Every finding on record at Shady Nook Care Center

Based on record review and interview, the facility failed to ensure accurate documentation was completed related to a resident's pain medication for 1 of 3 residents reviewed for accuracy of records. (Resident B) Findings include:The clinical record for Resident B was reviewed on 05/12/2026 at 9:14 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 02/19/2026, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, cancer (the uncontrolled growth and spread of abnormal cells in the body), chronic kidney disease (an illness were the kidneys are damaged and cannot effectively filter waste and extra fluid from the blood), and end-stage renal failure (severe kidney failure where kidney function is less than 15% of normal). A Progress Note, dated 04/27/2026 at 6:18 P.M., indicated Resident B was transferred to the hospital by ambulance. A Progress Note, dated 04/30/2026 at 10:03 A.M., indicated Resident B would not be returning to the facility from the hospital. A physician's order, dated 11/11/2025 through 04/29/2026, indicated Resident B was to receive Hydrocodone-Acetaminophen (a pain medication) oral tablet 5-325 Milligrams (MG) one tablet by mouth every six hours for pain. The April 2026 Electronic Medication Administration Record (EMAR) indicated on 04/28/2026 Resident B was administered a Hydrocodone-Acetaminophen at 06:00 A.M., and the resident had a pain level of four out of ten. During an interview, on 05/12/2026 at 1:47 P.M., Registered Nurse (RN) 2 indicated when administering a narcotic pain medication you asses the residents pain level prior to administering the medication, and once administered you chart in the electronic health record that it was administered successfully while recording the administration on the narcotic count book as well. During an interview, on 05/12/2026 at 2:49 P.M., the Director of Nursing (DON) indicated Resident B was at the hospital on [DATE], and the medication should not have been charted as administered. The current facility policy, dated October of 2010, titled, Administering Oral Medications, was provided by the Director of Nursing on 05/12/2026 at 3:05 P.M. The policy indicated, .6. Check the label of the medication and confirm the medication name and dose with the MAR .10.confirm the identity of the resident .21. Remain with the resident until all medications have been taken . This citation relates to Intake 3005015. 410 IAC (Indiana Administrative Code) 3.1-50(a)(2)

Based on interview and record review, the facility failed to ensure a resident diagnosed with an irreversible brain disorder that slowly destroyed memory, thinking skills, and simple tasks received appropriate supervision and interventions to attain his or her psychosocial well-being for 1 of 3 residents reviewed for dementia care. (Resident C) Findings include:The clinical record for Resident C was reviewed on 01/23/2026 at 1:47 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 12/14/2025, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, Alzheimer's disease with early onset (progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out simple tasks) and non-traumatic brain dysfunction. The resident was able to walk 150 feet with just supervision and had exhibited physical behaviors towards others for one to three days during the review period. A current care plan, with the start date of 10/16/2023 and revised date of 04/01/2025, indicated Resident C had experienced verbal behaviors such as yelling and cursing at staff and others as well as physical aggression towards staff and others due to belief of others were in her home. The interventions included, but were not limited to: dated 12/12/2025, if resident becomes resistive then allow resident to calm; have other staff approach resident; offer a snack or beverage to redirect for aggression/agitation and reapproach. A current care plan, with the start date of 03/03/2025 and revised date of 11/12/25, indicated Resident C had experienced delusions due to belief that this was her home and others need to leave. Resident C will address others within their personal space. The resident experienced auditory and visual hallucinations while at an inpatient behavior facility. The interventions included, but were not limited to: dated 03/03/2025, intervene as necessary to protect the rights and safety of others; staff were to approach and speak in calm manner; and remove the resident from situation and take to alternative location as needed. A Progress Note, dated 01/09/2026 at 4:20 P.M., indicated Resident C struck a staff member. A Progress Note, dated 01/12/2026 at 1:58 A.M., indicated Resident C was up in the hallway wandering. The staff were unable to redirect. A Progress Note, dated 01/12/2026 at 11:40 A.M., indicated Resident C became aggressive with another resident on the unit. The resident was noted to be yelling and grabbing another resident. The resident was not easily redirected with staff. During an anonymous staff interview, on 01/23/2026 between 9:00 A.M. and 12:00 P.M., Staff Member 10 indicated Resident C was a walking behavior, and within the past two and a half months she has become more aggressive. She has had behaviors with other residents in the last couple of months. She usually was more verbal with her aggression towards other residents, but recently she had gotten more physical towards other residents. She would randomly walk by someone and hit them or smack them on the butt. The staff would try to watch Resident C at all times. If the resident had a behavior towards another resident it should have been documented under progress notes but some people say they chart it under behavior notes. During an anonymous staff interview, on 01/23/2026 in between 9:00 A.M. and 12:00 P.M., Staff Member 8 indicated Resident C was a wild one and had behaviors with other residents. When she was mad you had to take her away from whomever she was mad at. Sometimes that worked, but not always. The staff would try to find things to keep her busy, but nothing worked. During an anonymous staff interview, on 01/23/2026 between 9:00 A.M. and 12:00 P.M., Staff Member 5 indicated they had witnessed Resident C get physically aggressive with another resident about 3 weeks ago, and it was reported to the nurse. She was passing another resident in the common area when she screamed in their face and shoved on their shoulder causing the other resident to step backwards. During an interview, on 01/23/2026 at 10:52 A.M., Registered Nurse (RN) 3 indicated she was the Unit Manager on the Dementia Unit and that resident behaviors were reported to her. She did not believe Certified Nursing Assistants (CNA's) were able to chart behaviors, but nurses could. Anytime a resident was verbally or physically aggressive it should be documented in the resident's clinical record. Resident C was mostly aggressive with staff members not residents. She had hit staff before while providing care. During an interview, on 01/23/2026 at 11:56 A.M., the Social Services Director indicated Resident C was currently out of the facility for aggressive behaviors after an incident with another resident. There were no behavior sheets completed on Resident C. The only behaviors she was aware of were what the nurses documented in the progress notes. She had never heard of Resident C hitting other residents until the incident on 01/12/2026. During an interview, on 01/23/2026 at 1:45 P.M., the Social Services Director indicated Resident C did have an altercation with another resident in November. The current facility policy titled, Dementia - Clinical Protocol with a revision date November of 2018, was provided by the Director of Nursing on 01/23/2026 at 1:10 P.M. The policy indicated, .Progressive or persistent worsening of symptoms and increased need of staff support will be reported to IDT.The IDT will adjust interventions and the overall plan depending on the individual's responses to those interventions, progression of dementia. This citation relates to Intake 2714547.

Based on interview and record review, the facility failed to ensure a resident to resident abuse did not occur for 1 of 3 residents reviewed for abuse. (Resident D) Findings include:The clinical record for Resident D was reviewed on 01/23/2026 at 2:00 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 11/13/2025, indicated the resident was severely cognitively impaired. The resident's diagnosis included, but was not limited to, Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroyed memory, thinking skills, and the ability to carry out simple tasks). A Progress Note, dated 01/12/2026 at 11:40 A.M., indicated Resident D was involved in an altercation with another resident, and was struck causing her glasses to break. There was bruising noted on her face and bilateral arms. A Weekly Skin Assessment, dated 01/13/2026 at 3:00 P.M., indicated Resident D had bruising located on her right and left antecubital arm, left periorbital area, and to the left side of her nose. During an observation, on 01/23/2026 at 1:18 P.M., Resident D was observed sitting in a recliner in the common area by the front door. She had a half dollar sized fading bruise to the top part of her left arm. The clinical record for Resident C was reviewed on 01/23/2026 at 1:47 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 12/14/2025, indicated the resident was severely cognitively impaired. The resident was able to walk 150 feet with just supervision and had exhibited physical behaviors towards others for one to three days during the review period. A Progress Note, dated 01/12/2026 at 1:58 A.M., indicated Resident C was up in the hallway wandering. The staff were unable to redirect. A Progress Note, dated 01/12/2026 at 11:40 A.M., indicated Resident C became aggressive with another resident on the unit (Resident D). Resident C was noted to be yelling and grabbing another resident (Resident D). Resident C was not easily redirected with staff. A current care plan, with the start date of 03/03/2025 and revised date of 11/12/25, indicated Resident C had experienced delusions due to belief that this was her home and others needed to leave. Resident C would address others within their space. The interventions included, but was not limited to: dated 03/03/2025, staff were to intervene as necessary to protect the rights and safety of others. During an anonymous staff interview, on 01/23/2026 between 9:00 A.M. and 12:00 P.M., Staff member 2 indicated they were working on January 12th and witnessed the incident between Resident D and Resident C. While they stood at the medication cart close to the dining room they heard someone scream. When they looked up, they witnessed Resident C grabbing and swatting at Resident D at the opposite end of the hallway. They immediately rescued Resident D and relocated her next to the medication cart. Resident C was put on one-on-one observations with another staff member. Resident D had red marks on her face and arm, and her glasses were broken into three pieces. During an anonymous staff interview, on 01/23/2026 between 9:00 A.M. and 12:00 P.M., Staff Member 10 indicated Resident D was the sweetest resident on the dementia unit. She never had any behaviors or bothered anyone. Resident C is a walking behavior, and within the past two and a half months she had become more aggressive. She has had behaviors with other residents in the last couple of months. She usually was more verbal with her aggression towards other residents, but recently she has gotten more physical towards other residents. She will randomly walk by someone and hit them or smack them on the butt. The staff tried to always watch Resident C. The current facility policy titled, Abuse Policy with a revision date of September of 2022, was provided by the Director of Nursing on 01/23/2026 at 1:10 P.M. The policy indicated, .The resident has the right to be free from abuse. residents must not be subjected to abuse by anyone, including, but not limited to, . other residents . This citation relates to Intake 2714547. 3.1-27(a)

Based on interview, observation, and record review, the facility failed to document an incident in the Electronic Health Record (EHR) and monitor a resident's skin conditions for 2 of 19 residents' records reviewed. (Resident 30 and Resident 25) Findings include:During an anonymous interview, from 12/30/25 through 01/06/26, Confident Interview 9 indicated there had been a recent incident/altercation in the locked dementia unit involving Resident 30 and Resident 25. Resident 30 had bruising and scratches on her face. An altercation involving Resident 25 and Resident 30 happened on 12/29/2025 after 6:00 P.M. During an observation, on 01/02/2026 at 2:29 P.M., Resident 30 was in her room, in the locked dementia unit, lying in bed on her right side with her eyes closed. The left side of her face had a bruise that was three to four inches long by one and a half inches wide extending from her left temple into her hairline on the top of her forehead. The bruise was green and yellow in color. She also had two scratches on her forehead with red dried blood. One scratch was approximately an inch long, and one was approximately one and a half inches long. During an observation, on 01/02/2026 at 3:09 P.M., with Unit Manager (UM) 3, the Resident was in her room in bed. The bruising and scratches were visible on her head. The Unit Manager indicated she was not sure what had happened to the resident. When asked if the resident's skin condition should be charted in the resident's health record, the Unit Manager indicated sometimes staff would chart on skin sheets for a bruise of that size, she had not been informed of a recent fall or anything. She had been off work for a few days. Sometimes something would be noted in daily charting. There should have been documentation in a Progress Note. During an interview and observation of Resident 30, on 01/02/2026 at 3:15 P.M., the Director of Nursing (DON) indicated she was not sure what had happened to the resident's face, it was her first time seeing the resident's injuries. During an interview, on 01/05/2026 at 3:46 P.M., Certified Nurse Aide (CNA) 6 indicated she was not aware of any incidents on the dementia unit, just the normal screaming and yelling. She did not notice the bruise on Resident 30. She had worked on 12/29/2025. During an interview on 01/02/2026 at 3:19 P.M., the DON indicated there should be behavior monitoring documented in the EHR if a resident had a behavior and she would be looking into the bruising/injury. During an interview with the Psych Nurse Practitioner (NP), on 01/05/2026 at 2:45 P.M., the NP indicated staff had not reported to him any aggressive behaviors towards other residents since she came back in November. The NP indicated he also routinely saw Resident 30. She was a sweet lady. He saw her on 12/08/2025 and today. She usually came out of her room for activities and meals. He usually came to the facility in the morning, and she was usually out in the common area at that time of day. The clinical record for Resident 25 was reviewed on 01/06/2026 at 12:38 P.M. A Quarterly MDS assessment, dated 12/14/2025, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, Alzheimer's disease, dementia, anxiety, and depression. The resident had physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) that occurred for 1 to 3 days of the 7-day review period. The resident had verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) that occurred for 1 to 3 days of the 7-day review period. Resident 25's Progress Note, dated 12/29/2025 at 12:30 A.M., indicated Resident was noted with behaviors this evening, staff redirected. During an interview, on 01/02/2026 at 3:16 P.M., UM 3 indicated she reviewed Resident 25's record. There was some recent behavior charting in the resident's progress notes that was not normal charting for the resident. There was no indication what the behavior charting was about. If nursing staff were charting no behaviors, there was a reason. If a resident exhibited behaviors, it should be documented in the progress notes what type of behavior the resident exhibited. It should be descriptive and it would be documented every shift. The clinical record for Resident 30 was reviewed on 01/02/2026 at 2:46 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 11/14/2025, indicated the resident was severely cognitively impaired. The resident was [AGE] years old. The resident used a wheelchair and needed substantial/maximal assistance from staff members for eating and dressing. The resident exhibited no behavioral symptoms during the review period. Resident 30's Progress Note, dated 01/02/2026 at 5:49 P.M., indicated the resident was assisted to bed after meals. She was noted with a bruise and scratches to face (this was the first note identifying the resident's injuries to her face). Resident 30's clinical record lacked progress notes documented from 12/23/2025 through 12/31/25. Resident 30's clinical record lacked documentation regarding what led to her skin impairments and the monitoring of her skin impairments in a timely manner. The Weekly Skin Review records for Resident 30 indicated the resident's skin was intact on 12/31/2025 and on 01/02/2026. The review record dated 01/03/2026, indicated the resident had a yellow/green bruise to her face and superficial scratches to her forehead. The records lacked documentation related to the resident's left hand. During an interview, on 01/04/2026 at 7:14 P.M., QMA 5 indicated he worked passing medications on night shift on the Dementia Unit on 12/29/2025. He didn't know anything about any altercations between any of the residents. He did not know anything about any bruises or injuries with Resident 30 or any other residents. Normally residents just got loud with each other, not physical with each other. Video camera footage of the common/dining area in the Dementia Unit from the evening of 12/29/2025 was reviewed with the Administrator and Maintenance Supervisor on 01/06/2026 at 11:30 A.M. Resident 30's room was visible on the footage as well as the beginning of the hall on the unit. The following was observed: - At 7:36 P.M., Resident 30 was in her room. Resident 25 was observed looking into Resident 30's room. - At 7:42 P.M., Resident 25 was not near Resident 30's room. - At 8:05 P.M., Resident 30 was in her wheelchair in the doorway of her room. Resident 25 was near the doorway to Resident 30's room. - At 8:11 P.M., Resident 30 wheeled herself towards the hallway past her room, out of view of the camera. Resident 25 was not within view of the camera. - At 8:13 P.M., CNA 6 and QMA 5 were sitting across from each other at a table in the common area. There were no residents in the common area. - At 8:16 P.M., CNA 6 and QMA 5 got up quickly from the table and went towards the hallway. - At 8:19 P.M., Resident 30 wheeled herself back from the hallway and stopped in the doorway in front of her room. - At 8:23 P.M., Resident 30 was still in her wheelchair in front of her doorway. QMA 5 and LPN 4 were talking to Resident 30. LPN 4 was holding and appeared to be assessing the resident's left hand. - At 8:27 P.M., LPN 4 brought supplies over to Resident 30 and appeared to be cleaning the resident's left hand. LPN 4, QMA 5, and CNA 6 were all gathered around Resident 30 looking at the resident's left hand. Resident 30 started to rub the left side of her head. LPN 4 appeared to assess the resident's head, looking closely at the left side. - At 8:31 P.M., staff assisted Resident 30 back to her room. During an interview, on 01/06/2026 at 12:54 P.M., the Maintenance Supervisor indicated there was also a camera in the hallway in the Dementia Unit that would have recorded activity in the hall outside of the resident's rooms, but he was unable to access that video for review. Following review of the video footage on 01/06/2026, the DON indicated she went and looked at Resident 30's hand and there was a skin impairment present. The current Change in a Resident's Condition or Status policy, with a revision date of February 2021, was provided by the DON on 01/06/2026 at 3:30 P.M. The policy indicated, .The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. 3.1-50(a)(1) 3.1-50(a)(2)

Based on interview and record review, the facility failed to administer a resident's medication as the physician prescribe related to hypotension for 1 of 19 residents reviewed for pharmacy services. (Resident 30) Findings include:The clinical record for Resident 3 was reviewed on 01/05/2026 at 10:58 A.M. An admission Minimum Data Set (MDS) assessment, dated 11/12/2025, indicated the resident was cognitively intact. The residents, diagnoses included, but were not limited to, fractures, cancer, heart failure, hypertension, diabetes, anxiety, and respiratory failure.An open-ended physician's order, with a start date of 12/09/2025, indicated the resident was to receive Midodrine (a hypotensive blood pressure medication) 5 milligrams (mg), three times a day with meals. The medication was to be held if the resident systolic (top number) blood pressure was 160 and over, the diastolic (bottom number) blood pressure was 100 and over, and heart rate was less than 55. The December 2025 and January 2026 Electronic Medication Administration Record (EMAR) were reviewed and indicated the resident had not received the medication when the resident's systolic blood pressure was less than 160 and the resident's diastolic blood pressure was less than 100 on the following dates and times:-On 12/24/2025 at 8:00 A.M., when the blood pressure was 149/97, -On 12/24/2025 at 12:00 P.M., when the blood pressure was 127/75, -On 12/24/2025 at 5:00 P.M., when the blood pressure was 124/77,-On 12/27/2025 at 8:00 A.M., when the blood pressure was 139/77, -On 12/27/2025 at 5:00 P.M., when the blood pressure was 137/86,-On 01/01/2026 at 8:00 A.M., when the blood pressure was 139/81, -On 01/01/2026 at 12:00 P.M., when the blood pressure was 135/69, and-On 01/01/2026 at 5:00 P.M., when the blood pressure was 104/57. The clinical record indicated the resident's heart rate was only monitored on the following dates and times from 12/24/2025 through 01/01/2026:-On 01/01/2026 at 5:20 P.M., the resident's pulse rate was 89During an interview, on 01/06/2025 at 10:48 A.M., RN 2 indicated a resident's medication should be administered per the physician's orders. If the resident's medication had specific parameters, she would obtain the vital signs prior to administering the medication. If the vital sign values were within the parameters she would administer the resident's medication. The resident's vital signs would be documented with the medication because the EMAR prompts the user to input the vital sign value before you signed out the medication. The current facility policy, titled General Dose Preparation and Medication Administration, with a revision date of 01/01/2022, was provided by the Director of Nursing on 01/06/2025 at 11:28 A.M. The policy indicated, .Facility staff should comply with Facility policy, Applicable Law and the State Operations Manual when administering medications.If necessary, obtain vital signs.3.1-37(a)

Based on interview, observation, and record review, the facility failed to monitor a resident's skin conditions related to bruising and scratches from the time of the occurrence for 1 of 19 residents reviewed for Quality of Care. (Resident 30) Findings include:During an observation, on 01/02/2026 at 2:29 P.M., Resident 30 was in her room, in the locked dementia unit, lying in bed on her right side with her eyes closed. The left side of her face had a bruise that was three to four inches long by one and a half inches wide extending from her left temple into her hairline on the top of her forehead. The bruise was green and yellow in color. She had two scratches on her forehead with red dried blood. One scratch was approximately an inch long, and one was approximately one and a half inches long. During an observation, on 01/02/2026 at 3:09 P.M., with Unit Manager (UM) 3, the Resident was in her room in bed. The bruising and scratches were visible on her head. The Unit Manager indicated she was not sure what had happened to the resident. When asked if the resident's skin condition should be charted in the resident's health record, the Unit Manager indicated sometimes staff would chart on skin sheets for a bruise of that size, she had not been informed of a recent fall or anything. She had been off work for a few days. Sometimes something would be noted in daily charting. There should have been documentation in a Progress Note. During an observation of Resident 30, on 01/02/2026 at 3:15 P.M., the Director of Nursing (DON) indicated she was not sure what had happened to the resident's face, it was her first time seeing the resident's injuries. During an interview on 01/02/2026 at 3:19 P.M., the DON indicated she would be looking into the resident's bruising/injury. During an interview, on 01/05/2026 at 3:46 P.M., Certified Nurse Aide (CNA) 6 indicated she was not aware of any incidents on the dementia unit, she did not notice the bruise on Resident 30. She worked on Sundays, Mondays, and Tuesdays. The clinical record for Resident 30 was reviewed on 01/02/2026 at 2:46 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 11/14/2025, indicated the resident was severely cognitively impaired. The resident was [AGE] years old. The resident used a wheelchair and needed substantial/maximal assistance from staff members for eating and dressing. The resident exhibited no behavioral symptoms during the review period.Video camera footage of the common/dining area in the Dementia Unit from the evening of 12/29/2025 was reviewed with the Administrator and Maintenance Supervisor on 01/06/2026 at 11:30 A.M. Resident 30's room was visible on the footage as well as the beginning of the hall on the unit. The following was observed: - At 8:23 P.M., Resident 30 was still in her wheelchair in front of her doorway. QMA 5 and LPN 4 were talking to Resident 30. LPN 4 was holding and appeared to be assessing the resident's left hand.- At 8:27 P.M., LPN 4 brought supplies over to Resident 30 and appeared to be cleaning the resident's left hand. LPN 4, QMA 5, and CNA 6 were all gathered around Resident 30 looking at the resident's left hand. Resident 30 started to rub the left side of her head. LPN 4 appeared to assess the resident's head, looking closely at the left side.- At 8:31 P.M., staff assisted Resident 30 back to her room. Following review of the video footage on 01/06/2026, the DON indicated she went and looked at Resident 30's hand and there was a skin impairment present. The Weekly Skin Review records for Resident 30 indicated the resident's skin was intact on 12/31/2025 and on 01/02/2026. The resident's clinical record lacked documented progress notes from 12/23/2025 through 12/31/25. Resident 30's Progress Notes included, but were not limited to, the following:-On 01/01/2026 at 12:20 A.M., the resident was in a pleasant mood with no behaviors noted this shift. -On 01/02/2026 at 9:53 A.M., the resident had no behaviors noted so far that shift, she was sitting in diningroom talking with other residents. -On 01/02/2026 at 5:49 P.M., the resident was assisted to bed after meals, the resident had a noted bruise and scratches to her face (this was the first note identifying the resident's injuries to her face). There was no mention of the wound on the resident's finger that was being assessed and cleaned in the video. The resident's record, dated 01/03/2026, indicated the resident had a yellow/green bruise to her face and superficial scratches to her forehead. The records lacked documentation related to the resident's left hand. During an interview, on 01/04/2026 at 7:14 P.M., QMA 5 indicated he worked passing medications on night shift on the Dementia Unit on 12/29/2025. He did not know anything about any bruises or injuries with Resident 30 or any other residents. The current Change in a Resident's Condition or Status policy, with a revision date of February 2021, was provided by the DON on 01/06/2026 at 3:30 P.M. The policy indicated, .The nurse will notify the resident's attending physician .when there has been .discovery of an injury of unknown source . record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. 3.1-37(b)

Based on record review and interview, the facility failed to ensure a resident was free from a significant medication error when Resident C received Resident L's morning medications. The deficient practice resulted in the resident's hospitalization, administrations of two doses of Narcan, monitoring of vitals, and laboratory values for 1 of 3 residents reviewed for medication errors. (Resident C) Findings include:The resident's clinical record was reviewed on 11/20/2025 at 10:13 A.M. A Quarterly Minimum Data Set assessment, dated 08/27/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, acute and chronic respiratory failure with hypoxia, diabetes, COPD (Chronic Obstructive Pulmonary Disease) and schizophrenia. The plan of care for Resident C, dated 08/19/2025 , indicated the resident had an altered respiratory status and difficulty breathing related to COPD. The interventions included, but were not limited to, administer medication/puffers as ordered. The plan of care for Resident C, dated 08/20/2025, indicated the resident used anti-convulsant medications related to neuralgia. The interventions included, but were not limited to, administer medications as ordered. The plan of care for Resident C, dated 08/20/2025, indicated the resident had dehydration or a potential fluid deficit. The interventions included, but were not limited to, administer medications as ordered. A Progress Note, dated 11/01/2025 at 8:00 A.M., indicated the resident had a medication administration error with new orders to send the resident to the emergency room (ER) for full evaluation. The resident was alert and oriented per his usual self. A Facility Triage Note, dated 11/01/2025, by NP 3 indicated Resident C inadvertently received Resident L's 9:00 A.M. medications. A Progress Note, dated 11/03/2025 at 4:05 P.M., indicated the resident had returned from the hospital. Resident C's record was reviewed on 11/20/2025 at 10:13 A.M., the physician recapitulation for Resident C's prescribed 9:00 A.M. medications indicated the resident was ordered the following medications: Dutasteride 0.5 mg, Ferrous Sulfate 325 mg, Fluoxetine 10 mg, Miralax 17 grams, pravastatin 20 mg, tamsulosin 0.4 mg (2) Benztropine Mesylate 1mg, Eliquis 5 mg, Famotidine 20 mg, Fluphenazine 10 mg, and Gabapentin 300 mg. Resident C had received his prescribed dose of insulin on the morning of 11/01/2025. Resident L's record was reviewed on 11/20/2025 at 10:18 A.M., the physician recapitulation for Resident L's prescribed 9:00 A.M. medications indicated the resident was ordered the following medications: Glipizide 5mg, Norco 5/325 mg, Levetiracetam 500 mg, Lisinopril 20 mg, Metformin 1000 mg, Propranolol 20 mg, Tramadol 50 mg, Alfuzosin extended release 10 mg, Aspirin 81 mg, Celecoxib 200 mg, Zyrtec 10 mg, Celexa 40 mg, Cyclobenzaprine 10mg, and Famotidine 20 mg. The medications Resident C inadvertently received had the following potential side effects: - Glipizide: low blood sugar, shakiness, nervousness, sweating, dizziness, fast heartbeat, weight gain, gastrointestinal issues, such as nausea, diarrhea, gas, or constipation, dizziness, or headache. - Norco: respiratory depression, nausea, vomiting, constipation, drowsiness, sleepiness, dizziness, or lightheadedness. - Levetiracetam: drowsiness, dizziness, fatigue, or irritability. - Lisinopril: dry, persistent cough, dizziness or lightheadedness, headache, excessive tiredness or weakness, nausea and/or vomiting, diarrhea, runny or stuffy nose, or rash. - Metformin: lactic acidosis, diarrhea, and nausea. - Propranolol: dizziness, fatigue, nausea, diarrhea, and cold extremities. - Tramadol: respiratory depression, nausea, vomiting, constipation, drowsiness, dizziness, headache, dry mouth, sweating, and itching. - Alfuzosin: a sudden drop in blood pressure, chest pain, dizziness, headache, and tiredness. - Aspirin: stomach upset and heartburn. - Celecoxib: chest pain, shortness of breath, and stomach bleeding and or ulcers. - Zyrtec: drowsiness, headache, and dry mouth. - Celexa: Suicidal thoughts or behaviors, heart rhythm problems, nausea, dry mouth, drowsiness, insomnia, increased sweating, diarrhea, tremor, and dizziness. - Cyclobenzaprine: heart problems, central nervous system issues, drowsiness, dry mouth, and dizziness, and - Famotidine: headache, dizziness, constipation, and diarrhea. During an interview, on 11/20/2025 at 10:56 A.M., RN 2 indicated she mistakenly gave Resident C medications that belonged to Resident L. After Resident C took the medications, she went out of his room and back to the medication cart. She looked at the computer and realized she was looking at Resident L's Electronic Health Record (EHR). Both residents looked similar, had the same first name, and lived near each other in the same hall. She immediately notified the Director of Nursing (DON). She assessed the resident and checked his vital signs, while the Assistant Director of Nursing (ADON) notified the NP. The NP ordered the resident to be sent to the local hospital for evaluation. RN 2 indicated she would normally verify a resident's first and last name and date of birth before administering medications. A hospital Nurse Practitioner (NP) 4 note from the Intensive Care Unit, dated 11/02/2025 at 7:33 A.M., was provided by the DON on 11/20/2025 at 12:43 P.M. The record indicated the resident was from this long-term care facility, had received someone else's medications, oxycodone, Ultram (both opioid pain medications), that the resident did not normally take. The resident received IV (Intravenous) fluids and two doses of Narcan, a medication that reverses the effects of a narcotic, 0.4 milligrams (mg) through his IV. A Urinary Drug Screen (UDS) test confirmed the resident had opiates in his system. A follow-up visit Progress Note from facility NP 5, dated 11/04/2025, indicated the resident appeared stable with no changes in diagnoses or medications. The resident had no critical lab values prior to the medication error or on day one and day two in the hospital. During an interview, on 11/20/2025 at 10:02 A.M., the DON indicated she received a call on the morning of 11/01/2025 from the nurse that was on shift saying she accidentally gave a resident the wrong medications. The resident was assessed right away, the NP was notified, and the resident was sent to the local hospital where he was admitted for observation. The facility educated all nursing staff and implemented an audit tool to monitor medication administration. The current General Dose Preparation and Medication Administration policy, with a revision date of 01/01/2022, was provided by the DON on 11/20/2025 at 12:43 P.M. The policy indicated, .Facility staff should.Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident, as set forth in facility's medication schedule. The deficient practice was corrected on 11/02/2025, after the facility implemented a systemic plan of staff education, medication administration audits, and monitoring to ensure implementation of the in-servicing was monitored related to medication administration. This citation relates to Intake 2661017. 3.1-48(c)(2)

Based on interview and record review, the facility failed to ensure a resident with urinary incontinence received services to maintain continence in a timely manner for 1 of 5 residents reviewed for urinary incontinence. (Resident B) Findings include: An Admission Minimum Data Set (MDS) assessment, dated 11/15/24, indicated Resident B was cognitively intact. The resident's diagnoses included, but were not limited to, malnutrition, arthritis, and retention of urine. The resident was incontinent of bowel and bladder. Hospital Discharge Instructions, dated 11/11/24, indicated Resident B had an ongoing problem with urinary retention. The resident had a scheduled appointment with Urology for 12/04/24 at 2:00 P.M., as well as an ultrasound scheduled, of her abdomen, on 12/04/24 at 1:00 P.M. During an interview, on 02/19/2025 at 10:35 A.M., the Director of Nursing (DON) indicated that Resident B's appointments for 12/04/24 had all been rescheduled locally to accommodate family attending, and that she would provide appointment confirmations for appointments being rescheduled. A Provider Progress Note, dated 12/05/24, indicated that on discharge from the hospital Resident B was supposed to have a urology appointment, an upcoming abdominal ultrasound, cardiology appointment, and optometry appointment. The only one visualized as scheduled was a cardiology appointment for that day. The concern was brought to the DON's attention. An Appointment Detail Document, provided by the DON on 02/19/25 at 11:20 A.M., indicated that a new patient urology appointment for Resident B was scheduled on 12/05/24 at 3:25 P.M. The appointment was scheduled for 01/07/25 at 1:30 P.M. The clinical record lacked information regarding the urology appointment on 01/07/25 prior to 02/19/25. During an interview, on 02/19/25 at 11:20 A.M. , the DON indicated that due to weather conditions on 01/07/25 the urology office closed for the day resulting in cancellation of the resident's appointment. An Appointment Detail Document, provided by the DON on 02/19/25 at 1:09 P.M., indicated that a urology appointment was rescheduled that day for 04/09/25 at 9:10 A.M. During an interview, on 02/19/25 at 1:35 P.M., the DON indicated that the facility scheduler had received a call from the urologist office today to reschedule the appointment for Resident B. When asked if there was proof of additional contact being made prior to today in the progress notes the DON was unsure. Progress notes for the past 90 days for Resident B were provided by the DON on 02/19/25 at 2:50 P.M. No progress notes were made prior to 02/19/25 about contact made with the urology office. During an interview with the Urology Office, on 02/19/25 at 1:36 P.M., they indicated that a new urology appointment for Resident B was scheduled today, and that the only other appointment they had scheduled prior to today was the 01/07/25 appointment. During an interview on 02/19/25 at 2:30 P.M., LPN 2 indicated that the facility would ensure residents made it to scheduled appointments, and if an appointment was canceled due to weather it should be rescheduled. The current facility policy, titled Physician Orders, with a revised date of 03/17/22, was provided by the DON on 02/19/25 at 3:02 P.M. The policy indicated, .The facility is obligated to follow and carry out orders of the prescriber in accordance with all applicable state and federal guidelines . The current facility policy, titled Urinary Tract Infections/Bacteriuria - Clinical Protocol, with a revised date of April 2018, was provided by the DON on 02/19/25 at 2:50 P.M. The policy indicated, .The physician and staff will identify individuals with a history of .risk factors (for example, an indwelling urinary catheter, kidney stones, urinary out-flow obstruction, ect.) .The Physician will help identify causes of, and factors contributing to . bladder outlet obstruction, .and medications that can cause urinary retention .1. The physician will order appropriate treatment . based on a pertinent assessment . This citation relates to Complaint IN00451861. 3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to prepare and store foods in a sanitary manner for 2 of 2 kitchen observations and failed to maintain resident snack refrigerators in a sanitary manner related to the storage of non-food items and outdate foods for 3 of 3 snack refrigerators observed. This deficient practice had the potential to affect on 82 of 82 residents who receive food from the kitchen or snack refrigerators. Findings include: 1. During the initial kitchen tour on 11/06/24 at 11:14 A.M., with the Dietary Manager (DM), the following was observed: - The dry storage room floor was littered with pieces of dry cereal, a package of crackers; a line of white powder, one and a half inches wide by two feet long running along the wall behind a wire rack of shelves; bits of white paper and straw; a large plastic bag, open to air, of white powder was sitting inside of an open cardboard box; and there was a large silver scoop laying in the bag on top of the powder. The DM indicated the white powder was food thickener and a scoop should not have been left in the bag with the thickener. - Two silver bowls, inverted and covering plates in the plate warmer had a brown/yellow sticky residue in the edges of the bowls, - Two black wheeled carts, with three shelves, were sticky and littered with crumbs. One cart held trays of the lunchtime dessert, and one cart held stacks of clean trays to be used for the meal service, - The lower shelves of three food preparation tables were littered with crumbs and crumbs along the floor under them, - The metal shelf unit holding the juice machine had several black, six inch by two inch, mechanical apparatuses attached to the back of the cart that were covered in gray dust as were the wires on the rack, and - Two black chunks of debris, one inch by two inches in length, were noted by the wall under food prep table near the door to the main dining room. The cleaning schedule for the week was posted on the wall in the kitchen and was provided by the DM on 11/06/24 at 11:41 A.M. The DM indicated staff would initial the area on the cleaning schedule after they had completed the tasks on their shift. The DM opened a drawer in her office that contained several older cleaning schedules, none of which were dated to indicate what week they applied to. The cleaning schedule for the week of 11/03/24 though 11/09/24 indicated no cleaning had been completed since day shift on Monday, 11/04/24. Cleaning tasks to be completed by the morning and evening shift staff members were listed for each day of the week. 2. During the second tour of the kitchen on 11/12/24 at 11:05 A.M., the following was observed: - The metal shelf unit holding the juice machine had several black, six inch by two inch, mechanical apparatuses attached to the back of the cart that were covered in gray dust as were the wires on the rack, - One black wheeled cart with three shelves had sticky spots and was littered with crumbs. The top two shelves of the cart held stacks of clean trays to be used for residents' meal service, - Two silver bowls, inverted to cover the top of stacks of plates in the plate warmer, had a brown/yellow residue in the edges of the bowls, and - A small shelf under the steam table contained stacks of small bowl sized plastic lids sitting with four loose paper clips. A nearby cup held several paperclips. 3. Residents' snack refrigerators were observed on 11/13/24 at 11:32 A.M., with the Assistant Director of Nursing (ADON), and contained the following: - The C-Street refrigerator contained a soft sided dark colored cold pack in the freezer that had no resident identifying marks. The pack was approximately 12 inches by 12 inches in size. The ADON indicated it had been in there for at least as long as she could remember, but did not know who or what it was for. The soft covered ice pack was labeled Cold Therapy, and - The resident snack refrigerator used for A and B Streets contained a plastic bag of small cups of ice cream in the freezer that were leaning against a large soft covered ice pack, labeled Cold Therapy. The pack was approximately 12 inches by 12 inches in size. 4. The resident snack refrigerator for D-Street was observed on 11/13/24 at 11:42 A.M., with Licensed Practical Nurse (LPN) 6, and contained the following: - A gray plastic grocery bag, labeled [NAME] C., that contained a bowl of coleslaw with a lid, dated 08/02/24, a small paper sack containing onion rings and a dirty spoon, and a sandwich box with 1/2 of a sandwich. LPN 6 indicated residents' items should be dated when put in the refrigerator and disposed of after 48 hours. During an interview on 11/13/24 at 11:50 A.M., the ADON indicated she did not know what the facility policy was related to having cold therapy ice packs in the residents' snack refrigerators. During an interview on 11/13/24 at 2:09 P.M., the Therapy Manager indicated they stored ice packs for residents in their therapy gym. The Nursing Manager had the code to enter the Therapy Gym should they need to. The therapy staff did not place resident ice packs in the resident snack refrigerators. The ice packs were soft sided and blue in color. During an interview on 11/13/24 at 2:21 PM., the ADON indicated all of the residents in the building received food from the facility kitchen. The undated Cleaning Schedule policy was provided by the Administrator on 11/13/24 at 1:46 P.M. The record indicated, .All small equipment .appliances .counters .dishes .Delivery carts . were to be cleaned after each use. The current Unit Kitchenettes and Pantries policy, with a reviewed date of 07/2023, was provided by the Administrator on 11/13/24 at 1:46 P.M. The policy indicated, .The food service manager will .remove outdated items . The current Foods Brought by Family/Visitors policy, with a revised date of October 2017, was provided following the Entrance Conference. The policy indicated, .Food brought .that is left with the resident to consume later will be labeled and stored in a manner that is clearly distinguishable from facility-prepared food .Perishable foods must be stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers will be labeled with the resident's name, the item and the use by date .The nursing and/or food service staff will discard any foods .that show obvious signs of potential food borne danger .for example .mold .past due package expiration dates . The current Cleaning and Sanitation of Food Service Areas policy, with a reviewed date of 07/2023, was provided by the Administrator on 11/13/24 at 1:46 P.M. The policy indicated, .The food service staff will maintain the sanitation of the .food service areas through compliance with a writen [sic], comprehensive cleaning schedule .A cleaning schedule will be posted for all cleaning tasks .Staff will be held accountable for cleaning assignments . 3.1-21(i)(3)

Based on observation and interview, the facility failed to appropriately store medications for 3 of 4 medication carts reviewed. (C Street Medication Cart 1, C Street Medication Cart 2, and B Street Medication Cart 1) Findings include: 1. On 11/12/24 at 9:59 A.M., C Street Medication Cart 1 was observed with RN 4 and contained the following: - A small round yellow pill and a small oblong pale green pill were lying loose in the bottom of the second drawer, and - A small round white pill was lying loose in the bottom of the third drawer. 2. On 11/12/24 at 10:03 A.M., C Street Medication Cart 2 was observed with RN 4 and contained the following: - One small round white pill and one half of a small round white pill were lying loose in the bottom of the second drawer. 3. On 11/12/24 at 10:11 A.M., Unit Manager 7 was observed removing a small round pink pill and a small round white pill from the bottom of the second drawer of the B Street Medication Cart 1. The pills were loose and not in a secured medication sheet. During an interview on 11/12/24 at 10:26 A.M., the Director of Nursing (DON) indicated loose pills should not be lying in the bottom of the medication carts. She was unaware of which residents the loose medications would have belong too. The current undated facility policy, titled MEDICATION STORAGE IN THE FACILITY, was provided by the DON on 11/13/24 at 10:23 A.M. The policy indicated, .Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier . 3.1-25(o)

Based on record review and interview, the facility failed to obtain physician ordered vital signs prior to medication administration for 1 of 21 residents reviewed for Quality of Care. (Resident 1) Findings include: The clinical record for Resident 1 was reviewed on 11/07/24 at 1:33 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 10/24/24, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, hypertension, diabetes, and dementia. The Electronic Medication Administration Records (EMAR) for September and October 2024, were provided by the DON on 11/13/24 at 12:54 P.M., and included, but were not limited to, the following: The September EMAR indicated the resident received the following medications: - Lisinopril, for hypertension, 20 milligrams (mg) one time a day. Staff were to hold (not give) the medication if the resident's systolic blood pressure (the top number) was less than 100 or if their heart rate was less than 60 beats per minute. The medication had a start date of 11/14/23. The record had places to document the resident's blood pressure (BP) and heart rate at 9:00 A.M., when the medication was due to be administered. The EMAR documents were left blank from September 3 through September 30, 2024. - Propranolol, for hypertension, 10 mg two times a day, at 7:00 A.M. and 7:00 P.M. Staff were to hold the medication if the resident's systolic blood pressure was less than 100 or if their heart rate was less than 60 beats per minute. The medication had a start date of 01/17/22. The record had places to document the resident's BP and heart rate, two times a day, that were left blank for the entire month of September 2024. The Vitals records for September 2024, were provided by the DON on 11/13/24 at 12:54 P.M., and indicated the resident's blood pressure and heart rate were documented on the following dates and times: - 09/01/24 at 7:10 A.M., - 09/01/24 at 8:28 P.M., - 09/02/24 at 7:17 A.M., - 09/03/24 at 12:20 A.M., - 09/03/24 at 6:45 A.M., - 09/04/24 at 11:46 P.M., - 09/05/24 at 11:03 P.M., - 09/10/24 at 7:31 A.M., - 09/14/24 at 8:13 P.M., - 09/19/24 at 11:42 P.M., and - 09/24/24 at 11:06 P.M. The Progress Notes for September and October 2024, were provided by the DON on 11/13/24 at 12:54 P.M. A Progress Note, dated 09/10/24 at 8:30 A.M., indicated the resident's medications, Propranolol and Lisinopril, had been held due to the resident's heart rate of 56, which was below the prescribed limit. The record lacked documentation of any refusals by the resident, or any other vital signs related to the prescribed times the medications were due to be administered. The Interdisciplinary Notes indicated the resident had falls on 09/03/24 and 09/24/24. No other falls were documented in the Progress Notes. Neurological Evaluation Flow Records for the falls on 09/03/24 and 09/24/24 were provided by the DON on 11/13/24 at 10:22 A.M. The records indicated the resident's blood pressure and heart rate were documented on the following dates and times that were within the two hour time frame the medications were to be administered: - 09/03/24 at 7:05 A.M., - 09/04/24 at 7:05 A.M., - 09/05/24 at 7:05 A.M., - 09/06/24 at 7:05 A.M., - 09/24/24 at 7:15 P.M., and from 09/25/24 through 09/29/24, the vital signs were documented twice a day, in the morning, AM, and in the evening, PM, with no specific times listed. The resident's clinical record lacked any vitial signs of BP or heart rate related to the administration of Lisinopril and Propranolol for the following dates: September 6, 7, 8, 9, 11, 12. 13, 20, 21, 22, 23 and 30, 2024. The October EMAR indicated the resident received the following medications: - Lisinopril, for hypertension, 20 mg one time a day. Staff were to hold the medication if the resident's systolic blood pressure was less than 100 or if their heart rate was less than 60 beats per minute. The medication had a start date of 11/14/23. The record had places to document the blood pressure and heart rate that were left blank from October 1, through October 25, 2024. - Propranolol, for hypertension, 10 mg two times a day, at 9:00 A.M., and 8:00 P.M. Staff were to hold the medication if the resident's systolic blood pressure was less than 100 or if their heart rate was less than 60 beats per minute. The medication had a start date of 01/17/22. The record had places to document the blood pressure and heart rate, twice a day, that were left blank from October 1, 2024, through the 9:00 A.M. dose on October 25, 2024. The Vitals records for October 2024, were provided by the DON on 11/13/24 at 12:54 P.M. The resident's blood pressure and heart rate were documented on the following dates and times: - 10/02/24 at 2:44 P.M., - 10/25/24 at 8:20 P.M., and from 10/26/24 through 10/31/24, the vital signs were documented twice a day, once in the morning, and once in the evening. The resident's clinical record lacked any vitial signs of BP or heart rate related to the administration of Lisinopril and Propranolol for the following dates: October 1 and October 3 through 24, 2024. During an interview on 11/08/24 at 9:47 A.M., RN 4 indicated the facility no longer used hard (paper) charts. During an interview on 11/12/24 at 3:29 P.M., RN 4 indicated there was a place on the EMAR for vital signs to be recorded if a medication required a parameter. Staff were to obtain the vital sign prior to the administration of the medication. There was a notation staff could put on the EMAR as to why the medication was held. Staff had to notify the physician if the medication was held. The current Administering Medications policy, with a revised date of December 2012, was provided by the DON on 11/13/24 at 10:45 A.M. The policy indicated, .Medications shall be administered in a safe and timely manner, and as prescribed .The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication .information must be checked/verified for each resident prior to administering medications .Vital signs, if necessary .As required or indicated for a medication, the individual administering the medication will record in the resident's medical record . 3.1-37(a)

Based on observation, interview, and record review, the facility failed to follow appropriate infection control guidelines related to indwelling urinary catheters for a resident who had a Urinary Tract Infection for 1 of 2 residents reviewed for urinary catheters. (Resident 7) Findings include: During an observation on 11/07/24 at 1:39 P.M., Resident 7 was in their wheelchair in the main dining room. Five to six inches of their indwelling urinary catheter tubing was laying on the floor under their wheelchair. During an observation on 11/08/24 at 11:57 A.M., Resident 7 was in their wheelchair in the main dining room eating lunch, five to six inches of their indwelling urinary catheter tubing was laying on the floor under their wheelchair. During an observation on 11/08/24 at 2:56 P.M., Resident 7 was in their wheelchair in the main dining room propelling herself, five to six inches of their indwelling urinary catheter tubing was dragging on the floor under their wheelchair. During an observation and interview on 11/08/24 at 2:58 P.M., the Director of Nursing (DON) indicated the indwelling urinary catheter tubing should not be touching the floor. During an interview on 11/08/24 at 3:30 P.M., Certified Nurse Aide (CNA) 2 indicated the urinary catheter bag and tubing should not be touch the floor. The clinical record was reviewed on 11/08/24 at 3:00 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 10/21/24, indicated the resident was cognitively intact. The residents diagnoses included, but were not limited to, hypertension, renal insufficiency, obstructive uropathy (a condition where the flow of urine is blocked), and diabetes. The resident had an indwelling urinary catheter. The November 2024 Electronic Medication Administration Record (EMAR) indicated the resident was to receive Bactrim (an antibiotic) 800-160 milligrams (mg) 1 tablet every morning for a Urinary Tract Infection (UTI) for 7 days, with a start date of 11/09/24, and Bactrim 400-80 mg 1 tablet every evening for a UTI for 7 days, with a start date of 11/08/24. The current Catheter Care, Urinary policy, with a revised date of December 2007, was provided by Administrator on 11/13/24 at 10:48 A.M. The policy indicated, .To prevent infection of the resident's urinary tract .Be sure the catheter tubing and drainage bag are kept off the floor . 3.1-41(a)(2)

Based on record review and interview, the facility failed to follow the physician's orders related to hold parameters for a medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 72) Findings include: The clinical record for Resident 72 was reviewed on 11/07/24 at 1:28 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 09/18/24, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, Parkinson's disease and ventricular fibrillation (irregular contraction of the heart muscle). The Electronic Medication Administration Records (EMAR) for October and November 2024, were provided by the Director of Nursing (DON) on 11/13/24 at 10:45 A.M. The records indicated the resident had the following current physician's order: - Metoprolol 25 milligrams (mg), give 12.5 mg by mouth, two times a day related to ventricular fibrillation. The medication was to be held (not given) if the resident's heart rate was less than 60 beats per minute. The start date for the medication was 10/04/24. The record indicated the medication had been administered outside of the ordered parameters, when the resident's heart rate was less than 60 beats per minute, on the following dates and times: - 10/06/24, at 9:00 A.M., the heart rate was 42, - 10/06/24, at 9:00 P.M., the heart rate was 56, - 10/11/24, at 9:00 A.M., the heart rate was 49, - 10/14/24, at 9:00 A.M., the heart rate was 52, - 10/19/24, at 9:00 A.M., the heart rate was 48, - 11/02/24, at 9:00 A.M., the heart rate was 46, - 11/02/24, at 9:00 P.M., the heart rate was 57, - 11/03/24, at 9:00 A.M., the heart rate was 58, and - 11/07/24, at 9:00 P.M., the heart rate was 51. During an interview on 11/08/24 at 9:47 A.M., RN 4 indicated the facility no longer used hard (paper) charts. During an interview on 11/12/24 at 3:29 P.M., RN 4 indicated there was a place on the EMAR for vital signs to be recorded if a medication required a parameter. Staff were to obtain the vital sign prior to the administration of the medication. There was a notation staff could put on the EMAR as to why the medication was held. Staff had to notify the physician if the medication was held. The current Administering Medications policy, with a revised date of December 2012, was provided by the DON on 11/13/24 at 10:45 A.M. The policy indicated, .Medications shall be administered in a safe and timely manner, and as prescribed .The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication .information must be checked/verified for each resident prior to administering medications .Vital signs, if necessary . 3.1-48(a)(6)

Based on record review and interview, the facility failed to ensure the accuracy of Minimum Data Set assessments for 3 of 21 residents reviewed. (Residents 8, 91, and 27) Findings include: 1. The clinical record for Resident 8 was reviewed on 11/13/24 at 1:15 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 10/14/24, indicated the resident was cognitively intact. The Swallowing/Nutritional Status section of the assessment indicated the resident received parenteral/intravenous feeding and had a feeding tube while he was a resident in the facility during the assessment review period. The resident's physician's orders for October 2024 lacked an order for tube feeding. During an interview on 11/08/24 at 9:45 A.M., the resident indicated he had never had a feeding tube. During an interview on 11/13/24 at 1:36 P.M., the MDS Coordinator indicated the resident didn't have a feeding tube. The Quarterly MDS assessment was incorrect. 2. The clinical record for Resident 91 was reviewed on 11/08/24 at 1:30 P.M. A Discharge MDS assessment, dated 10/04/24, indicated the resident was moderately cognitively impaired. The Identification section of the assessment indicated the resident discharged from the facility on 10/04/24. The discharge was planned, and the resident went to a short-term general hospital. During an interview on 11/08/24 at 10:56 A.M., the Therapy Manager indicated the resident went to another Long Term Care (LTC) facility. A Nursing Note, dated 10/4/2024 at 12:00 P.M., indicated the resident was discharging to another facility and was transported by the facility bus. During an interview on 11/13/24 at 1:51 P.M., the MDS Coordinator indicated the resident did not go to the hospital he went to another LTC facility. The assessment should have accurately reflected the resident's discharge destination. 33613 3. The clinical record for Resident 27 was reviewed on 11/13/24 at 2:02 P.M. A Quarterly MDS assessment, dated 08/22/24, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, diabetes, hypertension, dementia, and chronic obstructive pulmonary disease. Section O special treatments, procedures, and programs indicated the resident was receiving Hospice care while he was a resident in the facility during the assessment review period. The August 2024 physician orders, provided by the Director of Nursing (DON) on 11/14/24 at 2:15 P.M., lack documentation that the resident received Hospice care. During an interview on 11/13/24 at 1:36 P.M., the MDS Coordinator indicated the resident didn't receive Hospice care. The Quarterly MDS assessment was incorrect and she referred to the RAI manual for completing MDS assessments. 3.1-31(c)(5) 3.1-31(c)(6) 3.1-31(c)(8)

Based on record review and interview, the facility failed to administer routine insulin in a timely manner for 1 of 3 residents reviewed for pharmacy services. (Resident B) Findings include: The clinical record for Resident B was reviewed on 06/04/24 at 5:32 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 05/07/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, end stage renal disease, heart failure, hypertension, and diabetes. The resident was administered insulin during the review period. An open-ended physician's order indicated the resident was to be administered Tresiba (an insulin medication) 30 units at 9:00 P.M., every night for diabetes. The March, April, and May 2024 EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) indicated the resident had received the insulin two times in 24 hours on the following dates and times: - 03/12/24 at 2:44 A.M. and 8:11 P.M., - 03/25/24 at 2:14 A.M. and 8:39 P.M., - 05/28/24 at 1:04 A.M. and 8:20 P.M., - 04/15/24 at 12:49 A.M. and 9:17 P.M., - 04/27/24 at 12:50 A.M., and 9:23 P.M., - 05/05/24 at 1:14 A.M. and 9:01 P.M., - 05/08/24 at 12:23 A.M., and 9:12 P.M., and - 05/12/24 at 2:27 A.M., and 9:27 P.M. During an interview on 06/05/24 at 2:13 P.M. LPN (Licensed Practical Nurse) 2 indicated if a resident had a routine dose of insulin that was due at the same time every day or night then the nurse had a two hour window to give the medication, it should be given either and hour before or and hour after the scheduled administered dose time. It should never be administered after the one hour. During an interview on 06/05/24 at 4:25 P.M., Resident B indicated there were many nights they had to be woken up to get their insulin. The nurse would not bring it in until midnight or later, which was after the scheduled time it was to be given. The current facility policy titled, Insulin Administration was provided by the Administrator on 06/05/24 at 3:23 P.M. The policy indicated .To provide guidelines for the safe administration of insulin to residents with diabetes . The current facility policy titled, Administering Medications was provided by the Administrator on 06/05/24 at 3:23 P.M. The policy indicated, .Medications shall be administered in a safe and timely manner, and as prescribed .Medications must be administered within (1) hour of their prescribed time, unless otherwise specified . This citation relates to complaints IN00433817 and IN00435973. 3.1-37(a) 3.1-48(a)

Based on observation, interview, and record review, the facility failed to follow a physician's order related to weight monitoring for 2 of 21 residents reviewed for hydration status. (Residents 29 and 71) Findings include: 1. During an observation on 09/25/23 at 10:39 A.M., Resident 29 was sitting in the dining room with staff. The clinical record for Resident 29 was reviewed on 09/25/23 at 9:45 A.M. A Quarterly MDS (Minimum Data Set) assessment, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, anemia, heart failure, hypertension, and depression. An open-ended physician's order, with a start date of 07/01/23, indicated the resident was to have daily weights, once a day for health monitoring. The MD was to be notified of a 4 pound or greater weight gain. The July, August, and September 2023 EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) indicated the resident lacked a documented weight or had a weight gain of 4 or more pounds on the following dates with no indication the physician was notified: - On 07/05/23 the resident weighed 204.8 pounds and on 07/06/23 the resident weighed was 210.8 pounds, a 6-pound weight gain, - On 07/07/23, no weight was documented, - On 07/17/23, no weight was documented, - On 07/19/23, no weight was documented, - On 07/20/23, no weight was documented, - On 08/10/23, the resident weighed 197.8 pounds and on 08/11/23 the resident weighed 206.6, an 8.8-pound weight gain, - On 08/17/23, the resident weighed 200.2 pounds and on 08/18/23 the resident weighed 205.2, a 5.2-pound weight gain, - On 09/07/23, the resident weighed 196.6 and on 09/08/23 the resident weighed 205.6, a 9-pound weight gain, - On 09/15/23, the resident weighed 196.2 and on 09/16/23 the resident weighed 205.6, a 9.4-pound weight gain. The clinical record lacked documentation that the physician was notified or that the weights were obtained for the above dates. 33613 2. During an observation on 09/21/23 at 10:52 A.M., Resident 71 was sitting in her room watching the television. There were no concerns. The clinical record for Resident 71 was reviewed on 09/22/23 at 2:46 P.M. A Quarterly MDS assessment, dated 08/16/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, heart failure, anemia, hypertension, and diabetes. A physician's order, with a start date of 06/13/23 and stop date of 08/04/23, indicated the resident was to be weighed daily. The MD was to be notified if the weight was up or down by 2 pounds in a day. The June, July, and August, 2023 EMAR/ETAR indicated the resident lacked a documented weight on the following dates. - On 06/17/23, no weight was documented, - On 06/20/23, no weight was documented, - On 06/24/23, no weight was documented, - On 06/25/23, no weight was documented, - On 06/30/23, no weight was documented, - On 07/15/23, no weight was documented, - On 07/24/23, no weight was documented. An open ended physician's order, with a start date of 09/12/23, indicated the resident was to be weighed daily at 5:30 A.M. for congestive heart failure. The MD was to be notified for a weight gain of 3 pounds in a day or 5 pounds in a week. - On 09/12/23 the resident weighed 116 pounds and on 09/16/23 the resident weighed 123.8 pounds, a weight gain of 7.8 pounds in 4 days. - On 09/22/23 the resident weighed 121.8 pounds and on 09/23/23 the resident weighed 127.2 pounds, a weight gain of 5.4 pounds in 1 day. The clinical record lacked documentation that the physician was notified of the weights for the above dates. The current facility policy titled, Heart Failure - Clinical Protocol with a revised date of July 2013, was provided by the Administrator on 09/25/23 at 4:58 P.M. The policy indicated .In addition the nurse will assess and document/report the following: a. Vital signs; .The physician will review and make recommendations for relevant aspects of the nursing care plan; for example, what symptoms to expect, how often and what (weights, renal function, digoxin level, etc.) to monitor, when to report findings to the physician, etc . 3.1-46(1)

Based on observation, interview, and record review, the facility failed to follow physician orders related to insulin administration, notification, and hold parameters for 1 of 21 residents reviewed for quality of care. (Resident 48) Findings include: 1.a. During an observation and interview on 09/20/23 at 9:58 A.M., Resident 48 was lying in her bed. She indicated she had problems with her blood glucose levels being high and low. A Quarterly MDS (Minimum Data Set) assessment, dated 08/12/23, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, diabetes, hypertension, renal insufficiency, anxiety, and depression. A physician's order with a start date of 04/10/23 and discontinue date of 09/13/23, indicated the resident was to receive Novolog (an insulin medication), 18 units before meals for diabetes, give after the meal was eaten and hold for blood glucose < (less than) 100. The provider MUST be notified if blood glucose is < 60 and/or >(greater) 450 and documented. A physician's order with a start date of 09/14/23 and discontinue date of 09/21/23, indicated the resident was to receive Novolog, 14 units before meals for diabetes, give after the meal was eaten and hold for blood glucose < 100. The provider MUST be notified if blood glucose is < 60 and/or > 450 and documented. The June, July, August, and September 2023 Insulin Administration Record from the EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) indicated the resident had received the insulin mediation when the blood sugar was less than 100 and staff were to notify the physician of the blood glucose being greater than 450 on the following dates and times: - On 06/1/23 at 4:30 P.M., the medication was administered when the blood glucose level was 56, - On 06/15/23 at 11:30 A.M., the blood glucose was 475 with no indication the physician was notified, - On 06/17/23 at 4:30 P.M., the medication was administered when the blood glucose level was 92, - On 6/19/23 at 11:30 A.M., the blood glucose was 487 with no indication the physician was notified, - On 07/06/23 at 4:30 P.M., the medication was administered when the blood glucose was 97, - On 07/10/23 at 11:30 A.M., the blood glucose was 520 with no indicated the physician was notified, - On 07/15/23 at 4:30 P.M., the blood glucose was 557 with no indication the physician was notified, - On 07/20/23 at 4:30 P.M., the medication was administered when the blood glucose level was 78, - On 07/28/23 at 11:30 A.M., the blood glucose was 586 with no indication the physician was notified, - On 08/10/23 at 7:30 A.M., the medication was administered when the blood glucose level was 93, - On 08/14/23 at 7:30 A.M., the blood glucose was 553 with no indication the physician was notified, - On 08/17/23 at 4:30 P.M., the medication was administered when the blood glucose level was 96, - On 08/18/23 at 11:30 A.M., the blood glucose was 520 with no indication the physician was notified, - On 08/24/23 at 11:30 A.M., the blood glucose was 499 with no indication the physician was notified, - On 09/03/23 at 7:30 A.M., the blood glucose was 490 with no indication the physician was notified, - On 09/09/23 at 7:30 A.M., the medication was administered when the blood glucose level was 97, - On 09/10/23 at 7:30 A.M., the medication was administered when the blood glucose level was 79, and - On 09/14/23 at 7:30 A.M., the medication was administered when the blood glucose level was 87. The clinical record lacked documentation that the medication was held or that the provider was notified of the above blood glucose levels. During an interview on 09/22/23 at 10:08 A.M., LPN (Licensed Practical Nurse) 3 indicated if a resident had hold parameters for a medication, then the medication would be documented as held in the EMAR and it should be documented in a progress note. If the order had call parameters, then she would call the provider if it was indicated, and it should be documented in a progress note that they were notified. During an interview on 09/25/23 at 2:05 P.M., RN 6 indicated a check mark on the EMAR would mean the medication was given. 1.b An EMAR Progress Note, dated 08/10/23 at 8:36 P.M., indicated the resident's MD orders related to their blood glucose parameters were that staff were to call the physician if above 450 or below 70. The blood sugar (glucose) was 33. A soda and sugar packet were provided, and the resident was alert. She was diaphoretic and shaky. The blood sugar was checked at 15-minute intervals. Yogurt, cheese, and Glucerna were provided, and the blood sugar was steadily rising. At 11:30 P.M., the blood sugar was 189. The provider was aware. A Triage Note, dated 08/10/23, indicated a message was dispatched from the nurse at the facility, calling to report that the resident's blood glucose level was low. New orders were sent to monitor the residents accucheck (blood glucose) every 2 hours X (times) 3, then every 4 hours until the resident was seen by the primary care provider, continue to monitor for change in condition, and place in the acute book for the primary care provider. The clinical record lacked any documented blood glucose levels from 08/10/23 at 11:30 P.M., until 08/11/23 at 5:08 A.M., when the blood glucose was 225. The record lacked documentation that the every 4 hour blood glucose checks were entered into the resident record and followed. The primary care provider had not seen the resident from 08/10/23 until 08/31/23. A Care Plan that indicated the resident had diabetes with a start date of 11/04/21, included but was not limited to the following interventions: - administer diabetes medications as ordered with a start date of 11/04/21, and - fasting serum blood sugar as ordered by the doctor with a start date of 11/04/21. During an interview on 09/25/23 at 3:40 P.M., the DON and Administrator indicated if the order was to recheck the blood sugar, then it should have been documented. The current Insulin Administration policy, with a revised date of September 2014 and was provided by the Administrator on 09/25/23 at 4:58 P.M., indicated .to provide guidelines for the safe administration of insulin to residents with diabetes .The type of insulin, dosage requirements, strength, and method, of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's order .The nurse shall notify the Director of Nursing Services and Attending Physician of any discrepancies .Documentation .The resident's blood glucose result, as ordered . The current facility policy titled, Administering Medications, with a revised date of December 2012, was provided by the Administrator on 09/22/23 at 1:45 P.M. The policy indicated, .Medications must be administered in accordance with the orders, including any required time frame . The current facility policy titled, Change in a Resident's Condition or Status with a revised date of 12/16/21, was provided by the Administrator on 09/22/23 at 1:45 P.M. The policy indicated, .Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) .The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): .need to alter the resident's medical treatment significantly . 3.1-37(a)

Based on record review and interview, the facility failed to ensure resident specific interventions to provide trauma informed care were in place for 1 of 1 resident with a diagnosis of Post Traumatic Stress Disorder. (Resident 11) Findings include: Resident 11's clinical record was reviewed on 09/22/23 at 3:46 P.M., and indicated the following: - A Quarterly MDS (Minimum Data Set) assessment, dated 03/18/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, Alzheimer's dementia, anxiety, depression, and PTSD (Post Traumatic Stress Disorder). - A Quarterly MDS assessment, dated 03/24/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, Alzheimer's dementia, anxiety, depression, and PTSD. - An Annual MDS assessment, dated 06/23/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, Alzheimer's dementia, anxiety, depression, and PTSD. - A Quarterly MDS assessment, dated 06/30/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, Alzheimer's dementia, anxiety, depression, and PTSD. - A Quarterly MDS assessment, dated 07/17/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, Alzheimer's dementia, anxiety, depression, and PTSD. A Psychiatry Progress Note, dated 08/29/22, indicated the resident was being seen to assess and manage her chronic psychiatric diagnoses. The resident had a psychiatric history of anxiety, major depressive disorder, PTSD, Alzheimer's disease, and personality behaviors. The Assessment and Plan indicated the resident's PTSD was stable, and staff were to offer supportive measures. During an interview on 09/22/23 at 2:14 P.M., the Social Services Director indicated the resident did have a diagnosis of PTSD. The diagnosis was part of the resident's clinical record when she arrived at this facility. The resident had not really exhibited any signs of distress since admission to the facility. If a resident had a diagnosis of PTSD, she would investigate to try and determine what caused the PTSD and would create a care plan with resident specific interventions to try and minimize triggers and re-traumatization. She did not know what the resident's PTSD was related to. The resident had a Care Plan that listed PTSD as a diagnosis, but there were no specific interventions related to the PTSD. The resident's Care Plans were reviewed and included a Care Plan, initiated on 07/04/22 and revised on 06/02/23, that indicated the resident was at risk for an alteration in mood state related to depression, personality disorder, and PTSD along with anxiety. The Care Plan listed the following interventions: - Administer medications as ordered. Observe for and document side effects and effectiveness. - Allow the resident time to talk and encourage the expression of feelings. - Arrange for the resident's clergy or spiritual leader of choice to visit as requested. - Discuss with the resident/family/caregivers any concerns, fears, and issues regarding health. - Psychiatric consult as needed. - The resident needs adequate rest periods. - The resident needs to be reminded/escorted/encouraged to attend activities. The Care Plan lacked resident specific interventions related to their PTSD diagnosis. The current facility policy, titled Behavior Assessment, Intervention, and Monitoring, with a most recent revision date of September 2022, was provided by the Administrator on 09/25/23 at 4:42 P.M. The policy indicated, .Behavior symptoms will be identified using facility-approved behavioral screening tools and the comprehensive assessment .Interventions will be individualized and part of an overall care environment that supports physical, functional and psychological needs . 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure a resident who provided self care with an indwelling urinary catheter was educated on catheter care and infection control guidelines related to transmission based precautions for a urinary tract infection that required transmission base precautions for 1 of 4 residents reviewed for urinary tract infections. (Resident 77) Findings include: During an interview in his room on 09/19/23 at 1:39 P.M., Resident 77 indicated he had an indwelling urinary catheter. He had had several UTIs (urinary tract infections) and was currently being treated for a UTI with two different types of bacteria. Staff did not clean his catheter insertion site. He received a shower twice a week and it got cleaned at that time. He did not clean his urinary catheter insertion site himself. There were times that staff would empty his catheter drainage bag and the other times he would empty the bag himself and tell the staff how much urine there was. During the interview, the resident picked up his catheter drainage bag that was hanging on his walker with his bare hand, attempted to hang it on his bed frame, and then hung it back on his walker. The resident's urine was amber colored and there was no sediment observed. The resident did not perform hand hygiene before or after touching his catheter bag. There was no indication the resident was in TBP (transmission based precautions). The resident was observed in the therapy room on 09/21/23 at 9:45 A.M. The resident's catheter drainage bag was hanging on his walker. The resident's room was observed. There was no indication the resident was in TBP. The resident was observed in the therapy room on 09/22/23 at 9:23 A.M. The resident's room was observed. There was no indication the resident was in TBP. The resident's clinical record was reviewed on 09/22/23 3:35 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 07/11/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, renal failure, obstructive uropathy, diabetes, and depression. The resident had a UTI in the last 30 days. The resident had an indwelling urinary catheter and was continent of bowel. The resident required the limited assistance of 1 staff member for toileting and personal hygiene. During an interview on 09/25/23 at 10:40 A.M., CNA (Certified Nurse Aide) 5 indicated she routinely worked on the hall and was familiar with Resident 77. The staff did not provide peri-care or clean the resident's catheter insertion site for the resident. He emptied his catheter drainage bag by himself and would let them know his output. He did a lot of his bathroom stuff by himself. They might provide set up for care at times, meaning they might give him gloves and wipes, but he did it himself. The aides did routinely provide catheter care for the residents, but not for this resident. During an interview on 09/25/23 at 10:55 A.M., the DON (Director of Nursing) indicated the resident had the urinary catheter on admission, but he was fairly new to having one. He had to be educated on not pulling on the catheter and keeping the catheter off of the floor. If a resident was going to provide their own catheter care, they would be educated on the care needed and they should be able to provide a return demonstration of their ability to care for their own catheter. The education and return demonstration should be documented in the resident's record. Staff should still periodically check to make sure the resident was doing it correctly. A Nursing Note, dated 09/14/23 at 2:12 A.M., indicated the resident called staff and indicated he was burning in his catheter area. A new order was entered to obtain a urine sample. An Infection Note, dated 09/17/23 at 1:30 A.M., indicated the UA (urinalysis) results were received and staff were awaiting the culture and sensitivity results. A Lab Results Report, dated 09/17/23 at 2:31 P.M., indicated the resident had greater than 100,000 cfu/ml (colony forming unit per milliliter) of Pseudomonas Aeruginosa and greater than 100,000 cfu/ml of Methicillin Resistant Staphylococcus Aureus. The report indicated .***STAPH AUREUS IS MRSA*** . The report listed the appropriate antibiotics for the types of bacteria to treat the infection. During an interview on 09/25/23 at 2:51 P.M., the DON indicated the resident had two different types of bacteria in his urine, including MRSA. The resident should have been placed in contact isolation TBP and was not. Staff should have been wearing a gown, gloves, and a face shield when they were handling the resident's urine. The facility could provide no documentation of education provided to the resident related to urinary catheter care. The resident's complete Care Plan was provided by the Administrator on 09/25/23 at 3:00 P.M. and included a care plan that indicated the resident had an ADL Self Care Performance Deficit, that was initiated on 06/22/23. Interventions included, but were not limited to, an intervention that was initiated on 06/19/23, that indicated the resident required one staff member's participation to use the toilet. The current facility policy, titled INFECTION CONTROL, Prevention, Control, and Antibiotic Stewardship was provided by the Administrator on 09/19/23 at 1:00 P.M. The policy indicated, .The purpose .is to provide a safe, sanitary, and comfortable environment, to help prevent the development and transmission of communicable diseases and infections .A Resident newly diagnosed with MDRO [Multi Drug Resistant Organism] infection is evaluated for appropriate precautions and room placement . 3.1-18(b)(2) 3.1-41(a)(2)

Based on observation, record review, and interview, the facility failed to ensure appropriate fall interventions were implemented for 1 of 4 residents reviewed for falls. (Resident C) Findings include: On 09/21/23 at 11:03 A.M., Resident C was observed at a table during the bingo activity in the common area on the locked unit. The resident was in a wheelchair and was wearing a sling on her left arm. An Incident Note, dated 09/04/23 at 1:13 P.M., indicated a staff member was assisting the resident with getting dressed. The staff member bent down to pull up the resident's pants and the resident began to fall forward. The staff member stood and grabbed the resident, attempting to prevent a fall. The resident did fall, and landed head first on the floor on their left side. During the fall assessment, the resident was increasingly lethargic with decreased movement and her pupil size appeared to be decreasing. Neurological assessments were initiated, and abnormalities were noted. Pressure was held to the laceration on the resident's head. 911 was contacted and the resident was sent out to the local hospital for evaluation. Hospital documentation, dated 09/04/23 at 11:23 A.M., indicated the resident presented to the facility after a fall. Facility staff were changing the resident's clothes when she fell out of bed and hit the left side of her head and left shoulder. The resident was holding her shoulder and appeared to be in pain. The hospital assessment indicated the resident sustained a traumatic subdural hematoma without loss of consciousness and a 3-part fracture of the surgical neck of the left humerus. During an interview on 09/21/23 at 11:21 A.M., CNA (Certified Nurse Aide) 2 indicated she was with the resident when she fell . The resident was on the bed and the CNA was assisting her with getting dressed. The resident stood up just fine. The CNA was standing behind the resident and her hand was around the resident's hip. The resident's pants were down at her ankles and when the CNA went to pull up her pants, the resident bent down to pull up her pants too. The resident reached down and lost her balance, and the CNA couldn't catch her. The CNA was not using a gait belt. She didn't know why she didn't use one, she didn't have one on her. The resident required the assistance of one staff member with ADLs (Activities of Daily Living) . The resident's record was reviewed on 09/22/23 at 2:27 P.M. An Annual MDS (Minimum Data Set) assessment, dated 06/16/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to Alzheimer's disease, hypertension, and anxiety. The resident required the extensive assistance of two staff members for most ADLs including dressing, toileting, bed mobility, and transfers. During an interview on 09/25/23 at 10:40 A.M., CNA 5 indicated staff were to always use a gait belt if a resident needed assistance during transferring. If a resident required limited to extensive assistance, staff were to use a gait belt. During an interview on 09/25/23 at 10:54 A.M., the DON (Director of Nursing) indicated before the resident fell , she required the extensive assistance of one and sometimes two staff members. The CNA should have been using a gait belt and she didn't. The current facility policy, titled GAIT BELT USE, with a revision date of 05/27/21, was provided by the Administrator on 09/25/23 at 1:19 P.M. The policy indicated, .Nursing staff may utilize gait belts on residents who need one person assist or more for transferring and ambulation .using a gait belt while transferring or walking with a resident can provide you and the resident with increased safety and security. You can help control a resident's balance and keep the resident from falling using a gait belt . The current facility policy, titled Falls Prevention -- Potential Interventions, with a revision date of April 2012, was provided by the Administrator on 09/25/23 at 1:19 P.M. The policy indicated, .Staff Education .Gait belt for transfers and ambulation, as appropriate . This Federal tag relates to Complaint IN00416797. 3.1-45(a)(2)

Based on interview and record review, the facility failed to call emergency personnel for evaluation and treatment when a resident that had a full code status stopped breathing for 1 of 6 residents sampled for code status in a total sample of 6, this had the potential to affect 16 residents residing in the facility with a full code status. (Resident #B) This deficient practice resulted in an Immediate Jeopardy (IJ). The IJ was identified on [DATE] and began on [DATE] at 4:25 a.m. The Administrator and Director of Nursing (DON) were notified of the IJ on [DATE] at 5:00 p.m. The IJ was removed on [DATE] at 5:20 p.m., but the facility remains out of compliance at the level of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy, because all staff had not been inserviced and the continuing need to interview and monitor staff's knowledge regarding the protocol on a resident with a full code status. Findings include: During initial tour of the facility with RN #1 on [DATE] at 10:45 a.m., RN #1 provided an report sheet with all the residents residing in the facility with their room numbers and their code status. RN #1 indicated the residents' code status had been on nurses' report sheet for at least a year and half. The report sheet indicated there was 16 residents residing in the facility with a full code status, with a total population of 72 residents. Review of the record of Resident #B on [DATE] at 11:15 a.m., indicated the resident's [DIAGNOSES REDACTED]. The physician recapitulation for Resident #B for [DATE] indicated the resident's code status order was Cardiopulmonary Resuscitation (CPR), respirators, feeding tubes, [MEDICAL TREATMENT], transfer to the hospital and Intravenous therapy (IV) for acute treatment. The Advance Directives for Resident #B, dated [DATE], indicated "In the process of your admission to Shady Nook Care Center, you have received information from our social services department regarding Advance Directives." "Among other things, these directives allow you to inform health care providers about your preferences for treatment or non-treatment in the areas described below." "Is is suggested that you discuss these important decisions with your family and physician." "You may also desire to consult with member of the clergy." "After your deliberation, please indicated yes or no to each of the following." "This information will be placed in your medical record." The Advance Directives indicated the " Yes" to the following: Cardiopulmonary Resuscitation (CPR) (to restore stopped breathing and/or heartbeat by external cardiac massage, mouth to mouth resuscitation and appropriate medication. Respirators (machine use to maintain breathing requiring endotracheal tube or [MEDICAL CONDITION]). Feeding Tubes (inserted through the nose, throat or stomach to provide nutrition/hydration when the resident is unable to take food or water by mouth). [MEDICAL TREATMENT] (a method of cleaning a residents blood by machine when the kidneys fail to function). Transfer to the hospital for acute therapy. IV for acute treatment. The Advance Directive was signed by Resident #B's Power of Attorney (POA) and the physician. The physician fax for Resident #B, dated [DATE] at 4:27 p.m., indicated the resident requested an inhaler for shortness of breath, the resident states she has periods of shortness of breath at times and had an inhaler in the past. The physician ordered [MEDICATION NAME] inhaler two puffs every three hours as needed for shortness of breath. The medication sheet for Resident #B, dated [DATE], indicated the [MEDICATION NAME] inhaler had not been signed off as ever been given to the resident. The interdisciplinary progress record for Resident #B, dated [DATE] at 4:10 a.m., indicated the resident called and reminded staff she wanted to get ready for [MEDICAL TREATMENT] between now and 4:30 a.m. The resident was lying in bed. The note was signed by LPN #1. The interdisciplinary progress record for Resident #B, dated [DATE] at 4:15 a.m., indicated the resident complained of some shortness of breath with wheezing. The head of the bed is up. "No audible wheezing noted." Respirations were even and unlabored. The resident's oxygen saturation was 94 %. The resident was lying in bed. The note was signed by LPN #1. The interdisciplinary progress record for Resident #B, dated [DATE] at 4:25 a.m., indicated the resident had no respirations or pulse. CPR was started with no response. The resident had no vital signs. The note was signed by LPN #1. The interdisciplinary progress record for Resident #B, dated [DATE] at 4:30 a.m., indicated the physician was called and made aware of the resident with no vital signs, no pulse and no respirations. An order was received to release the body to the funeral home. The note was signed by LPN #1. This documentation indicates CPR was done for five minutes. Interview with LPN #1 on [DATE] at 1:55 p.m., indicated she was the nurse caring for Resident #B on [DATE] when the resident died . LPN #1 indicated there was another nurse in the building but the other nurse did not assist with CPR. LPN #1 indicated a Qualified Medication Administrator (QMA) #1 was in the resident's bedroom but did not assist with the CPR. LPN #1 indicated on [DATE] Resident #B had complained of shortness of breath, but there was no audible wheezing and the resident's oxygen saturation was in the 90's. LPN #1 indicated QMA #1 called her on an walkie talkie and told her Resident #B was unresponsive. LPN#1 indicated when she went in the resident's room and the resident was not breathing. LPN #1 indicated QMA #1 went and got the emergency cart and LPN #1 used an Ambu bag and chest compressions on Resident #B. LPN #1 indicated she did not know how long she did CPR on Resident #B. LPN #1 indicated she called the physician and the physician told her to call the time of death. LPN #1 indicated she thought she told the physician the resident was a full code, but she was unsure. LPN #1 indicated the reason she did not call 911 for emergency personnel was because the resident had no signs of life. LPN #1 indicated no IV's were started or any other measures done for Resident #B. QMA #1 who was present in Resident #B's room on [DATE] during CPR no longer works at the facility and could not be contacted for interview. QMA #1 was CPR certified. Interview with the physician on [DATE] at 2:35 p.m., indicated LPN #1 did tell her that Resident #B was a full code. The physician indicated she did not remember LPN #1 telling her she had done CPR on Resident #B. The physician indicated LPN #1 told her that she had walked into Resident #B's room and the resident was gone. The physician indicated she and LPN #1 talked about calling 911 and LPN #1 said "No, she is gone". The physician indicated she told LPN #1 she thought 911 should be called and LPN #1 kept saying "She is gone, she is gone." Interview with the DON on [DATE] at 3:00 p.m., indicated the protocol when a resident is a full code is to initiate CPR and call the physician and 911 at the same time if possible. Interview with the DON on [DATE] at 2:30 p.m., requested any inservices on full code the facility had done since the incident on [DATE]. Interview with the unit clerk on [DATE] at 3:05 p.m., indicated the facility had not had any inservices on full code status. The physician faxed the facility a prescription on [DATE] at 2:56 p.m., that indicated the cause of death for Resident #B was "Cardiopulmonary arrest secondary to [MEDICAL CONDITION] infarction ([MEDICAL CONDITION])." Interview with the DON on [DATE] at 1:55 p.m., indicated the facility did not have a policy on [DATE] with guidelines on when CPR should be stopped, when to call emergency personal or the physician. The DON indicated it was standard practice for a nurse to know to call emergency personal and the physician. The facility only had a policy on CPR technique. The IJ was identified on [DATE] and began on [DATE] at 4:25 a.m., when a resident who was a full code status stopped breathing and emergency personnel was not called to evaluate and treat the resident. The Administrator and Director of Nursing (DON) were notified of the IJ on [DATE] at 5:00 p.m. The IJ was removed on [DATE] at 5:20 p.m., when through record review of the facility's new policy on steps to take during a full code, inservices for staff on the new policy and interviews with facility staff in regard to their knowledge on what steps to take during a code situation., it was determined that the facility had implemented the plan of action to remove the IJ and that the steps taken removed the immediacy of the problem. Even though the facility's corrective action removed the IJ, the facility remained out of compliance at a reduced scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy. This federal tag relates to complaint number IN 670. 3XXX,[DATE](a)