Every finding on record at Rosewalk Village

Based on interview and record review, the facility failed to ensure staff were implementing the care plan with monitoring and documenting outputs for 1 of 1 resident reviewed for implementation of care plans. (Resident 3) Findings include:The clinical record for Resident 3 was reviewed on 3/2/26 at 11:30 a.m. The diagnosis included, but was not limited to: stroke with left side hemiplegia (loss of function/movement). An a.m. and p.m. assistance and monitoring of Activities of Daily Living care plan, dated 11/9/25, indicated the resident required assistance with elimination. One of the interventions on the care plan included staff documenting the residents urine and bowel outputs every shift. A toileting program care plan, dated 11/14/25, indicated Resident 3 was to be toileted by staff every shift; before and after meal service, upon rising and nightly checks. Resident 3's February 2026 and March 2026 output reports indicated the following days and shifts there were no recorded urine outputs: -On 2/1/26, no output was documented for the resident on day and evening shift,-On 2/2/26 through 2/6/26, no output was documented for the resident on each day all shifts,-On 2/7/26 through 2/9/26, no output was documented for the resident on each day and evening shifts,-On 2/10/26 through 2/13/26, no output was documented for the resident on each day all shifts,-On 2/14/26 through 2/16/26, no output was documented for the resident on each day and evening shifts,-On 2/17/26, no output was documented for the resident on all shifts,-On 2/18/26, no output was documented for the resident on night and evening shift,-On 2/19/26 through 2/21/26, no output was documented for the resident on day and evening shifts,-On 2/28/26, no output was documented for the resident on day and evening shift, and-On 3/1/25 through 3/3/26, no output was documented for the resident on all shifts An interview was conducted with the Director of Nursing (DON) on 3/4/26 at 1:10 p.m. She indicated the staff should be monitoring and recording Resident 3's urine and bowel outputs every shift. A care plan policy was provided by the DON on 3/6/26 at 11:15 a.m. It indicated, Policy: It is the policy of this facility that each resident will have an interdisciplinary comprehensive person-centered care plan developed and implemented based on Resident Assessment Instrument (RAI) process. The care plan must include measurable goals and resident specific interventions based on resident needs and preferences to promote the resident's highest level of functioning. 410 IAC (Indiana Administrative Code) 16.3.1-35(d)(1)

Based on interview and record review, the facility failed to timely conduct interdisciplinary care plan meetings for 2 of 2 residents reviewed for hospice and 1 of 2 residents reviewed for care planning (Residents 4, 6, and 9).Findings include: 1 The clinical record for Resident 4 was reviewed on 3/2/26 at 11:24 a.m. The resident's diagnoses included, but were not limited to, diabetes and dementia (mental decline). A Quarterly Minimum Data Set (MDS) Assessment, completed 2/4/26, indicated the resident had severely impaired cognition and received hospice services. Resident 4's clinical record contained a Care Plan Summary observation note, dated 2/4/26, that was not completed. The clinical record did not contain information that an Interdisciplinary Care Plan Meeting had been held after the completion on the Quarterly MDS Assessment. 2. The clinical record for Resident 9 was reviewed on 3/3/26 at 10:15 a.m. The resident's diagnoses included, but were not limited to, stroke (when blood flow to part of the brain was interrupted leading to lasting disability) and diabetes. The resident's clinical record contained a Care Plan Summary observation note, dated 2/11/26. The description indicated schedule care plan with hospice and family. The remainder of the observation note was not completed. A Significant Change of Status Minimum Data Set (MDS) Assessment, completed 2/18/26, indicated the resident had severely impaired cognition and was receiving hospice services. 3. The clinical record for Resident 6 was reviewed on 3/3/26 at 9:39 a.m. The resident's diagnoses included, but were not limited to, depression and diabetes. The resident's clinical record contained a Care Plan Summary observation note, dated 1/19/26. The description indicated a Quarterly care plan scheduled. A Quarterly MDS Assessment, completed 1/20/26, indicated the resident was cognitively intact. During an interview on 3/3/26 at 9:39 a.m., Resident 6 indicated he had not attended a care plan meeting. During an interview on 3/06/26 at 11:37 a.m., the Social Service Director (SSD) indicated there had not been interdisciplinary care plan meetings held for Resident 4, 9, and 6. The Interdisciplinary Care Plan Meetings should be held for each resident after an MDS Assessment was completed. On 3/6/26 at 10:29 a.m., the Director of Nursing Services provided the IDT Comprehensive Care Plan Policy, last reviewed October 2025, that read .Care plan review will be interdisciplinary and should include, to the extent possible, nursing, social services, activities, dietary, therapy, pharmacy, physician, direct care staff, and hospice personnel [if indicated]. Resident, resident's representative, or others as designated by resident will be invited to care plan review .Care plan problems, goals, and interventions must be reviewed and revised by the interdisciplinary team periodically and following completion of each OBRA[sic] MDS assessment . 410 IAC (Indiana Administrative Code) 16.3.1-35(e)

Based on interview and record review, the facility failed to ensure a resident received vision services for 1 of 1 residents reviewed for vision services. (Resident 50) Findings include: The clinical record for Resident 50 was reviewed on 3/2/26 at 11:30 a.m. The diagnosis included, but was not limited to, stroke (when blood flow to the brain was interrupted causing cells to die lead to lasting disability). The resident was admitted on [DATE]. A quarterly 1/14/26 Minimum Data Set (MDS) Assessment indicated Resident 50 was moderately cognitively impaired. A vision care plan, dated 10/4/23, indicated Resident 50's vision was impaired. The resident wore eye glasses. The staff were to arrange for eye doctor visits as needed. An ancillary consent, dated 10/6/23, indicated Resident 50 did want eye care. An interview was conducted with Resident 50 on 3/2/26 at 2:34 p.m. She indicated she was suppose to receive a new set of eye glasses. She had been waiting for 3 years and had never received them. She had not been seen by an eye doctor since admission. An interview was conducted with Social Services Director (SSD) on 3/4/26 at 2:49 p.m. She indicated Resident 50 had not been seen by an eye doctor since she had been admitted to the facility. She was unsure the reason why. A vision and hearing services policy was provided by the Nurse Consultant on 3/6/26 at 12:26 p.m. It indicated, Policy: It is the policy of this facility to ensure that residents are provided with vision and hearing services as needed. 410 IAC (Indiana Administrative Code) 16-3.1-39(a)(1)

Based on interview and record review, the facility failed to care plan behaviors and interventions for 1 of 1 resident reviewed for behavior management. (Resident 49) Findings include:The clinical record for Resident 49 was reviewed on 3/5/2026 at 4:00 PM. The medical diagnoses included, but were not limited to, anxiety, depression, and encephalopathy. An annual minimum data set assessment, dated 12/9/2025, indicated Resident 49 was cognitively intact, did not exhibit behaviors, hallucinations, delusions, or refusals of care. A care plan, dated 5/22/2024 and revised on 3/4/2026, indicated Resident 49 would refuse medications and weights. The interventions included, but were not limited to, providing space and educate Resident 49 on possible negative effects of refusing medications and weights. A care plan, dated 2/2/2026 and revised on 3/4/2026, indicated Resident 49 exhibited behaviors of becoming tearful. The interventions included, but were not limited to, provide psychosocial support and redirect as needed. A care plan, initiated 3/2/2026, indicated Resident 49 would become combative and aggressive when told she could not be in restricted areas. The interventions included, but were not limited to, to approach calmly, to maintain a safe distance, and ensure safety of the Resident 49. A care plan, dated 3/4/2026 and last revised on 3/4/2026, indicated Resident 49 had a history of becoming verbally or physically aggressive with staff if she could have what she wanted immediately. The interventions included, but were not limited, maintain safe distances, use calm reassurance, and use name and establish eye contact. A behavior note, dated 8/9/2025, indicated Resident 49 was arguing with a staff member about showering independently. An IDT (intradisciplinary team) progress note indicated on 8/12/2025 Resident 49 had a verbal episode of calling a staff member names and cursing. The progress note indicated the care plan was updated, and interventions included to educate Resident 49 about allowing staff to stand on the other side of the curtain when showering and the potential risk for not allowing care. The refusal care plan for Resident 49 did not list these interventions. A nursing progress note, dated 10/1/2025, indicated that Resident 49 became very verbally agitated and used extreme profanity. A nursing progress note, dated 10/30/2025, indicated Resident 49 was yelling at the nurses' station. During an interview with the Social Services Director, on 3/6/2026 at 12:36 p.m., she indicated Resident 49 had a history of behaviors including verbal aggression towards staff. Resident 49 would get fixated on things or people but Resident 49 had interventions which were helpful like preferred caregivers and diversional activities such as getting her nails done. SSD confirmed there were not on Resident 49's care plan nor were her verbally aggressive behaviors care planned prior to 3/4/2026. A policy, entitled Behaviors Management, was provided electronically by the Executive Director, on Friday, March 6, 2026, at 10:57 AM. The policy indicated, .Care plans should be initiated for any behavioral expression that is problematic or distressing to the resident, other resident or caregivers. Care plan interventions should include individualized and non-pharmacological interventions which address both proactive and responsive interventions. For behaviors which are new, worsening, or high risk, the nurse will record the staff should initiate an event in the charting system. New/Worsening Behaviors are defined as behaviors that are new for the resident, behaviors that are directed at another resident, Behaviors that are increasing in either frequency or severity, or behaviors that have potential for risk to others including sexual advances, intrusive wandering, exit seeking and chronic combativeness with care. If the behavioral expression is not new, worsening or high risk, the nurse will record the behavior in the progress notes for the IDT team to review the next day. If the behavior needed and IDT response then a behavior review would be complete, but if not, then the care plan would be reviewed and updated as needed. 410 IAC (Indiana Administrative Code) 16.3.1-37(1)

Based on observation, interview, and record review, the facility failed to provide assistance with scheduling and tracking dental services for 2 of 2 reviewed for dental services. (Resident 7 and Resident 25).Findings include: 1 The clinical record for Resident 7 was reviewed on 3/3/26 at 9:27 a.m. The resident's diagnoses included, but were not limited to, diabetes and hypertension (high blood pressure). A Request for Information from the facility dental provider form, dated 10/3/24, indicated Resident 7 consented to receive dental services. A Concern/Grievance Form, dated 11/11/24, indicated Resident 7 wanted to be seen by dental services. The resident was added the list to be seen by dental services on 11/20/24. A progress note, dated 11/21/24, indicated the dental provider had contacted the facility about an outstanding bill with the provider. Resident 7 had paid a portion of the bill but still had an outstanding balance. The outstanding bill needed to be paid in full before the dental provider would provide services. A Quarterly Minimum Data Set (MDS) Assessment, completed 12/22/25, indicated the resident was cognitively intact. A care plan, last reviewed 1/2/26, indicated Resident 7 was edentulous (absence of natural teeth) and wore upper and lower dentures. She was at risk for impaired dental hygiene. The goal was for her to be free from mouth pain, red or bleeding gums, and oral lesions. The interventions included, but was not limited to, dental consult as indicated. During an interview on 3/03/26 at 9:27 a.m., Resident 7 indicated her dentures were loose since she had lost weight. She would like to see about getting a new set of dentures. She had not seen the dentist about the loose dentures. During an interview on 3/3/26 at 2:26 p.m., the Social Service Director (SSD) indicated Resident 7 owed the dental provider an outstanding bill. The dental provider refused to see her until the bill was paid in full. The outstanding bill was from 2024. Resident 7 had not seen the dentist since she was readmitted to the facility in October 2024. During an interview on 3/04/26 at 2:58 p.m., the Executive Director indicated Social Services was working with the provider to work out the outstanding bill. 2. The clinical record for Resident 25 was reviewed on 3/2/26 at 3:30 p.m. The diagnosis included, but was not limited to: end stage renal disease (kidneys are functioning less than 10%). A quarterly Minimum Data Set (MDS) Assessment, completed 12/30/25, indicated the resident was cognitively intact. A dental care visit note, dated 3/19/25, indicated Resident 25 had received x-rays to send for prior authorization for a new partial and new set of dentures. A progress note, dated 6/27/25, indicated Resident 25 had an emergency dental appointment at 8:00 a.m. A physician's order, dated 7/16/25, indicated Resident 25 had an emergency dental appointment that day (7/16/25). Resident 25's clinical record did not include documentation that indicated the reason for the dental appointment nor if the resident made the 6/27/25 or 7/16/25 dental appointments. An interview was conducted with Resident 25 on 3/2/26 at 3:34 p.m. She indicated the dentist was supposed to address her dentures. They do not fit correctly. The bite was off. She had not been seen by a dentist in a while. An interview was conducted with the Social Services Director (SSD) on 3/4/26 at 2:49 p.m. She indicated Resident 25 had in the past been seen by an outside dentist. She was not in the role of social services prior to November 2025, but SSD had found a dental consultation that was in March 2025. That visit stated the resident was in the process of receiving prior authorization for new dentures. In July 2025, she had a dental appointment but did not make that appointment. SSD was unsure why the resident had not made that dental appointment. There was no documentation of the status of the new dentures or follow up on if the resident was needing a dental visit after July's missed appointment. On 2/10/26, Resident 25 had consented to receive dental services by the facility's dentist. A dental services policy was provided by the Nurse Consultant on 3/6/26 at 12:26 p.m. It indicated, Policy: The facility obtains needed dental services, including routine and emergency dental services, assists in providing these services and makes prompt referrals for dental services as needed. A Social Services Director description of position report was provided by the Director of Nursing on 3/6/26 at 10:35 a.m. It indicated, Summary of position functions: The Social Services Director provides medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident; and shares a responsibility toward creating and sustaining an environment that humanizes and individualizes each resident's living area. Essential position functions:.Collaborates with other departments, physicians, consultants, community agencies, and institutions to improve quality of services and to resolve identified problems.Demonstrates teamwork and prompt and regular attendance to work to ensure that quality care and services are provided to the residents. 410 IAC (Indiana Administrative Code) 16.3.1-34(a)

Based on observation, interview and record review, the facility failed to ensure a resident with a diagnosis of dementia who was at risk of elopement did not exit the facility unsupervised for 1 of 3 residents reviewed for accidents. (Resident B) Resident B was found in the community, had fallen, and was transported to the hospital for treatment.The immediate jeopardy began, on 10/28/25, when Resident B exited the facility unsupervised and without the staff's knowledge while wearing a wanderguard device (a wearable device used to alert staff when a resident approached restrictive areas/doors). The resident was located approximately 0.6 miles away from the facility. The resident was found lying face down on the ground by a concerned citizen. The resident was transported to the hospital and had sustained a laceration and hematoma to his forehead, preorbital edema (swelling around his eye), an abrasion to his left knee and shoulder, and skin tears to the 4th and 5th digit on his left hand. The Executive Director, Director of Nursing, and Regional Director of Clinical Operations were notified of the immediate jeopardy on 11/12/25 at 3:09 p.m. The immediate jeopardy was removed, and the deficient practice corrected on 10/31/25, prior to the start of the survey and was therefore past noncompliance.Findings include:The clinical record for Resident B was reviewed on 11/10/25 at 10:22 a.m. The diagnoses included, but were not limited to, vascular dementia, Alzheimer's dementia, and hypertension.A physician's order, dated 7/23/24, indicated to check the wanderguard device for placement every shift and for functioning once a day.A care plan, dated 7/23/24, indicated Resident B was at risk for elopement and had a wanderguard device. The interventions, initiated on 7/23/24, included, but were not limited to, the facility exits were to be secured and a wanderguard device was placed to his right lower extremity.A care plan, dated 11/1/24, indicated Resident B was an intrusive wanderer at times. He presented with increased confusion and had a diagnosis of Alzheimer's/vascular dementia. The resident's goal was that the resident would remain safe in the facility, and he would be free of exit seeking behavior. A quarterly Minimum Data Set (MDS) assessment, dated 10/14/25, indicated wander/elopement alarms were used daily and Resident B was severely cognitively impaired.An elopement assessment, dated 10/14/25, indicated the resident was at risk for elopement.A nursing facility progress note, dated 10/14/25, indicated Resident B had asked staff to let him out of the door.The electronic health record or facility progress notes did not indicate what time the facility noticed the resident was missing, when the code silver was called, or when staff began to search for the resident. A hospital document indicated Resident B arrived at the emergency room on [DATE] at 7:32 p.m. The admission note indicated according to the EMS run sheet the patient stated he felt dizzy all the sudden and fell face first. The patient was unsure if he lost consciousness. Small lacerations were found on the patient's face. The patient was unable to explain why he was multiple miles away from his living facility. He reported he was running away from a dog and fell.The hospital records indicated the injuries documented were a wound on the right forehead, abrasions to the left forehead and left knee, a left shoulder and hand abrasion, a left forehead laceration, a left scalp laceration with surrounding swelling and oozing blood, and evidence of a subgleal hematoma (bleeding in the space between the skull and the skin on the scalp).A nursing facility progress note, dated 10/29/25 at 5:57 p.m., indicated the resident was assessed upon his return from the hospital. He was found to have the following skin issues; a laceration from eye/left forehead, a bruised left eye with decreased periorbital edema, a skin tear to the left pinky and the 4th digit on left hand and an abrasion to the left shoulder.There were no progress notes in the electronic health record to indicate the resident had any of the documented skin issues prior to the elopement, on 10/28/25.There were no facility nursing progress notes documented from 10/14/25 until the resident returned from the emergency room on [DATE].During an observation, on 11/10/25 at 9:50 a.m., Resident B was on the locked memory care unit and was observed to have a healing abrasion to his left shoulder.During an interview, on 11/10/25 at 11:29 a.m., the Director of Nursing (DON) indicated Resident B left the facility and was found by someone who called 911. The resident was picked up by emergency medical services (EMS) and taken to the emergency room. The facility knew Resident B exited the facility through the G-hall exit door because there was video footage. She indicated the resident was found one block away on Arlington Avenue.During an observation, on 11/10/25 at 1:47 p.m., the Executive Director (ED) started a video from the facility cameras. The video started at 6:00 p.m., on 10/28/25. The camera faced the G-hall. Resident B was seen walking slowly down the G-hall at 6:04 p.m. The angle of the camera did not show the exit door at the end of the hall. On the video, a dark shadow could be seen at the end of the hall. The shadow became light and then disappeared. The ED played another video of the outside camera. The camera faced the parking lot and Resident B was seen walking east at 6:05 p.m. He turned left down the first side street and headed north. The facility believed the wanderguard device did not go off when the resident exited the building. This was during mealtime, and he believed the aides were looking for Resident B for dinner and noticed him missing. He did not know the exact time the staff noticed him missing. During an observation, on11/10/25 at 12:35 p.m., outside of the facility and to the north was 16th street. It had two (2) lanes of traffic. Arlington Avenue was east of the facility and had four (4) lanes of traffic. The posted speed limit was 35.An invoice from a facility hired door company, dated 10/30/25, indicated a resident eloped from the facilities G-hall exit. The double doors were found to have one antenna. The sensitivity on the antenna was turned up to get approximately 80 percent coverage for the double door. The door was then tested multiple times, and it was confirmed it was properly operating at that time. The door company would need to return to install a second antenna on the door for 100 percent coverage.During an interview, on 11/10/25 at 11:38 a.m., Maintenance 2 indicated the facility had three doors with the wanderguard device alarm system. The front door, the memory care unit, and the G-hall door. During an interview, on 11/10/25 at 3:08 p.m., RN 3, who was working at the time of the elopement, indicated she was aware of Resident B's elopement after the code-silver was announced. She did not hear a door alarm sound. During an interview, on 11/10/25 at 3:17 p.m., CNA 4, who was working at the time of the elopement, indicated she had not heard an alarm go off the evening of Resident B's elopement.During an interview, on 11/10/25 at 3:36 a.m., CNA 5, who was working at the time of the elopement, indicated he heard an alarm sound and a code silver alert was called about an hour after he had heard an alarm.During an interview, on 11/10/25 at 4:01 p.m., QMA 6, who was working at the time of the elopement, indicated she was familiar with Resident B. If he was not in his room, then he was in the hall by the dining room. It was abnormal for him to not be anywhere. She checked all the rooms and did not find him. She knew he was not in the facility and a code-silver was called. She indicated she did not hear any door alarms sound.QMA 6 did not indicate the time she had discovered Resident B was missing or the time she notified the nurse during her interview.During an interview, on 11/10/25 at 4:38 p.m., Resident B's family member indicated she was concerned he was found outside the facility as anything could have happened to him.During an observation and interview, beginning on 11/12/25 at 2:24 p.m., the doors were found to have keypad entrances. Pressure was applied to the doors to see if they would open and they did not. Maintenance 2 opened the G-hall doors and a high pitch loud alarm sounded. Maintenance 2 also demonstrated how if the door was not closed properly, the alarm would still sound.During an interview, on 11/12/25 at 3:26 p.m., the Regional Director of Clinical Service indicated the facility staff were interviewed related to the elopement and no one heard an alarm sounding. The facility did not have any more information to provide related to the elopement.During an interview, on 11/13/25 at 9:25 a.m., the Executive Director indicated he was unsure if the door company which came and inspected the doors after Resident B's elopement was the company which originally installed the system on the door due to the age of the system. He further indicated the door company only came out if there was an issue and the facility called them out.A current facility policy, titled Elopement Prevention and Response Program, dated 10/2020 and received from the Director of Nursing on 11/10/25 at 11:24 a.m., indicated .It is the policy of the facility that staff who have residents under their care are responsible for knowing the location of those residents, and the case of a missing resident, ensuring appropriate action is taken.A current facility policy, titled Abuse Prohibition, Reporting, and Investigating, dated 6/2023 and received from the Director of Nursing on 11/12/25 at 11:24 a.m., indicated .Failure to provide goods and services to a resident(s) necessary to avoid physical harm.Facility's indifference or disregard for resident care, comfort or safety resulting physical harm, pain, mental anguish, or emotional services.The past noncompliance immediate jeopardy began on 12/21/24. The immediate jeopardy was removed and corrected by 10/31/25 after the facility implemented a systemic plan that included the following actions: the facility completed elopement risks on all residents, elopement drills with staff, all staff were educated on the elopement procedure and high-risk behaviors, a second antenna on the G-hall double door exit was installed due to only having one antenna, proper operation the system was working properly was ensured, the range was increased, and the door codes were changed to prevent unauthorized exitsThis citation relates to Intake 2657596.3.1-45(a)(1)3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure expired food was disposed of timely with the potential to affect 98 of 98 residents that receive food from the kitchen. (Facility) Findings include: The facility kitchen was observed with Culinary Aide 2 (CA) on [DATE] at 9:45 a.m. The inspection of the dry storage was conducted with CA 2. During an interview with CA 2, he indicated the top dates on the boxes were delivery dates and bottom dates were expiration dates. The following food items were observed outdated in the dry storage: One bag of graham cracker crumbs - expired [DATE], Eleven bags of sugar free Jell-O - expired [DATE], Fourteen bags of pork flavored gravy mix- expired [DATE], Six bags of cream soup base- expired [DATE], Brownie mix- opened [DATE] and expired [DATE], Cake mix- expired [DATE], Streusel topping- expired [DATE], Chocolate chips- expired [DATE], Two boxes of assorted Jell-O- expired [DATE], Twelve bags of vanilla pudding- expired [DATE], Cake mix- expired [DATE], Four bags of gravy mix- expired [DATE], Nine boxes of corn starch- expired [DATE], A container of peanut butter - expired [DATE], Rainbow sprinkles - expired [DATE], Large storage bin of oatmeal- expired [DATE], and Large storage bin of thickener- expired [DATE]. During the inspection of the walk-in refrigerator, the Dietary Manager (DM) indicated the items that were expired should have been removed and disposed of properly. In the walk-in refrigerator, there were pies that were cut and ready for service. However, they were not covered while being stored in the walk-in refrigerator. The DM indicated the pies should have been covered while in the walk-in refrigerator. The following items were observed outdated in the walk-in refrigerator: Eight pre-made peanut butter and jelly sandwiches- expired [DATE], Box of green peppers- expired [DATE], Two bags of shredded lettuce- expired [DATE], Box of lettuce- expired [DATE], Shredded cheese- expired [DATE], and Six English cucumbers- expired [DATE]. During an interview on [DATE] at 10:05 a.m., the DM indicated all expired food items had been removed. The DM was planning on conducting an in-service with staff, on [DATE], to ensure the policies were understood and followed. On [DATE] at 1:35 p.m., the food storage policy, revised ,d+[DATE], was provided by the Executive Director. The policy indicated food should be covered and/or stored in covered containers. The food must be clearly labeled and dated with the date of preparation and the date the food should be discarded or consumed. Opened food should have the date marked and not exceed the manufacturer's use-by-date. During an interview on [DATE] at 11:16 a.m., the Director of Nursing indicated 98 residents receive a tray from the kitchen at each meal service. 3XXX,d+[DATE](i)(2) 3XXX,d+[DATE](i)(3)

Based on observation, interview, and record review, the facility failed to ensure infection control was maintained by not ensuring hand hygiene was performed prior to donning gloves, failed to utilize hand hygiene during a medication administration, popping pill medication in bare hands for 3 of 6 residents randomly observed for medication administration, and not donning personal protective equipment (PPE) during bathing and dressing for 1 of 1 resident reviewed for dialysis. (Resident 2, Resident 12, Resident 20, and Resident 24) Findings include: 1. The clinical record for Resident 20 was reviewed on 3/9/25 at 11:31 a.m. The diagnoses included, but were not limited to, diabetes. On 3/9/25 at 11:31 a.m., Licensed Practical Nurse (LPN) 25 was randomly observed performing a blood glucose check for Resident 20. LPN 25 gathered the supplies to conduct the blood glucose check from the medication cart, including a pair of disposable gloves. LPN 25 entered Resident 20's room and informed Resident 20 about the need to obtain a blood glucose check. LPN 25 donned the disposable gloves, cleansed Resident 20's finger with an alcohol swab, and performed the blood glucose check. LPN 25 did not perform hand hygiene prior to donning the disposable gloves. 2. The clinical record for Resident 12 was reviewed on 3/12/25 at 9:00 a.m. The diagnoses included, but were not limited to, hypertension. On 3/12/25 at 8:53 a.m., LPN 26 was randomly observed administering a nasal spray to Resident 12. LPN 26 gathered Resident 12's medications and nasal spray from the medication cart, along with a pair of disposable gloves. LPN 26 entered Resident 12's room and informed Resident 12 she had her medications and nasal spray. LPN 26 donned a pair of disposable gloves and administered Resident 12's nasal spray. LPN 26 then picked up the plastic cup of oral medications with her gloved hands and handed the cup to Resident 12. LPN 26 did not perform hand hygiene prior to donning the disposable gloves. During an interview on 3/12/25 at 9:05 a.m., LPN 26 indicated she normally performed hand hygiene prior to donning disposable gloves. 34850 3. The clinical record for Resident 24 was reviewed on 3/9/25 at 12:00 p.m. The diagnoses included, but were not limited to, chronic pain. A physician order, dated 11/15/24, indicated Resident 24 was to receive 1000 milligrams (mg) of Tylenol three times a day for moderate pain as needed (PRN). An observation was conducted of a medication administration for Resident 24 with Unit Manager (UM) 8 on 3/9/25 at 11:09 a.m. UM 8 was observed at the medication cart preparing to administer 1000 mg of Tylenol to Resident 24. UM 8 opened the medication cart and pulled a medication card out and popped two tablets of Tylenol in his bare hands. He then placed the two tablets in a medication cup and administered the medication to the resident. UM 8 had not utilized hand hygiene prior to preparing the medication administration. An interview was conducted with UM 8 on 3/9/25 at 11:15 a.m. He indicated he does not normally touch the medication with his bare hands. 4. The clinical record for Resident 2 was reviewed on 3/10/25 at 9:00 a.m. The diagnoses included, but were not limited to, renal disease. A Quarterly Minimum Data Set (MDS) assessment, dated 1/16/25, indicated Resident 2 was cognitively intact. A care plan, revision date of 1/23/25, indicated the resident required enhanced barrier precautions. The interventions included but were not limited to, the staff was to wear gown and gloves prior for high contact care activities. An observation was conducted of Resident 2 in her room on 3/10/25 at 9:15 a.m. The resident was observed in her bed wearing a gown. An enhanced barrier precaution sign was observed on her wall. The resident indicated, at that time, she had a port in her right leg for dialysis and a gastrostomy tube (surgically inserted tube in stomach). She will be going to dialysis soon. During that time, Certified Nurse Aide (CNA) 5 and CNA 7 had entered the resident's room and indicated they were going to get her ready for dialysis. The CNAs were observed going into the bathroom filling a basin of water and donning gloves. The CNAs were not observed donning on PPE prior to bathing and dressing the resident. An interview was conducted with Resident 2 on 3/11/25 at 12:19 p.m. She indicated the staff will don gloves, but do not don a gown while bathing and dressing her. A Standard and Transmission-Based Precautions (Isolation) Policy was provided by Director of Nursing on 3/11/25 at 2:08 p.m. It indicated, .hand hygiene . Perform hand hygiene: Before having direct contact with a resident .Enhanced Barrier Precautions (EBP): An intervention designed to reduce the transmission of resident organisms that employs targeted use of gown and glove use during high contact resident care activities. Enhanced Barrier Precautions expands the use of PPE beyond situations in which exposure to blood and body fluids is anticipated, it refers to the use of gown and gloves during high-contact resident are activities that provide opportunities for transfer of MDROs [multidrug resistant organism] to staff hands and clothing. Enhanced barrier precautions are used for: Resident(s) with chronic wounds and/or indwelling medical devices, regardless of their MDRO status . A hand hygiene policy was provided by the Director of Nursing on 3/11/25 at 2:08 p.m. It indicated, .Procedure: Healthcare personnel should use an alcohol-based hand rub or wash the soap and water for the following clinical indications .Immediately after glove or PPE removal .B. Indication for hand-rubbing but not limited to .Before and after removing glove . 3.1-18(b)(2) 3.1-18(l)

Based on interview and record review, the facility failed to ensure residents' dignity was respected for 3 of 4 residents reviewed for abuse. (Residents' J, K, and L) Findings include: 1. The clinical record for Resident K was reviewed on 3/10/25 at 10:00 a.m. The diagnoses included, but were not limited to, heart disease. A Quarterly Minimum Data Set (MDS) assessment, dated 1/8/25, indicated Resident K was cognitively intact. An interview was conducted with Resident K on 3/10/25 at 10:09 a.m. She indicated she had reported Licensed Practical Nurse (LPN) 22 to the Executive Director (ED). He was always hateful and rude towards her. LPN 22 was changing her humidifier for her oxygen, and during that time, the interaction between LPN 22 and Resident K was not respectful. LPN 22 had made rude statements to her and stuck up his middle finger. She had stated to him, you're not my daddy, and he responded, you're not my mama. She expected LPN 22 to apologize to Resident K for being treated that way, but she had not received an apology. LPN 22 no longer worked at the facility. A reportable incident to the Indiana Department of Health with an investigation file was provided, on 3/10/25 at 3:38 p.m., from the ED. The incident report, dated 2/4/25, indicated Resident K had reported customer care concerns with a staff member (LPN 22) on 2/3/25. The follow up completed indicated the other staff person, Certified Nurse Aide (CNA) 6, had been in the resident's room at the time of the incident and did not witness LPN 22 being rude to Resident K. The investigation file of the incident between LPN 22 and Resident K included, but was not limited to, the following documents: An e-mailed statement by CNA 6, dated 2/6/25, indicating she had asked LPN 22 to assist her with Resident K's roommate. During that time, she observed LPN 22 and Resident K bickering back-and-forth with each other. She did not hear any cussing during the interaction between LPN 22 and Resident K. She did hear Resident K request for LPN 22 not to speak to her. LPN 22's response was Okay. You don't want to talk to me. After, CNA 6 had exited the room first with LPN 22 coming from behind, so she had not observed LPN 22 sticking up his middle finger at Resident K prior to exiting the room. A typed statement by LPN 22, dated 2/3/25, indicated on 2/3/25 at approximately 5:00 a.m., he was in Resident K's room preparing to change out oxygen tubing and condenser water for Resident K. The resident, he believed, had gotten upset because she had been woken up while changing the oxygen supplies. The resident had declined for staff to change out her oxygen supplies at that time. LPN 22 had explained the oxygen items needed to be changed and exchange the old ones with new ones. CNA 6 provided care to Resident K's roommate and requested his assistance. During that time, Resident K was shouting random negative comments like you're not my dad so you can't tell me when to change anything. As LPN 22 was helping CNA 6, Resident K would say something negative towards LPN 22 about every two to three minutes, or so, with no reaction from LPN 22. LPN 22 and CNA 6 finished up with the roommate and as they both were walking out of the room and LPN 22 was pulling the door closed, Resident K yelled out she was going to tell everyone and today was LPN 22's last day. Typed resident statements were included in the investigation file. It indicated the following statements from Resident L and Resident J: Resident L was asked, Did nurse [LPN 22] ever cuss at you or made you feel upset? Resident L responded, When I'd [sic] didn't do what he wanted one day, we got into an argument, he was like, man F*** you. So, I told him, F*** you back. Resident J was asked, Did nurse [LPN 22] ever cuss at you or made you feel upset? Resident J responded, He is pushy and rude. Always trying to make me take stuff I don't want to take too forceful for me. 2. The clinical record for Resident J was reviewed on 3/10/25 at 12:00 p.m. The diagnoses included, but were not limited to, heart failure. A Significant Change MDS assessment, dated 1/14/25, indicated Resident J was cognitively intact. An interview was conducted with Resident J on 3/11/25 at 12:13 p.m. He indicated LPN 22 was pushy and demanding. He would wake him up in the middle of night and want him to do something. For example, Take a sip of water. If he declined, LPN 22 would not take no for an answer. Resident J had requested he did not want LPN 22 back in his room anymore due to being disrespectful. 3. The clinical record for Resident L was reviewed on 3/10/25 at 1:00 p.m. The diagnoses included, but were not limited to, quadriplegia. A Quarterly MDS assessment, dated 1/30/25, indicated Resident L was cognitively intact. An interview was conducted with Resident L on 3/11/25 at 2:19 p.m. He indicated he did have an argument with LPN 22 a while back. He rushes through care and doesn't listen. During an argument with LPN 22, he had stated to Resident L, shut the f*** up, and he responded, with repeating the same words he said back to him. The nurse just didn't want to listen to what he had to say. He had spoken to the Director of Nursing (DON) and the ED about the incident. LPN 22 was disrespectful. It was addressed and over now. It did not happen again. An interview was conducted with the ED on 3/13/25 at 9:49 a.m. He indicated he had completed the investigation into the reportable incident between Resident K and LPN 22. During the investigation, he had also spoken to Resident L and Resident J. A discussion with LPN 22 was provided and included education about his mannerisms. LPN 22 had stated to the ED he was just trying to coach the residents to have a better life and encourage them to be healthier. LPN 22 meant well, but he was disrespectful. LPN 22 has been on medical leave since the incident. A resident's rights policy was provided by the DON on 3/13/25 at 1:59 p.m. It indicated, .In accordance with this right to dignity and respect, residents are entitled to all of the freedom and privileges of any other citizen. The resident also has obligations and responsibilities to the Community staff and other residents .Every resident in a long-term care facility shall have at least the following rights . (18) Each resident shall be treated with consideration, respect, and full recognition of his dignity and individuality, including privacy in treatment and in care for his personal needs . This citation relates to complaint IN00451232. 3.1-3(t)

Based on observation, interview, and record review, the facility failed to ensure a call light was in reach for 1 of 1 resident reviewed for call lights (Resident G). Findings include: The clinical record for Resident G was reviewed on 3/11/25 at 10:00 a.m. The diagnoses included, but were not limited to, anemia, cancer, heart failure, diabetes, hemiplegia caused by stroke (weakness on one side of the body), and depression. A Quarterly Minimum Data Set assessment, completed 12/20/24, indicated Resident G's preferred language was Spanish, and she needed an interpreter to communicate with doctors or health staff. It also indicated Resident G was cognitively intact with impairment of her right upper extremity. An observation was conducted of Resident G on 3/12/25 at 9:39 a.m. Resident G was in bed and her call light cord was attached to the wall mount on the wall next to the bed. The cord went behind the resident's bed, and it was hanging in front of the headboard near the ground on the right side of the bed. The call light was out of sight and out of reach of the resident. In an interview with Resident G on 3/12/25 at 9:39 a.m., the resident indicated she was aware she did not have her call light. Sometimes she has it and sometimes she does not. She indicated when she does have her call light, she knows how to use it. At 10:36 a.m., Laundry Aide 11 was asked to give Resident G her call light. Laundry Aide 11 then told Certified Nurse Aide (CNA) 9, who was in another resident room, that Resident G needed her call light handed to her. When CNA 9 came out of the resident's room, she was asked if Resident G used her call button to request help and CNA 9 indicated Resident G does use the call light. During an observation of Resident G on 3/12/25 at 1:46 p.m., her call light was still in the same place and positioned behind her bed as it was that morning. The Director of Nursing (DON) was interviewed in Resident G's room on 3/13/25 at 10:48 a.m. The resident's call light cord was observed plugged into the wall on top left side of the bed, underneath her pillow, out of sight, and out of reach. The DON indicated their policy indicates the call light should be within reach, and she believed the call light was currently in reach of the resident. The resident was asked, at that time, to reach for her call light. The resident pulled the pillow from behind her head, then placed the pillow back, and attempted to feel around for her call light. She was unable to reach the call light. The DON then grabbed the call light and handed it to the resident. During an interview with the DON on 3/13/25 at 1:05 p.m., she indicated they do not have a policy on call lights, and they just follow the standards of care for call light use and availability. 3.1-3(v)(1)

Based on observation, interview, and record review, the facility failed to get residents up to a wheelchair and complete regular hair shampooing for 1 of 4 residents reviewed for ADLs (Activities of Daily Living). (Resident G) Findings include: The clinical record for Resident G was reviewed on 3/11/25 at 10:00 a.m. The diagnoses included, but were not limited to, anemia, cancer, heart failure, diabetes, hemiplegia caused by stroke (weakness on one side of the body), and depression. A Quarterly Minimum Data Set assessment, completed 12/20/24, indicated Resident G's preferred language was Spanish, and she needed an interpreter to communicate with doctors or health staff. It also indicated Resident G was cognitively intact with impairment of her right upper extremity. On 3/12/25 at 9:39 a.m., Resident G was observed in her room, lying in bed wearing a hospital gown. The resident's hair was oily, stringy, and tangled in the back. She indicated she had not had a shower, a full bed bath, or her hair shampooed in about 10-12 days. She asked the staff to wash her hair, but they did not. The staff had not gotten her up to her wheelchair in a long time. She used to have a wheelchair in her room, but she had not seen it for many days. No wheelchair was observed in the room. She indicated she would like to get up to a wheelchair. She does remember the staff using a machine to get her up, but she has not seen the machine in a long time. During an interview on 3/12/25 at 11:46 a.m. with Licensed Practical Nurse (LPN) 10, she indicated the resident's showers were scheduled for Tuesdays and Fridays. While the resident does not frequently refuse care, she has been known to in the past. She could communicate well with Resident G, who makes her needs known well enough. The resident was a Hoyer lift with a two people assist to transfer and said there should be a wheelchair in the resident's room. The Assistant Director of Nursing Services (ADNS), who attended the interview, indicated the resident does have a wheelchair, but she does not know where it was. The resident had told them she likes to stay in a hospital gown and stay in bed. During an interview with Certified Nurse Aide (CNA) 9 on 3/12/25 at 1:55 p.m., she indicated she gave the resident a partial bed bath the day prior (3/11/25) because the resident requested a partial bed bath instead of a full one. During an observation and interview with Resident G on 3/13/25 at 9:53 a.m., she indicated she had not yet received a complete bed bath or shower this week, and her hair had still not been washed. Resident G's hair was very oily, stringy, matted, and now had some flakes of skin near her scalp. She indicated a wheelchair was now in her room, and it was the first time she had seen one in many days. She would like to get up to the wheelchair. The Director of Nursing (DON) provided shower sheets, on 3/13/25 at 10:48 a.m., which covered the period from 2/4/25 to 3/11/25. According to the shower sheet for 3/11/25, the CNA documented she had given the resident a complete bed bath and shampooed the resident's hair. Prior to the 3/11/25 documentation, the last time staff documented washing the resident's hair was on 2/25/25. During an interview with the Occupational Therapist (OT) on 3/13/25 at 9:11 a.m., she indicated she did a new evaluation with the resident, on 3/12/25, after the Speech Therapist (ST) referred the resident to her for evaluation for a wheelchair. The ST wanted the resident to be up in a wheelchair in the dining room for meals. She thought she had an 18-inch wheelchair but needed a larger one. The resident's wheelchair was not available when she did her evaluation, and she could not speak to what nursing had been doing to get the patient out of bed. The resident had a decline in bed mobility since she was last seen a year ago, had right arm hemiparesis (weakness), increased left arm weakness, and needed a different wheelchair. She communicated well with the resident using gestures and the resident understood more English than she speaks. She indicated the resident did seem receptive to using the wheelchair and she will be working on getting a larger wheelchair for the resident. During an interview with the ST on 3/13/25 at 9:24 a.m., she indicated she evaluated Resident G, on 3/4/25, to assess swallowing due to the resident's emergency oral surgery. She wanted to make sure the resident was on an appropriate diet. She indicated Resident G did not want to try a puree diet and wanted to stay on a regular diet. She wants her up in a wheelchair in the dining room for meals, just to get her out of her room. During an interview with the Therapy Manager on 3/13/25 at 9:30 a.m., she indicated when Resident G first admitted , she was using an 18-inch wheelchair, but therapy then put her in a 20-inch wheelchair, and that should be utilized by nursing staff currently. During an interview with the DON on 3/13/25 at 10:48 a.m., she indicated the ADNS had found the resident's wheelchair and put it in the room that morning. The wheelchair may not have been in the resident's room this week if it had been taken to be cleaned. She indicated the night shift CNAs have assigned room wheelchairs to wash on different days of the week. They take the wheelchair to the shower room, wash it, then line them up in the gym to dry overnight. They bring them back in the morning once they are dry, but if they forget, the day shift will come get them. Otherwise, the wheelchair stays in the resident's room when not being cleaned. She indicated this morning, the resident asked LPN 10 if she could get up to her wheelchair. However, when the DON came in later to assist, the resident told her she did not want to get up. Resident G was observed shaking her head no while the DON made this statement. A care plan for ADLs, dated 4/12/24, indicated Resident G required assistance with ADLs related to impaired mobility and the history of a cerebrovascular accident (stroke). Her ability to participate in ADL care fluctuated from the morning to evening, and day to day. The goal was for Resident G to have their needs met daily with staff assistance as evidenced by being neat, clean, well-groomed, and dressed appropriately. Resident G was a two-staff person assisting with the use of a Hoyer (mechanical) lift and assistance with bathing as needed per the resident's preference. The approach was to offer showers twice a week with a partial bed bath in between. A care plan approach, added 3/12/25, indicated Resident G preferred to stay in bed most of the time. A care plan, dated 5/7/24, indicated the resident had impaired mobility related to right side body weakness. The care plan approaches included, Encourage resident to participate in transfer and bed mobility activities .Notify therapy of declines in mobility or improvement in mobility. A physician order, initiated on 5/24/24, indicated the resident was to have a Hoyer (a mechanical device that helps move people with limited mobility) and two people assist with transfers to bed and wheelchair. Another order, initiated on 10/16/24, indicated that a foam cushion should be on the seat of the resident's wheelchair. A care plan, dated 6/10/24, indicated Resident G Refuses ADL care at times. The care plan approach was to Educate resident on the possible negative effects from refusing ADL care at times. During an interview with the DON on 3/13/25 at 1:05 p.m., she indicated they do not have a policy on ADLs, and that they just follow standards of care. This citation relates to Complaint IN00453820. 3.1-38(a)(2)(A) 3.1-38(a)(2)(B) 3.1-38(a)(3)(B)

Based on observation, interview, and record review, the facility failed to ensure a resident with contractures (abnormal shortening or tightening of muscle tissue the renders the muscle highly resistant to stretching and can lead to permanent disability) received splint application as recommended by therapy staff for 1 of 2 residents reviewed for rehabilitation services. (Resident B) Findings include: The clinical record for Resident B was reviewed on 3/11/25 at 10:25 a.m. The diagnoses included, but were not limited to, hemiplegia (one-sided paralysis) and hemiparesis (one-sided muscle weakness) following cerebral infarction (stroke) affecting left non-dominant side, contracture of left wrist, contracture of left knee, contracture of left hand (fingers), contracture of left elbow, and muscle wasting and atrophy. An Admission Minimum Data Set (MDS) assessment, dated 1/10/25, indicated Resident B was cognitively intact, had impairment on one side of the upper and lower extremity, substantial assistance with upper body dressing, and dependent for lower body dressing. An activities of daily living (ADL) care plan, initiated on 1/4/25 and revised on 1/16/25, indicated Resident B required assistance with ADLs related to weakness and impaired mobility due to contractures to the left wrist, left knee, left fingers, and left elbow. The approach included physical and occupational therapy as ordered/indicated but no utilization of a splint. A physical therapy note, dated 1/24/25, indicated restorative nursing program set up and training for bilateral lower extremity and range of motion exercises. Restorative nursing aide demonstrated good understanding of the program. An occupational therapy note, dated 2/2/25, indicated the resident will safely wear a grip hand splint and an elbow extension splint on the left elbow for up to four hours with minimal signs of redness, swelling, discomfort or pain to prevent progression of contractures. An interview conducted with Therapy Manager, on 3/10/25 at 10:45 a.m., indicated Resident B had contractures and was receiving therapy services. Resident B fired all the therapy staff but was agreeable to receive the application of a splint, and such was done by nursing staff. The therapy staff conducted an in-service with all the nursing staff to ensure proper application of the splints. The clinical record for Resident B, reviewed on 3/11/25 at 10:27 a.m., did not include any physician orders for the application of splints. The clinical record for Resident B did not include any care plan related to the application of splints. An observation and interview conducted with Resident B, on 3/10/25 at 11:45 a.m., indicated no splint was observed to the left hand. Resident B indicated he should have a splint for his left hand, but the staff never apply the splint. An observation and interview conducted with Resident B, on 3/11/25 at 3:39 p.m., indicated no splint was observed to the left hand. A policy entitled Restorative Nursing Program, revised 11/2018, was provided by the Director of Nursing on 3/11/25 at 2:08 p.m. The policy indicated the restorative nursing programs include active or passive range of motion and splint or brace assistance. The process of the program was coordinated, supervised and carried out by nursing staff. A resident-centered care plan will be developed by the nurse and include measurable objectives, specific interventions to maintain or improve function, or to prevent, to the extent possible, further declines in resident function. This citation relates to Complaint IN00452635. 3.1-42(a)(2)

Based on observation, interview, and record review, the facility failed to hold insulin when a blood sugar was below the physician's prescribed perimeters for 1 of 1 randomly observed insulin administration (Resident 20). Findings include: The clinical record for Resident 20 was reviewed on 3/9/25 at 11:31 a.m. The diagnoses included, but were not limited to, diabetes. A care plan, dated 10/21/24, indicated she was at risk for adverse effects of hyperglycemia (high blood sugar), or hypoglycemia (low blood sugar) related to use of glucose lowering medication and diagnosis of diabetes. The goal was for her not to experience symptoms of hyperglycemia or hypoglycemia. The interventions included monitoring blood sugar and administer medications as ordered. A physician's order, dated 12/30/24, indicated she was to receive insulin lispro (fast acting insulin) 12 units three times a day with meals; hold if blood sugar was less than 150 milligrams per deciliter (mg/dL). On 3/9/25 at 11:31 a.m., Licensed Practical Nurse (LPN) 25 was randomly observed administering medications to Resident 20. LPN 25 performed a blood sugar check on Resident 20 with a reading of 122. She went to the medication cart and opened a new lispro insulin pen. She primed the pen with two units of insulin, looked at the Medication Administration Record to check the lispro insulin order, and then set the insulin pen to administer 12 units of insulin lispro. LPN 25 gathered her supplies and entered Resident 20's room. LPN 25 asked Resident 20 where she wanted to receive her insulin and Resident 20 indicated she would like the insulin shot in her left arm. LPN 25 cleansed an area on Resident 20's upper left arm with alcohol and was preparing to administer 12 units of lispro insulin to Resident 20. The insulin administration was stopped. During an interview on 3/9/25 at 11:55 a.m., LPN 25 indicated the physician's order for Resident 20 included to hold the lispro insulin if her blood sugar was less than 150. LPN 25 indicated Resident 20's insulin lispro, 12 units, should have been held and not given. On 3/12/25 at 11:00 a.m., the Clinical Nurse Consultant (CNC) provided the Medication Administration Skills Competency, last revised July 2023, which read .Perform the 5 rights of medications: Right Resident, Right Time, Right Dose, Right Route, Right Time . 3.1-48(c)(2)

Based on interview and record review, the facility failed to ensure a binding arbitration agreement was explained to the resident representative and signed by the resident representative for 2 of 3 residents reviewed for arbitration agreements. (Resident 42 and Resident 88) Findings include: 1. The clinical record for Resident 42 was reviewed on 3/13/25 at 11:09 a.m. The diagnoses included, but were not limited to, dementia, age-related physical debility, hypertension, cognitive communication deficit, muscle weakness, and difficulty in walking. Resident 42 was admitted to the facility on [DATE]. An Order Appointing Temporary Guardian document, file date 10/23/24, indicated a temporary guardian was ordered for Resident 42. The powers of the guardian included, but were not limited to, to consent in writing to the medical or surgical treatment of Resident 42 and to enter into contracts for the admission of Resident 42 to any health care facility reasonably deemed necessary for the safety and well-being of Resident 42. The temporary guardian preceded for a period of 90 days. An Admission Minimum Data Set (MDS) assessment, dated 11/4/24, indicated Resident 42 was severely cognitively impaired. An Arbitration Agreement, dated 10/31/24, indicated Resident 42 signed the arbitration agreement and initialed that she understood the nature of the agreement, understood she wasn't required to enter into the agreement, understood the right to terminate or withdraw from the agreement within 30 days of signing, and acknowledged she entered into the agreement freely and voluntarily. The document was also signed by Admission Staff 3. Admission Staff 3 signed the bottom of the Arbitration Agreement that indicated the following, .Acknowledgement: By signing below, I hereby attest that the Resident, who is in an alert and oriented state of mind, designated or authorized the above-named legal representative, in my presence, to sign this agreement on behalf of Resident An Order Appointing Guardian document, file date of 1/9/25, indicated Resident 42 was deemed incapable of managing their person and property because of a diagnosis of dementia and stroke. Resident 42 was rendered unable to make health care decisions on her own and found to be an incapacitated person. An interview conducted with Admission Staff 3, on 3/13/25 at 10:20 a.m., indicated Resident 42 admitted to the facility with no power of attorney, no family, or any contact person. Resident 42 ended up being a candidate for a guardian and was appointed one, effective January of 2025. Admission Staff 3 indicated she had to explain the agreement to Resident 42 about three times because it was difficult for Resident 42 to understand. 2. The clinical record for Resident 88 was reviewed on 3/13/25 at 10:58 a.m. The diagnoses included, but were not limited to, dementia, chronic pain, hypertension, age-related cognitive decline, and muscle weakness. Resident 88 was admitted to the facility on [DATE]. Resident 88's daughter was listed as her power of attorney (POA) for financial and health care purposes. An Admission MDS assessment, dated 9/12/24, indicated Resident 88 was cognitively impaired. An Arbitration Agreement, dated 9/9/24, indicated Resident 88 signed the arbitration agreement and initialed that she understood the nature of the agreement, understood she wasn't required to enter into the agreement, understood the right to terminate or withdraw from the agreement within 30 days of signing, and acknowledged she entered into the agreement freely and voluntarily. The document was also signed by Admission Staff 3. Admission Staff 3 signed the bottom of the Arbitration Agreement that indicated the following, .Acknowledgement: By signing below, I hereby attest that the Resident, who is in an alert and oriented state of mind, designated or authorized the above-named legal representative, in my presence, to sign this agreement on behalf of Resident An interview conducted with Admission Staff 3, on 3/13/25 at 10:20 a.m., indicated Resident 88's POA was her daughter. The POA had some personal items that came up and the daughter was unable to come into the facility and sign the paperwork that consisted of the binding arbitration agreement. So, Admission Staff 3 contacted Resident 88's POA over the phone and the POA verbally stated it was okay for Resident 88 to sign the binding arbitration agreement. Admission Staff 3 indicated there was an option to sign the binding arbitration agreement electronically.

Based on observation and interview, the facility failed to ensure postings of current daily working staff. This had the potential to affect 98 of 98 residents that reside in the facility. Findings include: Random observations were made of the facility on 3/09/25 at 10:35 a.m., 10:44 a.m., and 11:27 a.m. The posting of current daily working staff in the facility was dated 3/07/25. An interview was conducted, on 3/13/25 at 9:42 a.m., with the Nurse Schedule Coordinator (NSC). She indicated she completes the staffing sheets that are posted in the facility daily and leaves them for the night shift nurse to post them first thing the following morning. She indicated the night shift nurse forgot to remove the daily working staffing sheet, dated 3/07/25, and post the current staffing sheet. During an interview with the Executive Director (ED) on 3/13/25 at 10:10 a.m., he indicated the NSC usually posted the current daily working staff sheet. If it is a Saturday, nursing staff may forget to post the sheet. The NSC does come in on the weekends at times to help with supplies, so she will also post the daily work schedule if it had not been done. On 3/13/25 at 2:00 p.m., the Director of Nursing (DON) provided the Posted Nurse Staffing Data and Retention Requirements policy. It indicated, .Policy: It is the policy of [name of facility corporation] to make staffing information readily available in a readable format and publicly posted to residents and visitors at any given time .Procedure: 1. The facility must post the following information at the beginning of each shift. a. The facility name b. The current date c. Resident census d. The total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: i. Registered nurses ii. Licensed practical nurses iii. Certified nurse aides .

Based on observation, interview, and record review, the facility failed to timely address and follow up on a resident's change of condition; administer a resident his medication for insomnia, as ordered; address a resident's skin condition, per policy; administer treatments, as ordered; and accurately monitor fluid consumption for a resident, as ordered, for 2 of 2 residents reviewed for hospitalization , 1 of 5 residents reviewed for unnecessary medications, 1 of 3 residents reviewed for abuse, and 1 of 4 residents reviewed for skin conditions. (Residents 1, 20, 45, 66, and 104) Findings include: 1. The clinical record for Resident 104 was reviewed on 2/8/24 at 2:42 p.m. The diagnosis for Resident 104 included, but was not limited to, acute kidney disease. A care plan dated 9/20/23 indicated Resident is at risk for abnormal/excessive bleeding due to use of anticoagulant. The approaches included but was not limited to, observe for signs of bleeding: blood in urine/BM [bowel movement], dark tarry stools, blood tinged sputum, excessive bruising, bruise increasing in size, oozing from superficial injuries, bleeding gums. A physician order dated 9/19/23 indicated Resident 104 was to receive 2.5 milligrams of Eliquis twice a day. The November 2023 Medication Administration Record indicated the resident receive the scheduled 2.5 milligrams of Eliquis on 11/9/23 at 7:00 a.m. - 11:00 a.m., and 7:00 p.m. - 11:00 p.m. A nursing progress note dated 11/9/23 at 2:12 p.m., indicated Resident examined by writer d/t [due to] reported rectal bleeding. Scant rectal bleeding noted. No obvious s/s [signs or symptoms] visible hemorrhoids. Call placed to on call MD [medical doctor]. Awaiting call back. Reported to oncoming Nurse. A nursing progress note dated 11/9/23 at 11:45 p.m., indicated Writer was called to the patient room in regard to bleeding noticed by CNA [Certified Nursing Aide] while doing patient's care. After assessment, writer noticed bleeding coming out of patient rectum, call placed to MD, awaiting call back. A nursing progress note dated 11:55 p.m. Call back received, new order to send patient to ER [emergency room ] for evaluation via 911. 911 called, awaiting arrival. A hospital transfer form for Resident 104 dated 11/10/23 at 12:00 a.m., indicated the resident was being transferred to hospital with black blood clot coming out of resident's rectum. A nursing progress note dated 11/10/23 at 12:17 a.m. Resident 104 had left the facility. An interview was conducted with the Director of Nursing Services (DNS) on 2/9/24 at 9:24 a.m. She indicated on 11/9/23, the staff had observed a scant of blood on Resident 104's brief at approximately 2:00 p.m. The CNA reported the observation to the nurse. The nurse notified the medical provider by leaving a message for a return call. It was at the end of her shift, so she left for the day. The nurse was not sure if the medical provider called back with orders. The DNS indicated there was no documentation by the nursing staff of follow up with the medical provider and/or orders received by the provider that afternoon. The next incident of observing blood was later that night at approximately 11:45 p.m., the nurse notified the medical provider and received orders to send the resident to the hospital. An interview was conducted with CNA 5 on 2/12/24 at 11:19 a.m. She indicated she had observed the blood on Resident 104's brief on the afternoon of 11/9/23, day shift. It was not a lot of blood just a little spot on her brief. She reported the observation to the nurse as she has been told to always report to the nurse if observe residents with blood. That was the first time she had noticed blood on Resident 104's brief. An interview was conducted with Physician 7 on 2/12/24 at 3:20 p.m. She indicated after reviewing her call report, she did not have any record a nurse staff person called her office about blood on Resident 104's brief on 11/9/23 approximately 2:00 p.m. She does not know the condition of the resident after 2:00 p.m., that day until she was sent to emergency room later that night. She would have held the scheduled evening dose of Eliquis medication. The resident was declining, and the end result would have been the same. It had been recommended on the last hospitalization , Resident 104 to be placed on palliative care. The family had declined the recommendation at that time. The resident's family agreed for the resident to be placed on palliative care on the 11/9/23 hospitalization . The resident at that time was made comfortable and past away at the hospital. A Resident Change of Condition Policy was provided by the DNS on 2/12/24 at 12:13 p.m. It indicated .d. If the physician has not returned the call by the end of the shift, the oncoming nurse will be notified for follow up. e. If unable to contact attending physician or alternate timely, the Medial Director will be notified for response and intervention for the resident change of condition. f. Document resident change of condition and response in the medical record. Documentation will include time and family/physician response. g. The licensed nurse responsible for the resident will continue assessment and documentation in the medical record every shift until the resident's condition has stabilized. 30344 2. The clinical record for Resident 66 was reviewed on 2/8/24 at 10:30 p.m. His diagnoses included, but were not limited to, dementia. The physician's orders indicated to administer one 5 mg tablet of melatonin at bedtime, starting 6/6/22, and half of a 50 mg tablet (25 mg) of trazodone at bedtime, starting 12/20/23. The 1/24/24 psychiatry note indicated to continue the Melatonin 5 mg every evening and the Trazodone 25 mg every evening, both for insomnia. It indicated a dose reduction for either medication was contraindicated due to high risk of symptom escalation. The February, 2024 MAR (medication administration record) indicated the Melatonin was not administered on 2/6/24 and 2/7/24 due to the medication being unavailable. It indicated the Trazodone was not administered on 2/5/24, 2/6/24, and 2/7/24 due to the medication being unavailable. An interview was conducted with the DNS (Director of Nursing Services) on 2/12/24 at 12:25 p.m. She indicated their process for ensuring medications were available for administration was to reorder them on time. She was unsure why the Melatonin and Trazodone was not administered on the above dates, as both medications were available in their emergency drug kit, so the nurse could have administered them. The Medication Shortages/Unavailable Medications policy was provided by the DNS on 2/12/24 at 2:20 p.m. It read, PROCEDURE .3. If a medication is unavailable is [sic] discovered after normal Pharmacy hours: 3.1 A Facility nurse should obtain the ordered medication from the Emergency Medication Supply. 3. The clinical record for Resident 1 was reviewed on 2/7/23 at 3:00 p.m. Her diagnoses included, but were not limited to: hypertension, seizures, neuropathy, congestive heart failure, osteoarthritis, and diabetes mellitus. The at risk for skin breakdown care plan, last reviewed/revised 12/25/23, indicated the goal was for her to be free from skin breakdown. An approach was to assess and document skin condition weekly and as needed and to notify the physician of abnormal findings, starting 3/1/23. The 12/6/23 weekly skin and vital sign assessment, completed by RN (Registered Nurse) 11, indicated she had scattered bruising to her bilateral arms. There was no description of the bruising to include size, color, or otherwise. There was no skin event or wound management entry in the electronic health record regarding the scattered bruising to Resident 1's bilateral arms. RN 11 was unavailable for interview. An interview was conducted with the DNS (Director of Nursing Services) on 2/9/24 at 12:37 p.m. She reviewed Resident 1's clinical record and indicated she did not see the scattered bruising was reported to Resident 1's physician or her representative. There was no skin event for further assessment of the bruising, but one should have been initiated. The wound nurse also should have been notified for further evaluation of the bruising and a wound management entry created. She was uncertain if the bruising would be considered suspicious for any reason, as they had no further information on it. An interview was conducted with CNA (Certified Nursing Assistant) 9 on 2/9/24 at 2:35 p.m. He indicated he didn't usually work on the unit where Resident 1 resided, but on 12/6/23, he did. What he saw was kinda spotty, discoloration, like bluish, purple on her right and left forearms. She wore geri-sleeves, but often refused them. He informed RN 11, who was caring for another resident at the time, of the spotty discoloration on Resident 1's arms. An observation of Resident 1's arms were made on 2/9/24 at 3:45 p.m. with the DNS. She was not wearing geri-sleeves. No bruising was observed. Resident 1 indicated during this observation that she did not like wearing her geri-sleeves. The Skin Management Program policy was provided by the DNS on 2/9/24 at 12:02 p.m. It read, Any skin alterations noted by direct care givers during daily care and/or shower days must be reported to the licensed nurse for further assessment, to include but not limited to bruises, open areas, redness, skin tears, blisters, and rashes. The licensed nurse is responsible for assessing all skin alterations by the direct caregivers on the shift reported 1. Alterations in skin integrity will be reported to the MD/NP [Nurse Practitioner,] the resident and/or resident representative as well as to the direct care staff 4. All newly identified areas after admission will be documented on he New Skin Event. 5. The wound nurse/designee will be notified of alterations in skin integrity. a) The wound nurse/designee is responsible for communicating to IDT [interdisciplinary team] on a weekly basis for pressure and non-pressure wounds. b) The wound nurse/designee will complete further evaluation of the wounds identified and complete the appropriate skin evaluation on the next business day. The 'observed' date indicated on the Wound Management document is the date the wound was assessed, including but not limited to measurements, staging, condition of tissue, and drainage ii) Wound management entries will be completed for non-ulcers (bruises, skin tear, abrasion, rashes). If no signs of complications or worsening in condition of skin alteration and doesn't meet the guideline for IDT Weekly Wound Review the wound management entry can be closed after 72 hours. 40287 4. The clinical record for Resident 45 was reviewed on 2/7/24 at 11:22 a.m. The Resident's diagnosis included, but were not limited to, dermatitis and diabetes. A physician's order, dated 1/6/23, indicated he was to receive Eucerin skin calming cream to his bilateral upper and lower extremities and face daily. A physician's order, dated 8/25/23, indicated he was to receive Anti-Dandruff shampoo twice weekly on Tuesdays and Fridays with his evening shower. A Quarterly MDS (Minimum Data Set) Assessment, completed 1/16/24, indicated that he was cognitively intact and dependent on staff for bathing. A care plan, last reviewed 1/30/24, indicated Resident 45 was at risk for skin breakdown, skin tears and bruises related to his weakness and decreased mobility secondary to his dx of Diabetes with polyneuropathy (damaged nerves), requires assist with toileting and bed mobility. He occasionally had moist skin and a potential for friction/shearing. The goal was for him to be free from further skin breakdown, skin tears, and bruising. The interventions included, but were not limited to, preventative treatment as ordered, initiated 10/10/2019, assess and document skin condition weekly and as needed. Notify physician of abnormal findings, initiated 10/10/2019, and provide incontinent care as needed using peri wash and moisture barrier, initiated 10/10/2019. On 2/7/24 at 11:22 a.m., Resident 45 was observed laying in bed in his room. He was wearing a hospital gown and had scattered small, scabbed areas on his forehead and around his nose and chin. His hair appeared greasy and unwashed. His skin was flakey and dry. He was scratching his face and arms. Resident 45 indicated his skin was itching and that he needed a shower. On 2/8/24 at 2:47 p.m., Resident 45 was observed laying in his bed with his eyes closed. He was in a hospital gown and his hair appeared unwashed. During an interview on 2/09/24 at 10:40 a.m., Resident 45 indicated that the staff did not put lotion on his face or arms. He was observed laying in his bed. His hair looked greasy, and his face had flakey skin. During an interview on 2/09/24 at 10:41 a.m., CNA (Certified Nursing Assistant) 2 indicated Resident 45 received partial baths each morning and he received his showers on the evening shift. He did not normally refuse any care. On 2/9/24 at 11:01 a.m., the treatment cart was observed with RN (Registered Nurse) 3. Resident 45 had an opened 7-ounce bottle of Anti-Dandruff shampoo with a pharmacy fill date of 8/23/23. There was no Eucerin cream labeled with Resident 45's name available in the treatment cart. During an interview on 2/9/24 at 2:09 p.m., Pharmacy Technician 40 indicated that Resident 45's Anti-Dandruff Shampoo had last been filled by the pharmacy on 11/14/23 and that a 7-ounce bottle of shampoo should last approximately 3 to 4 days when administered as ordered twice weekly. The pharmacy had provided a 226-gram bottle of Eucerin on 6/12/23 and a 226-gram supply should have lasted 45 days when applied daily as ordered. During an interview on 2/9/24 at 2:36 p.m., the DNS (Director of Nursing Services) indicated that the Eucerin cream was provided by the pharmacy and that the ordered medications should be available at the facility and applied as ordered. During an interview on 2/09/24 at 2:43 p.m., Resident 45 indicated that his hair had just been washed and he had just had cream put on his face. His itching was a lot better now that the lotion had been applied. 41129 5. The clinical record for Resident 20 was reviewed on 2/8/24 at 2:28 p.m. Resident 20's diagnoses included, but not limited to, chronic obstructive pulmonary disease (COPD), chronic respiratory failure, congestive heart failure (CHF), chronic kidney disease (CKD), and diabetes type II. A physician's order dated 1/29/24 indicated, Resident 20's diet included a fluid restriction. The total amount of fluid allowed per day was 1000 ml. The total amount of fluids allowed with meals was 500 ml and the total amount allowed between meals was 500 ml. The order included special instructions that read Special Instructions: Night Shift to calculate the 24 hr total by adding up FLUIDS consumed from the Vitals section plus mL's[sic] given between meals to come up with 24 hour total 166mL's[sic] allowed for each meal 166mL's[sic] allowed from nursing each shift Every Shift. The resident did not have a care plan in place to address the resident's noncompliance with fluid restriction as ordered. Resident 20's November and December 2023 Medication/Treatment Administration Record (MAR)(TAR) indicated the following total of all 3 shifts of fluid consumption during medication administrations were recorded: 11/2/23 - 240 ml of fluid consumed 11/3/23 - 500 ml of fluid consumed 11/6/23 - 120 ml of fluid consumed 11/8/23 - 500 ml of fluid consumed 11/9/23 - 60 ml of fluid consumed 11/15/23 - 1000 ml of fluid consumed 12/1/23 - 1500 ml of fluid consumed 12/7/23 - 1500 ml of fluid consumed 12/16/23- 1500 ml of fluid consumed 12/21/23 - 166 ml of fluid consumed 12/28/23 - 120 ml of fluid consumed The following were recorded fluid consumption per shift, and the resident's total fluid consumption in the 24 hour day: 11/2/23 - 6:00 a.m. - 2:00 p.m. = 452 ml consumption, 2:00 p.m. - 10:00 p.m. = 286 ml consumption, 10:00 p.m. - 6:00 a.m. = 240 ml consumption, the total amount of fluid consumption that day was documented as 240 ml. 11/3/23 - 6:00 a.m. - 2:00 p.m. = 498 ml consumption, 2:00 p.m. - 10:00 p.m. = 286 ml consumption, 10:00 p.m. - 6:00 a.m. = 166 ml consumption, the total amount of fluid consumption that day was documented as 1000 ml. 11/6/23 - 6:00 a.m. - 2:00 p.m. = 452 ml consumption, 2:00 p.m. - 10:00 p.m. = 286 ml consumption, 10:00 p.m. - 6:00 a.m. = 120 ml consumption, the total amount of fluid consumption that day was documented as 120 ml. 11/8/23 - 6:00 a.m. - 2:00 p.m. = 452 ml consumption, 2:00 p.m. - 10:00 p.m. = 320 ml consumption, 10:00 p.m. - 6:00 a.m. = 166 ml consumption, the total amount of fluid consumption that day was documented as 500 ml. 11/9/23 - 6:00 a.m. - 2:00 p.m. = 452 ml consumption, 2:00 p.m. - 10:00 p.m. = 332 ml consumption, 10:00 p.m. - 6:00 a.m. = 60 ml consumption, the total amount of fluid consumption that day was documented as 60 ml. 11/15/23 - 6:00 a.m. - 2:00 p.m. = 452 ml consumption, 2:00 p.m. - 10:00 p.m. = 332 ml consumption, 10:00 p.m. - 6:00 a.m. = 166 ml consumption, the total amount of fluid consumption that day was documented as 1500 ml. 12/1/23 - 6:00 a.m. - 2:00 p.m. = 498 ml consumption, 2:00 p.m. - 10:00 p.m. = 332 ml consumption, 10:00 p.m. - 6:00 a.m. = 166 ml consumption, the total amount of fluid consumption that day was documented as 1500 ml. 12/7/23 - 6:00 a.m. - 2:00 p.m. = 452 ml consumption, 2:00 p.m. - 10:00 p.m. = 332 ml consumption, 10:00 p.m. - 6:00 a.m. = 166 ml consumption, the total amount of fluid consumption that day was documented as 1500 ml. 12/16/23 - 6:00 a.m. - 2:00 p.m. = 452 ml consumption, 2:00 p.m. - 10:00 p.m. = 240 ml consumption, 10:00 p.m. - 6:00 a.m. = 166 ml consumption, the total amount of fluid consumption that day was documented as 1500 ml. 12/21/23 - 6:00 a.m. - 2:00 p.m. = 452 ml consumption, 2:00 p.m. - 10:00 p.m. = 286 ml consumption, 10:00 p.m. - 6:00 a.m. = 166 ml consumption, the total amount of fluid consumption that day was documented as 166 ml. 12/28/23 - 6:00 a.m. - 2:00 p.m. = 452 ml consumption, 2:00 p.m. - 10:00 p.m. = 286 ml consumption, 10:00 p.m. - 6:00 a.m. = 120 ml consumption, the total amount of fluid consumption that day was documented as 120 ml. Resident 20's January and February 2024 Medication/Treatment Administration Record (MAR)(TAR) indicated the following total of all 3 shifts of fluid consumption during medication administrations were recorded: 1/2/24 - 120 ml of fluid consumed 1/12/24 - 166 ml of fluid consumed 1/22/24 - 2834 ml of fluid consumed 2/1/24 - 240 ml of fluid consumed 2/8/24 - 240 ml of fluid consumed The following were recorded fluid consumption per shift, and the resident's total fluid consumption in the 24 hour day: 1/2/24 - 6:00 a.m. - 2:00 p.m. = 498 ml consumption, 2:00 p.m. - 10:00 p.m. = 332 ml consumption, 10:00 p.m. - 6:00 a.m. = 120 ml consumption, the total amount of fluid consumption that day was documented as 120 ml. 1/12/24 - 6:00 a.m. - 2:00 p.m. = 498 ml consumption, 2:00 p.m. - 10:00 p.m. = 332 ml consumption, 10:00 p.m. - 6:00 a.m. = 166 ml consumption, the total amount of fluid consumption that day was documented as 166 ml. 1/22/24 - 6:00 a.m. - 2:00 p.m. = 406 ml consumption, 2:00 p.m. - 10:00 p.m. = 332 ml consumption, 10:00 p.m. - 6:00 a.m. = 166 ml consumption, the total amount of fluid consumption that day was documented as 2834 ml. 2/1/24 - 6:00 a.m. - 2:00 p.m. = 600 ml consumption, 2:00 p.m. - 10:00 p.m. = 360 ml consumption, 10:00 p.m. - 6:00 a.m. = 240 ml consumption, the total amount of fluid consumption that day was documented as 240 ml. 2/8/24 - 6:00 a.m. - 2:00 p.m. = 520 ml consumption, 2:00 p.m. - 10:00 p.m. = 1000 ml consumption, 10:00 p.m. - 6:00 a.m. = 240 ml consumption, the total amount of fluid consumption that day was documented as 240 ml. Resident 20's care plan dated 9/20/19 and last revised/reviewed on 11/16/23 indicated, Resident 20 was at risk for fluid imbalance related to diuretic medication, fluid restriction, and diagnoses of CHF, CKD and diabetes. Interventions included, but not limited to, diet as ordered and to document intake. An interview with Director of Nursing (DON) conducted on 2/9/24 at 3:13 p.m. indicated, tracking the fluid intakes was difficult and the template they use needs to be revamped. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to provide showers, as preferred, for 1 of 4 residents reviewed for ADL (Activities of Daily Living) care (Resident 45). Findings include: The clinical record for Resident 45 was reviewed on 2/7/24 at 11:22 a.m. The Resident's diagnosis included, but were not limited to, dermatitis and diabetes. A physician's order, dated 9/21/23, indicated to encourage showers 2 times weekly on Tuesday and Friday and to document any refusals. A Preferences for Customary Routine and Activities Observation, dated 1/15/24, indicated that it was very important to Resident 45 to choose between a tub bath, shower and bed bath. The type of bathing he was used to were showers. A Quarterly MDS (Minimum Data Set) Assessment, completed 1/16/24, indicated that he was cognitively intact and dependent on staff for bathing. A care plan, last reviewed on 1/29/24, indicated that Resident 45 had a self-care deficit related to weakness and decreased mobility. He needed assist with ADLs including bathing, dressing, grooming, personal hygiene, toileting, transfers, bed mobility, and eating. His ability fluctuated from morning to evening and day to day. The goal was for him to have his basic needs met daily with staff assist as evidenced by being neat, clean, well-groomed and dressed appropriately. The interventions included, but were not limited to, encourage showers biweekly, initiated 9/22/23, he preferred to wear hospital gown at times, initiated 10/4/22, and offer showers two times per week with partial bath in between, initiated 10/10/2019. On 2/7/24 at 11:22 a.m., Resident 45 was observed laying in bed in his room. He was wearing a hospital gown and had scattered small, scabbed areas on his forehead and around his nose and chin. His hair appeared greasy and unwashed. His skin was flakey and dry. He was scratching his face and arms. Resident 45 indicated his skin was itching and that he needed a shower. He could not remember the last time he had a shower. The staff gave him bed baths instead and he didn't feel like they got all of the soap off, which caused him to itch. He had taken a shower every day while he was at home. He had told the staff that he would like to have showers. On 2/8/24 at 2:47 p.m., Resident 45 was observed laying in his bed with his eyes closed. He was in a hospital gown and his hair appeared unwashed. During an interview on 2/09/24 at 10:40 a.m., Resident 45 indicated that he had not had a shower. He was observed laying in his bed. His hair looked greasy, and his face had flakey skin. During an interview on 2/09/24 at 10:41 a.m., CNA (Certified Nursing Assistant) 2 indicated Resident 45 received partial baths each morning and he received his showers on the evening shift. He did not normally refuse any care. On 2/12/24 at 8:59 a.m., the Nurse Consultant provided Resident 45's bathing documentation for January and February 2024, which indicated he had received complete bed baths instead of showers. The documentation did not indicate he had refused to be showered. 3.1-3(u)(1)

Based on interview and record review, the facility failed to assess vision status, as instructed in the RAI (Resident Assessment Instrument) manual, while completing the MDS (Minimal Data Set) Assessments for 1 of 3 residents reviewed for vision (Resident 24). Findings include: The clinical record for Resident 24 was reviewed on 2/7/24 at 3:38 p.m. The Resident's diagnosis included, but were not limited to, diabetes and hypertension. An Admission MDS (Minimum Data Set) Assessment, completed 6/16/23, indicated that Resident 24 was cognitively intact, had adequate vision, and did not wear glasses. A Consultation Note from an eye surgeon, dated 8/7/23, was provided on 2/12/24 at 4:18 p.m., by the Nurse Consultant. The consultation note indicated that Resident 24 had Combined Senile Cataracts in the right and left eyes. Resident 24 had experienced blurred vision for years and it was bothersome to Resident 24, affecting his ability to watch television and recognize faces from across the room. The plan was that the Cataract on his right eye was causing his decreased vision, but Resident 24 needed to have medical clearance prior to having the surgery. The cataract on the left eye was not to be removed due to corneal scaring on the left eye. Quarterly MDS Assessments, completed 9/5/23 and 11/29/23, indicated that he was cognitively intact, adequate vision, and did not wear glasses. During an interview on 2/7/24 at 3:38 p.m., Resident 24 indicated that he needed to see the eye doctor. He had cataracts and needed to have them checked. He was supposed to see the eye surgeon for a follow-up, but the appointment had been canceled. During an interview on 2/12/24 at 3:04 p.m., Resident 24 indicated that he did not wear glasses, but could not see the television very well because of the cataracts in his eye. He didn't turn the television on often, and when it was on, he normally was just listening to it. He couldn't always see fine details. During an interview on 2/13/24 at 10:35 a.m., the SSD (Social Services Director) indicated she completed the vision portion of the MDS Assessment. To complete the vision portion she would look at the residents' diagnosis in the chart and see if they wore glasses. If the resident did not have a diagnosis that would indicate visual impairment and did not wear glasses, then she would code vision as adequate. The SSD indicated she did not have the residents read anything while completing the vision portion of the MDS Assessment, that would be what an optometrist would do. During an interview on 2/13/24 at 10:45 a.m., the MDSC (Minimum Data Set Coordinator) indicated that she was unsure why Resident 24's vision had been coded as adequate and that the facility used the RAI Manual as the policy for completing the MDS. Current RAI Manual guidelines from October 2023 for completing vision read .Steps for Assessment 1. Ask family, caregivers, and/or direct care staff over all shifts, if possible, about the resident's usual vision patterns during the 7-day look-back period [e.g.[sic], if the resident is able to see newsprint, menus, greeting cards?]. 2. Then ask the resident about their visual abilities. 3. Test the accuracy of your findings: Ensure that the resident's customary visual appliance for close vision is in place .Ensure adequate lighting. Ask the resident to look at regular-size print in a book or newspaper. The ask the resident to read aloud, starting with larger headlines and ending with the finest, smallest print. If the resident is unable to read a newspaper, provide material with larger print, such as a flyer or large textbook .Code 0, adequate: if the resident sees fine detail, including regular print in newspapers/ books .

Based on interview and record review, the facility failed to ensure a resident had a care plan to address his insomnia and create a vision careplan for a resident with visual difficulties for 1 of 5 residents reviewed for unnecessary medications and 1 of 4 residents reviewed for vision or hearing services. (Residents 24 and 66) Findings include: 1. The clinical record for Resident 66 was reviewed on 2/8/24 at 10:30 p.m. His diagnoses included, but were not limited to, dementia. The physician's orders indicated to administer one 5 mg tablet of melatonin at bedtime, starting 6/6/22, and half of a 50 mg tablet of trazodone at bedtime, starting 12/20/23. The 1/24/24 psychiatry note indicated to continue the Melatonin 5 mg every evening and the Trazodone 25 mg every evening, both for insomnia. It indicated a dose reduction for either medication was contraindicated due to high risk of symptom escalation. The February, 2024 MAR (medication administration record) indicated the Melatonin was not administered on 2/6/24 and 2/7/24 due to the medication being unavailable. It indicated the Trazodone was not administered on 2/5/24, 2/6/24, and 2/7/24 due to the medication being unavailable. An interview was conducted with the DNS (Director of Nursing Services) on 2/12/24 at 12:25 p.m. She indicated their process for ensuring medications were available for administration was to reorder them on time. She was unsure why the Melatonin and Trazodone was not administered on the above dates, as both medications were available in their emergency drug kit, so the nurse could have administered them. There was no care plan in Resident 66's clinical record to address his insomnia. An interview was conducted with the DNS on 2/12/23 at 2:20 p.m. She indicated the only care plan that referenced Resident 66's insomnia was an at risk for adverse side effects care plan related to the use of psychotropic medication which included the Trazodone for insomnia. The 11/11/22 at risk for adverse side effects related to use of psychotropic medication care plan, last revised 2/6/24, indicated an antidepressant medication for insomnia was added on 12/5/23. It did not include specific approaches to address Resident 66's insomnia. 40287 2. The clinical record for Resident 24 was reviewed on 2/7/24 at 3:38 p.m. The Resident's diagnosis included, but were not limited to, diabetes and hypertension. A Quarterly MDS (Minimum Data Set) Assessment, completed 11/29/23, indicated that he was cognitively intact. During an interview on 2/7/24 at 3:38 p.m., Resident 24 indicated that he needed to see the eye doctor. He had cataracts and needed to have them checked. He was supposed to see the eye surgeon for a follow-up, but the appointment had been canceled. During an interview on 2/12/24 at 11:11 a.m., the DNS (Director of Nursing Services) indicated that Resident 45 had been scheduled for an eye consult recently, but it had to be canceled because of transportation difficulties. On 2/12/24 at 4:18 p.m., the Nurse Consultant provided a Consultation Note from an eye surgeon, dated 8/7/23. The consultation note indicated that Resident 24 had Combined Senile Cataracts in the right and left eyes. Resident 24 had experienced blurred vision for years and it was bothersome to Resident 24, affecting his ability to watch television and recognize faces from across the room. The plan was that the Cataract on his right eye was causing his decreased vision, but Resident 24 needed to have medical clearance prior to having the surgery. The cataract on the left eye was not to be removed due to corneal scaring on the left eye. During an interview on 2/14/24 at 10:20 a.m., the DNS indicated there was not a care plan related to vision present in Resident 24's medical record. On 2/13/24 at 1:00 p.m., the Regional Infection Preventionist provided the IDT (Interdisciplinary Team) Comprehensive Care Plan Policy, last reviewed August 2023, which read .It is the policy of this facility that each resident will have an interdisciplinary comprehensive person-centered care plan developed and implemented based on Resident Assessment Instrument [RAI] process. The care plan must include measurable goals and resident specific interventions based on resident needs and preferences to promote the resident's highest well-being . 3.1-35(b)(1)

Based on interview and record review, the facility failed to invite a resident's representative to her care plan meetings for 1 of 2 residents reviewed for care planning. (Resident 1) Findings include: The clinical record for Resident 1 was reviewed on 2/7/23 at 3:00 p.m. Her diagnoses included, but were not limited to: hypertension, seizures, neuropathy, congestive heart failure, osteoarthritis, and diabetes mellitus. The 11/20/23 Significant Change MDS (Minimum Data Set) assessment indicated she had a BIMS (brief interview for mental status) score of 1, indicating she was severely cognitively impaired. Resident 1's face sheet in her electronic clinical record indicated her emergency contact, durable POA (power of attorney,) and health care representative was Family Member 13. It did not indicate the specific family member relationship between Resident 1 and Family Member 13. An interview was conducted with Family Member 13 on 2/7/24 at 3:15 p.m. He indicated he was not invited to routine care plan meetings by the facility. He received phone calls sometimes from an outside nurse who provided services at the facility, but nothing routine and scheduled by the facility. Ideally, it would be great to have them, so I know where things are at. The 7/5/23 IDT (Interdisciplinary Team) Care Plan Summary indicated the care plan meeting occurred on 7/5/23 at 11:29 a.m. and only the IDT was in attendance. It read, Resident's son has no questions or concerns at this time and did not want to participate in care plan meeting. The notes section read, Resident's son did not want to participate in care plan meeting. The 9/27/23 IDT Care Plan Summary indicated the care plan meeting occurred on 9/27/23 at 3:28 p.m. and only the IDT was in attendance. It read, Residents POA was invited to care plan meeting, however did not want to participate and had no questions or concerns. The notes section read, POA had no questions or concerns. There was no information in the electronic health record to indicate Family Member 13 was invited to the 7/5/23 and 9/27/23 care plan meetings prior to 7/5/23 and 9/27/23. An interview was conducted with the SSD (Social Services Director) on 2/8/24 at 2:51 p.m. She indicated care plan meetings were held whenever a resident wanted one, quarterly, and at significant change assessments. The SSA (Social Services Assistant) was in charge of care plan invitation to residents and families. A resident received a care plan invitation card and was verbally informed of the meeting. Family was called via telephone and if they indicated they wanted a meeting, they would give the resident a care plan card, but didn't actually mail a care plan invitation to the family. An interview was conducted with the SSA on 2/8/24 at 3:19 p.m. She indicated when she called family to invite them to care plan meetings, if they said they didn't have any questions or concerns and didn't want to participate, she completed the care plan summary observation in the electronic health record at that time. She did not recall speaking with Family Member 13 on 7/5/23 and 9/27/23. She was familiar with Resident 1, but not Family Member 13. Follow-up telephone interviews were conducted with Family Member 13 on 2/8/24 at 10:30 a.m. and 2/8/24 at 11:08 a.m. He indicated he was Resident 1's grandson, not Resident 1's son, and had tried to resolve that with the facility prior. He attended a meeting at the facility in the spring of 2023, when Resident 1's therapy was ending and in November, 2023 when Resident 1 moved to a different unit of the facility. He would be fine with doing the meetings over the phone, as he had to wait 20 to 30 minutes for both meetings for the staff to be ready. He was not invited to any meetings in between those times. He indicated he was reviewing his incoming call log for any missed or incoming calls on 9/27/23 and 7/5/23, and did not miss or receive any calls from the facility on either date. He had one missed call on 7/5/23 from his dentist, but no missed or incoming calls from the facility. He had no missed or incoming calls on 9/27/23 from the facility or anyone else. He had 3 different phone numbers for the facility saved into his phone, so he would know it was them calling. The IDT Comprehensive Care Plan policy was provided by the SSD on 2/8/24 at 3:24 p.m. It read, Purpose: Create an organized, resident-centered review on a routine basis to improve communication with residents, resident families and/or representative regarding the resident goals, total health status, including functional status, nutritional status, rehabilitation and restorative potential, ability to participate in activities, cognitive status, psychosocial status, sensory and physical impairments, as well as care and services provided to maintain or restore health and well-being, improve functional level or relieve symptoms. Improve relationships between resident, families and/or representative, and facility caregivers through understanding of resident's social history, culture and preferences to enhance the resident's life. Procedure: .Resident, resident's representative, or others as designated by resident will be invited to care plan review. The IDT Care Plan Review Guidelines was provided by the RIP (Regional Infection Preventionist) on 2/13/24 at 10:00 a.m. It read, Prior to the Meeting IDT members must ensure the following: .Care plan invitation has been mailed to the resident representative. 3.1-35(d)(2)(B)

Based on interview and record review, the facility failed to ensure a resident (Resident B), who was deemed dependent on staff for bed mobility and transfers, did not experience increased pain and swelling after being transferred by a staff member and later identified with a fracture, and not ensuring the use of a gait belt during a transfer for 1 of 1 resident reviewed for injury of unknown origin. Findings include: The clinical record for Resident B was reviewed on 11/16/22 at 11:10 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, [CONDITION(S)], [CONDITION(S)], age-related [CONDITION(S)], cognitive communication deficit, and spinal stenosis. The Quarterly Minimum Data Set (MDS) assessment, dated 8/15/22, indicated Resident B was severely cognitively impaired, required extensive assistance of 2 staff person for bed mobility, transfers, and toilet use, along with extensive assistance with one staff person for locomotion on/off unit, dressing, and personal hygiene. There were no impairments to Resident B's upper and/or lower extremities, no falls since admission and/or previous assessment, and wheelchair was marked for mobility device. A care plan, revised 8/26/22, indicated Resident B was at risk for pathological fracture related to diagnosis of [CONDITION(S)]. An approach was listed for assistive devices as needed. A fall care plan, revised 8/26/22, indicated Resident B was at risk for falls and required assistance with transfers and bed mobility. An approach was listed for assistance with one staff for transfers. A progress note, dated 11/2/22 at 2:53 p.m., indicated Resident B was having increased pain with transfers and swelling to the right knee. A progress note, dated 11/2/22 at 9:02 p.m., indicated Resident B was sent to the emergency room due to abnormal finding on x-ray of right femur. An incident reported to the Indiana State Department of Health Survey Report System, dated 11/2/22 at 7:20 p.m., indicated the following, .While rendering morning ADL [activities of daily living] care, resident noted to have [CONDITION(S)] to right leg and knee with complaints of leg and knee pain .Type of Injury .right hip with offset large oblique spiral fracture of the proximal femoral diaphysis .Follow up .IDT [interdisciplinary team] determined, while transferring resident from bed to wheelchair, resident turned without moving her feet, causing the spiral fracture. All staff to be educated related to transfers and providing ADL care to residents with [CONDITION(S)] An interview conducted with Nurse 2, on 11/16/22 at 12:05 p.m., indicated Resident B's level of assistance would depend on how she was feeling. If Resident B was resistive to ADL care, we would have 2 staff members assist with her ADL care. An interview conducted with Certified Nursing Assistant (CNA) 3, on 11/16/22 at 12:10 p.m., indicated Resident B wasn't a morning person. CNA 3 was able to transfer Resident B with one person unless Resident B was being resistive with care and then she would need 2 staff members to assist her. Resident B would refuse ADL care such as being transferred, toileted, and dressed. There were good and bad days for Resident B. CNA 3 came into work on 11/2/22 at 7:30 a.m. and noted Resident B up in her wheelchair in her room. CNA 3 passed the breakfast tray to Resident B and the resident was crying and stating, my hip. CNA 3 commented on how Resident B's right hip looked swollen, and she proceeded to tell the nurse about it. An interview conducted with CNA 4, on 11/16/22 at 12:28 p.m., indicated she arrived at work on 11/2/22 at 6:00 a.m. to work on the hallway where Resident B resided. There was a get up list and Resident B, along with 3 other residents, was on that list. She proceeded to provide ADL care to Resident B while she was lying in bed and got her dressed for the day. She took her arms and went underneath Resident B's arms and grabbed the back waist of Resident B's pants to lift her up and transfer her from her bed to her wheelchair. CNA 4 commented on how Resident B did not bear weight, but she was light as a feather. CNA 4 also commented on how it was her first day working on the unit that Resident B resided on as well as the nurse working that morning. So, the 2 staff members were not familiar with the residents and how they transferred back there. She knew there were no residents who transferred with a mechanical lift. Resident B was nice and not resistive to care that morning. She didn't complain of any pain before, during, or after the transfer. CNA 4 indicated there was not a gait belt located in Resident B's room for use and such was not utilized during the transfer for Resident B while transferring her from the bed to the wheelchair. An interview conducted with Nurse 6, on 11/16/22 at 12:02 p.m., indicated they had determined that Resident B's feet stayed grounded during the transfer from her bed to wheelchair and along with her diagnosis of [CONDITION(S)] could be what caused the spiral fracture. A skills validation titled TRANSFER TO WHEELCHAIR, dated 2/2010, was in the investigative file for the incident involving Resident B. The document indicated the following, .Procedure Steps .11. Place gait belt around resident's waist .12. Grasp belt securely on both sides .13. With legs on the outside of the resident's legs, brace resident's lower legs to prevent slipping .14. Instruct resident on count of three to slowly rise to a stand .15. Help resident to pivot to front of wheelchair with back of resident's legs against wheelchair .19. Remove gait belt This Federal tag relates to Complaint IN 992. 3.1-45(a)(1) 3.1-45(a)(2)

Based on interview and record review, the facility failed to adequately assess, monitor, and provide treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: The clinical record for Resident F was reviewed on 12/1/21 at 1:44 p.m. The Resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A weekly skin and vital signs assessment, dated 9/17/21, indicated he had a reddened area on his coccyx. On 9/23/21, he was discharged to an acute care hospital for an unrelated condition. A wound consult note from the acute care hospital, dated 9/27/21, indicated he had shearing (friction) to his bilateral buttocks which measured 10cm x 8 cm and was red in appearance. It was being treated with [NAME] Butt Paste ([MEDICATION(S)]) and covered with an abdominal pad and paper tape. A readmission assessment, dated 9/28/21, indicated he had an abrasion on his coccyx which measured 4 cm (centimeters) x 2 cm and was red and yellow in appearance and a wound on his sacrum measuring 4cm x 2 cm. A pressure ulcer risk assessment, dated 9/28/21, indicated he was at moderate risk for pressure ulcers. An event report, completed on 9/29/21, indicated that he had an open area, which was dark red in appearance, on his buttocks. There were no measurements of the area included in the event report. the wound treatment orders for the area were listed as not applicable. There were no new orders regarding the open area referenced in the 9/29/21 event report. The September and October 2021 TAR (Treatment Administration Record) indicated that house barrier cream had been applied to his buttocks after incontinent episodes every shift from 9/28/21 through 10/6/21. A wound management observation, dated 10/6/21 at 11:30 p.m., indicated he had [CONDITION(S)] in the rectal area and inner area of buttocks, which was 10 cm x 6 cm. An IDT (Interdisciplinary Team) progress note, dated 10/6/21 at 11:58 p.m., indicated he had moisture associated damage to his bilateral buttocks. There was no signs or symptoms of infection, and the root cause was determined to be exposure to moisture and or fecal matter for long periods of time. The current treatment order was triple compound. The physician had been notified. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . It was documented as having been completed, as ordered, from 10/7/21 through 10/20/21. A progress note, dated 10/7/21 at 2:16 p.m., indicated the treatment had been done to his buttocks. A foul odor was noted, and the physician was made aware. There had been no new orders received during the shift. He was resting on a special air mattress. A Significant Change of Status MDS (Minimum Data Set) Assessment, completed 10/8/21, indicated he was cognitively intact. He required extensive assistance with bed mobility and toileting, and he had moisture associated skin damage. He was always incontinent of bowel and had an indwelling urinary catheter. A weekly skin and vital signs assessment, dated 10/12/21, indicated he had an open area on his coccyx. There were no measurements or description of the open included in the assessment. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no description or measurements of the abscess present in the clinical record. A care plan, dated 10/13/21, indicated he had [CONDITION(S)] in the rectal area. The goal was for the area to heal without complications. The approaches included, but were not limited to, assess skin condition weekly and document measurements and description, apply house barrier cream as needed, observe for signs or symptoms of infection such as warmth, redness, pain, malodorous drainage, increased size, or depth, and notify physician of changes in skin condition or signs of infection. A care plan, dated 10/13/21, indicated he a rectal abscess. The goal was for the wound to heal without complications. The approaches included, but were not limited to, assess the wound weekly and document the measurements and description, administer treatments and antibiotics as ordered, observe for signs of infection such as redness, pain, drainage, or increase in size or depth of the wound, and to notify the physician of changes in the wound such as worsening or signs of infection. A weekly skin and vital signs assessment, dated 10/19/21, indicated that he had an open area on his coccyx. There were no measurements or description of the open area included in the assessment. A Nurse Practitioner progress note, dated 10/20/21, indicated she had seen Resident F for complaints of pain in the buttocks when sitting in his wheelchair during an appointment he went on that day. When he was laying in bed his pain was 4 of 10. He was diaphoretic (sweating) and reported that he just wanted to sleep. A pressure ulcer was noted on his coccyx with an approximate size of 13 cm long x 11.5 cm wide. An opening was noted in the ulcer which was approximately 4 cm x 4 cm x 4 cm deep with tunneling (passageway under the skin) and undermining (erosion of tissue underneath the margins of the wound). Fecal matter was draining from the open area. The wound bed had approximately 60% slough (yellow, dead tissue). His white blood cells were elevated. He was to be sent to an acute care hospital for further evaluation of the wound. An acute care hospital emergency department provider note, dated 10/20/21 at 3:12 p.m., indicated he was sent to the emergency room for a bed sore, which was newly discovered today. He reported that he has had pain in the area for a while, but the sore had just been found. An emergency department consultation note, dated 10/20/21 at 4:35 p.m., indicated he was being admitted to the hospital for further care and evaluation of a pressure ulcer to his sacral region. During an interview on 12/1/21 at 3:20 p.m., Resident F indicated he thought the pressure ulcer began as a scratch and then got worse. During an interview on 12/2/21 at 1:30 p.m., the Nurse Consultant indicated that she would expect that an abcess that was receiving antibiotic therapy would be monitored for changes. During an interview on 12/2/21 at 2:10 p.m., LPN (Licensed Practical Nurse) 5 indicated that she had first seen the open area on his buttock when he was transferred to her hallway around 10/6/21. When she first saw it was open and had slough present. She had informed the wound nurse. She had felt the wound had an odor and had informed the wound nurse. He had not reported pain during the treatments to her. She had completed the treatment as ordered each day that she cared for him and did not feel it was getting better. She had informed the wound nurse and was told the treatment was appropriate. During an interview on 12/2/21 at 2:46 p.m., LPN 6 indicated she had received the antibiotic order for the abscess on 10/12/21. She had made a new event on the abscess in the computer system on that day. The wound nurse should have followed up the next business day. She was unsure if he had done that. During an interview on 12/2/21 at 3:20 p.m., LPN 7 indicated she had cared for him during the end of September and early October prior to him being transferred to another hall His skin on his buttocks had started breaking down and was red, but not open. They had been treating it with skin barrier cream because it was not open. During an interview on 12/2/21 at 3:35 p.m., NP (Nurse Practitioner) 8 indicated she had seen him on 9/29/21. If she had been informed of a problem with his skin on 9/29/21, she would have assessed it and her note from that visit did not reflect that she assessed his skin. She saw the wound on his coccyx for the first time on 10/20/21. It was open and deep. He was soiled and it was hard to tell if the feces was coming from the wound or just present in the wound bed. The wound nurse was unavailable for interview, as he was no longer employed at the facility. On 12/2/21 at 12:14 p.m., the Executive Director provided the Skin Management Program policy, revised 7/2021, which read .Policy: It is the policy of . to ensure that each resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing Procedure for alteration in skin integrity- pressure and non-pressure 1. Alterations in skin integrity will be reported to the MD [sic]/ NP [sic], the resident and / or resident representative as well as to the direct care staff. 2. Treatment order will be obtained from MD [sic]/ NP [sic]. 3. All alteration in skin integrity will be documented in the medical record on the admission observation (new admitted and readmitted resident). 4. All newly identified area after admission will be documented on the New Skin Event. 5. The wound nurse/ designee will be notified of alterations in skin integrity. a) The wound nurse/ designee is responsible for communicating to IDT on a weekly basis for pressure and non-pressure wounds. b) The wound nurse/ designee will complete further evaluation of the wounds identified and complete the appropriate skin evaluation on the next business day. The 'observed' date indicated on the Wound Management document is the date the wound was assessed, including but not limited to measurements, staging, condition of tissue, and drainage. i) Wound Management for ulcers . will be updated weekly until resolved .6. A plan of care will be initiated to include resident specific risk factors and contributing factors with appropriate interventions implemented. 7. IDT [sic] will review residents with alterations in skin integrity weekly following the IDT [sic] Weekly Wound Review Policy . This Federal tag relates to Complaint IN 360.

Based on observation, interview and record review, the facility failed to conduct an IDT (interdisciplinary team) post fall analysis and implement interventions after a fall event, in which, a fall occurred that resulted in a facial fracture for 1 of 3 residents reviewed for accidents. (Resident F) Findings include: 1a. The clinical record for Resident F was reviewed on 3/15/18 at 3:39 p.m. The [DIAGNOSES REDACTED]. Resident F was admitted to the facility on [DATE]. An Admission Minimum Data Set (MDS) assessment, dated 1/1/18, noted a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderate cognitive impairment. A progress note, dated 1/2/18 at 7:09 a.m., indicated the following, .RES (resident) found laying on bedroom floor on her back. Res (resident) stated she was trying to walk. small (sic) bruise to Rt (right) shoulder. did (sic) no c/o (complaints of) pain at this time. neuro (neurological) checks iniated (sic), q15min (every 15 minute) check started .floor mat placed by bed side. Res (resident) needs a personal bed and chair alarm A Fall Event document, dated 1/2/18 at 4:37 a.m., indicated the following, .1/2/18 .Description .Res (resident) found laying on the bedroom floor on her back .What intervention (s) was put into place to prevent another fall .Res (resident) re-education to use call light before getting up There were no progress notes that indicated an IDT post fall analysis was conducted for the fall on 1/2/18 in regards to Resident F. A document titled Daily CQI Meeting Minutes, dated 1/2/18, noted Resident F's name with toileting program and schedule written. The document was provided by the Assistant Director of Nursing (ADON) on 3/16/18 at 11:35 a.m. An interview conducted with the ADON, at that time, indicated the toileting program for Resident F wasn't implemented until 1/18/18. He was unable to state, as to why, the toileting program wasn't implemented for Resident F until a later date. A progress note, dated 1/4/18 at 6:42 p.m., indicated the following, .Writer called to room found resident on floor next to bed. Resident c/o (complained of) serve (sic) R (right) shoulder pain limited ROM (range of motion)(sic). Resident has ST (skin tear) to R (right) face .Resident states she was trying to get in bed .Resident sent to (name of hospital) for eval (evaluation) A Fall Event document, dated 1/4/18 at 6:25 p.m., indicated the following, .1/4/18 .Description .Resident lying next to bed on R (right) side with arm backwards .What intervention (s) was put into place to prevent another fall .Resident is to be laid down after meals A fall care plan, revised 3/16/18, did not have any interventions added after the fall events on 1/2/18 and 1/4/18. Hospital records, dated 1/4/18, indicated the following, .Chief Complaint .Fall .fell from bed approx (approximately) 2.5 ft (feet) off the ground, c (cervical) collar placed by ems (emergency medical services), bruising on R (right) eye from previous fall, hematoma on R (right) forehead, unsure if from previous or current fall .Clinical Impression .Closed fracture of facial bone .Frequent falls An interview conducted with Resident F, on 3/15/18 at 4:08 p.m., indicated she doesn't recall how she fell in January. She just knew she hit her head and face during the fall. No hipsters were observed on Resident F during the interview. When asked if she was wearing hipsters, Resident F, indicated she was not wearing hipsters at that time. There was no floor mat noted beside her bed as well. On 3/16/18 at 8:25 a.m., a floor mat was noted beside Resident F's bed. 1b. Upon review of the progress notes for Resident F, there were indications of a fall event occurring on the following date(s): 1/2/18, 1/4/18, 1/11/18, 2/9/18, 2/25/18, 2/27/18, 3/1/18, 3/3/18, & 3/5/18. The fall event, dated 2/27/18, was written in a progress note but there were no fall event/incident report completed for the fall on 2/27/18. A fall care plan, revised 3/16/18, noted the followig interventions: Body pillow for tactile boundaries that was added 2/9/18, Touchpad call light added 2/26/18, Hipsters to prevent serious injury added 3/2/18, Floor Mat added 3/5/18, & Bed at lowest position at night added 3/16/18. A written physician order, dated 1/5/18, indicated the following, .hipsters to be work @ (at) all times except hygiene There were no active physician orders [REDACTED]. The fall intervention for hipsters were not added to the care plan until 3/2/18. An interview and observation conducted with the ADON, on 3/16/18 at 11:00 a.m., indicated after the fall event, on 1/2/18, there was an intervention for a toileting program but it was not implemented until 1/18/18. He was unsure as to why it was delayed on being implemented. There were no interventions implemented after the fall, on 1/4/18, that resulted in a facial fracture. The ADON was unsure as to why there were no interventions implemented after the fall event on 1/4/18. The ADON indicated an IDT note is done by the Unit Managers and they document the root cause analysis and put an immediate intervention in place, after each fall event. They also determine if the fall intervention, immediately put into place, was appropriate or not. It appears that there were no IDT notes completed for Resident F for any of her fall events from January, (YEAR) to current. He was unable to find an indication of an intervention being added to the care plan and/or implemented for the fall events on 1/4/18, 2/27/18 and 3/3/18. There was no fall event report completed for the fall on 2/27/18 for Resident F. A policy titled Fall Management Program, revised 11/2017, was provided by the Executive Director (ED), on 3/14/18 at 2:32 p.m. The policy indicated the following, .Procedure .Post fall .5. A fall event will be initiated as soon as the resident has been assessed and cared for .The report must be completed in full in order to identify possible root causes of the fall and provide immediate interventions .6. All falls will be discussed by the interdisciplinary team and the 1st IDT meeting after the fall to determine root cause and other possible interventions to prevent future falls .The fall event will be reviewed by the team .IDT not will be written .The care plan will be reviewed and updated, as necessary This Federal tag relates to Complaint IN 111. 3.1-45(a)(2)

Based on interview and record review, the facility failed to implement a fall intervention used to reduce injury from a fall resulting in a hospitalization with subdural hematoma for 1 of 3 residents reviewed for falls. (Resident #A) Findings include: The clinical record for Resident #A was reviewed on 2/3/14 at 12:00 p.m. She was admitted to the facility the evening of 1/22/14. Her daughter, Family Member #1, was present upon her admission. The [DIAGNOSES REDACTED]. The 1/23/14, 5:19 p.m. Comprehensive Admission Assessment indicated the following: Oriented to: person Mental status: alert Answers questions: inappropriately Eye condition/vision: impaired vision-bilateral Neuro: upper body weakness, lower body weakness Non-verbal indicators of pain: Resident makes non-verbal sounds that may indicate pain: i.e. crying, whining, gasping, moaning or groaning The 1/22/14 care plan for Resident #A indicated the problem was, "Resident is a new admission to the facility." The goal was, "Resident needs will be met." The approaches to be implemented by nursing in regard to safety/mobility were, "Supervise and assist with mobility and safety as needed. Resident will have no injury related to falls. Observe for fall risk contributors such as medications, hypotension, pain, unsteady gait. Encourage and remind resident to use call light. Refer to therapies for screening. Provide assistance for transfers, bed mobility. Keep room free of clutter. Provide appropriate assistive devices. Non skid footwear, bed alarm 1/23/14, bed against wall 1/23/14, mat on floor 1/24/14, chair alarm 1/24 (1/24/14), composure mattress 1/24/14." A telephone interview was conducted with Family Member #1 on 2/3/14 at 2:00 p.m. She indicated she was present at her mother's admission to the facility around 7:00 p.m. the evening of 1/22/14. She indicated, "I told the nurse on admission I was very concerned there were no bed rails." Family Member #1 indicated when she left the facility that evening, there was no mat on the floor next to her mothers bed, no rails on the side of the bed, and the bed was not against the wall. She indicated she spoke with (name of Social Services Director) and another staff member, whose name she could not recall, by telephone the following day regarding her mother not having rails on the side of her bed and her concern with her mother "falling out of bed." She indicated she was told the rails were illegal and would need an order. Family Member #1 indicated she returned to the facility at 4:30 p.m. the afternoon of 1/23/14 to visit her mother and "the bed was against the wall." She indicated there was no mat on the floor on the other side of the bed. She indicated, "I left that evening, maybe an hour later. I got a call at 1:30 a.m. that she fell out of bed and was sent to (name of hospital.)" The 1/22/14, 7:21 p.m. nurses note indicated, "Admit this (age and race) female to (room and bed), resident is alert...nurse informed by daughter that resident has a torn rotator cuff..." The 1/22/14, 8:00 p.m. nurses note indicated, "PT (patient) lying in bed at this time...Family has left. Daughter and POA (Power of Attorney) had concern about 2 medicines ordered..." The 1/23/14, 8:06 a.m. Social Services progress note indicated, "Met with resident this morning to complete the initial assessment. Resident is alert to self, but not oriented to time or place. Resident was not able to answer any of the questions from this writer. Resident was not able to complete the initial assessments due to lack of ability to respond...This writer shall call the family to gather necessary info (information.)" This note was created by the Social Services Director. The 1/23/14, 10:47 a.m. Social Services progress note indicated, "This writer spoke with residents dtr (daughter) via phone, was able to gather social hx (history) per dtr. Dtr explained that res (resident) was living with her husband in the community home and her plan is to be able to rehab (rehabilitate) to home. Resident was alert and oriented x3 (person, place, time) prior to her hospitalization and was very independent. Dtr explained that resident has psoarsis (sic) and hepatic [DIAGNOSES REDACTED] which caused increased confusion and disorientation and that she had high ammonia (sic) levels. Dtr explained that since admission to the hospital, res has not been oriented to time/place, however does seem to recognize family members. Res is not able to communicate her needs at this time...CP (care plan) meeting has been scheduled via phone for tomorrow afternoon." An interview was conducted with the SSD (Social Services Director) on 2/3/14 at 2:32 p.m. The SSD indicated the other staff member present during the telephone conversation with Family Member #1 was Resident #A's Nurse Case Manager. An interview was conducted with Resident #A's Nurse Case Manager on 2/3/14 at 2:45 p.m. regarding Family Member #1's concern with Resident #A potentially falling out of bed. She indicated Resident #A being a fall risk was discussed with Family Member #1. She stated, "I remember discussing side rails are for seizure precautions and we don't use them for fall risk." Regarding what fall interventions were in place for Resident #A she indicated, "We used a bed alarm, bed against wall, floor mat at bedside." Regarding the mat on the floor not having been implemented until after Resident #A's fall on 1/24/14, she indicated, "I don't know why." Regarding what intervention to reduce and/or prevent injury from a potential fall was in place for the other side of Resident #A's bed, given one side of the bed was against the wall, she indicated, "I can't answer what was in place for the other side of the bed." Regarding if there was any intervention in place to reduce or prevent injury from a fall as care planned , she indicated, "Not that I can see." The 1/24/14, 2:00 a.m. nurses note indicated, "CNA (Certified Nursing Assistant) reported hearing resident alarm an (sic) entered room, resident on floor next to bed. bed in lowest position, c/o (complains of) severe pain to right arm, skin tear to chin and right arm. unable to move right arm. on call notified, resident sent to (name of hospital) for eval (evaluation) via care ambulance, Daughter and Husband notified, ADNS (Assistant Director of Nursing) notified, all appropriate paperwork sent with resident." The 1/24/14, 1:46 a.m. Fall Event indicated the following: "Was fall witnessed: No Describe what the resident was doing prior to the fall: in bed Describe the position of the resident when first observed after fall: prone (body lying face down) Describe location of the fall: room/bedside Is the resident in pain and or experiencing difficulty in movement of extremities: Yes, right arm Did the resident hit his/her head: Yes Describe injuries, if any, and the immediate treatment provided: skin tear to chin, right arm, c/o pain severe to right arm. Resident or witness statement of how fall occurred: resident unable to say how fall occurred, CNA stated hearing alarm, entered resident romm (sic), resident on floor next to bed What intervention (s) was put into place to prevent another fall: mat on floor." The 1/24/14, 8:10 a.m. IDT (Interdisciplinary Team) progress note indicated, "IDT Review of fall that occurred at 115AM. Staff entered room due to alarm sounding to find resident on the floor next to the bed in prone position. Resident with complaints of pain to right arm. Family and MD notified of fall and RUE (right upper extremity) pain. Orders were obtained to send resident to ER (emergency room ) for eval of right arm pain although resident has a history of right rotator cuff tear. Family notified of new orders to transfer to ER. Short term 15 minute checks and neurochecks initiated immediately after fall. A mat was placed on the floor next to bed immediately after fall as well to create one safe exit from bed. Will also place a scoop mattress to provide bed boundaries while resident is in bed. Resident was assisted back to bed with assistance of 2 and gait belt with RUE support. Resident remains out at the hospital at this time. Will continue all previous interventions and continue to monitor." This note indicated the ADNS was in attendance for this fall review. An interview was conducted with the ADNS on 2/3/14 at 3:00 p.m. regarding the information used to determine which fall interventions were appropriate for Resident #A and Resident #A's bed having been against the wall with no mat on the floor next to her bed prior to the fall. She indicated, "We used to have a separate fall risk assessment on admission," but currently used the admission assessment and the IDT fall risk assessment for determining appropriate interventions. "It was determined she did not need a mat on the floor...We do bed against wall to give less of a risk for rolling out of bed. I don't know why there was no mat in place. I guess we didn't feel there was a need...It's not typical to have the bed against the wall and no mat. She didn't move a lot. Some people have mats; some don't. If they (a resident) had a fall, we will put a mat down. She wasn't determined to be at risk for falling out of bed, but yes, she did have her bed against the wall as a fall prevention." Regarding whether Resident #A had been determined as being more likely to fall or roll out of one side of bed as opposed to the other, she indicated, "I don't believe so." Regarding the purpose of having a mat on the floor next to a resident's bed, she indicated, "A resident wouldn't injure themselves as badly with a mat next to the bed." Regarding the relationship between Resident A's injury after her fall and not having a mat next to her bed, the ADNS indicated, "She did obtain a subdural hematoma. If it (the mat) were in place prior, it may have prevented a subdural hematoma." The ADNS provided a copy of the IDT Fall Risk Assessment on 2/3/14 at 3:30 p.m. It indicated all new admissions were at risk for falls. It indicated risk factors identified for Resident #A were a history of falls, impaired vision, difficulty with standing, walking or transfers, and used a mobility device. The 1/24/14, 11:48 IDT progress note indicated, "IDT-care plan scheduled via phone this morning with dtr...Dtr states that res is at the hospital at this time and will not be returning..." The 1/24/14, 12:18 p.m. Nurse Practitioner note indicated, "Apparently patient fell last night and was sent out to the hospital for evaluation. She was admitted for subdural hematoma." The 1/24/14 History and Physical from the hospital indicated, "History of present illness: The patient was admitted to the hospital with [REDACTED]. There, she fell apparently and suffered a lip laceration. The head CT showed subdural hematoma. She is now admitted for management of this...Diagnostic Data: I reviewed her x-rays. She has an acute hematoma on the right frontotemporal region, 4 mm thick, and moderate cerebral atrophy...Impression: 1. Subdural hematoma...4. Arm pain, quite exquisite. I will order films of the elbow and wrist to look for occult fracture." The 1/24/14 hospital notes indicated the following: "EXAM: CT HEAD WO IV CONTRAST. INDICATION: Head injury. COMPARISON: 01/15/2014 FINDINGS: There is an acute extra-axial hematoma over the right frontotemporal region. This measures up to 4 mm in thickness... IMPRESSION: Acute right frontotemporal extra-axial hematoma, likely subdural. This measures up to 4 mm in thickness and exhibits no significant mass effect. This critical result was discussed with (name of doctor) in the emergency room at 4:20 AM on 01/24/2014." The 1/29/14, 3:53 p.m. Significant Event note from the hospital indicated, "1439 (2:39 p.m.). No palpable pulse. No audible respirations." The Fall Management Program policy was provided by the Administrator on 2/3/14 at 1:40 p.m. It indicated, "It is the policy of (name of facility) to ensure residents residing within the facility will maintain maximum physical functioning through the establishment of physical, environmental, and psychosocial guidelines to prevent injury related to falls...Fall Risk...2. All new admissions will be considered at fall risk based upon his/her new living arrangements, and his/her reasons for being admitted in to the nursing facility..." This Federal tag relates to Complaint IN 397. 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure the safety of a resident, in that when a resident who was assessed as dependent upon two staff members for transfer and bed mobility, the nursing staff failed to ensure the aide protected the resident while providing care, for 1 of 3 residents reviewed for injury in a sample of 6. This resulted in the resident requiring hospital treatment following a fall from bed. (Resident "C"). Findings include: The record for Resident "C" was reviewed on 09-22-11 at 11:50 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. Review of the Minimum Data Set assessment, dated 07-07-11 indicated the resident was cognitively impaired, and required extensive assistance with transfer and bed mobility - 2+ staff members, and total assist of 1 staff member with hygiene. The siderail assessment, dated 10-09-11 indicated the resident required the use of 2 - 1/2 rails. "Use of side rails provides tactile bed boundaries for a resident with sensory deficit or poor muscle coordination, prevent accident roll out or the resident is not able to get out of bed voluntarily." The nurses notes, dated 09-19-11 at 9:45 a.m. indicated the following:"Hospice CNA at resident's bedside providing ADL (activities of daily living) care. Alerted writer to resident, stating resident fell out of bed when rolled to left side for pericare. Writer found resident lying on stomach on side of bed with copious amounts of blood coming from facial area. 911 called r/t (related to) bleeding and multiple lacerations to face and head." Review of the Fall Circumstance Report, dated 09-19-11 at 9:45 a.m. indicated "fall witnessed - receiving care by the Hospice Aide, laying on stomach, no clothes, resident hit head, bruises to bridge of nose, laceration to bridge of nose, forehead and hairline. Hospice aide states resident was rolled onto left side for pericare and (resident) rolled out of bed. Sent to ER (emergency room ) for eval. (evaluation) and tx. (treatment)." Review of the local area hospital facility return notation, dated 09-21-11, indicated and instructed the nursing staff as follows. "Scattered abrasions to forehead/face/bruises noted to hands. Bactroban ointment to laceration on face after cleaning with peroxide and drying." During an observation on 09-23-11 at 9:40 a.m., the resident was observed in bed, with side rails padded and the gastrostomy feeding infusing. The resident was observed with bilateral brownish/gray/yellow bruising to eyes, forehead, and across the bridge of the resident's nose. When interviewed on 09-23-11 at 3:00 p.m., the Director of Nursing Services indicated the Hospice aide is supposed to notify the nurse upon arrival and the facility staff would make themselves available to assist during care. Interview on 09-27-11 at 9:30 a.m., the Executive Director and Director of Nursing Services indicated a meeting was scheduled for 09-28-11 to discuss the injury sustained by the resident while under the care of the Hospice Aide, in addition this would be a part of the facility CQI (Continuous Quality Improvement) program and the inclusion of the Medical Director. 3.1-45(a)(2)