments for 3 of 4 residents reviewed for pressure ulcers (Residents Q, L, and D). Findings include:1. On 6/1/26, at 10:15 a.m., the wife of Resident Q indicated she was concerned regarding Resident Q's care. She indicated that Resident Q was admitted to the facility, following a hospital stay, on 5/8/26 with intact skin. She indicated Resident Q had never had a pressure ulcer prior to his stay at the facility. Upon admission there was a Low Air Loss (LAL) mattress (a specialized medical-grade mattress used to prevent and treat bedsores) on his bed, but staff removed it, indicating his skin was intact and he didn't need it. On 5/26/26, physical therapy told Resident Q's wife they saw what appeared to be an open area on Resident Q's coccyx (tailbone). Up until that point no staff member had communicated any skin issues to her. On 5/31/26, she noticed Resident Q had some dark areas on his left ankle, left heel and left big toe and was able to provide pictures of the areas which confirmed her statement. He was then immediately provided with an LAL mattress and a wheelchair cushion. On 6/1/26, at 11:00 a.m., Resident Q's medical record was reviewed. Resident Q was a rehabilitation (rehab) resident whose diagnoses included type 2 diabetes, need for assistance with personal care, reduced mobility and generalized muscle weakness.Resident Q was admitted to the facility on [DATE], after a hospital stay from 5/4/26 to 5/8/26. The hospital discharge paperwork, dated 5/8/26, lacked documentation of the resident having had any skin issues prior to or during the hospital stay. On 5/8/26, the facility performed a Braden skin assessment (the most widely used evidence-based assessment tool to predict a patient's risk of developing pressure injuries) which showed Resident Q was at mild risk of developing a pressure ulcer. On 5/25/26, a wound assessment was completed which indicated Resident Q had a new pressure ulcer on his coccyx measuring 1.37 centimeters (cm) long by 1.76 cm wide and an area of Moisture Associated Skin Damage (MASD) (inflammation and erosion of the skin caused by prolonged exposure to moisture, such as urine, sweat, or wound drainage) on his coccyx measuring 1.47 cm long by 1.77 cm wide. The assessment lacked documentation of a description of the wound, what stage the wound was and a treatment plan for the wound. Based on the picture attached to that assessment, it appeared the pressure ulcer was to the right of Resident Q's coccyx and the area of MASD was to the left side of the coccyx, and the area of MASD appeared to be open from what could be seen in the picture. The record lacked documentation of treatment orders or preventative interventions related to Resident Q's newly acquired pressure ulcer and MASD from 5/25 until 5/28/26. The record lacked documentation that Resident Q's family had been notified of those new skin issues from 5/25 until 5/28/26. On 5/28/26, a wound assessment was completed which indicated the pressure ulcer and area of MASD on Resident Q's coccyx had merged into one large wound across the sacrococcygeal area (the region connecting the sacrum (the base of the spine) and the coccyx). That wound measured 5.6 cm long by 6.67 cm wide, was considered unstageable (a severe wound with full-thickness tissue loss where the true depth is hidden by dead tissue) and had a mixture of purulent (a thick, milky, or opaque fluid that oozes from a wound) and had serous (a clear or pale yellow, watery fluid that leaks from wounds during the healing process) drainage. Resident Q had an active order for an LAL mattress with a start date of 5/28/26. On 5/31/26, a wound assessment was started but indicated it was still in progress. The wound was still considered unstageable, but no measurements were documented on this assessment. A progress note, dated 5/31/26, at 6:27 p.m., indicated Resident Q had new suspected Deep Tissue Injuries (DTI) (a severe form of pressure injury that originates in the muscle layers closest to the bone) on the left heel, left big toe, and left 2nd and 3rd toes. Resident Q had active orders for pro heal critical care supplement (a liquid supplement used to promote wound healing), a wheelchair cushion and treatment orders for the sacrococcygeal pressure ulcer and DTIs to the left heal and left big toe all with a start date of 5/31/26. The record lacked documentation of a treatment order for suspected DTI to the left 2nd and 3rd toes.Resident Q had a care plan that indicated they had current wound orders and were at risk for further skin breakdown dated 5/31/26. The record lacked documentation of a pressure ulcer related care plan before 5/31/26. Resident Q had an active order for pressure-relieving boots with a start date of 6/1/26 at 3:00 p.m. During an interview on 6/1/26, at 12:10 p.m., the Assistant Director of Nursing (ADON) indicated she was also the wound nurse and oversaw the management of wounds in the facility. She indicated she was notified of an open wound on Resident Q's bottom on 5/25/26 by the floor nurse who was caring for the Resident on that shift. She indicated the Resident was getting ready to eat breakfast when she and the floor nurse went in to assess the wound initially. There was an open pressure ulcer to the right of Resident Q's coccyx and an area of what she determined was MASD to the left of his coccyx. The ADON indicated she told the floor nurse to put a hydrocolloid dressing (a waterproof, self-adhesive bandage containing gel-forming agents used to absorb minor wound fluid to create a healing environment that speeds up recovery and minimizes scarring) on the pressure ulcer and she would reevaluate the wound when she did her wound rounds. The ADON indicated she assumed the floor nurse would follow up with the Medical Director (MD) for orders, which she guessed was something she should not have done. She followed up during wound rounds on 5/28/26 where she indicated the pressure ulcer had gotten worse and merged with the area of MASD the Resident had, creating one large wound. The ADON indicated she was unaware of Resident Q's DTIs until 6/1/26. The Executive Director (ED) indicated she had noted them the previous day on 5/31/26. The ED indicated Resident Q had a DTI in the left outer area of the heel, on the tip of the left big toe and on the left big toe knuckle. The ED indicated Resident Q did not have any darkened areas or DTIs on the ankles when she observed him. 2. On 5/29/26, at 2:45 p.m., Resident L was observed as they were lying in bed resting with their eyes closed. The resident had their feet crossed at the ankles and their heels lying directly on the surface of the mattress. Resident L only had nonskid socks on their feet. On 5/29/26, at 3:00 p.m., Resident L's medical record was reviewed. They were a long-term care resident whose diagnoses included dementia and a pressure ulcer of unspecified site and stage. A progress note, dated 12/16/25, at 5:00 p.m., indicated Resident L arrived at the facility and noted that the resident had a pressure ulcer on their right heel from a busted blister and an intact fluid filled blister on their left heel. The note indicated there was a protective foam dressing on each heel from the hospital. An order was added on 12/19/25, for the floor nurse to cleanse Resident L's left heel wound with wound cleanser, pat dry, apply skin barrier to the peri wound (healthy skin surrounding the wound), apply a hydrofera blue dressing (a highly absorptive, antibacterial polyvinyl alcohol (PVA) foam dressing used to promote wound healing) to the wound bed and secure it with rolled gauze daily. The record lacked documentation of wound care orders for the pressure ulcer to the right heel. The record lacked documentation of wound care orders for the left heel before 12/19/25. A health status note, dated 12/26/25, indicated a referral to a wound care service was ordered. The order for the floor nurse to cleanse Resident L's left heel wound with wound cleanser, pat dry, apply skin barrier to the peri wound, apply a hydrofera blue dressing to the wound bed, and secure it with rolled gauze was discontinued on 12/26/25. An order was added on 12/26/25, for the floor nurse to cleanse Resident L's left and right heel wound with wound cleanser, pat dry, apply skin barrier to the peri wound, apply a xeroform (fine-mesh gauze pads or strips impregnated with petrolatum and 3% bismuth tribromo phenate), dressing to the wound bed, and secure it with rolled gauze daily. The record lacked documentation of any wound care orders for the right heel before 12/26/25. A skin issue note written by a contracted wound care provider, dated 1/3/26 for an assessment done on 1/2/26, indicated Resident L had a pressure ulcer on their left heel and a Deep Tissue Injuries (DTI) (a severe form of pressure injury that originates in the muscle layers closest to the bone) on their right heel. The description of those wounds was as follows: wound one was a stage 3 pressure ulcer (a serious, deep wound characterized by full-thickness skin loss where subcutaneous fat is usually visible, but underlying muscles, tendons, or bones are not exposed) on the left heel that measured 6 cm long by 4 cm wide by 0.1 cm deep that was identified on 12/26/25 and developed while the resident resided in the facility. The treatment to be ordered for wound one was for the floor nurse to apply collagen (a wound dressing that stimulates the bodies natural healing process.), a bordered dressing (a wound dressing that features a central, non-adherent absorbent pad surrounded by an adhesive border), apply rolled gauze to cover and an ace wrap for compression. Wound two was a suspected DTI on the right heel that measured 5 cm long by 4.5 cm wide and was 75% eschar (dead tissue). The treatment to be ordered for the suspected right heel DTI was for the floor nurse to paint the wound bed with betadine (a broad-spectrum, over-the-counter topical antiseptic used to kill bacteria, fungi, and viruses to prevent infections), let it dry, apply an Abdominal (ABD) pad (a multi-layer, highly absorbent medical dressing used to cover, cushion, and protect large or heavily draining wounds), rolled gauze and an ace wrap for compression. It was requested to offload Resident L's heels by providing a Low Air Loss (LAL) mattress (a specialized medical-grade mattress used to prevent and treat bedsores) and apply pressure relieving boots when the resident was in bed. The record lacked documentation of an order for the wound care requested by the contracted wound care provider for Resident L's left and right heel wounds, an order for the requested LAL mattress, or an order for requested pressure relieving boots being added after the assessment on 1/3/26. A skin issue note written by a contracted wound care provider, dated 1/9/26 for an assessment done on 1/9/26, indicated Resident L had a pressure ulcer on their right heel and a DTI on their left heel. The description of those wounds was as follows: wound one was a stage 3 pressure ulcer on the right heel that measured 5 cm long by 8.5 cm wide by 0.2 cm deep that was identified on 12/26/25 and developed while the Resident resided in the facility. The treatment to be ordered for wound one was for the floor nurse to apply collagen, a 4X4 gauze pad to the wound, apply rolled gauze to cover and an ace wrap for compression. Wound two was a suspected DTI on the left heel that wasn't measured. The treatment to be ordered for the left heel DTI was for the floor nurse to apply xeroform, apply an ABD pad, rolled gauze to cover and an ace wrap for compression. It was again requested to offload Resident L's heels by providing an LAL mattress and apply pressure relieving boots when the Resident was in bed. The record lacked documentation of an order for the wound care requested by contracted wound care service for Resident L's right heel wound, an order for the requested LAL mattress, or an order for requested pressure relieving boots being added after the assessment on 1/9/26. A skin issue note written by a contracted wound care provider, dated 1/17/26, for an assessment done on 1/16/26, indicated Resident L had a pressure ulcer on their right heel and a pressure ulcer on their left heel. The description of those wounds was as follows: wound one was a stage 3 pressure ulcer on the right heel that measured 2 cm long by 2 cm wide by 0.1 cm deep that was identified on 12/26/25 and developed while the resident resided in the facility. The treatment to be ordered for wound one was for the floor nurse to apply Santyl (a prescription ointment used to remove dead tissue from chronic skin ulcers) to the wound bed, apply calcium alginate (a highly absorbent, non-woven wound dressing made from natural brown seaweed or kelp) to the wound, wrap with rolled gauze to cover and an ace wrap for compression. Wound two was a DTI that turned into a stage 3 pressure ulcer on the left heel that measured 2 cm long by 3 cm wide by 0.1 cm deep was identified on 1/16/26 and developed while the resident resided in the facility. The treatment to be ordered for wound two was for the floor nurse to apply xeroform, apply an ABD pad, rolled gauze to cover and an ace wrap for compression. It was requested to offload Resident L's heels by providing an LAL mattress and apply pressure relieving boots when the Resident was in bed for a third time. An order was added on 1/17/26, for the floor nurse to apply skin prep to the peri wound of Resident L's right heel wound apply Santyl to the wound bed, apply calcium alginate to the wound, wrap with rolled gauze to cover and an ace wrap for compression daily. The record lacked documentation of an order for the requested LAL mattress or an order for requested pressure relieving boots being added after the assessment on 1/17/26. A skin issue note written by the contracted wound care service provider, dated 1/23/26 for an assessment done on 1/23/26, indicated Resident L had a pressure ulcer on their right heel and a pressure ulcer on their left heel. The description of those wounds was as follows: wound one was an unstageable pressure ulcer on the right heel that measured 3 cm long by 2.5 cm wide by 0.2 cm deep that was identified on 12/26/25 and was developed while the Resident resided in the facility. The treatment to be ordered for wound one was for the floor nurse to apply Santyl to the wound bed, apply calcium alginate to the wound, wrap with rolled gauze to cover and an ace wrap for compression. Wound two was a stage 3 pressure ulcer on the left heel that measured 2 cm long by 3 cm wide by 0.1 cm deep that was identified on 1/16/26 and developed while the Resident resided in the facility. The note indicated the cap (the top layer of skin, which typically presents as a dry, firm, or boggy eschar (a scab-like, dark-colored covering or a thick, blood-filled blister) fell off the wound revealing red exposed dermal layer. The treatment to be ordered for wound two was for the floor nurse to apply xeroform, apply an ABD pad, rolled gauze to cover and an ace wrap for compression. The note indicated the unstageable pressure ulcer on Resident L's right heel had worsened since the last assessment and they may need to do sharp debridement (a medical procedure that uses sterile surgical instruments to carefully remove dead, damaged, or infected tissue from a wound bed) when the Resident was to be seen next. The note indicated a lidocaine patch would need to be placed on the wound 30 minutes to one hour before wound rounds to numb the area. It was requested to offload Resident L's heels by providing an LAL mattress and apply pressure-relieving boots when the Resident was in bed. The record lacked documentation of an order for the requested LAL mattress or an order for requested pressure relieving boots being added after the assessment on 1/23/26. A skin issue note written by the wound care service provider, dated 1/30/26 for an assessment done on 1/30/26, indicated Resident L had a pressure ulcer on their right heel and a pressure ulcer on their left heel. The description of those wounds was as follows: wound one was an unstageable pressure ulcer on the right heel that measured 2.5 cm long by 2.5 cm wide by 0.3 cm deep that developed on 12/26/25. The treatment to be ordered for wound one was for the floor nurse to apply Santyl to the wound bed, apply calcium alginate to the wound, wrap with rolled gauze to cover and an ace wrap for compression. Wound two was a stage 3 pressure ulcer on the left heel that was considered healed upon assessment. The treatment to be ordered for wound two was for the floor nurse to apply skin prep to the healed areas to prevent reopening. The note indicated the unstageable pressure ulcer on Resident L's right heel had worsened since the last assessment and they planned to do a sharp debridement next assessment due to the requested lidocaine patch not being ordered or applied before wound rounds on that assessment. The note indicated again a lidocaine patch would need to be placed on the wound 30 minutes to one hour before wound rounds to numb the area. It was requested to offload Resident L's heels by providing an LAL mattress and apply pressure relieving boots when the Resident was in bed. The record lacked documentation of an order for the requested LAL mattress or an order for requested pressure relieving boots being added after the assessment on 1/30/26. The order for the floor nurse to cleanse Resident L's left and right heel wound with wound cleanser, pat dry, apply skin barrier to the peri wound, apply a hydrofera blue dressing to the wound bed and secure it with rolled gauze was discontinued on 1/30/26.The order for the floor nurse to apply skin prep to the peri wound of Resident L's right heel wound apply Santyl to the wound bed, apply calcium alginate to the wound, wrap with rolled gauze to cover and an ace wrap for compression was discontinued on 1/30/26. From 1/17/26 until 1/30/26, there were two separate orders for different types of wound care to be applied daily An order for Resident L to float their heels while in bed using pressure relieving boots was added on 4/3/26. At the time of exit, the record lacked documentation of an order for the requested LAL mattress. 3. On 5/29/26, at 11:00 a.m., Resident D's medical record was reviewed. They were a memory care resident whose diagnoses included dementia, type 2 diabetes, pressure ulcers to the left and right heels and need for assistance with personal care. Resident D was admitted to the facility on [DATE] from a hospital stay. Hospital discharge paperwork, dated 3/17/26, indicated the hospital ordered wound care instructions were as follows: twice a day or after incontinence episodes the floor nurse was to cleanse the buttock and perineal [the space between the anus and the genitals] area with baza cleanse and protect (an all-in-one, no-rinse perineal lotion ), pat dry and apply a thin layer of critic aide moisture barrier paste (a high-performance moisture barrier ointment designed to protect, treat, and heal skin irritation) to the area. The instructions included preventative measures that were to have been put in place upon admission that included but were not limited to providing an LAL mattress for the resident. The record lacked documentation of an order for the requested treatment for Resident D's buttock and perineal area. The record lacked an order for an LAL mattress as requested in the hospital discharge instructions. An admission assessment, dated 3/17/26, indicated Resident D did not have any skin abnormalities. An admission Minimum Data Set (MDS) assessment, dated 3/17/26, indicated Resident D was at risk for pressure ulcers. A progress note, dated 3/17/26, indicated Resident D was being admitted to the facility for a rehab stay and they had wounds on both lower extremities and a rash on their perineal area and bottom. A physician's note, dated 3/21/26, indicated Resident D had chronic wounds (a wound that does not heal in an orderly, timely manner) on both lower extremities and the wound care team would see the resident. A progress note, dated 3/24/26, indicated Resident D had a new skin tear on her coccyx that measured 2.22 cm long and 2.18 cm wide. A skin issue note written by a contracted wound care provider, dated 4/4/26, indicated Resident D had an initial assessment of several wounds, some new and one identified prior to the provider seeing the resident. The description of those wounds included but was not limited to as follows: Skin issue three was a new unstageable pressure ulcer on Resident D's right heel that measured 4 cm long by 3 cm wide by 0.1 cm deep, was 67-100% dead tissue and was identified on 4/3/26 while the resident resided in the facility. Skin issue one was a stage 2 pressure ulcer on Resident D's coccyx that measured 1.41 cm long by 1.73 cm wide and developed on 4/3/26 while the resident was at the facility. An order was added on 5/14/26 for an LAL mattress. During an interview on 5/29/26, at 12:30 p.m., the ADON indicated the wound on Resident D's coccyx was initially assessed as a skin tear by someone, she wasn't sure who, however upon reviewing the photo taken at the time of the assessment she would not have considered it a skin tear, it looked like an open area in her opinion. On 5/29/26, at 1:18 p.m., a copy of a current facility policy titled Prevention of Pressure Injuries, dated 4/2020, was provided. That policy indicated, . The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Skin Assessment. 1. Conduct A comprehensive skin assessment upon (or soon after) admission. Prevention. 4. Use a barrier product to protect skin from moisture. Support Surfaces and Pressure Redistribution 1. Select appropriate support surfaces based the residents risk factors. Monitoring. 2. Review the interventions and strategies for effectiveness on an ongoing basis. On 5/29/26, at 1:18 p.m., a copy of a current facility policy titled Pressure Ulcers/Skin Breakdown- Clinical Protocol, dated 4/2018, was provided. That policy indicated, .Assessment and Recognition. 3. The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. Treatment/Management. 1. The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorbative, etc.), and application of topical agents. This citation is related to Intake 29757009 and 3031446. 410 IAC (Indiana Administrative Code) 16.2-3.1-40

Based on observation, interview, and record review, the facility staff failed to report an injury of unknown origin to the Administrator in a timely manner, which delayed the investigation for 1 of 5 residents reviewed for abuse and neglect. (Resident C)Findings include:A clinical record review for Resident C was completed on 5/28/26 at 11:26 a.m. Diagnoses included vascular dementia, osteoarthritis, osteoporosis, and a fracture of the fourth metacarpal bone in the left hand.A nursing progress note, dated 5/14/26 at 11:23 p.m., included a CNA had alerted the nurse that Resident C had complained about her left hand. Upon assessment, the nurse noted her left pinky and ring fingers were swollen and red and were painful to touch. The resident indicated she messed her hand up on her wheelchair. The provider was notified and an order was given to obtain an X-ray of her left hand.A nursing progress note, dated 5/15/26 at 7:23 a.m., included the Xray was completed and results were pending, and the nurse notified the daughter.The X-ray result, received on 5/14/26, indicated that the resident had an acute nondisplaced fracture to her fifth proximal phalangeal shaft.During an interview on 5/28/26 at 3:57 p.m., the Administrator indicated she had not been informed of Resident C's fracture until 5/20/26. She sent the incident report upon learning of the injury of unknown origin and started her investigation. She indicated the staff should have reported this on 5/14/26 upon learning the resident had an injury.A current facility policy, revised 4/2021, titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, left on the conference table during break on 5/29/26 and received at 2:04 p.m., included the following: .Reporting Allegations to the Administrator and Authorities 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law.This citation is related to Intake 3019913.410 IAC (Indiana Administrative Code) 16.2-3.1-28(c)

Based on record review and interview, the facility failed to ensure physician's orders were obtained for and treatments were provided for an enterocutaneous fistula (an abnormal passage between the bowel and the skin, allowing intestinal contents to leak onto the abdominal wall) while a resident awaited surgical intervention for the area for 1 of 3 residents reviewed for quality of care (Resident B). Findings include:Resident B's record was reviewed on 3/31/26 at 10:31 a.m. Census information indicated the resident was admitted to the facility on [DATE] and hospitalized on [DATE]. Diagnoses on the resident's profile included, but were not limited to, fistula of the intestine. A history and physical from the resident's previous hospital admission, dated 1/6/26, indicated the resident had an enterocutaneous fistula, required a wound care consult, and had been referred to the hospital for possible surgical intervention related to the fistula. A discharge summary report from the hospitalization on 1/6/26, indicated the resident had an enterocutaneous fistula that required surgical intervention. Due to the resident's ongoing need for skilled nursing care, and upcoming required surgical intervention, the resident would be admitted to a skilled nursing facility until the enterocutaneous fistula could be surgically repaired. Post hospital discharge requirements indicated, .Wound Care: Ongoing meticulous wound care for the enterocutaneous fistula until surgical intervention. An admission assessment, dated 2/12/26, indicated the resident had moisture associated skin damage on his abdomen around the stoma (opening on the abdomen that allows bodily waste to exit the body). A care plan, initiated on 2/12/26, indicated the resident had an alteration in intestinal status due to a fistula. Interventions included, but were not limited to, use ostomy appliance to manage fistula output. The care plan lacked documentation of specific treatment orders or instructions for when and how to treat the fistula and surrounding skin. A Nurse Practitioner (NP) progress note, dated 2/13/26, indicated to continue the ostomy bag over open wound, change as able, and follow up soon for surgical consult. The note lacked documentation orders were provided with specific parameters or instructions for treatment of the resident's fistula. A skilled progress note, dated 2/15/26, indicated the resident had a colostomy (a surgical procedure that creates an opening in the abdominal wall, bringing a portion of the large intestine through the surface to allow stool to exit the body). An NP progress note, dated 2/16/26, indicated to continue the ostomy bag over open wound, change as able, and follow up soon for surgical consult. The note lacked documentation orders were provided with specific parameters or instructions for treatment of the resident's fistula. An NP progress note, dated 2/18/26, indicated to continue the ostomy bag over open wound, change as able, and follow up soon for surgical consult. The note lacked documentation orders were provided with specific parameters or instructions for treatment of the resident's fistula. An NP progress note, dated 2/20/26, indicated to continue the ostomy bag over open wound, change as able, and follow up soon for surgical consult. The note lacked documentation orders were provided with specific parameters or instructions for treatment of the resident's fistula. A skin assessment, dated 2/20/26, indicated the resident had incontinence associated dermatitis to the abdomen. The assessment lacked documentation there was a treatment for the area. An NP progress note, dated 2/23/26, indicated to continue the ostomy bag over open wound, change as able, and follow up soon for surgical consult. The note lacked documentation orders were provided with specific parameters or instructions for treatment of the resident's fistula. An NP progress note, dated 2/25/26, indicated to continue the ostomy bag over open wound, change as able, and follow up soon for surgical consult. The note lacked documentation orders were provided with specific parameters or instructions for treatment of the resident's fistula. A skin assessment, dated 2/27/26, indicated the resident had redness around the stoma and fistula sites related to moisture associated dermatitis. The assessment lacked documentation of a treatment to the area. An NP progress note, dated 3/4/26, indicated to continue the ostomy bag over open wound, change as able, and follow up soon for surgical consult. The note lacked documentation orders were provided with specific parameters or instructions for treatment of the resident's fistula. Physician's orders, dated 2/12/26 to 3/6/26, lacked documentation of an order for treatment, care, or monitoring of the resident's fistula or a treatment for the moisture associated skin damage to the abdomen. Medication Administration Records (MARs) and Treatment Administration Records (TARs), dated February and March 2026, lacked documentation of treatment, care, or monitoring of the resident's fistula or the moisture associated skin damage on the abdomen. During an interview, on 3/31/26 at 2:02 p.m., the Director of Nursing (DON) indicated the resident had a fistula, not a surgically created ostomy. They had to use an ostomy bag over it because it oozed constantly. The resident needed surgical intervention. They should have kept the area clean and treated it with the ostomy appliances. During an interview, on 4/1/26 at 11:20 a.m., the DON indicated she was unable to find physician's orders for the treatment of the resident's fistula. There should have been physician's orders in place for treatments to the area. Physician's orders should have been obtained when the resident was admitted , and she was not sure how it was missed. On 4/1/26 at 12:40 p.m., the DON provided a document titled, Colostomy/Ileostomy Care, last revised in October 2010. The policy indicated, .Purpose: The purpose of this procedure is to provide guidelines that will aid in preventing exposure of the resident's skin to fecal matter.Steps in Procedure.8. When evaluating the condition of the resident's skin, note the following.b. Excoriation.Documentation: The following information should be recorded in the resident's medical record: 1. The date and time the colostomy/ileostomy care was provided. 2. The name and title of the individual(s) who provided the colostomy/ileostomy care. 3. Any breaks in the resident's skin, signs of infection.or excoriation of the skin. 4. How the resident tolerated the procedure. 5. If the resident refused the procedure, the reason(s) why and the intervention taken. 6. The signature and title of the person recording the data. This citation relates to Intake 2799346. 410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on record review, interview, and observations, the facility failed to implement interventions to treat pressure ulcers and failed prevent pressure to residents' bony prominences for 2 of 3 resident's reviewed (Resident H and G).Findings include:1. On 3/31/26 at 11:40 a.m. Resident H was not in her room. She had a regular mattress. A heel protector sat next to her bed on a fall mat. On 3/31/25 at 11:52 a.m., Resident H was observed sitting in her wheelchair, head down with her eyes closed in the Activity room. She was dressed appropriately with non-skid socks on, with her feet resting on her foot pedals. Staff assisted resident back to her room. Her heels were observed. The right heel skin was intact. The left heel's skin was a hard, black eschar (dead cells), measuring approximately 5 centimeters (cm) by 5 cm. Resident did not complain of pain. RN 6 was in the room and proceeded to wheel the resident out of the room without protecting her heel from pushing into her leg rest. On 3/31/26 at 1:00 p.m., a record review was completed for Resident H. She had the following diagnoses which included, but were not limited to, fracture of left femur (leg bone), dementia, and anxiety.On 3/13/26 at 10:44 p.m., a progress note indicated Resident H returned to the facility after a hospital stay for a fractured hip. The nurse documented resident left heel was mushy (soft and lacking firmness), with possible deep tissue injury (DTI) (a serious wound characterized by localized, purple/maroon discolored intact skin or blood-filled blisters, resulting from intense pressure or shear).On 3/13/26 at 11:28 p.m., a progress note indicated the resident's left heel was not open but noted it was mushy to touch.On 3/16/26 at 5:11 p.m., a progress note indicated a skin issue. New skin issue, left heel, laterally (side), unstageable (full-thickness wound where the base is covered making it impossible to determine the true depth or stage) presenting as DTI, measuring 3.13 cm by 2.78 cm. The note also indicated it was unknown how long the wound had been present. Education was provided to certified nursing aide (CNA) regarding caring for resident ensuring continuous off-loading of area when in bed, provider notified, and new order written for suspected deep tissue injury (SDTI) on the left heel.An order was received on 3/16/26 for betadine (medication to destroy or inhibit microorganisms and prevent infection) to be applied to the left heel three times daily (TID) for SDTI pressure ulcer, leave open to heal.On 3/31/26 at 5:11 p.m., a progress note indicated an assessment of left heel unstageable/SDTI. The wound measured 4.5 cm by (x) 4.3 cm, skin intact. Previously presented as a fluid filled blister. Fluid has reabsorbed. Wound was approximately 60% light pink/normal skin color and 40% black color. The surrounding skin was intact (closed) and normal skin color. Wound had evolved as expected. The plan was to continue the current plan of care, off-loading boot replaced to left foot after assessment. Right foot off-loaded using pillow under calf to keep outer ankle off the mattress. A care plan, dated 3/16/26, indicated the resident had a documented pressure ulcer. Location and staging were not mentioned. The goal, dated 3/16/26, indicated prevention of future pressure ulcers. The care plan lacked an intervention to off-load resident's heels.On 3/31/26 at 2:38 p.m., the DON was made aware that RN 6 had left the resident's heels pushing into the wheelchair pedals and that resident's heel protector was sitting in resident's room. She indicated the resident had re-admitted with a boggy, mushy heel. 2. On 3/31/26 at 10:59 a.m., Resident G was observed in bed with a fall mat to the left side of her bed. She had body pillows on both sides of her body. She had a low air loss (LAL) mattress that was set to the firmest setting. Her feeding tube was infusing Nutren (tube-feeding formula) as ordered. She was talkative.On 4/1/26 observed Resident G in bed with her eyes closed. Her LAL settings were at approximately 160. On 3/31/26 at 10:30 a.m., a record review was completed for Resident G. She had the following diagnoses which included but were not limited to age-related physical debility, hyperlipidemia (high cholesterol), dysphagia, major depressive disorder, respiratory failure, and generalized weakness. Resident G had a care plan, dated 9/17/25, indicating she was at risk for impairment to skin integrity due to decreased mobility with potential for friction and shear, moisture to skin, impaired sensory perception, enteral nutrition through the night and pleasure food for meals, bi-lateral (both) buttock shearing. The goal, dated 9/17/26, indicated shearing to bilateral buttocks will heal by next review. An intervention, dated 9/17/25, indicated to use a draw sheet to avoid shearing. The care plan lacked an intervention for the use of a LAL mattress. On 4/1/26 at 11:10 a.m., during an interview with the Director of Nursing and Assistant Director of Nursing (ADON), the ADON indicated the resident's mattress setting should be set according to resident's weight. She was informed that the manufacturer's guideline cut off at page 7, therefore, it did not include the information she verbally provided. She indicated she would get the rest of the guidelines, but it was not received at the time of exit. A review of resident's weight in her medical record on 4/1/26 at 12:00 p.m. indicated she weighed 163.8 pounds. A policy titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol with a revision date of April 2018, was provided by the DON on 4/1/26 at 1:42 p.m. It indicated, .During the physician visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or poorly-healing wound.The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions.410 IAC (Indiana Administrative Code) 16.2-3.1-40

Based on observations, interviews and record reviews, the facility failed to prevent a fall with injury when they inappropriately transferred a resident (Resident H) resulting in actual harm of a hip and femur fracture, and when a resident's personal items were not within reach resulting in a fall with a brain bleed (Resident C) for 2 of 4 residents reviewed for falls resulting in a major injury.Findings include:1. On 3/31/25 at 11:52 a.m., Resident H was observed sitting in her wheelchair, head down with her eyes closed in the Activity room. She was dressed appropriately with non-skid socks on, with her feet resting on her foot pedals. On 3/31/26 at 1:00 p.m., a record review was completed for Resident H. She had the following diagnoses which included, but were not limited to, vertigo (dizziness), fracture of left femur (leg bone), essential hypertension (HTN), muscle weakness, dementia, and anxiety. Resident H had a care plan, dated 10/23/23, indicating she was at risk for falls related to gait/balance problems, had a diagnosis of dementia with impaired safety awareness, used a wheelchair, and had history of falls, unsteady gait (walking), and possible side effects from medications. The goal, dated 3/16/26, indicated she would have no major injury related to falls. An intervention, dated 10/16/23, indicated to encourage resident to lay down after breakfast and between meals. Another intervention, dated 10/6/23, indicated to assist resident to bed if she was noted to be restless or tired. She had an intervention indicating she needed prompt response to all requests for assistance. Resident H had a care plan, dated 10/3/23, indicating she had an Activities of Daily Living (ADL) self-care performance deficit for bed mobility, transfers, eating, and toileting related to limited mobility and has a history of dementia and may have fluctuation in daily ability to participate in her ADLs. A goal, dated 3/16/26, indicated she would have her needs met per staff interventions. Interventions, dated 10/3/23, indicated she required extensive assistant with toileting with 1 to 2 staff members for toileting needs, resident required total assistance of 2 staff members to move between surfaces and used a lift. Resident used a wheelchair. A review of her progress notes indicated, on 3/9/26 at 6:56 a.m., staff were providing care for resident and as they were trying to dress her, resident screamed out in pain of her left hip. She was assessed; the physician was notified and received orders for acetaminophen (Tylenol) 500 milligram (mg), two tablets by mouth and a left hip x-ray. A progress note, dated 3/9/26 at 11:38 a.m., indicated she was seen by the Nurse Practitioner and new orders were received to send resident to the emergency room (ER). A progress note, dated 3/9/26 at 11:49 a.m., indicated the nurse aide reported that resident was being weird while she was getting dressed for breakfast. The nurse went to assess and found the left hip warm to touch with no redness, and resident was unable to verbalize she was in pain. When the nurse lifted her leg off of the bed, resident grabbed toward her left hip and screamed ouch. The next progress note entered was on 3/13/26 at 10:44 p.m., indicating resident arrived back at the facility. She had 11 staples to the left upper lateral (side) hip surgical site and 5 staples to left lower lateral hip. Resident's Minimum Data Set (MDS) dated [DATE] indicated she was severely impaired when it came to making decisions regarding tasks of her daily life. Staff were unable to complete a Brief Interview of Mental Status (BIMS) due to her cognitive loss. The Administrator reported an injury of unknown origin to the Indiana Department of Health (IDOH) on 3/10/26. The report indicated Resident H complained of pain in her hip area. The nurse assessed and when she lifted her leg to assess, the resident indicated she hurt. The Administrator initiated an investigation into causative factors. The resident's neck of left femur was fractured and an acute impacted femur intertrochanter fracture with [NAME] angulation of the fracture fragments. Acute nondisplaced left superior pubic ramus fracture. The follow up indicated injury of unknown origin. On 3/10/26 Certified Nursing Assistant (CNA) 10 provided a statement on the residents' fractures. She indicated she came in on Saturday morning (3/7/26). Resident H was still in bed. She tried to get resident up and the resident fell backwards into the bed. She then picked her up to transfer to the chair and she put her on the floor and she called Qualified Medication Assistant (QMA) 11 to help her get resident off the floor. On 3/23/26 at 3:19 p.m., a statement was received by QMA 11. She indicated she was doing her normal rounds on 3/7/26 when she was called to Resident H's room by CNA 10. CNA 10 asked QMA 11 to help her get Resident H off the floor. QMA 11 asked CNA 10 if resident fell and CNA 10 indicated, resident did not fall. She was heavy and had to lower her to the floor. She did not have immediate pain but later in the shift she started to complain of pain, and this was reported to Registered Nurse (RN) 9. On 4/1/26 at 1:18 p.m., the Unit Manager (UM) was interviewed. She indicated Resident H was a Hoyer lift. She indicated the incident happened over the weekend. She went to the resident's room, her legs were lying on one side of the bed. She barely touched her hip and she was immediately in pain. She was lowered to the floor over the weekend. She indicated they did not use assignment sheets. On 4/1/26 at 1:20 p.m., CNA 10 was interviewed via phone. She indicated Saturday on 3/7/26 before breakfast, Resident H was in bed. She had to get her up. She laid back in bed when attempting to transfer her. While she transferred the resident to the chair, the resident went down to the floor. The resident was having a problem with her leg. CNA 10 did not know the resident was having problems standing. She lowered the resident to the floor. She asked QMA 11 for assistance to pick the resident up. She indicated QMA 11 checked everything and resident was not in pain. Later in the day, Resident H was receiving a shower and when she was transferred to the shower chair, she was crying out in pain. She indicated she told the nurse and the nurse responded she would call the doctor. On 4/1/26 at 1:49 p.m., Licensed Practical Nurse (LPN) 5 indicated CNA 10 thought QMA 11 was a nurse. On 4/1/26 at 1:56 p.m., RN 9 reported she was not informed of resident being in pain on 3/7/26. She came in on 3/9/26 and staff reported to her that resident was in pain. She completed an assessment, including her vital signs, called the on-call team and informed them of resident guarding her leg and pain. The physician ordered Tylenol and a x-ray STAT. She called the family. She was in too much pain, so they sent her out to the ER. On 4/1/26 at 2:31 p.m., during an interview with QMA 11, she indicated CNA 10 asked her for help to get resident off the floor because she was heavy. They picked her up by placing their arms underneath resident's armpits and pulling her up with her pants. Resident had no abnormal behaviors. She doesn't talk only says hi and bye and blew her a kiss. She did not express any pain. She indicated she was with RN 9 counting narcotics when the resident's pain was reported. She indicated she told RN 9 to look at the resident for signs and symptoms of pain. On 4/1/26 at 2:38 p.m., during an interview with the DON, she indicated a resident lowered to the floor wasn't considered a fall. The DON was not present during the incident. She expected all staff to inform the nurse when a resident was lowered to the floor. She indicated she was lifted by one person when she should've been a mechanical lift. There were no assignment sheets, and she was working on creating assignment sheets for the staff. She indicated the resident should have been assessed before moving her. Staff need to anticipate her needs and be proactive instead of reactive. She indicated she would look for staff education regarding this incident. At the survey exit, no education was provided. She indicated a dementia resident should be checked every hour. She indicated the residents' cognition was moderately impaired. 2. On 3/31/26 at 12:00 p.m. Resident C's medical record was reviewed. They were a long-term care resident whose diagnoses included, but were not limited to, traumatic subdural hemorrhage (a life-threatening, often acute collection of blood between the brain and its outer covering). A progress note, dated 1/23/26 at 4:24 p.m., indicated an unknown Certified Nursing Assistant (CNA) and Resident C's roommate alerted Licensed Practical Nurse (LPN) 5 to Resident C's room. When LPN 5 arrived in the doorway she observed Resident C face down on the floor beside their bed. The note indicated Resident C had flipped off their bed when they tried to reach for their personal cell phone. LPN 5 assessed Resident C and observed a quarter sized knot on the left side of the resident's forehead. The note indicated Resident C was immediately sent to the hospital to be evaluated. A progress note, dated 1/24/26 at 4:36 p.m., indicated Resident C had been admitted with a diagnosis of an acute head injury (a sudden injury to the brain caused by an external force, such as a blow, jolt, or penetrating object, which alters brain function) with bilateral subdural hematomas (a life-threatening, often trauma-induced, accumulation of blood on both sides of the brain). Resident C's most recent Minimum Data Set (MDS) (a standardized, federally mandated clinical assessment tool used in Medicare/Medicaid-certified nursing homes to evaluate resident functional capabilities, health needs, and preferences) assessment indicated they were dependent on clinical staff to help with all Activities of Daily Living (ADLs). Resident C had a care plan, dated 12/29/26, indicating they were at a high risk for falls. Interventions for this problem included but were not limited to, anticipate and meet the resident's needs, ensure personal items are within reach and a fall mat was placed on the floor next to the side of the bed. The record lacked documentation of what the resident's status was or if they planned to return to the facility or not. On 3/31/26 at 12:56 p.m. Resident C's daughter indicated when the resident arrived at the hospital after the fall on 1/23/26. She required immediate attention due to having several skull fractures and blood on their brain. She indicated Resident C was very frail and stayed at the hospital until the resident ultimately passed away on 2/14/26. During an interview on 4/1/26 at 10:15 a.m. LPN 5 and Registered Nurse (RN) 6 indicated standard fall precautions for all residents, regardless of if they had had a fall or not, included, but was not limited to, ensuring the resident's personal items were within their reach. LPN 5 and RN 6 indicated they did that by keeping the residents things on their bedside table to the side of their bed. They indicated if a resident had limited range of motion and needed their personal items closer, they would put the items on the over the bed bedside table, so the items were right in front of them and easy to reach. During an interview on 4/1/26 at 11:24 a.m. the Director of Nursing (DON) indicated she agreed with LPN 5 and RN 6's explanation of standard fall precautions and what it meant to keep personal items within the residents' reach. During an interview on 4/1/26 at 12:15 p.m. LPN 5 indicated Resident C's CNA was in the room getting them situated on 1/23/26. After the CNA was done, she left and moved on to assist another resident. When the CNA left, she heard Resident C's roommate start to yell out to Resident C to stop moving around in bed or Resident C was going to fall. The CNA went to the door and yelled for LPN 5 to come quickly. When LPN 5 arrived at Resident C's door she indicated Resident C was observed lying face down on the floor, at the time LPN indicated it looked like the bedside table had been parallel to the bed instead of over her bed because when LPN 5 observed the Resident on the floor, Resident C was situated between the bed and the bedside table. LPN 5 indicated Resident C told her they were trying to reach their personal cell phone that was on the bedside table when they rolled off of the bed. LPN 5 could not remember if there was a fall mat next to Resident C's bed or not. LPN 5 indicated at the time of the fall, Resident C had recently gained a little more range of motion in their lower arms, but they had little to no control of them. She indicated from the elbows down Resident C could flop their arms where they wanted them to go, but it wasn't controlled. LPN 5 compared the resident's movements to a fish out of water, very floppy and uncontrolled. A policy titled, Falls and Fall Risk, Managing, was provided by the DON on 4/1/26 at 1:15 p.m. It indicated, .According to the MDS, a fall is defined as unintentionally coming to rest on the ground, floor or other lower level, but not as a result of overwhelming external force (e.g. a resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. This citation relates to Intakes 2706508 and 2807265. 410 IAC (Indiana Administrative Code) 16.2-3.1-45(a)

Based on record review and interview, the facility failed to notify the Ombudsman of a discharge and failed to send a bed hold notification with the resident or to the family representative for 2 of 3 residents reviewed (Resident F and H). Findings include:1. On 3/31/26 at 1:00 p.m., a record review was completed for Resident H. She had the following diagnoses which included, but were not limited to, dysphasia (difficulty swallowing), dementia, and anxiety.A progress note, dated 3/9/26 at 11:38 a.m., indicated she was seen by the Nurse Practitioner and new orders were received to send resident to the emergency room (ER).The resident's record lacked notification of the Ombudsman, and a bed hold notice was not given to the resident and/or family representative.2. On 3/31/26 a record review was completed for Resident F. He had the following diagnoses which included, but were not limited to, Pick's disease (a rare form of dementia), aphasia (difficulty speaking), and repeated falls. A progress note, dated 3/1/26 at 7:45 a.m,. indicated Resident F was found on the floor in his room at 7:30 a.m. He was alert and awake, blood noted from a gash above his left eyebrow. He was able to move all extremities (arms and legs), no other trauma was noted after an assessment was completed. Resident was assisted to his wheelchair. His vital signs were obtained, and the ambulance was notified to transfer resident to the ER. The DON, primary physician and family were notified. Resident was picked up by an ambulance at 7:45 a.m.The resident' record lacked notification of the Ombudsman, and a bed hold notice was not given to the resident and/or family representative.On 4/1/26 at 2:38 p.m., the Director of Nursing indicated the Social Worker did not notify the Ombudsman and bed holds were not sent with residents and family representatives were not made aware of bed holds. On 4/1/26 at 1:40 p.m., a policy was requested for the discharge process, but it was not received before the exit conference.This citation relates to Intake 2807265.

Based on interviews and record review, the facility failed to ensure appropriate baseline care plans (a required, preliminary care plan developed for nursing home residents within 48 hours of admission to ensure safe, effective, and person-centered care until a comprehensive care plan is finalized) were in place for a newly admitted resident (Resident J) within the required timeframe for 1 of 8 residents reviewed for baseline care plan implementation.Findings include:On 3/31/26 at 2:30 p.m. Resident J's medical record was reviewed. They were a long-term care resident whose diagnoses included, but were not limited to, bipolar disorder and hypertension (high blood pressure).A progress note, dated 3/28/26, indicated Resident J was admitted to the facility.On 4/1/26 Resident J's care plans were reviewed.Resident J's medical record lacked documentation of baseline care plans.During an interview on 4/1/26 at 11:24 a.m. the Director of Nursing (DON) indicated it was the facilities policy that within 48 hours a baseline care plan was to be put in place for all new admissions.On 4/1/26 at 12:44 p.m. a copy of a current facility policy titled, Care Plans- Baseline, undated was provided. That policy indicated, . A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission.This citation relates to Intake 2799346.410 IAC (Indiana Administrative Code) 16.2-3.1-30(a)

Based on record reviews and interviews, the facility failed to ensure a newly admitted resident had a code status ordered and displayed in their chart for 1 of 1 residents reviewed for code status concerns (Resident G). Findings include:On [DATE] at 11:35 a.m. Resident G's record was reviewed. They were a long-term care resident whose diagnoses included, but were not limited to, hypertension (high blood pressure) and type 2 diabetes. At the time of the review Resident G was their own responsible party. The medical record lacked an order for Resident G's code status. Hospital records, dated [DATE] at 3:15 p.m., indicated Resident G's code status for that hospital stay was a full code status. During an interview on [DATE] at 9:25 a.m. Resident G indicated they wanted to be a full code status and wished to have all interventions in place. During an interview on [DATE] at 10:57 a.m. Licensed Practical Nurse (LPN) 7 indicated she knew Resident G was a full code from the hospital records and they had the Physician Orders for Scope of Treatment (POST) (a medical document that turns a seriously ill patient's treatment wishes into portable physician's orders, covering decisions like CPR, life support, and antibiotics to ensure preferences for end-of-life care are followed) form ready for the resident's family to fill out. Resident G's family visited the Resident on [DATE]. LPN 7 indicated they knew she had visited but did not have time to have her fill the paperwork out while she was at the facility. At the time of exit a copy of a current facility policy titled, Advanced Directives, was provided. That policy indicated . The resident has the right to formulate an advanced directive, including the right to accept or refuse medical or surgical treatment. Advanced directives are honored in accordance with state law and facility policy. Determining Existence of Advanced Directive 1. Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or legal representative, about the existence of any written advanced directives. Decision-Making Capacity 1. Upon admission the interdisciplinary team assesses the residents decision-making capacity and identifies the primary decision-maker if the resident is determined not to have decision making capacity This citation relates to Intake 2696487. 3.1-4(d)3.1-4(e)3.1-38(f)3.1-4(l)(4)

Based on observation, record review, and interview, the facility failed to update a resident's care plan after an allegation and incidents occurred for 3 of 5 residents reviewed for care plans (Residents B, C, and F).Findings include: 1. On 12/22/25 at 11:28 a.m., Resident B was observed sitting up in a wheelchair. She denied any pain when asked. She was noted to have bruising over the bridge of her nose, along with both eyes. She denied knowing how she received the bruising.On 12/22/25 at 1:30 p.m., observed Resident B up ambulating with her chin to her chest, making it hard to see where she was going. A record review was completed on 12/22/25 at 1:45 p.m. She had the following diagnoses to include, but not limited to, gastric reflux, anxiety disorder, hypertension, hallucinations, and Alzheimer's disease. A progress note, dated 10/11/25 at 5:12 p.m., indicated she had a history of wandering aimlessly about the unit.She had a care plan, dated 7/11/25, indicating she was at risk for wandering/elopement, she had a history of wandering into other residents' rooms and space related to diagnosis and unable to identify boundaries or safety.She had a care plan, dated 7/28/25, indicating she was at risk for falls related to confusion, dementia and refuses to wear shoes and likes to walk around bare footed. She had a care plan, dated 12/22/25, indicating she was on anticoagulant therapy.She had an order, dated 7/12/25, for aspirin 81milligrams (mg) by mouth daily for abnormal EKG (electrocardiogram).Her bruising was not updated on the care plan.2. On 12/22/25 at 1:41 p.m., Resident C was observed sitting in a wheelchair. She indicated she was at a children's party and denied any pain. She denied any allegations of sexual abuse.A record review was completed for Resident C. She had the following diagnoses which included, but were not limited to, hypertension, vitamin D deficiency, delusional disorder, osteoporosis, dementia, and schizoaffective disorder.A progress note made on 12/18/25 at 6:51 p.m., indicated Resident C made an allegation that a teacher sexually assaulted her. An investigation was initiated.On 12/22/25 at 1:51 p.m., spoke with the daughter and she indicated her mother had a urinary tract infection at the time of the allegation and she believed it was the infection that made her mother make the allegation.On 12/18/25 at 7:42 p.m., physician orders were noted by the physician for labs and to obtain urine for testing.On 12/22/25 a progress note was made indicating the urine results were reviewed by the physician and she started on an antibiotic for 5 days for a urinary tract infection.Resident C had a care plan, dated 12/2/22, indicating she had impaired cognitive functioning and impaired thought processes/encephalopathy, experiencing consistent delusions related to others trying to harm her and will ruminate on the same delusion for sometimes several days.Her care plan was not updated after the allegation of sexual abuse.3. On 12/22/25 at 1:41 p.m., observed Resident F sitting up in a chair with bruising noted to her right jawline. She denied any pain. On 12/23/25 at 10:13 a.m., a record review was completed for Resident F. She had the following diagnoses which included but were not limited to Alzheimer's disease, vascular dementia, bradycardia (slow heartbeat), and cardiomyopathy (disease of the heart muscle). On 12/15/25 a progress note indicated resident had discoloration to her jaw area after being suctioned last Friday.On 12/16/25 a progress note indicated resident had discoloration to right jaw related to being suctioned. Her record lacked a care plan for the bruising to her jawline. During an interview on 12/23/25 at 1:31 p.m., the Administrator indicated the care plans were updated after being informed the records were lacking care plans.A policy titled, Care Plans, Comprehensive Person-Centered, dated March 2023, was provided by the Administrator on 12/23/25 at 3:45 p.m. It indicated, .Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's condition change.This citation relates to Intakes 2697032 and 2685850.3.1-35(c)(2)

A. Based on observations, interviews, and record review, the facility failed to ensure resident specific care was initiated to ensure quality of care was provided to a newly admitted resident (Resident G) for 1 of 6 residents reviewed for quality of care. B. Based on record review and interview, the facility failed to follow physician orders to monitor resident's weight daily for fluid overload and notify the physician of weight gain in 24 hours as ordered for 1 of 4 residents reviewed for quality of care (Resident D). Findings include:On 12/22/25 at 10:30 a.m. Resident G was observed yelling out from their room for help. The call light was on, and the resident was lying in bed. Resident G indicated they were desperate for someone to help them get comfortable in bed and that they had been calling for help for a while now. Resident G had on a hospital type gown, their arms were swollen, and they had very limited Range of Motion (ROM) in their arms and hands. There was a catheter bag hanging on the side of the bed that was draining urine and an oxygen concentrator set to 2 liters that was connected to a nasal cannula and was observed in Resident G's nose. Resident G's TV was playing cartoons, they indicated the TV did not work, it only had two channels, and it had been on cartoons since they had got there. Resident G indicated they didn't mind the cartoons, but it was not what they wanted to watch. Upon observing the remote, the only buttons that worked on the resident's remote were the power button and the volume buttons. On 12/22/25 at 11:00 a.m. an unknown Certified Nursing Assistant (CNA) was assisting Resident G with getting comfortable in bed, when she became frustrated with the resident. The CNA indicated to Resident G that she could not help them because they already had been pulled up and already had pillows underneath them. Resident G indicated she needed to be pulled up more. Reluctantly, the unknown CNA and an unknown QMA pulled Resident G up to the very top of the bed. Resident G indicated it was better, but they wanted a rolled-up towel under their right hip so that they were off their wound that hurt. The unknown CNA continued to be frustrated with Resident G indicating she would not put a towel under them because it could cause a wound. After hearing what was going on from the hall, Registered Nurse (RN) 8 came into the room to help the unknown CNA. RN 8 placed a pillow under Resident G's right hip, and the resident indicated they were comfortable. RN 8 indicated she would let maintenance know about the resident's TV. The resident's call light was placed within reach, but the staff members left the resident's personal cell phone on the dresser in front of the bed. On 12/22/25 at 11:15 a.m. Resident G's family member came to visit the resident. She was very upset because the facility did not have her down as the first emergency contact, so she had not been notified of Resident G being discharged from the hospital or being admitted to the facility. On 12/22/25 at 2:10 p.m. Resident G was observed as they sat in their wheelchair in their room. The call light was not on. The resident was frantic and thankful someone had come to help them because the wound on their bottom hurt. Resident G had a pillow on the floor to their left, and their left arm was trapped between their body and the arm of the wheelchair. To Resident G's right there was a pillow between their body and the wheelchair, a pillow on top of the arm of the wheelchair and their left arm was dangling off the side of the wheelchair. Resident G was not sure how long they had been sitting there, but because of the swelling in their arms and hands, their right arm had become indented from where it was trapped. The resident's lunch tray was sitting on their bedside table out of reach. The liquids that were on the tray were a thin consistency. Resident G's call light was sitting on the bed out of reach of the resident at the time of the observation. Resident G had a new remote, but they indicated it did not work either, the news was playing on the TV. Upon observation, the new remote had the same issue as the previous remote had. The call light was pushed on behalf of the resident, an unknown CNA came to answer the call light, Resident G indicated they wanted to get back in bed. The CNA indicated she would go get linen to make the bed, then get the resident back in bed and tell maintenance about the TV again. On 12/22/25 at 11:35 a.m. Resident G's medical record was reviewed. They were a long-term care resident whose diagnoses included, but were not limited to, dysphagia (difficulty swallowing), functional quadriplegia (paralysis of all four extremities), and weakness. Resident G was admitted to the facility on [DATE] at approximately 4:00 p.m. Resident G had an active order to be in Enhanced Barrier Precautions (EBP) because they had an indwelling urinary catheter. Resident G had an active order for levothyroxine (a medication used to treat hypothyroidism) that indicated it was for hyperthyroidism. The Resident did not have hyperthyroidism or hypothyroidism listed as one of their diagnoses. Resident G had an active order for atorvastatin (a medication used to treat high cholesterol) that indicated it was for hyperlipidemia (high cholesterol). The Resident did not have hyperlipidemia listed as one of their diagnoses. The medical record lacked orders for Resident G's catheter use, catheter care, and parameters for the use of the catheter. The medical record lacked orders for Resident G's oxygen use, oxygen/respiratory care, and parameters of oxygen use. The medical record lacked orders for Resident G's code status. Hospital Speech therapy records, dated 12/19/25, indicated the hospital Speech Therapist (ST) recommended Resident G have no liquids with their meals, and only small sips of ice water between meals after strict oral care (Frazier Protocol). A progress note, dated 12/19/25, indicated Resident G arrived at the facility at approximately 4:00 p.m. with 1 to 2 liters of oxygen on through a nasal cannula, they had a wound on their tailbone and paralysis to both arms was noted. This note lacked documentation of Resident G having an indwelling urinary catheter. A clinical admission progress note, dated 12/19/25 at 10:01 p.m., indicated Resident G had her own teeth, was incontinent of bowel, had a size 14 French (fr) indwelling urinary catheter, they had impaired ROM to all four extremities, and they were non-weight bearing. A lift/transfer evaluation progress note, dated 12/19/25 at 11:47 p.m., indicated Resident G was non-weight bearing, did not have upper extremity strength and was not able to assist with repositioning in the bed or the chair. A skilled evaluation note, dated 12/20/25 at 7:34 p.m., indicated Resident G did not receive oral care because they were independent, there was no edema (swelling) was present, they were not incontinent of bowel, they had a size 16 fr indwelling urinary catheter, and they had no impairment in ROM for all four extremities. A skilled evaluation note, dated 12/20/25 at 9:02 p.m., indicated Resident G did not receive oral care because they were independent, no edema was present, no oxygen was in use, they were not incontinent of bowel, they had a size 16 fr indwelling urinary catheter and they had no impairment in ROM for all four extremities. In the vitals portion of the note, it indicated Resident G had 97% oxygen saturation on oxygen through a nasal canula. Resident G had an active care plan, initiated on 12/22/25, that indicated they were on EBP for an indwelling urinary catheter and wounds. The interventions for this care plan included but were not limited to catheter care as ordered and direct care staff would use gloves and a gown with all direct care. An inventory sheet, dated 12/22/25, indicated Resident G had their own clothes available to wear. This inventory sheet also indicated Resident G had upper and lower partial dentures. On 12/23/25 at 9:25 a.m. Resident G was observed as they lay in bed. An EBP sign was observed on the wall near the door that was not there the day before. The resident had on what appeared to be the same hospital type gown as the day before, they had a pillow under each arm, and they appeared crooked in bed. Resident G's breakfast tray was sitting next to them on the bedside table; it had not been touched. On the tray were several containers of thin liquids. During an interview on 12/23/25 at 10:57 a.m. LPN 7 indicated Resident G was only on EBP because they had a wound. The Infection Prevention (IP) nurse indicated they were also on EBP because they had an indwelling catheter. The LPN 7 indicated Resident G had a size 16 fr catheter. RN 8 indicated she had cleaned Resident G's catheter on all her shifts, because she knew you needed to keep them clean from when she worked in the hospital, but she did not realize there were no orders for the care of the resident's catheter. RN 8 indicated Resident G was incontinent of bowel, had a lot of edema at their baseline, and was dependent with all care including oral care. The LPN 7, the IP nurse and RN 8 all indicated they were not aware Resident G had upper and lower partial dentures. The LPN 7 indicated there were a lot of admissions the day Resident G was admitted , so she thought the nurses probably got the residents mixed up and charted the wrong things on some people, but she indicated the admitting nurse should have put in the standing orders for Resident G's indwelling urinary catheter, oxygen, and code status. During an interview on 12/23/25 at 12:33 p.m. the Rehab Director indicated they tried to evaluate newly admitted residents within 24 hours. Resident G's speech evaluation was done on 12/22/25 because no one was able to evaluate them over the weekend. The Rehab Director indicated it was their expectation that nursing staff would follow any hospital speech evaluation recommendations until the facility speech therapist was able to evaluate them. The Rehab Director indicated the admitting nurse should have put the order in for what the hospital speech therapist recommended for the resident's diet until the resident could be evaluated. During an interview on 12/23/25 at 12:41 p.m. the ST indicated they were still in the process of evaluating Resident G but they would most likely be recommending mildly thickened liquids. The ST indicated she had talked to the Dietary Director on 12/22/25 around lunch time and she indicated she would put a note on all future meal trays to only provide thickened liquids at meals. During an interview on 12/23/25 at 1:00 p.m. the Director of Nursing (DON) indicated it was her expectation that the admitting nurse put in all pertinent standing orders within their scope, and if they were unable to do that it was the expectation that they would pass it on to the next shift to be completed. At the time of exit a copy of a current facility policy titled, Charting and Documentation was provided. That policy indicated . All services provided to the resident, progress towards the care plan goals, or any changes in the residence medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care . 2. The following information is to be documented in the resident medical record: a. Objective observations. c. Treatments or services performed. 3. Documentation in the medical record will be. complete, and accurate. 7. Documentation of procedures and treatments will include care specific details, including: a. The date and time the procedure/treatment was provided; b. The name and title of the individual(s) who provided the care. At the time of exit a copy of a current facility policy titled, admission Assessment and Follow Up: Role of the Nurse was provided. That policy indicated . The purpose of this procedure is to gather information about the residence physical, emotional, cognitive, and psychosocial condition upon admission for the purpose of managing the resident, initiating the care plan, and completing required assessment instruments, including the MDS [Minimum Data Set]. Steps in the procedure. 7. Conduct an admission assessment (history and physical), including: c. A list of active medical diagnoses and patient problems (such as. impaired mobility), especially those most related to reasons for admission to the facility and those that are affecting function, nutrition, hydration, quality of life. d. Current medications and treatments. 10. Determine if the resident has existing advanced directives. if not, provide the resident with information on his/her rights to have advanced directives and initiate the process of establishing them. 11. Reconcile the list of medications from the medication history, admitting orders, the previous MAR [Medication Administration Record] (if available), and the discharge summary from the previous institution, according to established procedures This citation relates to Intake 2696487. B. On 12/22/25 at 10:39 a.m., Resident D observed to have lower leg edema with bandages covering his lower legs to help reduce edema. On 12/22/25 at 10:39 a.m., a record review was completed for Resident D. He had the following diagnoses which included, but were not limited to, low blood pressure, congestive heart failure, unstageable ulcer of his left heel, presence of cardiac pacemaker, muscle weakness, and multiple falls. He had a care plan intervention, dated 8/31/25, for no shoes on left foot for wound healing and ACE wraps, compression wraps toe to knee both legs for edema. On 10/23/25 at 1:47 p.m., his weight recorded was 224.0 pounds in a risk meeting note. The note indicated he was on daily weights due to fluid volume overload. As of the record review on 12/22/25, Resident D had a current physician orders for a daily weight and to call if weight greater than 3 pounds in 24 hours or 5 pounds in one week. On 12/4/25 his weight was 198.9 pounds and on 12/5/25 his weight was 205.0 pounds. Resident D gained 6.1 pounds in a 24 hour period. Resident D's record lacked documentation that the physician was notified. On 12/15/25 his weight was omitted. A policy titled, Weight Assessment and Intervention, was provided by the Administrator on 12/23/25 at 3:45 p.m. It indicated, Residents are weighed upon admission and at intervals established by the interdisciplinary team. This citation relates to Intake 2681660. 3.1-37

Based on observations, interviews, and record review, the facility failed to ensure proper infection control practices were used when caring for a resident who was in Enhanced Barrier Precautions (EBP) for 1 of 3 residents reviewed for infection control concerns (Resident G). Findings include:On 12/22/25 at 10:30 a.m. Resident G was observed in her room from the hallway. The resident was lying in bed calling out for help, the resident's call light was on at the time of the observation. Resident G had a catheter bag hanging on the side of their bed that was draining urine. There was no EBP sign on or around her door. The inside of Resident G's room was observed and there was no EBP sign in the room at the time of the observation. On 12/22/25 at 10:45 a.m. an unknown Certified Nursing Assistant (CNA) and an unknown physical therapy assistant were observed as they assisted Resident G with moving up in bed. Both staff members only wore gloves during the care they provided. On 12/22/25 at 11:00 a.m. the same unknown CNA and an unknown Qualified Medication Aide (QMA) were observed as they assisted Resident G with getting comfortable in bed. Both staff members only wore gloves during the care they provided. On 12/22/25 at 11:15 a.m. the unknown QMA left the room and RN 8 came in to assist the unknown CNA with adjusting Resident G. Both staff members only wore gloves during the care they provided. On 12/22/25 at 11:35 a.m. Resident G's medical record was reviewed. They were a long-term care resident who was admitted to the facility from the hospital on [DATE] at approximately 4:00 p.m. A clinical admission note, dated 12/19/25, indicated Resident G had a pressure ulcer on her coccyx (tailbone) and had an indwelling urinary catheter. On 12/23/25 at 9:25 a.m. Resident G was observed as she lay in bed. There was an EBP sign observed inside the resident's room. There was a Personal Protective Equipment (PPE) cart next to the room next door to Resident G's room, but not one next to the resident's room. RN 8 was observed helping Resident G with getting comfortable. RN 8 only wore gloves during the care she provided. During an interview on 12/23/25 at 10:57 a.m. LPN 7 indicated Resident G was only on EBP because they had a wound. The Infection Prevention (IP) nurse indicated they were also on EBP because they had an indwelling catheter. The IP nurse indicated gloves, and a gown should be worn any time someone would be in high contact with the resident. On 12/23/25 at 1:20 p.m. Resident G's catheter bag was observed laying on the ground next to the bed. At the time of exit a copy of a current facility policy titled, Policies and Practices- Infection Control was provided. That policy indicated .This facility's infection control policies and practices are intended to facilitate maintaining a safe, comfortable environment and to help prevent and manage transmission of diseases and infections. 2. The objective of our infection control policies and practices are to: a. prevent.infections in the facility. EBP was not discussed in this policy, and no other policy was provided. This citation relates to Intake 2696487. 3.1-18(b)

Based on observation, and interview, the facility failed to maintain clean and sanitary conditions in pantry and pantry refrigerators in 2 of 2 food storage and food preparation areas (Healthcare and Memory Care). This deficient practice had the potential to affect 61 of 62 residents who received solid and liquid oral nutrition. Findings include: A Facility Reported Incident (FRI) during the survey indicated, on 11/14/25, a fire occurred on the Memory Care unit (MC) in the closed pantry which remained locked. Staff were alerted to the fire when smoke was seen and the fire alarm sounded. Staff extinguished the fire, which was noted to be paper towels on top of the stove. On 12/1/25 at 10:12 a.m., observation of the MC pantry with the Housekeeping Supervisor, the Infection Preventionist/Licensed Practical Nurse (LPN) 5, and the Assistant Housekeeping Supervisor. The pantry was observed to have an odor of smoke as the door was opened. There was a space observed between the counter and microwave stand, the Housekeeping Supervisor indicated was from where a stove had previously been placed until a recent fire, and there was an empty fire extinguisher sitting on the floor by the wall. The floors, cabinets, and sink were heavily soiled with unidentified dried liquids and debris, and the sink had standing water from a plugged sink. Underneath the sink was observed to be packed with a large plastic tote containing random objects to include 12 flower vases, a small gray wash pan, a plastic packet of disposable eating utensils, a partially filled water bottle containing pink liquid, and all the objects were heavily coated in dust. A refrigerator was observed to be heavily soiled inside, torn pieces of paper towel were dried to the top glass shelf, and a bagged aluminum food container was on the second shelf without an identifying name or date. LPN 5 indicated the refrigerator was used for resident food and drink storage. The Assistant Housekeeping Supervisor indicated after the fire, on 11/14/25, housekeeping staff had worked hard to clean the pantry and had scrubbed the room with soap and water and chemicals to remove the soot, dry chemical residue from the fire extinguishers, and smoke smell. The Housekeeping Supervisor indicated housekeeping staff were responsible for cleaning the pantry, and the dietary staff were responsible for cleaning the refrigerator. On 12/1/25 at 2:23 p.m., observation of the Healthcare pantry refrigerator with the Administrator (ADM) and Qualified Medication Aide (QMA) 10. The shelves contained a large purple soft sided lunch bag belonging to a QMA, and 2 containers of food for Resident X dated 11/14. There was a black plastic take out container of food, a styrofoam cup of soda and a plastic cup containing a milk shake with a spoon sticking out of the opened top both from restaurant chains, a chicken salad sandwich in a white plastic bag, food stored between two paper plates in a plastic bag, all with no name or dates. The refrigerator doors held an opened half empty bottle of protein drink with no name or date, an uncovered container of vanilla pudding dated 11/29, two mostly empty bottles of water with no name or date, a large metal tumbler with no name or date, a bagged styrofoam container of wilted salad with mom on the top and no date, and a container of unidentified food that smelled putrid and was entirely covered in bright green mold with no name or date. The ADM indicated she was unsure how long perishable foods could be left in the refrigerator. A memo on green paper taped to the front of the refrigerator indicated, 5/29/24 All food is to be labeled and dated before putting into the refrig/freezer. On 12/1/25 at 2:44 p.m., Dietary Aide 11 was observed placing a tray carrying 12 bagged snacks for residents, onto the top shelf of the refrigerator next to QMA 10's purple lunch bag. The resident snack bags were all dated, had resident names, and listed the contents of the bags. On 12/1/25 at 2:28 p.m., observation of the Healthcare pantry with the ADM and QMA 10. There was a metal ice machine in the corner with the front panel secured shut with white duct tape. Double metal sinks were soiled with unidentified white substances, a squirt bottle of multipurpose cleaner sat on the counter, and the surface of the counter felt gritty and sticky with unidentified substances. A microwave oven mounted over the counter was observed to be soiled both on the outside and inside with food debris. There was a blue bucket, a section of PVC pipe, an opened bottle of dandruff shampoo, and a box of bug killer being stored under the sink. A black 3-tiered utility cart sat next to the wall with 2 metal dispensers labeled coffee and hot water among a copious amount of spilled white granular substance and empty sugar packets on the top shelf. Hot chocolate packets and jelly packets lay on the second shelf next to containers of beverage accoutrements. During an interview on 12/1/25 at 2:53 p.m., the Healthcare Unit Manager (UM) 12 indicated the staff was supposed to keep their food in the staff breakroom refrigerator. UM 12 indicated she was unsure who was responsible for monitoring and cleaning the resident refrigerator in the Healthcare pantry, but she would find out. On 12/1/25 at 3:02 p.m., UM 12 indicated the kitchen staff were supposed to clean the pantry refrigerators monthly, and the supervisors were supposed to monitor and maintain between the dietary cleanings. Quarterly Detail Refrigerator Clean logs for Memory Care and the Healthcare, indicated dietary staff had dated and signed on 1/17/25, 4/21/25, 7/24/25 and 10/22/25. During the exit conference, LPN 13 indicated there was a total of 1 resident who had an enteral feeding tube between the Healthcare and MC units. On 12/1/25 at 3:09 p.m., LPN 5 provided a Refrigerators and Freezers policy, dated December 2014, and indicated the policy was the one currently being used by the facility. The policy indicated, .6. Information regarding acceptable storage periods for perishable foods will be kept in the supervisor's office. A condensed version will be posted by each refrigerator and freezer for reference.8. Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates.10. Refrigerators and freezers will be kept clean, free of debris, and mopped with sanitizing solution on a scheduled basis and more often as necessary. This citation relates to Intake 2669612. 3.1-21(i)(3)

Based on observations, interviews, and record review, the facility failed to ensure food in the main kitchen during meal prep were covered and protected from potential contamination, failed to ensure foods in the walk-in refrigerator were labeled/dated and covered from the potential for contamination, and failed to ensure the dish washing machine reached the minimum sanitation temperatures. This deficient practice had the potential to affect 53 of 53 residents served from the kitchen. Findings include:1. During an initial kitchen tour on 9/16/25 at 9:40 a.m., with the Lead [NAME] present, the following was observed: The kitchen floors were littered with food crumbs and spills under prep tables. Behind the stove and hot boxes there was a significant buildup of grease, food debris, and standing water. Three large trash cans were full of refuse and had been left uncovered. Several flies were observed throughout the kitchen near storage and preparation stations. Nearly all food being prepped was left uncovered while flies were active in the area. Approximately 30 portions of cake were cut and placed on racks uncovered, and a large bowl of drained pasta was left in a prep sink uncovered during the observation. In the walk-in freezer, six tubs of ice cream were stored directly on the floor. Multiple items had been removed from their original packaging and were not labeled or dated. In the walk-in refrigerator, uncovered food items included: two trays of prepared fish fillets, three trays of clam chowder, two trays of individual jello, and a pan of pork chops. The Lead [NAME] indicated he had been away from work for several days and had not had the chance to check on food storage, but it was all the staff's responsibility to ensure food was covered, labeled and dated. In the walk-in refrigerator, there was a large red tub at the back of the unit which contained standing water which had accumulated from a cut-off PVC pipe that had been sawed off, allowing condensation from the refrigeration system to drip into the tub. The Lead [NAME] indicated this had been an improvised repair solution, after the refrigeration unit had some constructive repairs done in the previous weeks. The Lead [NAME] did not know when the maintenance department would return to seal the leaking pipe, but until then, the bucket collected the water and staff were supposed to empty it every shift. On 9/17/25 at 2:00 p.m., the Kitchen Manager provided a copy of current facility policy titled, Pest Control, dated 2022. The policy indicated, Team members must take preventative measures to restrict and eliminate pests from the operation. store food and supplies away from walls and six inches from the floor. On 9/17/25 at 2:00 p.m., the Kitchen Manager provided a copy of current facility policy titled, Labeling and Date Marking, dated 2022. The policy indicated, All food must be properly labeled and dated. 2. The industrial dishwasher was labeled as high temperature sanitizing machine but failed to reach the required sanitizing rinse of 180 F, after three observations. The highest recorded rinse temperature was 153 F. There were three separate temperature reading options; the built-in dial temperature, a secondary (Dishwasher Chemical Company name) digital temperature gauge, and a black plastic thermometer disk which could be manually run through the wash. On 9/16/25 at 9:50 a.m., the Kitchen Manager arrived. The Lead Cook, the Dishwasher, an unidentified kitchen aide, and the Kitchen Manager were all asked which of the three temperature gauges was used to test the dishwasher's temperature. The Lead [NAME] and unidentified aide did not know. The Dish Washer indicated he used the digital (Dishwasher Chemical Company name) result, and the Kitchen Manager indicated she used the plastic dish which she placed in a wash cycle at that time. The disk came out of the wash, and only read 157 F. A review of the dish washer temperature log revealed no recorded high temp of 180 F had been obtained for the month of September 2025. On 9/17/25 at 1:29 p.m., the Kitchen Manager and an Dishwasher Chemical Company Consultant Technician were present for a second visit to the kitchen. At that time, a was cycle was observed and all three of the temperature dials registered the sanitizing cycle to reach 180 F. The Consultant indicated he guessed the staff forgot to turn on the hot water booster, because everything else seemed to be in working order. He confirmed the machine did require temperatures to reach 180 F for the final rinse to sanitize the dishes. The Kitchen Manager indicated she thought the final rinse only needed to be 160 F, but she would re-educate her staff to ensure the booster was turned on and rinse cycles reached 180 F. 3.-21(i)(1)3.-21(i)(3)

A. Based on observation, interview, and record review, the facility failed to ensure a resident's right to make decisions regarding her care and treatments for 1 of 15 residents reviewed for resident rights (Resident K). B. Based on observation, interview, and record review, the facility failed to maintain residents' right to dignity when providing wounds treatments in common areas, using inappropriate clothing protectors at meal times, during activities, and when speaking with residents for 11 of 15 residents reviewed for resident rights (Residents E, F, G, H, J, L, M, P, 28, 48, and 55). Using the reasonable person concept this deficiency had the potential to cause residents discomfort and humiliation. Findings include: A. On 9/16/25 at 2:35 p.m. Resident K was observed as she sat in her wheelchair in her room. Resident K indicated her healthcare POA was not a family member, just someone she had known a long time and previously trusted. She indicated the POA lived in Oregon but instead of talking to her about her care the staff ask her POA. Resident K indicated she did not trust her POA anymore and did not feel she had her best interest at heart. Resident K was able to recall many details from her life both prior to living at the facility and after moving into the facility. The resident had one pair of glasses sitting on her bedside table, she indicated she needed new ones because she could not read with that pair. On 9/17/25 at 10:15 a.m. Resident K's medical record was reviewed. She was a long-term care resident whose diagnoses included, but were not limited to, chronic kidney disease and hypertension (high blood pressure). There was no dementia diagnosis for this resident. Resident K's most recent Brief Interview for Mental Status (BIMS) score was 11 out of 15 indicating moderate cognitive impairment. Resident K's living will and POA paperwork was signed July, 16th 1998. This document indicated the POA would become effective upon Resident K's disability or incompetence determined by the resident's health care provider. Resident K's current POST form was signed by the former Assisted Living (AL) Director who was the current Minimum Data Set (MDS) Coordinator and another staff member and was dated 2/29/24. This document indicated the Resident was to be a Do Not Resuscitate (DNR), comfort measures only, use antibiotics consistent with treatment goals and no artificial nutrition was to be used. On 9/18/25 at 12:31 p.m. Resident K was observed as she sat in her wheelchair eating lunch in her room, she was able recall the conversation on 9/16/25. Resident K indicated she did not recall the staff members talking to her about her wishes at this time for her code status. She indicated she was unsure of what she would want and was unaware of all the options she had. She indicated she was unaware that a POST form had been signed on her behalf by her POA, voicing again her mistrust of her POA. An optometry consent form, dated 7/15/24, indicated it had been signed by the POA via verbal consent. A flu vaccination consent from, dated 9/12/24, indicated staff received verbal consent from the POA for Resident K to receive the vaccination. A social services progress note, dated 10/3/24, indicated that Resident K's insurance did not cover glasses for the resident, but the resident had already picked out frames to be paid for out of pocket. The note indicated the POA was notified via voicemail of the cost of the glasses. A social services progress note, dated 10/7/24, indicated that another voicemail was left about the cost of Resident K's glasses. A social services progress note dated 10/10/24 indicated that another voicemail was left about the cost of Resident K's glasses. A social services progress note dated 10/14/24 indicated that another voicemail was left about the cost of Resident K's glasses. A social services progress note, dated 12/5/24, indicated that the Interdisciplinary Team (IDT) met with the POA for a care plan meeting and discussed optometry services and Resident K ordering reading glasses. The POA indicated the resident had many pairs of glasses that she didn't wear. A care plan conference summary, dated 12/5/24, indicated all topics were discussed with the POA and not the Resident. The summary indicated the POA attended the care conference via telephone. A care plan conference summary, dated 2/20/25, indicated all topics were discussed with the POA and not the resident. The summary indicated topics discussed were code status, medications, food, and pain. The summary indicated the POA attended the care conference via telephone. A care plan conference summary, dated 8/14/25, indicated all topics were discussed with the POA who was incorrectly assumed to be her daughter by the staff member filling out the summary and not the resident. The summary indicated the POA gave verbal consent for the flu vaccine, she would send chocolate shakes and snacks monthly, but would not send clothes. The summary indicated the POA attended the care conference via telephone. On 9/23/25 at 1:25 p.m. Resident K was observed as she sat in her wheelchair outside of her room in the hallway eating lunch. Resident K indicated she did not receive anything from her POA monthly. The resident was able to recall the year she signed the POA paperwork. Resident K's record lacked documentation of an order or documentation indicating a physician had deemed Resident K incompetent or incapable of making safe healthcare decisions for herself. During an interview on 9/23/25 at 2:19 p.m. the Social Services Director (SSD) indicated Resident K loved to reminisce about old times, but she knew what she wanted and had great conversations. During an interview on 9/23/25 at 2:34 p.m. QMA 21 and 25 indicated Resident K was more cognitively aware than not. They indicated she had off days but most days she was aware and capable of making decisions for herself. During an interview on 9/23/25 at 2:50 p.m. the DON indicated code status was to be discussed and in the resident's chart within 3 hours of admission. She indicated she did not allow a POA to sign consents unless the POA had been invoked, whether that be upon signature or upon physician decision. The DON indicated given Resident K's current BIMS score she would expect staff to have a discussion with the Resident regarding her care decisions, and to get a new POST form signed based on the resident's preference. Resident K should have been asked for consent before staff went to the POA to sign consents forms. During an interview on 9/23/25 at 3:17 p.m. the former AL director indicated she called the POA and she wasn't available in person so they got verbal consent for Resident K's POST form. She indicated Resident K was very out of it when that POST was signed due to being admitted from the hospital after being very ill. Now that Resident K was with it more and her BIMS was higher she would agree with the DON that another POST form should have been discussed and signed by the resident and that consents should be signed by the resident whenever possible before going to the POA. B1. On 9/16/25 at 11:08 a.m., Resident 55 was observed. She was seated in a recliner chair in the main TV lounge with an over-bed table in front of her with the remainder of her breakfast meal. An unidentified Hospice nurse arrived and removed her breakfast tray. Without wiping off the surface of the table, the Nurse set down supplies for a dressing change and put on gloves without hand hygiene. She pulled a chair up beside Resident 55, proceeded to remove an old bandage from Resident 55's right forearm, and completed a wound treatment. The resident was not moved to a private location, and the hospice nurse was not reminded by facility staff to complete medical treatments in private. Cross reference F880. 2. On 9/16/25 at 11:12 a.m., Speech Therapist (ST) 18 entered the unit to provide an activity for several residents. She went to the TV lounge with a plastic container of colorful children's toys. The toys included, but were not limited to, a Pop-It, a colorful cushioned square with raised areas inside that can be pushed in, and a Fidget blanket with buttons, zippers, ribbons etc. ST 18 handed the Pop-It toy to Resident E and indicated in a tone people would use with a baby, awwww would you like to see the pop-pop? She approached Resident F, who appeared to be asleep as her eyes were closed and her head dropped down, but placed the cushioned square on her lap. The ST 18 approached Resident G and placed the Fidget blanket on his lap and indicated in a tone people would use with a baby, do you want to see the blanket? All the Feels on there? Yea, see the zip-zip? 3. On 9/16/25 at 2:41 p.m., Resident G was observed. He was seated in a Broda wheelchair (a specialized wheelchair for residents with positioning needs) in the main TV lounge. At this time, Licensed Practical Nurse (LPN) 12 repositioned Resident G next to common seating area couch. LPN 12 sat on the couch and placed treatment supplies on the surface of the couch without cleaning the surface. LPN 12 proceeded to complete a dressing change on Resident G's left forearm without moving him to a more private location. Cross reference F880. 4. On multiple meal observations of breakfast and lunch, Resident E was observed at the table with either a hospital gown or towel draped over his chest to act as a clothing protector instead of a napkin or appropriate clothing protector. On 9/16/25 at 12:45 p.m., Resident E had not been dressed for the day and was seated at the table wearing a hospital gown, with a towel draped over his chest as the clothing protector. 5. On 9/18/25 at 10:00 a.m., several residents of different ethnicities, including Residents 28, 48 and E, were gathered in the TV lounge and were exposed to a television program containing racially offensive material, and sexually inappropriate jokes. Staff did not change the program until after the offensive content was aired. 6. On 9/17/25 at 10:30 a.m., activity staff conducted a ball-toss game in the Memory Care lounge. Residents E, F, G, H, L, M, and P, who were unable to participate, were struck in the face or body by the ball. The residents grimaced, turned away, or withdrew in discomfort. Staff continued the activity until Resident M, verbally complained of pain when the ball rolled into her face, startled her awake, and she indicated, oohhhh ooowww, and rubbed her nose. 7.On 9/18/25 at 10:30 a.m., Activity staff conducted a balloon bat game where the residents were given pool noodles and rubber balloons to bat across the table to each other. Residents E, F, G, J, L, M and P, who were unable to participate, were struck in the face with the balloons, startled awake, grimaced, turned away, and withdrew in discomfort. During an interview on 9/22/25 at 3:00 p.m., the Regional Nurse Consultant (RNC) indicated residents should receive care in private settings, be dressed appropriately in personal clothing, and participate only in activities that preserve dignity and comfort. During an interview on 9/23/25 at 3:02 p.m., the above dignity concerns were reviewed with the Administrator, (ADM). The ADM indicated all residents had the right to be treated with dignity, and in memory care, just because they don't or can't say they don't like something, staff should be aware of their dignity on their behalf. On 9/19/25 at 2:50 p.m., the Director of Nursing (DON) provided a copy of current facility policy titled, Dignity, revised February 2021. The policy indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life and feeling of self worth and self esteem. Residents are treated with dignity and respect at all times . The facility culture supports dignity and respect for residents. When assisting with care, residents are supported in exercising their rights, for example, residents are: encouraged to dress and clothing that they prefer. provided with a dignified dining experience. staff speak respectfully to residents at all times. Staff promote, maintain, and protect resident privacy, including bodily privacy, during assistance with personal care and during treatment procedures. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents . Promptly responding to a residence request for toileting assistance. 3.1-3(a)

Based on observation, interview, and record review, the facility failed to ensure grievance resolutions were provided, or effectively addressed ongoing concerns related to call lights response times and staffing availability to meet the resident's needs and preferences for 1 of 15 residents reviewed for grievances (Residents H) and for 6 of 6 residents who participated in a resident council meeting. Findings include: On 9/16/25 at 11:11 a.m., Resident H was observed. She wore shorts and had a thin sheet over her lap as a blanket. Resident H's husband arrived and indicated to Certified Nursing Aide, (CNA) 11, he was upset to keep finding her dressed in shorts because she got cold easily and preferred long pants and long sleeve shirts. Resident H's husband indicated he had complained about it on several occasions and just went to check her closet and found no long pants. He apologized to CNA 11 and indicated it was not her fault, but he was frustrated that he had to keep reminding staff to put her in long pants. During an interview on 9/16/25 at 11:15 a.m., Resident H's husband indicated he had ongoing concerns with her not being dressed the way she preferred, and that she was often served last at meals. He started coming more regularly and adjusted his visit schedule around mealtimes to ensure she got her plate when it was still warm and stayed to help ensure she ate, because he wasn't sure staff would. During a Resident Council Meeting on 9/18/25 at 2:32 p.m., with 6 members present, the council indicated they were short staffed and needed more CNAs. It often took a long time to get call lights answered, or staff would come in, turn off the light, and not come back. On 9/22/25 at 12:07 p.m., Grievances were reviewed and revealed:a. On 3/21/25 the Resident Council complained nursing was not answering call lights. There was no grievance follow up or evidence of investigation or corrective action taken by the facility.b. On 3/3/25, a resident grievance indicated, she had been laid down when her whole body started aching and she pressed the call light. Staff turned off the call light without providing assistance, and she did not receive her pain medication until the next morning. There was no documented investigation or resolution.c. On 4/22/25, a resident's friend filled a grievance which indicated, the resident was left on a bed pan for 3 hours and the resident's wife had to help with peri care every day since admission. The grievance file noted a skin check but lacked evidence of follow-up or corrective action.d. On 7/25/25, a resident filed a grievance and indicated, she waited for over an hour before she received help with her call light. There was no documented investigation or corrective action.e. On 7/30/25, a resident filed a grievance and indicated she experienced a nosebleed in the dining room and staff did not respond promptly.f. On 8/6/25 a resident's daughter filed a grievance which indicated, Resident hasn't had a shower or hair wash since admitting, [only getting bed baths] staff said 'too busy down there,' for showers. The grievance resolution dated 8/15/25 confirmed the resident continued to miss showers, with no corrective action documented.g. On 8/29/25, Resident H's husband filed a grievance which indicated, he was .upset because staff always feed her [Resident H] last and with no empathy or compassion, and aides don't talk to the residents (not all aides were like this). The grievance resolution, dated 9/4/25, indicated, things were better but still needed improvement, without documented corrective steps to ensure sustained improvement. During an interview on 9/22/25 at 3:00 p.m., the Social Service Director (SSD) indicated she was new, and could not find the resident council response forms, and did not know about resolutions or have additional documentation to provide for the above grievances. On 9/19/25 at 2:50 p.m., the SSD provided a copy of current facility policy titled, Resident Rights, revised 2017. The policy indicated, You have the right to voice grievances to the facility or other agencies that hears grievances without the fear of discrimination or reprisal, including: grievances regarding your care and treatment, the behavior or staff. other concerns regarding your facility stay. you have the right to information about how to file a grievance or complaint, including the right to: a copy of the facility's grievance policy, file a grievance verbally or in writing, file a grievance anonymously. a written decision regarding the grievance, immediate action taken to prevent further violations for your rights [NAME] a grievance is being investigated. 3.1-3(g)

Based on observation, interview, and record review, the facility failed to ensure residents who resided in the secured memory care unit received necessary care and services for activities of daily living (ADL) including eating, toileting, and grooming for 10 of 15 residents reviewed for ADLS (Residents E, F, G, H, J, K, L, M, N and P). Findings include:During a continuous observation on 9/16/25 from 10:10 a.m. until 1:00 p.m., in the secured memory care unit (MCU), the following was observed: Resident N was asleep on a couch in the TV lounge area and there was a strong odor of urine from him. Resident E was provided a small plastic cup of a supplemental chocolate shake but had fallen asleep and spilled the shake on his lap. LPN 12 took the empty cup from him but did not wipe off his lap. Residents F, G, H, J, and M's hair were observed to be unbrushed. Resident G's hair appeared greasy, Resident M's hair was falling out of a loose ponytail, and Resident F's hair was unbrushed and fell over her face. Resident G's fingernails were observed to be long and had debris under them. At 12:20 p.m., lunch was brought to the MCU and staff began to pass trays. LPN 13 and CNA 14 came to help residents eat. Residents E, F, G, J, L, M, and P all required total assistance and/or constant reminders/encouragement to eat. LPN 13 assisted Residents E and L at the same time. CNA 14 assisted Resident P while CNA 11 assisted Resident G and LPN 12 assisted Resident M. No one was available to assist or give constant reminder to Residents F and J who both just stared at their plates and other residents until eventually Resident J fell asleep at the table. When CNA 11 finished helping Resident G eat, she got up to encourage Resident J to eat. Resident J began to feed herself slowly and used her fingers. As she took the time to encourage and help Resident J eat, Resident G did not have any assistance to finish his lunch. LPN 13 left the table for several minutes to assist a resident who returned to the unit from therapy, which left Residents E and L without assistance. CNA 11 woke Resident F up and helped her take one bite, but then had to return to assist Resident G. Resident F did not attempt to take any more bites. It took over an hour to get the totally dependent residents fed. Resident K was observed to wear a name brand pair of socks which appeared to be too tight as they compressed into his lower legs and a red abrasion was observed around the whole of his right middle leg. He indicated the abrasion was because his socks were too tight and he couldn't pull them up far enough. Cross reference F686. On 9/17/25 at 9:04 a.m., Resident F was asleep at the table with only about 25% of her meal consumed. Her hair was unbrushed and hung loose in her face. Resident M was in the TV lounge in her wheelchair with her hair unbrushed and falling out of a messy, loose ponytail. Resident G's hair remained long unbrushed, and he had facial stubble. His fingernails remained long with debris under the nails. On 9/17/25 at 1:39 p.m., a resident was calling out to go to the bathroom. CNA 11 and 14 who had been assisting Residents L and P to finish their lunch, had to stop assisting them with eating as they took a Hoyer lift into the room to assist the other resident to the bathroom. On 9/17/25 at 1:40 p.m., Resident N was in his wheelchair sitting beside the couch he liked to sleep in and called over to LPN 12 that he was ready to go to the bathroom and lay down. LPN 12 was assisting Residents M and E with their lunch and indicated back to Resident N that he would have to wait a few minutes. On 9/17/25 at 1:44 p.m., another resident stood from her table and indicated she needed to go to the bathroom. LPN 12 had to stop assisting the residents she was helping eat and took the other resident to the bathroom. At that time there were 12 unsupervised residents as both aides and the nurse were behind closed door helping other residents for over 5 minutes. When LPN 12 returned to the table to finish helping with lunch, another resident attempted to go into the front public bathroom. LPN 12 called out that she could not use that bathroom but did not get up to assist her to her room or allow her to use the public restroom. On 9/17/25 at 1:50 p.m., Resident N indicated he needed to use the bathroom and wanted to lay down. LPN 12 indicated he would still have to wait as she needed to finish helping Resident M eat. On 9/17/25 at 2:10 p.m., LPN 12 assisted a resident down the hall past Resident N, who called to her that he needed to use the bathroom and wanted to lay down. She walked past him without answering. By 2:19 p.m., Activity Assistant (AA) 17 began to set up a hand message activity, but was told that Resident N was still waiting to go to the bathroom. AA 17 indicated she was also a CNA, and could help him, so she took him to the bathroom at 2:20 p.m. Resident N waited over 30 minutes to be assisted to the restroom, and upon AA 17 returning him to the activity space, she indicated he had been incontinent of urine and had a soiled brief. On 9/18/25 at 9:05 a.m., upon entrance into MCU, breakfast was being cleared away and residents were gathered in the TV lounge. Resident E was observed with facial stubble. Resident G's hair remained unbrushed and his nails were long. Resident L's hair was unbrushed and pressed to the side of her head from sleeping on it. On 9/18/25 at 12:30 p.m., CNA 14 had to assist multiple residents at once for lunch and indicated there were not enough staff to help all the residents who needed assistance, so sometimes they had to wait. On 9/19/25 at 9:12 a.m., Resident G's hair remained unbrushed and his facial stubble had grown more prominent. Resident E's facial stubble had become more prominent. During an interview, on 9/22/25 at 2:43 p.m., Resident L's husband indicated he was still able to and preferred to help his wife with as much as he could, but often if he couldn't be there, Resident L and others were not assisted in a timely manner and things like oral care, hair brushing and nail trimming might not get done. On 9/19/25 at 2:50 p.m., the Director of Nursing (DON) provided a copy of current facility policy titled, Activities of Daily Living (ADLs), Supporting, revised March 2018. The policy indicated, . Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently with the consent of the resident and in accordance with the plan of care. This deficiency was cited on 8/18/25. The facility failed to implement a systemic plan of correction to prevent recurrence.3.1-38(a)(3)

A. Based on observation, interview, and record review, the facility failed to ensure a resident with a history of fall-related fractures was transferred with two staff persons in accordance with the plan of care, and failed to ensure post fall procedures were followed for 1 of 3 residents reviewed for falls (Resident D). This deficient practice resulted in a fall while in the shower room and the resident sustained fractures of two left ribs, the spine, and the sacrum. B. Based on interview, observation, and record review, the facility failed to ensure cleaning chemicals were stored in a manor to prevent residents from accessing them for 1 of 3 residents reviewed for accidents, with the potential to effect 19 of 19 residents residing on the secured memory care unit (Resident K). Findings include: A. During a confidential interview conducted during the survey, the interviewee indicated Resident D fell , and her family took her to the hospital where she was found to have two broken ribs. Resident D's record was reviewed on 11/13/24 at 3:00 p.m. Diagnoses on Resident D's profile included, but were not limited to, muscle weakness, difficulty walking, and repeated falls. A physician order, dated 5/31/24, ordered 1 tablet daily of Sertraline (antidepressant) HCI 50 milligrams (mg) for depression. The National Institute of Health (NIH) indicated studies reported serotonin uptake inhibitors (SRRIs) were associated with an increased risk of falls in the elderly. The admission and state optional MDS (Minimum Data Set) assessments, completed on 6/6/24, assessed Resident D as usually having the ability to make herself understood and to understand others. A brief interview for mental status (BIMS) score of 10/15 indicated she had moderately impaired cognition. The resident required extensive assistance of two plus (+) persons physical assist for bed mobility, transfers, and extensive assistance of one person physical assist for toilet use. Mobility devices included a manual wheelchair (WC) and walker. Resident D had no falls in the 6 months prior to admission. The admission and state optional MDS (Minimum Data Set) assessments, completed on 6/6/24, did not reflect the resident's recent fall with fractures requiring hospitalization and surgical repair 5/27/24. Fall Risk Data Collection assessments, dated 6/1/24 and 6/10/24, indicated no falls in the last 90 days. The Fall Risk Data Collection assessments, dated 6/1/24 and 6/10/24, did not reflect the resident's recent fall with fractures requiring hospitalization and surgical repair on 5/27/24. A late entry progress note, effective date 5/31/24 at 8:51 p.m., indicated the resident was admitted to the facility via ambulance. She was total care, required extensive assistance with all activities of daily living (ADL's), and all transfers were done with 2 staff members. A care plan, dated 6/3/24, indicated the resident was at risk for falls related to history of falls, impaired vision, use of WC, and decreased mobility with possible side effects from medications. The goal was for Resident D to be free from falls through the next review. Interventions included call light within reach and encourage resident to use it, educate resident/family/caregivers about safety reminders and what to do if falls occur, ensure resident wore proper footwear, follow fall protocols, physical therapy (PT) to evaluate and treat as ordered or needed, and review information on past falls and attempt to determine cause of falls. Record possible root causes, alter/remove any potential causes if possible. The care plan, dated 6/3/24, did not reflect the resident required extensive assistance of two plus (+) persons physical assist for bed mobility, transfers, and extensive assistance of one person physical assist for toilet use requiring extensive 2 person physical assistance for transfers as indicated in the admission and state optional MDS (Minimum Data Set) assessments, completed on 6/6/24. A physician order, dated 7/1/24, ordered the resident to continue participating in skilled occupational therapy (OT) intervention to address deficits in strength, balance, transfers, and ADL performance. A physician order, dated 8/13/24, ordered 1 tablet daily of Cyanocobalamin (a form of Vitamin B12) 100 milligram (mg) related to difficulty walking. A physician order, dated 8/13/24, ordered 1 tablet daily every 2 days of Ferrous Sulfate (used to treat iron deficiency anemia) 325 mg related to muscle weakness. A progress note, dated 8/14/24 at 3:15 p.m., indicated Resident D had returned from an emergency room (ER) visit, on antibiotics (ATB) for right lower extremity (RLE) cellulitis, to be completed in 3 days. Therapy evaluated for leg position for comfort, family at bedside, no further concerns noted, and call light was within reach. A History and Physical note, dated 8/14/24, the Nurse Practitioner (NP) indicated Resident D was readmitted to the skilled nursing facility (SNF) on 8/13/24 following hospitalization on [DATE] for RLE discoloration and edema. The resident was completing a course of cephalexin (Keflex antibiotic) for RLE cellulitis. Prior to this, she was admitted to SNF on 5/31/24 following hospitalization from [DATE] for a fall. A progress note, dated 8/15/24 at 8:00 a.m., indicated Resident D's daughter requested that her mother be sent to the ER for evaluation post fall that occurred on the evening of 8/14/2024. Head to toe assessment completed. No injury noted. The resident complained of hitting her head and that her left ribs were hurting. Resident skin warm and dry, no distress noted. Alert and responding verbally. A progress note, dated 8/15/24 at 9:00 a.m., indicated emergency transport arrived to transport resident to (a local hospital) for evaluation and treatment, the family accompanied resident to hospital. Transfer medical paperwork sent with emergency medical services (EMS). Resident transported by stretcher. A late entry progress note, effective date 8/15/24 at 9:20 a.m., created 8/16/24 at 8:13 a.m., the Director of Nursing (DON) documented discoloration noted to RLE, no redness, no drainage, no open areas noted, +1 pitting edema noted, continue ATB for cellulitis of RLE, added note to previous note regarding skin. Previous late entry notes 8/15/24 resident left to local hospital at 9:30 a.m., daughter at bedside. A late entry progress note, effective date 8/15/24 at 9:20 a.m., created 8/16/24 at 8:13 a.m., the DON documented resident lying in bed, complaint of pain to left (L) side, alert and oriented, head to toe assessment completed, no discoloration noted to body, no raised areas, per family resident complained of numbness to face, writer assessed no hardened or raised areas noted, skin normal to touch, resident able to feel writer touching face, no change in speech pattern, no change in mental status, family request resident be transferred to ER for evaluation and treatment related to fall previous day, positive range of motion (ROM) noted, no skin alterations noted, resident to be transferred to (a local hospital) per family request, no further concerns noted. A physician's order, dated 8/15/24, indicated transfer resident to (a local hospital) per family request for evaluation and treatment. A transfer form, dated 8/15/24, indicated discharge to hospital for pain. The resident ambulated only with human assistance. On 8/15/24 a new intervention was added to the care plan, dated 6/3/24, after the resident discharged to the hospital, indicating to use 2 staff at all times for transfers. A hospital emergency department visit note, dated 8/15/24 at 10:15 a.m., chief complaint was a fall from a standing position, leg pain, and chest pain. The note indicated the patient presented from a nursing home after a fall. Nursing staff reported to EMS that the patient lost her balance getting out of the shower and was helped to the ground. The patient reported she fell and struck the back of her head. Physical exam comments indicated the left pupil was sluggishly reactive, and the right pupil was nonreactive. Extensive bruising noted to right upper and lower leg. A hospital emergency department visit note, dated 8/15/24 at 11:15 a.m., indicated a resident presented to the hospital post fall and hit her head, and complained of pain to head, neck, and lower extremities. Assessment/Plan, the patient was recently admitted for fall that resulted in multiple lower extremity injuries requiring operative repair on 5/27/24. Obtained computed tomography (CT - noninvasive x-rays to creature detailed pictures of the body) imaging which demonstrated rib, transverse process, and sacral fractures. Also obtained CT angiography of the head and neck after the fall to evaluate for possible cerebral occlusion leading to the fall, but there were no acute findings on the studies. The patient was admitted to the trauma team for further management. CT radiology study of abdomen pelvis with contrast indicated: a. Slightly displaced left 10th and 11th rib fractures. b. Nondisplaced L3 right transverse process fracture (a break in the bony projection on the side of the third lumbar vertebra in the spine). c. Probable subacute left sacral (a mending fracture in the left side of the triangular bone at the base of the spine) and acute right sacral nondisplaced fractures (new breaks in the right side of the large triangular bone at the base of the spine), not visualized on recent comparison study 5/27/24. d. Healing subacute right superior and inferior rami fractures (fracture of the pelvic ring). An Interdisciplinary Team (IDT) note, dated 8/16/24 at 1:40 p.m., indicated IDT met to review witnessed fall. The resident was noted to be lowered to the ground by a staff member while attempting to transfer from a shower chair to a WC. The resident's legs became weak, and she was lowered to the ground. She did not hit her head, positive ROM noted, no change in mental status, no visible injuries noted. Factors contributing to the fall: a wet floor, no non- skid footwear in place, and currently being treated for cellulitis of RLE. Diagnoses included muscle weakness, cognitive communication deficit, glaucoma, and falls. Root causes included weakness, unsteady weak gait, complaints of pain to RLE from cellulitis, shower chair malfunction with locking of wheels. New interventions included maintenance requested to fix shower chair brakes, and resident to be a two-person transfer. During an interview on 11/14/24 at 2:55 p.m., Registered Nurse (RN) 23 indicated the resident had been unable to transfer or ambulate on her own, she required 2 person assistance for safety. Review of the resident record with RN 23, dated 8/13/24 - 8/15/24, he indicated the resident record documentation did not reflect the resident had fallen on 8/14/24. The record lacked documentation on the day of the fall to include progress notes with description and root cause, the required fall risk and pain assessments, neurological assessments, or documentation the physician (MD) and resident representative were notified. There was no follow up documentation after the fall to indicate the resident's condition was being monitored. RN 23 indicated when a resident had a fall, the nurse should assess the resident for injury to include vital signs and start neurological checks if the fall was unwitnessed or if the resident had complaint of head injury. The nurse should have documented the fall, root cause, and follow up in the progress notes, and as having notified the DON, family and MD. Documentation was required in the resident's record. During an interview on 11/15/24 at 10:30 a.m., the Administrator (ADM) indicated Licensed Practical Nurse (LPN) 9 had been in charge at the time of Resident D's fall on 8/14/24, her contact information was not available on the staff contact list. During an interview on 11/15/24 at 11:19 a.m., the resident record was reviewed with the ADM. The ADM indicated she did not see documentation in the record to reflect the resident had fallen on 8/14/24. During an interview on 11/15/24 at 11:38 a.m., the ADM indicated LPN 9 had been terminated the prior day related to issues including lack of documentation. During a confidential interview conducted during the survey, the interviewee indicated when viewing the resident record there was no documentation in the progress notes on 8/14/24 to reflect the resident had fallen, or a fall assessment had been completed. They had found a confidential internal document in risk management, dated 8/15/24 at 12:44 a.m., to indicate a fall on 8/14/24. The internal document lacked the name of the Certified Nursing Aide (CNA) involved with the fall, and date or time of the fall. Incident Description indicated resident eased down to the floor in shower room, she lost her balance, and CNA eased her to the floor. Resident assessed, no injury noted, ROM within normal limits, denied hitting head, resident put back in chair. Documentation on the internal form indicated the MD was notified on 8/16/24 at 3:52 a.m., two days after the resident discharged to the hospital, and the Power of Attorney (POA) was notified 8/21/24 at 3:53 a.m., six days after the resident discharged to the hospital. The electronic medical record documentation indicated the resident had a shower on 8/14/24 at 10:37 p.m. The interviewee indicated CNA 18 had been the aide responsible for Resident D's shower on 8/14/24. An Employee Incident/Event Investigation Statement, dated 8/15/24, conducted by LPN 22 and signed by the DON, indicated on 8/14/24 (untimed) Resident D was being assisted out of shower chair to transfer to WC by CNA (unidentified). The resident became weak while standing and shower chair moved backwards while locked. The resident was lowered to the ground by CNA. The resident did not hit their head, no injuries noted. Resident assisted by 3 staff members off floor to WC. A Teammate Termination Notice, dated 11/14/14, indicated LPN 9 was terminated for failure to follow expectations regarding documentation/assessments as asked. Failure to follow expectations regarding documentation outlined in the job description: Documents all pertinent information regarding nursing care, care plans, observation of the residents' overall condition and behavior . Employee refused to sign. During an interview on 11/15/24 at 12:32 p.m., the ADM had contacted the prior DON who indicated on the morning of 8/15/24, the daughter came in and referred to a fall the resident had the prior evening. The daughter indicated the resident was having hallucinations and face numbness. The DON had investigated the allegation of a fall and found the resident had been given a shower by CNA 18, had slipped and been lowered to the floor. Neurological checks had not been initiated as Resident D had no head injury. The ADM indicated, on 8/15/24, the family called 911 to have the resident transferred to the hospital. During an interview on 11/15/24 at 12:50 p.m., CNA 18 indicated on 8/14/24 after dinner probably between 6:00 p.m. and 7:00 p.m., she had given Resident D a shower in the shower room located on the hallway. After the shower had been completed, she put lotion on the resident, put a shirt on her, pulled the resident's pants halfway up to her knees, and stood behind the resident as the resident stood up with the WC in front of her to hold onto. The resident's leg started to give out and as the resident leaned back against CNA 18. CNA 18 eased the resident down, sliding her on the CNA's clothes. CNA 18 indicated that the resident did not fall or hit her head. The CNA then opened the shower room door and yelled at LPN 9 to come to the shower room. LPN 9 assessed the resident, took vital signs, and asked about pain, which the resident denied. CNA 18 and another aide then placed the resident in her WC where she remained for another 90 minutes then was put to bed per her request. CNA 18 indicated, to her knowledge, the resident only required 1 person physical assistance for transfers, but she could not confirm this information. CNA 18 indicated that Resident D had been able to stand up with assistance, she had transferred the resident by herself without another staff member's assistance, and she was not aware of issues with the shower chair, so had not checked the shower chair prior to use when giving the resident a shower. Logs with documentation of preventative maintenance, concerns with the functionality of shower equipment, or response in fixing the defective shower chair in response to the incident with Resident D were not provided during the survey process. During an interview on 11/22/24 at 11:06 a.m., LPN 9 indicated Resident D had been alert and oriented. LPN indicated she thought the resident required 1 or 2 person assistance for bed mobility, and she could not ambulate, just pivoted into her WC. The resident had been working with therapy, but she had never seen her walk. Indicated on 8/13/24 the resident had a big bruise on her leg, she had been to the hospital related to cellulitis. On 8/14/24 CNA 18 gave Resident D a shower, called LPN 9 to the shower room and indicated the resident had been pushing away from her, and she lowered the resident to the floor. The resident denied pain or injury, so was assisted into a WC by CNA 18 and CNA 25. The CNAs got her dressed, and she was left in her WC awhile before going to bed. LPN 9 indicated she had documented the fall in the nurse's notes, and completed a fall assessment, she was not sure why the documentation was not in the electronic medical record (EMR). On 11/13/24 at 12:00 p.m., the ADM provided a Fall Management Programming Healthcare policy, dated 11/14/23, and indicated the policy was the one currently being used by the facility. The policy indicated, definition of a fall, .the unintentional change in position coming to rest on the ground, floor or onto the next surface .Post Fall: There are three key elements of the post-fall response and management. 1. Initial post fall evaluation. 2. Documentation and follow-up - including ongoing monitoring for resident changes in condition where medically indicated. 3. Plan of care will be reviewed and updated as indicated .Documentation and Follow-up: Following the post fall evaluation and any immediate measures to protect the resident .a. Perform neuro-checks according to the organizational policy and guidelines. b. Immediately notify the attending physician and family or guardian of condition changes .c. Transfer the resident for further evaluation and treatment where medically indicated. 2. Complete an incident report using Point Click Care (PCC - electronic documenting system) Risk Management Module .4. A detailed progress note should be entered into the resident record including the results of the post-fall evaluation. 5. Refer the resident for further evaluation by physician to ensure other serious injuries have not occurred where medically indicated. 6. Implement 72 hour every shift post fall documentation. 7. Notification of fall and intervention(s) on 24-hour report for communication to oncoming shifts for purposes of 72 hour every shift follow up documentation .Reporting and Notification: 1. Falls will be reported in the daily stand-up meeting and immediately following in the clinical meeting daily (M-F) The policy did not address fall prevention related to two staff to perform transfers according the resident assessment. A policy related to preventative maintenance, and monitoring and checking the function of equipment was not provided during the survey process. This citation relates to Complaint IN00445487. 34129 B. A confidential interview was conducted during the survey and indicated Resident K, on the secured memory care unit, had supposedly swallowed a poisonous substance on 11/11/24. Resident K's record was reviewed on 11/14/24 at 11:07 a.m. Resident K was admitted to the facility on [DATE] with diagnoses included, but not limited to, chronic obstructive pulmonary disease with acute exacerbation (a common lung disease that makes it difficult to breathe and worsens over time), dyspnea (the feeling of not being able to breathe fast enough or deeply enough), and dementia (a loss of cognitive functioning, such as thinking, remembering, and reasoning, that interferes with daily life). A quarterly Minimum Data Set (MDS) assessment, dated 9/11/24, indicated the resident had a severe cognitive impairment, required supervision or touching assistance for eating, oral hygiene, and dressing, was partial to moderate assistance for toileting hygiene, and was substantial to maximal assistance for personal hygiene and bathing. A care plan, initiated on 3/9/24 and revised on 6/17/24, indicated Resident K had impaired cognitive function/impaired thought processes, and resided on a locked memory care unit due to the diagnosis of dementia with the care plan interventions, all dated 3/9/24, to administer medication per physician orders and notify physician with any change in resident's condition; encourage/engage resident to participate in activities on the memory care unit; and monitor resident for safety when walking around the unit. A nurse's progress note, written by Licensed Practical Nurse (LPN) 16, dated 11/11/24 at 4:35 p.m., indicated Resident K drank Faboloso (multi-purpose cleaner) and poison control was contacted. The resident drank 240 milliliters (mL) of milk and ate a few graham crackers with no complaints of illness or sickness. The Faboloso cleaner label information indicated the following instructions: Keep out of reach of children; Do not swallow; If inhaled, move to fresh air; If swallowed, rinse mouth and drink 1-2 glasses of water; Contact a poison control center or doctor. The Material Safety Data Sheet (MSDS) for Faboloso indicated Faboloso cleaner was harmful if swallowed and do not drink milk or alcohol. Resident K's record lacked documentation of progress notes or other documentation to indicate the physician or resident's representative were notified of the resident ingesting a poisonous chemical. There was not a physician's order for follow up of signs or symptoms of the resident ingesting a poisonous chemical and no care plan was initiated for the resident ingesting a poisonous chemical. The record lacked progress notes or assessments related to the resident ingesting a poisonous chemical, no physician's or nurse practitioner's note to indicate they were made aware of the resident ingesting the chemical, and no orders for follow up. During a tour of the memory care unit, on 11/14/24 at 11:30 a.m., the memory care unit laundry room door was observed propped open and the unlocked laundry room cabinet contained an empty bottle of Faboloso Original Multi-Purpose Cleaner and ECOLAB Home-style solid laundry detergent with color safe bleach plastic wrapped brick in a box. On 11/14/24 at 11:58 a.m., Housekeeper 21 observed going in and out of Memory Care Unit residents' rooms and the shower room, pushing around a housekeeping cart with the cabinet that stored cleaning products unlocked. Housekeeper 21 was observed walking away from the housekeeping cart to go into the shower room. Housekeeper 21 indicated she had keys for the housekeeping cart, and it should have been locked, but the lock was broken. The cart contained the cleaning chemicals of a bleach urine remover spray bottle, a plastic bottle container of liquid hand soap, a container of stainless steel cleaner and polish, a 32-ounce (oz.) foaming acid cleaner spray bottle, a spray bottle of 32-oz. disinfecting acid bathroom cleaner, a spray bottle with 32-oz. of multi-surface peroxide, a spray bottle of 32-oz. glass force professional strength glass cleaner, a 32-oz. squeeze bottle of heavy duty toilet bowl cleaner, a 32-oz. bottle of micro-kill concentrated disinfectant cleaner, and a deodorizer spray bottle. She indicated she had not used the cleaning solution Faboloso in the facility. During an interview, on 11/14/24 at 12:19 p.m., Certified Nursing Aide (CNA) 15 indicated, on Monday, 11/11/24 at about 9:00 a.m., CNA 15 cleaned the dining room tables with Faboloso Cleaner and a cleaning towel. CNA 15 sat the Faboloso cleaner bottle on the countertop island by the tables in the dining room/activity area and then helped another staff member with two residents' showers in the shower room and forgot about the Faboloso cleaning bottle on the counter. She had gotten the bottle of Faboloso from the activity cabinet. CNA 15 indicated she had finished the residents' showers and went on with the rest of the day. On the evening shift, staff observed Resident K drinking the bottle of Faboloso and they told the memory care unit nurse. CNA 15 indicated she was not on the memory care unit at the time of the incident, she had just heard about the incident. The Memory Care Director had texted CNA 15, on 11/12/24, and asked if she had left the bottle Faboloso cleaner out on the memory care unit common area counter. CNA 15 had texted back, that yes, she had left the cleaning solution out on the counter in the memory care unit. MC texted back that Resident K had drunk some of the cleaner and staff had contacted the Director of Nursing (DON) and poison control. Resident K was okay, but staff had to put stuff away. The residents do not know any better. CNA 15 texted back to MC that yes, she had left the cleaning solution bottle on the memory unit counter, and it was an honest mistake. She was just trying to hurry and clean the dining tables and forgot to put the cleaner back into the cabinet. CNA 15 indicated she had worked at the facility for about a year and six months and could not recall the facility training her about keeping chemicals away from the memory care unit residents. On 11/15/24 at 1:02 p.m., the Director of Environmental Services (EVS) indicated the facility did not have a policy for keeping chemicals away from the residents but had a staff training class outline that specified all chemical bottles should be properly labeled and stored in a locked cabinet. The facility had not purchased the cleaner. The facility did not stock Faboloso cleaner, the memory care unit staff must have brought the cleaner onto the memory care unit. The Administrator (ADM), on 11/15/24 at 12:34 p.m., indicated she did not know about the Faboloso cleaner incident with Resident K, on Monday 11/11/24, but found out about the incident in the morning meeting on Tuesday 11/12/24. One of the staff had observed Resident K holding a bottle of Faboloso cleaner and staff had called the Director of Nursing (DON) and poison control. ADM indicated, the Executive Director (ED) had told the ADM, since Resident K did not ingest the Faboloso chemical there was nothing to report to the Indiana Department of Health. The facility did not purchase the Faboloso cleaner. The staff had brought in the cleaner. CNA 20 observed Resident K with the Faboloso in her hand and heard Resident K indicate, This thing smells like sh-t! Staff had contacted the DON and reported that Resident K had the bottle of Faboloso in her hand and had yelled out Yuck! Staff had assessed the resident and looked into her mouth and there was not a smell of the cleaner in the mouth with the mucous membrane moist and normal color. No one saw Resident K drink the cleaner and the resident yelled out Yuck. ADM indicated, on 11/11/24 at 4:12 p.m., the Nurse Practitioner (NP) was notified, and she ordered to call poison control. At 4:15 p.m., poison control indicated to give the resident milk and a snack and to monitor for any changes in condition or seizures. Resident K was sitting with staff and drinking fluids and having snacks. Staff removed Faboloso cleaner from the memory care unit. ADM indicated today, 11/15/24, ADM had ordered staff to do a complete search of the memory care unit for Faboloso, and staff had removed a bag of items out of the memory care unit. The ADM indicated the DON had written a statement and indicated the nurse on the memory care unit had her back turned and did not see the incident. ADM asked the Executive Director (ED) if the incident was a reportable and the ED had responded that staff did not observe the resident ingest the Faboloso cleaner, therefore it was not a reportable. If the incident was a poisoning, the facility would have sent the resident out to the hospital. ADM was unable to find documentation of the physician being notified of the incident nor assessments of the resident for the incident. On 11/15/24 at 3:32 p.m., ADM provided written statements from CNA 20, the nurse, and the DON about the 11/11/24 incident. CNA 20's handwritten statement indicated, she was sitting with another resident when she heard Resident K say, This thing smelled like sh-t! and when CNA 20 turned around she saw Resident K holding the bottle of Faboloso cleaner. CNA 20 took the bottle from Resident K and told the nurse. Licensed Practical Nurse (LPN) 22's handwritten statement indicated, on 11/11/24 at 4:00 p.m., a call came to the healthcare unit to come to the memory care unit, because Resident K was observed with a bottle of Faboloso cleaner in her hand and yelled out, Yuck! Resident K was assessed and there was no smell of Faboloso cleaner in her mouth with the mucous membranes moist and a normal color with no noted changes in Resident K. No staff saw Resident K drink the cleaner. The Faboloso cleaner bottle was in the resident's hand and the resident yelled out, Yuck! At 4:12 p.m., the nurse notified the nurse practitioner of the incident and was advised to call poison control. At 4:15 p.m., the nurse contacted poison control who instructed the nurse to give Resident K water and milk with a snack and monitor for a change in level of consciousness or seizures. At 4:30 p.m., Resident K was observed sitting with staff, no noted changes and drinking fluids and having snacks. At 4:40 p.m., the Faboloso cleaner bottle was removed from the memory care unit and discarded into the trash. The DON's handwritten statement indicated she had received a notification that the nurse needed help on the memory care unit. When the DON arrived on the memory care unit, she observed LPN 22 and CNA 20 standing next to Resident K and LPN 22 had a Faboloso bottle in her hand. When the DON asked what happened, CNA 20 had indicated she had heard Resident K say, This smells like sh-t and CNA 20 observed Resident K with the Faboloso cleaner bottle towards Resident K's face. CNA 20 took the bottle away from Resident K immediately and Resident K was assessed by the nurse and within normal limits with no odor on the resident's breath and no evidence of Faboloso observed on the resident's tongue. Resident K was in good spirits with no changes in level of consciousness. The Nurse Practitioner and resident's family were notified of the incident. Poison control was called, and instructions were followed. CNA 20 denied seeing Resident K drink the Faboloso cleaner. Precautions were taken and staff were educated about keeping chemicals out of reach of the residents. On 11/15/24 at 3:40 p.m., ADM provided documentation of the facility's internal incident documentation, dated 11/11/24 at 7:42 p.m., which indicated, incident description with nursing description of, Resident K was in the common area standing around and the nurse had not seen the resident drink Faboloso but the CNA had reported they saw Resident K drink a little of the Faboloso and the CNA quickly took the bottle away from Resident K. The nurse assessed the resident with no reactions or complaints of illness from the resident with the vitals within normal limits. Poison control was contacted, and the nurse was instructed to give the resident milk and a snack. Resident K drank 240 mL of milk and ate a few graham crackers. The physician, DON, and family were notified of the incident. An Interdisciplinary Team (IDT) progress note, written by the MC, dated 11/12/24 at 10:08 a.m., which indicated IDT reviewed the incident and Resident K showed no adverse signs or reaction from the cleaning product. A nurse's focused charting follow-up note, dated 11/13/24 at 11:07 p.m., indicated Resident K remained on fall follow-up, resident ate in the dining room [TRUNCATED]

Based on observation, interview, and record review, the facility failed to prevent pressure ulcers, complete follow-up assessments, track wound progression, follow interventions, and notify the physician with worsening of wounds up to and including, infections for 5 of 5 residents reviewed for pressure ulcers (Residents B, C, D, E, and F). Resident B's Stage 2 ulcer progressed to an unstageable ulcer with a wound infection and Resident C's stage 3 ulcer worsened to a Stage 4 with signs of infection. The immediate jeopardy began on [DATE] when staff failed to complete assessments and notify the physician of a pressure ulcer with symptoms of infection which resulted in the pressure ulcer being a stage 3 when assessed and worsening to a stage 4. The Executive Director (ED) and Regional Director of Clinical Operations (RDCO) were notified of the immediate jeopardy at 3:17 p.m. on [DATE]. The immediate jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. Record review was completed for Resident C on [DATE] at 10:27 a.m. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment for Resident C, dated [DATE], indicated the resident required extensive assistance of two or more persons for bed mobility and transfers, and extensive assistance of one person for toilet use and personal hygiene. The resident had an unhealed stage 3 (full thickness skin loss involving damage of subcutaneous tissue) pressure ulcer that was not present upon admission to the facility. A care plan, initiated [DATE], for Resident C indicated, the resident had a potential for alteration in skin integrity due to impaired mobility, and debility in condition related to [DIAGNOSES REDACTED]. The goal indicated, the resident would have no worsening of skin alteration through review. Interventions included, but were not limited to, apply moisture barrier as needed and as indicated, assist resident with turning and reposition as needed when in bed, evaluate skin condition on a daily and weekly basis, keep skin clean and dry, resident needed heels floated, and the resident needed pressure redistribution/reduction seat cushion. A second care plan indicated, Resident C had a pressure ulcer on the right gluteal fold area. The goal indicated, the resident would have no signs of worsening pressure ulcer through review date. Interventions included, but were not limited to, keep the resident clean and dry as needed and as indicated, provide a pressure-relieving mattress on bed, provide adequate nutrition and hydration, turn and reposition as needed and as indicated when in bed, and skin assessment weekly on Monday in the electronic medical record. A Progress Note for Resident C, dated [DATE] at 10:05 p.m., indicated, dressing to left gluteal fold changed, pressure ulcer was cleaned with normal saline and covered. Ulcer was foul smelling and oozing sanguineous (bloody) drainage, Allevyn (fluid absorbing dressing) used to temporarily cover the wound. There was no documentation the physician had been notified of wound condition. An untitled progress note for Resident C, the Director of Clinical Services (DCS) indicated, was from the wound physician, dated as faxed to the facility on [DATE], indicated, on [DATE], the resident had a stage 3 wound on the right ischium (lower and back part of the hip bone) measuring 4.5 centimeter (cm) x 3.5 cm x 0.9 cm, with minimal to moderate drainage. The physician documented, there was an uninflated pressure relieving cushion, and resident needed to be in bed. New treatment orders were received, to include, but were not limited to, bed bound until healed, change positions every 2 hours, and occupational therapy to inflate pressure relieving cushion. A physician's orders [REDACTED]. Resident to be up for meals only and then lay down. Check pressure relieving cushion on wheelchair before getting up and make sure inflated. A Weekly Wound Data Collection Flow Sheet for Resident C, dated [DATE], indicated, information from the wound physician visit on [DATE] regarding an in-house acquired wound had been transposed onto the form with no additional information. There was no documentation to indicate a time or date the physician or family were notified. A Weekly Wound Data Collection Flow Sheet for Resident C, dated [DATE], indicated, the form had not been filled out. A physician's orders [REDACTED]. Change every 3rd day or as needed. A Weekly Skin Assessment forms for Resident B, indicated, random and inconsistent documentation was completed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. An untitled progress note for Resident C, the DCS indicated, was from the wound physician, dated as faxed to the facility on [DATE], indicated, on [DATE], the resident had a stage 4 wound (can extend into deep tissues like muscle, tendons, ligaments, and bone) on the right ischium (lower and back part of the hip bone) measuring 5.0 cm x 1.5 cm x 2.9 cm, with moderate drainage. The physician documented, there the pressure relieving cushion was still deflated. New treatment orders were received. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A nursing progress note, dated [DATE] at 11:25 p.m. indicated, the resident had died with the son at his bedside. During an interview with Wound Physician 13 on [DATE] at 10:43 a.m., he indicated, he had been contacted by Resident B's daughter to assess the resident for a wound on his right ischium. On [DATE] the resident was assess to have a stage 3 wound. The resident was observed to be sitting up with his Roho (type of redistribution cushion) flatter than a filter, and he was getting no pressure relief in bed. The wound physician gave orders for the resident to be up only for short periods to eat, otherwise to be in bed to terminate pressure. On [DATE] the wound had deteriorated to a stage 4 pressure wound, and undermining was observed. The Roho cushion was again observed still not being inflated, he was unsure if staff were not inflating the cushion or if there was a slow leak. This wound was purely pressure based from sitting with no pressure relief. The wound physician indicated, he had not been made aware the resident had passed away. During an interview with the primary care physician on [DATE] at 1:32 p.m., he indicated, he wrote several advance care planning notes, and spoke extensively with the family. The primary care physician also indicated, he had personally requested the wound physician and his team be made available for consult on all wounds in the facility, and any recommendations made by the wound physician be considered as orders and written as such. He was not sure why his physician's notes had not been made available during the survey process as requested, or why the wound assessments had to be faxed over and were not available on the residents' charts. 2. A record review was completed for Resident B on [DATE] at 4:20 p.m. [DIAGNOSES REDACTED]. Resident B's care plans, created on [DATE], indicated Resident B had potential or actual impairment to skin integrity, and had pressure ulcers on the right heel and left plantar upon admission. There was no documentation the care plans had been revised or new interventions added to reflect the resident's current wound status or needs. A physician's orders [REDACTED]. A quarterly Minimum Data Set (MDS) assessment for Resident B, dated [DATE], indicated, the resident required extensive assistance of 1 person for bed mobility, toilet use, and personal hygiene. The resident required extensive assistance of two or more persons for transfers. The resident was at risk for pressure ulcers, there was no documentation of unhealed pressure ulcers. A physician's orders [REDACTED]. A Weekly Wound Data Collection Flow Sheet for Resident B, dated [DATE], indicated the resident had a pressure ulcer on the right buttock, first identified as an in-house acquired wound on [DATE]. The wound was documented as being 2.0 cm x 2.0 cm x 0.2 cm, and a stage 2 (partial thickness skin loss involving the top layer of skin). A summary indicated, the resident was found with pressure ulcers to bilateral buttocks with surrounding redness. Received new orders for treatment. Roho cushion (pressure relieving cushion used when sitting) was half flat. Educated staff to turn resident often. A Weekly Wound Data Collection Flow Sheet for Resident B, dated [DATE], indicated the resident had a pressure ulcer on the left buttock, first identified as an in-house acquired wound on [DATE]. There was no documentation to indicate a time or date the physician or family were notified. The wound was documented as being 1.0 cm x 1.0 cm x 0.2 cm, and a stage 2. A Progress Note, dated [DATE] at 5:27 p.m., indicated the resident had a skin wound or ulcer. The primary care provider recommended dry dressing on right heel, and [MEDICATION NAME] (protects skin from moisture) on coccyx. A late entry Progress Note for Resident B, dated [DATE] at 1:27 p.m., and created by Registered Nurse (RN) 10 on [DATE] at 11:48 p.m., indicated the resident had pressure ulcers to bilateral buttocks and right heel. A late entry Progress Note for Resident B, dated [DATE] at 9:27 p.m., and created by RN 7 on [DATE] at 9:56 p.m., indicated the resident was on follow up for a change of condition of skin on bilateral buttocks. The wound had a red area and dark skin. A Weekly Wound Data Collection Flow Sheet for Resident B, dated [DATE], indicated the resident had a pressure ulcer, first identified as an in-house acquired wound on [DATE], which had resolved. There was no documentation to of the site of the wound, or type. A Weekly Wound Data Collection Flow Sheet for Resident B, dated [DATE], indicated the resident had an in-house acquired pressure ulcer on the coccyx/sacrum, first identified on [DATE]. The wound was documented as being 6.0 cm x 6.0 cm x 0.2 cm, and a stage 2. A summary indicated, bilateral pressure ulcers had combined and worsened, now included the sacrum and coccyx. Treatment was continued. There was no documentation to indicate a time or date the physician or family were notified. A Progress Note for Resident B, dated [DATE] at 6:27 p.m., indicated the resident's bilateral buttocks pressure ulcer had worsened, it now included the sacrum and coccyx. Treatment as ordered. No documentation of physician notification of change. A Progress Note for Resident B, dated [DATE] at 10:27 p.m., indicated the resident had bilateral ulcers to the buttocks and were not getting better, but worsening, and now included stage 2 (break in the skin extending into deeper layers of the skin). Treatment as ordered. No documentation of physician notification of change. An untitled progress note for Resident B, the DCS indicated, was from the wound physician, dated as faxed to the facility on [DATE]. The progress note indicated, on [DATE], the resident had a wound on the sacrum measuring 7.4 cm x 3.0 cm x 2.0 cm, with moderate drainage. The patient was directly on the non-healing wound. There was dead tissue to the sacrum. New treatment orders were received. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A Progress Note for Resident B, dated [DATE] at 2:29 a.m., indicated resident continued on antibiotic therapy for infection of open area of buttocks. Treatment as ordered. An untitled progress note for Resident B, the DCS indicated, was from the wound physician, dated as faxed to the facility on [DATE]. The progress note indicated, on [DATE], the resident had a wound on the sacrum measuring 5.5 cm x 4.5 cm x 2.1 cm, with moderate drainage. The patient complained of pain when sitting up. Documentation indicated, patient needed to be off the wound, no sitting up in bed only left to right or flat, and the cushion on chair needed to be inflated. New treatment orders were received. A physician's orders [REDACTED]. A Progress Note for Resident B, dated [DATE] at 9:24 p.m., indicated the physician was made aware of worsening wound condition, and he contacted a wound specialist. An untitled progress note for Resident B, the DCS indicated, was from the wound physician, dated as faxed to the facility on [DATE]. The progress note indicated, on [DATE], the resident had a wound on the sacrum measuring 9.7 cm x 9.5 cm x 1.2 cm, with moderate drainage, and friction/sheer. Documentation indicated, there was no pressure relief, the patient was on the wound with a pillow under the wound. The note indicated sliding to the right during transfers, and on-going damage to the left side of wound, with friction/shear to the right. New treatment orders indicated, no pillow under wound, the resident cannot be slid to the right, and this was creating on-going trauma/friction and shearing to left side. A physician's orders [REDACTED]. .Make sure resident is rolled completely, rolled on each hip only, besides sitting up 90 degree every shift. A physician's orders [REDACTED]. A Progress Note for Resident B, dated [DATE] at 10:10 p.m., indicated, the resident was found deceased in a sitting position in bed. During an interview on [DATE] at 10:33 a.m., Wound Physician 13 indicated, he had been contacted to visit Resident B on [DATE] due to a new wound on the sacrum. He could not say the resident's wound was unavoidable without further information. He saw the resident again on [DATE] and the resident's wound had worsened with undermining in several areas. The wound physician spoke with staff at that time about care as he had previously given instructions for off-loading pressure to her wound, and when he entered to visit, the resident was found lying on her back causing direct pressure to her sacral area. On [DATE] the wound had again worsened, was more black, and he found staff had been sliding the resident to the side causing friction/shearing to the same area. Staff were again educated by the wound physician and instructions given to roll the resident, not to slide. The wound physician indicated, original copies of his wound reports to include description of the wound, site, measurements, and new orders were always left in the facility with each visit, he was not sure why Resident B's reports could not be found in the facility. The wound physician indicated, he had not been made aware the resident had passed away. 3. During a random observation of Resident D on [DATE] at 1:40 p.m., the resident was sitting in her wheelchair at bedside with blue foam heel protectors on both heels. Bandages to bilateral feet were dated [DATE]. During a random observation of Resident D on [DATE] at 9:22 a.m., the resident was observed lying on her right side in bed, eyes open, heels and sides of her feet in direct contact with the bed, and blue foam heel protectors were on the couch in her room. During an observation of Resident D on [DATE] at 9:33 a.m., with Certified Nursing Assistant (CNA) 4, the resident was lying on her right side in the bed, ankle socks on both feet, heels and sides of her feet in direct contact with the bed, no foam heel protectors, and 4 bandages on her feet dated [DATE]. CNA 4 indicated, the resident wore the blue foam heel protectors when she was out of bed in her wheelchair. During an observation of Resident D on [DATE] at 10:05 a.m., the resident was lying on her right side in bed, eyes closed. Her heels and the sides of her feet were in direct contact with the bed, and blue foam heel protectors on the couch in her room. During an observation of Resident D on [DATE] at 10:55 a.m., RN 5 indicated, during the skin sweep the previous evening, the resident was found to have 3 additional wounds the staff had not been aware of. During an observation of Resident D with Wound Physician 14 and RN 5 on [DATE] at 11:06 a.m. Resident D was observed to flinch when the dressings were removed from her feet and her feet were examined. The Wound Physician Assistant indicated, on [DATE] Resident D had 4 wounds on her feet. During this observation the resident had 6 wounds documented on her right foot, 3 wounds on her left foot, and 2 wounds on her buttocks. Wound measurements included: a. right heel 2.0 cm x 0.9 cm with minimal drainage, b. right anterior foot 5.2 cm x 2.4 cm with minimal drainage, c. right anterior foot 1.3 cm x 1.3 cm with minimal drainage, d. left 2nd toe 0.2 cm x 0.4 cm, e. right 1st toe 0.6 cm x 0.4 cm, f. under the right 1st toe 0.8 cm x 0.7 cm, g. posterior right heel 1.8 cm x 1.0 cm with minimal drainage, h. dorsal (upper side or back) left foot 1.8 cm x 1.2 cm with minimal yellow drainage, i. left toe 3.5 cm x 2.7 cm with minimal drainage, j. buttock 1.2 cm x 1.1 cm x <0.1 cm with minimal drainage, k. buttock 0.3 cm x 0.1 cm x <0.1 cm with minimal drainage. Wound Physician 14 indicated, the right and left heels were healed, as the eschar on both heels could have been peeled off. The remaining wounds were getting larger, and could improve with proper care, and the wounds could possibly have been prevented if staff could have kept Resident D from rubbing her feet together. During an observation of Resident D with Wound Physician 14 and RN 5 on [DATE] at 11:22 a.m., RN 5 indicated, the resident had 2 additional wounds found that morning to include, a deep red discolored area on her right outer calf, visualized as approximately 5.0 cm x 7.0 cm, from rubbing against the wheel chair leg rest, and a 1.0 cm circular stage 2 open area on the top of right lower leg from the strap of the blue pressure booties, these wounds were not documented. Record review was completed for Resident D on Record review completed on [DATE] at 1:45 p.m. [DIAGNOSES REDACTED]. A quarterly MDS for Resident D, dated [DATE], indicated, the resident required extensive assistance of one person for transfers, bed mobility, eating, toileting, and personal hygiene. The resident had 6 stage 2 pressure ulcers that were not present upon admission, and 1 venous or arterial ulcer present. Resident D's care plans indicated, care plans were created on [DATE] and [DATE] for potential or actual impairment to skin integrity, and having pressure ulcers on the heels and feet. There was no documentation the care plans had been revised or new interventions added to reflect the resident wound status or needs. A physician's orders [REDACTED]. New wound orders were received on [DATE] for her legs, feet, and toes. An order was obtained [DATE] for cleansing of a wound without a specified wound site. A Progress Notes for Resident D, dated [DATE] - [DATE], indicated there was no documentation to indicate the resident was being provided routine nursing preventative wound care interventions, or the physician and family representative were being kept apprised of wound status. An untitled progress note for Resident D, the DCS indicated, was from the wound physician, dated as faxed to the facility on [DATE]. The progress note indicated on [DATE] the resident was seen regarding trauma wounds on her left great toe, 2 areas on the right anterior foot, and the right heel. A Weekly Wound Data Collection Flow Sheet for Resident D, dated [DATE] - [DATE] indicated, there was random and inconsistent documentation regarding multiple in-house acquired ulcers to the resident's toes and feet. There was no documentation to indicate the physician and family representative were consistently being notified of the wounds. A Weekly Wound Data Collection Flow Sheet for Resident D, dated [DATE] indicated, the resident had a pressure ulcer to the sacrum, measuring 7.0 cm x 6.0 cm x 0.1 cm unstageable (full thickness skin loss in which the depth is obscured by dead tissue), with slough (dead tissue) noted to the center of the wound bed. A Weekly Wound Data Collection Flow Sheet for Resident D, dated [DATE] indicated, the resident had a pressure ulcer to the sacrum, there was no measurements or description of the wound to indicate progress toward healing or worsening of the wound. A Weekly Skin Assessment forms for Resident D, indicated, random and inconsistent documentation were completed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. During an interview with the DCS on [DATE] at 10:35 a.m., she indicated, she was unaware of what happened to Resident D's toes as that documentation started in (MONTH) of 2019. The resident was to have her blue protection booties on at all times. The aides were responsible for assuring the resident had her blue protection booties on, with the nurses were responsible for monitoring compliance. During an interview with the DCS on [DATE] at 12:03 p.m., she indicated, Resident D had a newer in-house acquired open area on her sacrum that had been measured, but was not documented on her tracking forms. The DCS could not find documentation to indicate the physician or family had been notified. During an interview with the wound physician on [DATE] at 10:22 a.m., he indicated, he had first documented Resident D as having trauma to the tops of her toes as a result of rubbing, he was not sure if that was on her shoes or possibly her chair. The right medial toe was also pressure as it was pressing against another toe. On his last visit [DATE] he documented Resident D's wounds as getting better and still believed her shoes were causing superficial wound damage, he wondered if they could have changed the resident's shoes to avoid the wounds. During an interview with the ADM on [DATE] at 11:58 a.m., he indicated, he was not sure if therapy had been involved in wound prevention for Resident D, such as positioning concerns. 4. During a random observation on [DATE] at 9:26 a.m., Resident [NAME] was observed lying in bed on his left side, and eyes opened. The resident nodded his head when spoken to but did not respond verbally. During an observation of Resident E's dressing to the left lower buttock, on [DATE] at 9:39 a.m., with RN 7. The RN indicated, she did not routinely work with the resident, was unsure of how often the resident's dressing was to be changed, but would check the order. Resident [NAME] indicated, the nurses changed his dressings every day, they were good about that. During an observation of Resident E's wound on [DATE] at 11:37 a.m., the resident was observed to flinch when the dressing was being removed and the area around the wound palpated. RN 12 indicated, last week there was slough from the wound, today the wound was clean with no drainage. The wound could have been caused by a cyst under the skin but she was unsure. Record review was completed for Resident [NAME] on [DATE] at 2:15 p.m. [DIAGNOSES REDACTED]. An annual MDS for Resident E, dated [DATE], indicated the resident required extensive assistance of one person for bed mobility, and extensive assistance of two or more persons for transfers, toilet use, and person hygiene. The resident was at risk for developing pressure ulcers, no documentation of unhealed pressure ulcers at the time of the assessment. Resident E's care plans indicated, there was a care plan initiated [DATE] regarding potential for impairment to skin integrity. A care plan initiated [DATE] indicated the resident had a reddened area to the left buttock related to a recent biopsy, with an intervention for observing the resident for healing of the area on the right buttock. Any new or worsening symptoms should have been reported to the physician. A physician's orders [REDACTED]. A Progress Note for Resident E, dated [DATE], indicated, the resident had a skin wound or ulcer. The primary physician had been notified with new orders to apply hydrogel and allevyn dressing every 3 days. A Weekly Skin Integrity Review form for Resident E, dated [DATE], indicated red area to left buttock where resident has a biopsy done. No measurements were documented. Resident E's medical record indicated there was not Weekly Wound Data Collection Flow Sheet completed for the in-house acquired pressure ulcer. During an interview with the DCS on [DATE] at 10:39 a.m., she indicated, Resident [NAME] was tall, talkative, and would tell staff when he wanted to lay down, therefore she was surprised he had a pressure ulcer. The current area on Resident E's bottom was a newly acquired in-house pressure area, it was not from the previous left biopsy site. During an interview on [DATE] at 10:55 a.m., Wound Physician 13 indicated, he was not aware Resident [NAME] had a wound on his bottom, he had not been asked to assess the resident. During an interview on [DATE] at 1:27 p.m., the primary care physician indicated, he was not aware Resident [NAME] had a wound on his bottom, the nursing staff may have asked the wound physician to follow Resident E's wound. 5. During a random observation on [DATE] at 9:29 a.m., Resident F was observed sitting up in bed, laptop on his over the bed table in front of him, talking on his cell phone. A low air loss mattress was observed on the bed. During an observation on [DATE] at 9:55 a.m., Resident F was observed sitting up in the bed working on his laptop. The resident indicated, he had a history of [REDACTED]. The facility had provided him with a specialty mattress, and the nurses changed his dressing every 3rd day. During an observation on [DATE] at 9:50 a.m., Resident F was sitting up in bed working on a laptop. The resident indicated, he had a history of [REDACTED]. During an observation with RN 12 on [DATE] at 11:42 a.m., Resident F was observed to have three small areas of scabbing on his sacral area, there was no drainage or slough. Resident F indicated, he did not get turned at night, he was not sure if that was his fault as he didn't ask, and he was on a specialty mattress. Record review was completed for Resident F on [DATE] at 4:00 p.m. [DIAGNOSES REDACTED]. A quarterly MDS for Resident F, dated [DATE], indicated, the resident required extensive assistance of one person for bed mobility, toilet use, and personal hygiene. Extensive assistance of two persons for transfers. Resident was at risk for development of pressure ulcers, no documentation to indicate a pressure ulcer at the time of the assessment. Resident F's care plans indicated, on [DATE], the resident was care planned for potential/actual impairment to skin integrity. Interventions included evaluate skin condition on a daily and weekly basis. A Progress Note for Resident F, dated [DATE] at 2:01 p.m., indicated skin wound or ulcer. Primary care provider recommended new orders to cleanse area with normal saline, pat dry and apply foam dressing every 3 days. There was no documentation to describe the wound, or to indicate the family had been notified. A Progress Note for Resident F, dated [DATE] at 2:00 p.m., indicated the resident remained on follow up for new pressure area to mid lower back. A Progress Note for Resident F, dated [DATE] at 1:56 p.m., indicated the resident with shearing no pressure injury to lower mid back. A subsequent Progress Note on [DATE] at 9:05 p.m., indicated, resident was on follow up for a new pressure area to the mid lower back. A Weekly Wound Data Collection Flow Sheet for Resident F, dated [DATE], indicated, the resident had moisture associated skin damage (MASD) on the coccyx, first identified as an in-house acquired on [DATE], and reported to the physician and family on [DATE]. The wound was documented as being 6.0 cm x 3.8 cm x 0.2 cm. A summary indicated, during assessment the resident was identified as having MASD surrounding friction site. Orders were received for a low air loss mattress, and to be up in the chair only 2 hours at a time. A Weekly Wound Data Collection Flow Sheet for Resident F, dated [DATE], indicated, the resident had an area of friction to the lower [MEDICATION NAME] spine, first identified as an in-house acquired on [DATE], and reported to the physician on [DATE]. The wound was documented as being 0.3 cm x 0.3 cm x 0.1 cm. A Weekly Wound Data Collection Flow Sheet for Resident F, dated [DATE], indicated the resident had a MASD/friction on the coccyx, first identified as an in-house acquired on [DATE], and reported to the physician and family on [DATE]. The wound was documented as being 5.0 cm x 3.0 cm x 0.2 cm. A Weekly Skin Assessment forms for Resident F, indicated incomplete documents were completed on [DATE] and [DATE]. There were no documentation to indicated, additional weekly skin assessments had been completed. A Weekly Wound Data Collection Flow Sheet for Resident F, dated [DATE], indicated the resident had a friction wound on the coccyx, first identified as an in-house acquired on [DATE], and reported to the physician and family on [DATE]. The wound was documented a

Based on observation, record review, and interview, the facility failed to ensure pressure ulcer prevention interventions were evaluated and revised to prevent a resident, who was admitted without a pressure ulcer, from developing a stage 2 (partial thickness skin loss) pressure ulcer that increased to a stage 4 (full thickness skin loss) pressure ulcer for 1 of 2 residents reviewed for pressure ulcers (Resident #3). Finding includes: Resident #3's record was reviewed on 2/9/2016 at 11:32 a.m. The record indicated Resident #3 had a stage 4 (full thickness tissue loss with exposure of bone) pressure ulcer to her sacrum (vertebra at the bottom of the spine). Resident #3's [DIAGNOSES REDACTED]. A Nursing Admission Data Collection, dated 11/9/2015, indicated Resident #3 had no history of skin issues and no pressure ulcer on admission. The resident had diabetes, with a history of decreased appetite, and did not have a terminal diagnosis. A care plan, dated 11/9/2015, indicated Resident #3 had a potential for an impairment to skin integrity due to being incontinent of bowel. A goal, dated 11/16/2015, indicated the resident would be free from skin breakdown. Interventions included: apply moisture barrier as needed and as indicated by the physician; assist with turning and repositioning as needed; Braden scale and skin assessment per protocol; observe skin for any alteration in skin such as rash, persistent redness or skin discoloration, open areas and report to physician; pressure redistribution/reduction mattress on bed to help prevent skin breakdown; use disposable pads with specialty beds or mattress. No linen with low air loss mattress; use caution during transfers and bed mobility to prevent striking all body surfaces. A Braden scale, dated 11/9/2015, indicated Resident #3 had a score of 13 out of 23 with a potential for impairment to skin integrity. An Admission Minimum Data Set (MDS) assessment, dated 11/16/2015 indicated Resident #3 was not admitted with a pressure ulcer and not at risk of developing pressure ulcers. The record indicated Resident #3 required extensive assistance of one person with bed mobility, transfers, toileting, and locomotion on the unit. A physician's orders [REDACTED].#3 had a low air loss mattress. A lab specimen report, dated 11/17/2015, indicated Resident #3 had a complete blood count with a red blood cell (RBC) lab value of 3.48 (normal levels 3.9- 5.4), hemoglobin (protein molecule in red blood cells that carries oxygen to the body's tissues) lab value of 10.8 (normal levels 12- 16), and a hematocrit (volume of blood that consists of red blood cells) lab value of 33% (normal levels 36- 48%). A Braden scale, dated 12/1/2015, indicated Resident #3 had a score of 12 out of 23, indicating the potential for impairment to skin integrity. The record indicated Resident #3's usual food intake pattern was probably inadequate (rarely eats a complete meal and generally eats only about 1/2 of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement). A Weekly Skin Integrity Review, dated 12/17/2015, indicated Resident #3 had an observation of 2 areas of redness to her buttocks. A Weekly Wound Data Collection, dated 12/23/2015, indicated Resident #3 acquired a stage 2 pressure ulcer to the sacrum. The 12/23/2015 document indicated, Summary: resident is not eating meals well, will follow up with dietitian. A Dietary Progress note, dated 1/11/2016, indicated Resident #3 had a stage 2 pressure ulcer to her sacrum and lacked documentation of nutritional interventions to facilitate wound healing. A Weekly Wound Data Collection, dated 1/27/2016, indicated Resident #3's pressure ulcer to her sacrum had increased to a stage 4 pressure ulcer with measurements of 3 centimeters (cm) x 2.8 cm x 1.4 cm, with tunneling of 1.4 cm at 11 o'clock. The wound base included 80% granulation (new connective tissue), 10% slough (yellow [MEDICATION NAME] tissue thought to be associated with bacterial activity), and 10% of bone exposure. Resident interventions included: air mattress, wheelchair cushion, and vitamin therapy. The document indicated, Summary: wound has continued to decline. Resident is only eating around 25% of most meals. Staff is encouraging resident at meals. Resident receives Magic Cup and multivitamin daily. A Weekly Wound Data Collection, dated 2/4/2016, indicated Resident #3's stage 4 pressure ulcer to her sacrum increased in size with measurements of 3.3 cm x 3 cm x 1.2 cm with tunneling from 10 to 12 o'clock 2 cm deep. The wound base included 90% granulation tissue and 10% of bone exposure. The document indicated, Summary: has appt (appointment). with wound clinic 2/5/16. A physician's orders [REDACTED]. A care plan, dated 2/8/2016, indicated Resident #3 had a stage 4 pressure ulcer to her sacral area. The goal, dated 2/8/2016, indicated the resident will show signs of healing as evidenced by a decrease in size. Interventions included: administer treatments and medications as ordered by physician; keep resident clean and dry as often as necessary throughout the day; keep physician and family informed of any change in condition; provide resident with pressure relieving device on bed as needed i.e.; low air loss mattress; provide diet as ordered and observe nutritional status and dietary needs and offer supplements as indicated; turn and reposition as regularly as needed; wound rounds to be completed per protocol. A Weights and Vitals Summary was reviewed on 2/9/2016 and indicated Resident #3 had a negative 7.5% weight loss from her admission weight of 117.8 lbs. on 11/9/2015 to her 2/8/2016 weight of 104.8 lbs. A Dietary Progress note, dated 2/12/2016, indicated Resident #3 had a 5.2 % weight loss in 1 month, a 10.4% weight loss in 3 months, and an estimated consumption of 25%, which had decreased in the last 30 days. Her BMI had decreased to 18.6. The record indicated Resident #3's pressure ulcer had increased from a stage 2 pressure ulcer to a stage 4 pressure ulcer and the resident required increased protein requirements. During an observation on 2/12/2016 at 3:00 p.m., Resident #3's wound dressing change was observed with the Director of Nursing (DON) and Assistant Director of Nursing (ADON). Resident #3's wound measurements to her stage 4 pressure ulcer to her sacrum were 4 cm x 3.3 cm x 3 cm, with tunneling from 10 to 1 o'clock of 2.9 cm, and tunneling from 6 to 8 o'clock with 2.1 cm, and 40% of bone exposure and a minimal odor. No slough or drainage was observed. The resident did not display verbal or non-verbal symptoms of pain or tearfulness. The DON indicated the pressure ulcer had declined with increased measurements and tunneling. During an interview on 2/11/2016 at 3:43 p.m., CNA #33 indicated her assignment sheet did not specify a turning schedule for Resident #3. She indicated she turned Resident #3 every 2 hours and she was a check and change every 2 hours for incontinence. During an interview on 2/12/2016 at 9:33 a.m., the DON indicated she performed wound rounds weekly and assessed Resident #3's acquired stage 2 pressure ulcer on 12/23/2015 and determined the resident's declining nutritional status had contributed to the development of the pressure ulcer. She indicated Resident #3 had a history of [REDACTED]. She indicated nutritional interventions had not been revised until the pressure ulcer increased to a stage 4 on 1/27/2016. She indicated Resident #3 had not been evaluated by the wound clinic until 2/5/2016. The DON indicated she determined efficacy of Resident #3's wound and nutritional interventions by assessment of weekly weights and wound status. She indicated the current interventions failed based on her decreased weight and increased pressure ulcer status from a stage 2 to a stage 4. During an interview on 2/12/2016 at 11:24:27 a.m., the Registered Dietitian (RD) indicated he recommended nutritional interventions based on standard dietary guidelines that also included pressure areas. He indicated he had not recommended a pre-[MEDICATION NAME] lab draw or increased protein until he assessed her on 2/12/16 for significant weight loss and increased pressure ulcer status to a stage 4. A policy, titled, Wound Observation and Pressure Ulcer Staging, dated 11/2007, and identified by the DON as current on 2/12/2016 at 4:00 p.m., indicated, All licensed nurses should follow established guidelines and protocols to observe, describe tissue, evaluating, measuring wounds and staging of pressure ulcers .notify the health care provider of any changes, progress or alternative interventions to promote healing. 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to support a resident's nutrition to facilitate wound healing and prevent significant weight loss for 1 of 2 residents reviewed for nutrition (Resident #3). Findings include: Resident #3's record was reviewed on 2/9/2016 at 11:32 a.m. The record indicated Resident #3 had a stage 4 (full thickness tissue loss with exposure of bone) pressure ulcer to her sacrum (vertebra at the bottom of the spine). Resident #3's [DIAGNOSES REDACTED]. The record lacked indication a [MEDICATION NAME] (blood test to determine protein levels and possible malnutrition) or [MEDICATION NAME] (blood test to determine protein levels) labs had been drawn from Resident #3's admission to the facility to 2/9/2016. A Weights and Vitals Summary was reviewed on 2/9/2016. The record indicated Resident #3 had a negative 7.5% weight change from her admission weight from 1/26/2016 to 2/8/2016 and indicated the following weights for Resident #3: a. 11/9/2015: 117.8 pounds (lbs.) b. 11/17/2015: 117 lbs. c. 11/19/2015: 117 lbs. d. 11/25/2015: 117 lbs. e. 12/1/2015: 114.8 lbs. f. 12/4/2015: 114.8 lbs. g. 1/5/2016: 111.2 lbs. h. 1/6/2016: 110.6 lbs. i. 1/12/2016: 110.6 lbs. j. 1/26/2016: 106 lbs. k. 2/5/2016: 102 lbs. l. 2/8/2016: 104.8 lbs. A Nutrition Lookback, dated 11/10/2015 to 2/10/2016 was reviewed on 2/12/2016. The record lacked documentation of meal consumption intakes, or if resident was unavailable for meal, for Resident #3, on 12/25/2015, 12/26/2015, 1/3/2016, 1/9/2016, 1/10/2016, 1/11/2016, 1/14/2016. The record lacked documentation of meal consumption intakes of lunch and dinner, or if resident was unavailable for meal, for Resident #3, on 12/27/2015, 12/28/2015, 12/29/2015, 1/1/2016, 1/4/2016, 1/6/2016, 1/12/2016, 1/13/2016, 1/15/2016, 1/18/2016, 1/23/2016, 1/24/2016, 1/26/2016, 1/27/2016, 1/28/2016, 1/29/2016, 2/3/2016, 2/5/2016, 2/6/2016, and 2/7/2016. The record indicated Resident #3 had varied intakes from 0- 25% to 75- 100% of meals. A physician's orders [REDACTED].#3 was to have a Magic Cup (nutritional supplement) two times a day for vitamin insufficiency with lunch and dinner. The Medication Administration Record [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A Nutrition Risk Review, dated 11/12/2015, indicated Resident #3 weighed 117 lbs., was 63 inches tall, and had a BMI (Body Mass Index) of 20.7 (normal weight: 18.5- 24.9) on admission. The resident's ideal weight range was between 103 to 127 lbs. The record indicated Resident #3 had intakes of 51 to 75% with a diet consistency of puree with nectar thick liquids. Resident #3 had intact skin without history of pressure ulcers and left 25% plus at most meals. The record lacked indication an [MEDICATION NAME] (protein) level had been drawn on admission and that nutritional supplement recommendations were provided on admission. An Admission Minimum Data Set (MDS) assessment, dated 11/16/2015 indicated Resident #3 was not admitted with a pressure ulcer. The record indicated Resident #3 required extensive assistance of one person with eating, with an admission weight of 118 lbs and 63 inches tall, without or unknown weight loss of 5 percent or more in the last month or loss of 10 percent or more in the last 6 months, and required a mechanically altered diet (change in texture of food or liquids). A physician's orders [REDACTED].#3 was to receive a pureed diet with honey liquids consistency. A physician's orders [REDACTED].#3 was to be weighed monthly. A care plan, dated 11/19/2015, indicated Resident #3 was at nutritional risk as evidenced by: dysphagia, need of a mechanically altered diet, and leaving 25 percent of some meals. A goal, dated 2/5/2015, indicated Resident #3 would have no significant weight change through review. Interventions included: diet as ordered, monitor labs as ordered, monitor meal intake with each meal, and monitor weights as ordered. A Weekly Wound Data Collection, dated 12/23/2015, indicated Resident #3 acquired a stage 2 (partial thickness skin loss) pressure ulcer to the sacrum. The 12/23/2015 document indicated, Summary: resident is not eating meals well, will follow up with dietitian. A Dietary Progress note, dated 1/11/2016, indicated, Has stage 2 area to sacrum. Has a poor appetite .Current weight at 111 lbs. Is given Magic Cup twice a day for lunch and dinner. Is given 8 ounces (oz) of nectar milk with meals, 8 oz water nectar thick with meal. Have requested to weigh weekly. A Weekly Wound Data Collection, dated 1/27/2016, indicated Resident #3's pressure ulcer to her sacrum had increased to a stage 4 (full thickness tissue loss with exposure of bone) pressure ulcer. The document indicated, Summary: wound has continued to decline. Resident is only eating around 25% of most meals. Staff is encouraging resident at meals. Resident receives Magic Cup and multivitamin daily. A physician's orders [REDACTED]. A Dietary Progress note, dated 2/12/2016, indicated, Weight for 2/16 at 104.8 lbs., a 5.2% weight loss in 1 month. Is weighed weekly. Has a 10.4% weight loss in 3 months. Ideal weight range 103- 127 lbs. BMI of 18.6. Magic Cup offered BID (twice a day). Has stage 4 area to sacrum. Protein requirements of 62 to 71 grams (gm) daily. physician's orders [REDACTED]. Consumes an estimated 25%, has decreased in last 30 days .Recommend to order a [MEDICATION NAME] level next lab day, provide 2 cal med pass supplement 60 ml three times a day, Vitamin C 500 mg BID, and Zinc Sulfate 220 mg daily. During an observation on 2/11/2016 at 9:27 a.m., Resident #3 was observed eating 75% of her puree breakfast and 120 ml of her thickened fluids in the dining room. She required total assistance from staff with eating. During an observation on 2/12/2016 at 12:58 p.m., Resident #3 was observed eating 25% of her lunch and 50% of her Magic Cup in the dining room. She required total assistance from staff with eating. Thickened milk was not observed to be served to the resident and her dietary card lacked documentation milk was to be served with her meal. During an observation on 2/15/2016 at 9:19 a.m., Resident #3 was observed eating 25% of her meal in the dining room and consumed 120 ml of fluids. She required total assistance from staff with eating. During an interview on 2/11/2016 at 9:28 a.m., Restorative Nursing Assistant (RNA) #30 indicated Resident #3 ate in the dining room and required total assistance from staff with eating her meals. She received her Magic Cup at lunch and dinner with her meals from the kitchen. She indicated the resident ate her Magic Cup and consumption varied from 25 to 100%. She indicated Resident #3's intake varied daily and she was aware the resident had weight loss. She indicated Resident #3 did not have identified food preferences and she was offered substitutes when she refused to eat a meal. During an interview on 2/11/2016 at 3:49 p.m., Licensed Practical Nurse (LPN) #31 indicated Resident #3 received a Magic Cup supplement twice a day with her meals. She indicated the nursing staff did not administer or document consumption of the supplement. During an interview on 2/12/2016 at 9:33 a.m., the Director of Nursing (DON) indicated she assessed Resident #3's acquired stage 2 pressure ulcer on 12/23/2015 and determined the resident's declining nutritional status contributed to the development of the pressure ulcer. She requested a consult with the Registered Dietitian and he had not recommended additional nutritional supplement. The facility began to weigh the resident weekly in January 2016. She indicated Resident #3's consumption decreased to an average of 25% of meals when Resident #3's pressure ulcer increased from a stage 2 to a stage 4 on 1/27/2016. New nutritional interventions included: increased encouragement of consumption from staff and family, family brought in puree meals from home, and increased butter and seasoning of food. The DON indicated she could not provide documentation of the nutritional interventions. She indicated there was no documentation of Resident #3's Magic Cup consumption. The DON indicated she measured the efficacy of nutritional interventions by assessment of weekly weights and wound status. She indicated the current interventions failed based on her decreased weight and increased pressure ulcer status from a stage 2 to a stage 4. During an interview on 2/12/2016 at 11:24 a.m., the Registered Dietitian (RD) indicated he recommended nutritional interventions based on standard dietary guidelines that also included pressure areas. He indicated he was notified of Resident #3's increased pressure ulcer to a stage 4 and he had scheduled to assess the resident on 2/12/2016. He indicated he was at the facility weekly. He indicated Resident #3's dietary card should have indicates milk with meals since January 2016 and he couldn't provide documentation of milk consumption. The RD indicated Resident #3's current BMI was 18.6 and in normal range parameters. He indicated he had not recommended a pre-[MEDICATION NAME] lab draw or increased protein needs until her significant weight loss and increased pressure ulcer status. During an interview on 2/12/2016 at 3:24 p.m., the DON indicated weights are monitored every Tuesday by the DON and Dietary Manager. She indicated Resident #3 had significant weight loss on 2/5/2016 and the resident's physician had been notified. The physician referred Resident #3 to be evaluated by the RD. The RD had been out of the facility that week and could not evaluate the resident until 2/12/2016. She indicated the facility had no other dietitian coverage. During an interview on 2/15/2016 at 11:40 a.m., the DON indicated meal consumption documentation is completed by the CNAs in their computer system and the Unit Manager was responsible for ensuring completion of the charting. She indicated she was aware of incomplete consumption charting for Resident #3. She indicated the facility had experienced difficulties with the computer system and she could not provide documentation of consumption for the dates without consumption charting. During an interview on 2/15/2016 at 11:42 a.m., the Dietary Manager indicated she monitored Resident #3's intakes and the trend had shown the resident had a poor appetite and had weight loss. She indicated the decreased consumption indicated a new supplement should have been introduced to Resident #3. She indicated she had not provided Resident #3 with new nutritional supplements based on her decreased intake. A policy, titled Resident Nutrition Services, dated 10/2015, and identified by the DON as current on 2/12/2016 at 2 p.m., indicated, .The interdisciplinary team, including Clinical Services, the Healthcare Provider and the Dining Services shall review each resident's nutritional needs, food likes, dislikes and eating habits. The shall develop a resident care plan based on this review .clinical services shall review and document food intake. Clinical services will evaluate flood intake per Healthcare provider order .Significant variations from usual eating or intake patterns shall be recorded in the resident's medical record. Clinical services and/or Dining Services shall review significance of such information and report it, as indicated, to the Healthcare Provider and legal representative 3.1-46(a)(1)

Based on observation, record review, and interview, the facility failed to develop a plan of care for pressure areas with interventions to promote healing which resulted in harm to a resident as evidenced by a stage I pressure area increasing to a stage III pressure area. This deficient practice affected 1 of 1 residents reviewed for the development of care plans for pressure areas (Resident #11). Findings: During an observation of wound care on 12/18/2013 at 9:57 A.M., Resident #11 was observed to have a circular shaped stage III open area to his left buttock. Resident #11's record was reviewed on 12/17/2013 at 9:52 A.M. Resident #11 had [DIAGNOSES REDACTED]. The record lacked documentation of a care plan which addressed Resident #11's history of pressure areas. An untimed nurse's note dated 11/20/2013, indicated, "CNA (Certified Nursing Assistant) reported small open area with slight redness to coccyx/sacral. Physician office notified n/o (new order) for EPC (cream) q (every) shift." The record lacked documentation of the wound, peri-wound, or the stage of the wound. An untimed physician's orders [REDACTED].#11's bed, Resident #11 was to remain in his bed except for meals, and a special cushion (roho) was to be placed in his recliner. The record indicated a care plan was not immediately developed when the open area was noted. A wound evaluation flow sheet dated 12/4/2013, indicated Resident #11's pressure area was staged at a stage 3, measured 1.8 centimeters (cm) in length, 1.4 cm in width, and 0.3 cm in depth, had a scant amount of serous exudates, the wound bed had 100 percent granulation, the periwound was red, and the surrounding tissue was red/pink. A wound care evaluation flow sheet dated 12/7/2013, indicated Resident #11's wound improved slightly with measurements of 1.8 cm length, 1.2 cm width, and 0.2 cm depth. During an interview on 12/18/2013 at 11:16 A.M., the Administrator indicated the nurse who discovered the pressure wound failed to document it on the twenty-four hour report. The Administrator indicated there was a delay in notifying the wound care nurse and a delay in developing and implementing interventions in a care plan to facilitate wound healing. During an interview on 12/19/2013 at 9:47 A.M., the facility's wound nurse indicated he was not notified of Resident #11's pressure wound until 12/4/2013. He indicated the area had previously been open and indicted he would have aggressively treated the area if he had been notified of the area when it was discovered on 11/20/13. He indicated as soon as he found out about the wound he immediately contacted the doctor and obtained orders to change his mattress to a low air loss mattress and implemented the roho cushion in his recliner. The facility's wound care nurse stated, "He did not have the special mattress or the roho cushion in his recliner until I saw him." During a telephone interview on 12/19/2013 at 10:24 A.M., Licensed Practical Nurse (LPN) #1 indicated she was the nurse who first noted the open area. She stated, "He had a little spot so I called the doctor.... I am not a wound nurse and I don't know a lot about wounds.... I should have put it on the 24 hour report sheet but I didn't...." A document dated 2010, and titled "Pressure Ulcers/Skin Breakdown-Clinical Protocol" identified as a current facility policy by the Administrator on 12/18/2013 at 1:27 P.M., indicated, "...Assessment and Recognition...the nurse shall assess and document/report the following...full assessment of pressure sore including location, stage, length, width, and depth, presence of exudates or necrotic tissue... The physician will help the staff review and modify the care plan as appropriate, especially when... new wounds develop despite existing interventions...." 3.1-35(a)

Based on observation, record review, and interview, the facility failed to ensure residents with pressure sores received prompt necessary treatment and services to promote healing which resulted in harm to a resident as evidenced by a stage I pressure area increasing to a stage III pressure area. This deficient practice affected 1 of 1 residents reviewed with pressure areas greater than stage 2 (Resident #11). Findings include: During an observation of wound care on 12/18/2013 at 9:57 A.M., Resident #11 was observed to have a circular shaped stage III open area to his left buttock. Resident #11's record was reviewed on 12/17/2013 at 9:52 A.M. Resident #11 had [DIAGNOSES REDACTED]. The record lacked documentation of a care plan which addressed Resident #11's history of pressure areas. An untimed nurse's note dated 11/20/2013, indicated, "CNA (Certified Nursing Assistant) reported small open area with slight redness to coccyx/sacral. Physician office notified n/o (new order) for EPC (cream) q (every) shift." The record lacked documentation of the wound, peri-wound, or the stage of the wound. An untimed physician's orders [REDACTED].#11's bed, Resident #11 was to remain in his bed except for meals, and a special cushion (roho) was to be placed in his recliner. The record indicated a care plan was not immediately developed when the open area was noted and did not indicate a care plan for preventing pressure ulcers prior to 12/4/13. A wound evaluation flow sheet dated 12/4/2013, indicated Resident #11's pressure area was staged at a stage 3, measured 1.8 centimeters (cm) in length, 1.4 cm in width, and 0.3 cm in depth, had a scant amount of serous exudates, the wound bed had 100 percent granulation, the periwound was red, and the surrounding tissue was red/pink. A wound care evaluation flow sheet dated 12/7/2013, indicated Resident #11's wound had improved slightly with measurements of 1.8 cm length, 1.2 cm width, and 0.2 cm depth. During an interview on 12/18/2013 at 11:16 A.M., the Administrator indicated the nurse who discovered the pressure wound failed to document it on the twenty-four hour report. The Administrator indicated there was a delay in notifying the wound care nurse and a delay in developing and implementing interventions in a care plan to facilitate wound healing. During an interview on 12/19/2013 at 9:47 A.M., the facility's wound nurse indicated he was not notified of Resident #11's pressure wound until 12/4/2013. He indicated the area had previously been open and indicted he would have aggressively treated the area if he had been notified of the area when it was discovered on 11/20/13. He indicated as soon as he found out about the wound he immediately contacted the doctor and obtained orders to change his mattress to a low air loss mattress and implemented the roho cushion in his recliner. The facility's wound care nurse stated, "He did not have the special mattress or the roho cushion in his recliner until I saw him." During a telephone interview on 12/19/2013 at 10:24 A.M., Licensed Practical Nurse (LPN) #1 indicated she was the nurse who first noted the open area. She stated, "He had a little spot so I called the doctor.... I am not a wound nurse and I don't know a lot about wounds.... I should have put it on the 24 hour report sheet but I didn't...." A document dated 2010, and titled "Pressure Ulcers/Skin Breakdown-Clinical Protocol" identified as a current facility policy by the Administrator on 12/18/2013 at 1:27 P.M., indicated, "...Assessment and Recognition...the nurse shall assess and document/report the following...full assessment of pressure sore including location, stage, length, width, and depth, presence of exudates or necrotic tissue... The physician will help the staff review and modify the care plan as appropriate, especially when... new wounds develop despite existing interventions...." 3.1-40(a)(2)

Based on record review and interview, the facility failed to ensure accurate nursing assessments were completed related to [MEDICAL CONDITION] to bilateral lower extremities after an ordered medication for [MEDICAL CONDITION] was not administered for five days (Resident #30), and signs and symptoms of infection at a gastrostomy tube site (Resident #40) resulting in delays in antibiotic treatments. This deficiency affected 2 of 2 residents reviewed for nursing assessments and care in a sample of 15. Findings include: 1. The clinical record for Resident #30 was reviewed on 10/16/12 at 12:45 P.M. [DIAGNOSES REDACTED]. Nursing notes, dated 8/09/12 at 4:30 P.M., indicated ".....[MEDICATION NAME] 20 mg. PO (orally), daily....Family notified." The August 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The August 2012 MAR indicated [REDACTED]. The first dose was administered on 8/14/12, as indicated on the MAR. Nursing notes did not indicate any assessment was completed related to not receiving [MEDICATION NAME], 8/9 to 8/13/12. During an interview with the DON on 10/17/12 at 11:00 A.M., she indicated the use for [MEDICATION NAME] (diuretic), for Resident #30, was chronic lower extremity [MEDICAL CONDITION] but, no assessments of the [MEDICAL CONDITION] were completed by nursing staff. Physician notes, dated 8/16/12, indicated +1 and +2 [MEDICAL CONDITION] to the lower extremities, equal bilaterally. Physician notes, dated 8/28/12, indicated "[MEDICATION NAME] was not given for several days and [MEDICAL CONDITION] became worse (at) one point." Nursing notes, dated 9/01/12 at 11:00 A.M., indicated "Residents bilat (bilateral) [MEDICAL CONDITION] has gotten worse, laid her down in bed to elevate her legs....also c/o (complains of) pain in legs. Both legs are very tight. + (plus sign) [MEDICAL CONDITION].will continue to monitor her legs...." On 9/28/12 at 11:00 A.M., nursing notes indicated, "Left foot, 2nd (second) toe very red....tender- + (plus sign) [MEDICAL CONDITION] whole foot, +3 to +4 [MEDICAL CONDITION]- call to Dr. (physician name) - Keflex order." Nursing notes, dated 9/28/12 at 9:40 P.M., indicated, "Res (resident) is on ATB (antibiotic) for [MEDICAL CONDITION] at left foot 2nd (second) toe..." During an interview with the DON on 10/17/12 at 11:00 A.M., she indicated the [MEDICAL CONDITION] was not properly assessed. During an interview with Resident #30 on 10/18/12 at 2:00 P.M., she indicated she did not know names of medications she received and did not ask because she trusts the nurses to do their job. Additionally, she said she's "had painful swelling to her lower legs for two, or so, months, approximately. They (legs) were swollen, tight, and painful." 2. The clinical record for Resident #40 was reviewed on 10/15/12 at 1:00 P.M. [DIAGNOSES REDACTED]. Nursing notes on 9/07/12 indicated, "Area around [DEVICE] (gastrostomy tube) site drsg (dressing) when changed has lg. (large) amt. (amount) of greenish slimmy (sic) odorous drainage noted. Passed on to day nurse." During an interview with RN #1, on 10/16/12 at 1:05 P.M., she stated "The communication between the night shift nurse and the day shift nurse, on 9/07/12, was not clear. The day shift nurse told her (RN #1) he was not aware of a possible infection around Resident #40's [DEVICE] (gastrostomy tube) site, on 9/07/12." RN #1 indicated there was a lack in communication between the nurses that resulted in the physician not being notified of a change in condition, thus resulting in a delay in treatment. Physician orders, dated 9/27/12, indicated an antibiotic was ordered,[MEDICATION NAME] mg. (milligrams), crush tablet and sprinkle around [DEVICE] site, daily for 7 days. On 9/28/12 at 9:45 A.M., nursing notes further indicated, "Res. (resident) is on ATB (antibiotic) for GI (gastrointestinal) site infection....." Resident #40 received antibiotic (Cipro) treatment for [REDACTED]. During the daily conference on 10/16/12, information related to further assessments of the area around the [DEVICE] was requested. The DON and RN#1 voiced agreement and understanding. As of the exit conference on 10/18/12, this requested information/documentation was not presented. 3.1-37(a)

Based on record review and interview, the facility failed to ensure medications were administered, as ordered, by the physician, resulting in increased, painful [MEDICAL CONDITION] to the resident's bilateral lower extremities. This deficiency affected 1 of 1 resident reviewed for medication errors in a sample of 15. (Resident #30) Findings include: The clinical record for Resident #30 was reviewed on 10/16/12 at 12:45 P.M. [DIAGNOSES REDACTED]. Nursing notes, dated 8/09/12 at 4:30 P.M., indicated ".....[MEDICATION NAME] 20 mg. PO (orally), daily, KCl (potassium chloride) 8 mEq (milliequivalent) PO, daily. Family notified." The August 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The August 2012 MAR indicated [REDACTED]. The first dose was administered on 8/14/12, as indicated on the MAR. The August 2012 MAR indicated [REDACTED]. The August 2012 MAR indicated [REDACTED]. The first dose was administered on 8/14/12, as indicated on the MAR. Physician notes, dated 8/16/12, indicated +1 and +2 [MEDICAL CONDITION] to the lower extremities, equal bilaterally. Physician notes, dated 8/28/12, indicated "[MEDICATION NAME] was not given for several days and [MEDICAL CONDITION] became worse (at) one point." During an interview with RN#1 on 10/17/12 at 4:30 P.M., she indicated she was aware that the [MEDICATION NAME] was not given. She said the medication nurse "overlooked" the order for [MEDICATION NAME] and an incident report was completed. A facility incident report, dated 9/06/12, provided by the Administrator on 10/18/12 at 9:00 A.M., included, but was not limited to, the following: "[MEDICATION NAME] 20 mg and K Cl 8 mEq was ordered daily on 8/9/2012. On 8/14/2012 Medication nurse that day noted that the medications had not been given. Medications were written on the MAR, however, no times to be given were noted on the MAR. Spoke with Nurse who had passed the meds (medications) to that resident on 8/10 - 8/13 as to why meds were not given. That nurse stated I must have overlooked them." A document titled "Weekly Skin Integrity Review," with an entry dated 9/01/12, indicated "[MEDICAL CONDITION] bilat (bilateral) legs." On 9/28/12 at 11:00 A.M., nursing notes indicated, "Left foot, 2nd (second) toe very red....tender- + (plus sign) [MEDICAL CONDITION] whole foot, +3 to +4 [MEDICAL CONDITION]- call to Dr. (physician name) - Keflex order." Nursing notes, dated 9/28/12 at 9:40 P.M., indicated, "Res (resident) is on ATB (antibiotic) for [MEDICAL CONDITION] at left foot 2nd (second) toe....." During an interview with Resident #30 on 10/18/12 at 2:00 P.M., she indicated she did not know names of medications she received and did not ask because she trusts the nurses to do their job. Additionally, she said she's "had painful swelling to her lower legs for two, or so, months, approximately. They (legs) were swollen, tight, and painful." 3.1-48(c)(2)