Every finding on record at Springhill Village

Based on observation, interview, and record review, the facility failed to ensure they implemented a policy to ensure proper storage of respiratory equipment for 3 of 4 residents reviewed for respiratory care (Residents 14, 1, and 34) and they failed to ensure a physician order was obtained for respiratory equipment for a resident's use for 1 of 4 residents reviewed for respiratory care (Resident 14). Findings include:1. During an interview, on 2/18/26 at 8:20 a.m., Resident 14 indicated she used a continuous positive airway pressure (CPAP- a method of respiratory therapy in which air is pumped through the nose or nose and mouth during spontaneous breathing) machine at night. The machine was hers that was brought from home to use. She indicated the facility could not get the equipment quick enough for her and she needed to have it because of her sleep apnea (a common, serous disorder where breathing repeatedly stops and starts during sleep, preventing restful sleep and reducing blood oxygen levels). During an observation on 2/18/26 at 8:26 a.m., Resident 14's unbagged CPAP mask was on the resident's nightstand table next to the CPAP machine. The resident was resting in bed, watching T.V. During an observation on 2/18/25 at 11:04 a.m., Resident 14's unbagged CPAP mask was on the resident's nightstand table on top of a clear plastic bag, next to the CPAP machine. The resident was resident in bed, watching T.V. During an observation on 2/19/26 at 8:30 a.m., Resident 14's unbagged CPAP mask was lying next to the resident on her bed. There was an empty clear plastic bag noted on the resident's nightstand table. During an observation on 2/19/26 at 10:34 a.m., Resident 14's unbagged CPAP mask was on the resident's side table next to the bed, the mask was next to a dirty paper towel, telephone, remote, and an aluminum can. There was an empty clear plastic bag hanging from the CPAP machine. Resident 14's record was reviewed on 2/19/26 at 10:16 a.m. The profile indicated the resident's diagnoses included, but were not limited to, obstructive sleep apnea (caused by throat muscles relaxing and blocking the airway) and generalized anxiety disorder (a mental health condition characterized by persistent, excessive, and uncontrollable worry about everyday events, lasting for at least 6 months). Facility census information indicated Resident 14 was admitted to the facility on [DATE]. An admission Minimum Data Set (MDS) assessment, dated 2/11/26, indicated the resident was cognitively intact and was not marked as using a CPAP mask. Resident 14's record lacked a physician order was obtained for the use of the CPAP equipment. Resident 14's record lacked the implementation of a care plan for the use of CPAP equipment. Review of progress note, dated 1/30/26 at 6:58 p.m., indicated Resident 14 reported to the nurse she needed a CPAP and her significant other would bring it to the facility the next day. Review of physician progress note, with an encounter date of 2/3/26, indicated Resident 14 used a CPAP machine and reported no problems with its use. Review of hospital discharge instructions, dated [DATE], indicated a nocturnal (occurring at night) CPAP was ordered. During an interview, on 2/19/26 at 8:38 a.m., Licensed Practical Nurse (LPN) 9 indicated staff should store respiratory equipment in the bag when not in use. During an interview, on 2/19/26 at 10:41 a.m., Licensed Practical Nurse (LPN) 10 indicated staff should obtain an order from the physician for the use of CPAP equipment The residents were allowed to use the equipment from home if necessary but there should be an order for its use. During an interview, on 2/19/25 at 1:21 p.m., the Executive Director (ED) indicated the facility did not have a specific policy related to respiratory equipment. During an interview, on 2/19/26 at 2:02 p.m., the Director of Nursing (DON) indicated she would have to verify if Resident 14 had an order for the use of CPAP equipment, she was aware she used one. During an interview, on 2/19/26 at 2:45 p.m., the DON indicated she was unable to find an order for the use of CPAP equipment for Resident 14, and indicated it had gotten missed. During a random observation on 2/19/26 at 2:12 p.m., LPN 10 and Registered Nurse (RN) 11 were walking down the 200 hallway with clear plastic bags and a black marker, LPN 10 indicated to RN 11 make sure everyone with respiratory equipment had a plastic bag in their room. 2. During an observation, on 2/18/26 at 9:39 a.m., Resident 1's CPAP (a method of respiratory therapy in which air is pumped through the nose or nose and mouth during spontaneous breathing) mask was observed setting on top of the resident's bedside table. The mask was unbagged. At the same time, Resident 1 indicated the facility had never provided a bag for the mask to be placed in. During a random observation, on 2/19/26 at 8:32 a.m., the resident was sitting on the side of his bed eating his breakfast. His CPAP mask was sitting on top of his bedside table unbagged. At the same time, he indicated he wears the CPAP at night. He had been up for about 2 hours, and no one had come in to do anything with it. During a random observation, on 2/19/26 at 1:50 p.m., the resident was observed in his bed. The CPAP mask was sitting unbagged on his bedside table. Resident 1's record was reviewed on 2/18/26 at 3:14 p.m. The profile indicated the resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD- a progressive, long-term lung disease that makes it hard to breathe due to damaged, inflamed, and narrowed airways) and obstructive sleep apnea (a common, serious sleep disorder where throat muscles relax too much during sleep, causing the airway to collapse and repeatedly block breathing). A care plan, dated 8/5/25, indicated the resident had the potential for impaired gas exchange related to COPD and experiences shortness of breath (SOB) with lying flat. Interventions included, but were not limited to, resident wears a CPAP at times. A significant change Minimum Data Set (MDS) assessment, dated 1/11/26, indicated the resident had no cognitive deficit and required oxygen therapy. A physician's order, dated 1/5/26, indicated special instructions for the resident's CPAP to be placed on at bedtime and off when awake. The record lacked a physician's order for the storage of the CPAP mask when not in use. During an interview, on 2/19/27 at 1:50 p.m., Licensed Practical Nurse (LPN) 10 indicated CPAP masks and tubing should be cleaned once daily. The mask should be placed in a clean dated bag when not in use. 3. On 2/17/26 at 11:00 a.m., during initial observation noted nebulizer tubing and medication chamber lying on top of a clear storage bag dated 2/15/26 on a chair in the room of Resident 34. Observed bilevel positive airway pressure (BiPap, a non-invasive, mask-based ventilation device that helps people breathe by pushing pressurized air into the lungs with two distinct pressures: a higher pressure for inhaling and a lower pressure for exhaling) mask and tubing lying on top of a clear plastic bag on top of the resident's bedside table. On 2/18/26 at 9:04 a.m., observed nebulizer tubing and medication administration chamber lying on chair in Resident 34's room on top of a plastic storage bag. Observed the BiPap mask and tubing unbagged on top of bedside table. The resident indicated she administered nebulizer treatments herself. On 2/18/26 at 9:10 a.m., during an interview, RN 13 indicated she set up the nebulizer treatment for Resident 34 and stood by while the resident administered her own breathing treatment. She indicated she cleaned the equipment and hung it up to dry. On 2/18/26 at 9:23 a.m., during an interview, Licensed Practical Nurse (LPN) 10 indicated the nurse should assess the resident during and after the nebulizer treatment. Once completed the nurse should rinse out the nebulizer tubing and medication chamber and allow the equipment to air dry then place equipment in a bag. On 2/19/26 at 8:31 a.m., observed nebulizer tubing and medication administration chamber unbagged laying on top of dated bag in a chair in the resident's room. Observed BiPap mask and tubing unbagged on top of bedside table. On 2/23/26 at 12:58 p.m., the ED provided a document with a revised date of 9/23, titled, BIPAP/CPAP and indicated it was the currently policy being used by the facility. The policy indicated .1. Verify resident and physician's order 2. Physician's order should include: a. CPAP or BIPAP pressure b. oxygen therapy with sleep, if indicated. d. size and type of mask/prongs e. back up rate, if indicated. This deficiency reflects State Findings cited in accordance with 410 Indiana Administrative Code (IAC) 16.2-3.1-47(a)(6).

Based on observation, record review, and interview, the facility failed to address a significant weight discrepancy and re-evaluate a resident's weight for 1of 2 residents reviewed for nutrition (Resident 57). Findings include:On 1/17/26 at 12:00 p.m., observed resident sitting in the activity lounge area with a noon meal. The resident did not have dentures in place and was attempting to eat a sandwich. She was very restless during the meal and refused to allow staff to assist her. On 1/18/26 at 9:00 a.m., the medical record of Resident 57 was reviewed. The resident was admitted to the facility on [DATE]. Diagnoses included but were not limited to, dementia (the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities) and anxiety (a feeling of fear, dread, and uneasiness). According to documented weights the resident has lost 12.5% weight loss in 6 months and 1.14% weight loss in 30 days. The monthly weight record indicated on 8/6/23 the resident's weight was recorded as 100 pounds (lbs.), on 9/2/25 weight was recorded 102 lbs., on 10/9/25 weight was recorded as 94 lbs. A care plan, dated 8/25/23, indicated the resident was at risk for altered nutritional status due to but not limited to varied intake of diet and dementia. Interventions included, but were not limited to, regular diet, super cereal at breakfast, ice cream with lunch and dinner, and mighty shake with breakfast lunch and dinner. A physician order, dated 12/12/23, indicated to administer Ensure Plus 237 ml (milliliters) daily. An annual Minimum Data Set assessment (MDS), dated [DATE], indicated the resident was severely cognitively impaired and required extensive assistance from the staff with daily care needs. The MDS indicated the resident had not had a significant weight loss of more than 10% in 6 months. Review of the Medication Administration Records (MAR) for January and February 2026 indicated the Ensure amount the resident consumed was not recorded for 18 days. On 2/18/25 at 1:40 p.m., during an interview, Licensed Practical Nurse (LPN) (18) indicated Resident 57 would not keep her dentures in and she often took them out. She indicated the resident liked to snack and run. They had difficulty keeping her sitting still long enough for meals and the resident got ensure daily around 2 p.m., but she also got lots of snacks.On 2/20/26 at 1:55 p.m., during an interview Certified Nurse Aide (CNA) (21) indicated the resident ate all day and she liked to snack. She indicated she was very active and wandered around a lot. On 2/23/26 at 1:00 p.m., during an interview the Director of Nurses indicated the resident's weight had consistently been about the same. The resident was noted to have a significant weight variance for 4 dates, and she believed the weights were wrong and thus an incorrect weight loss percentage was triggered. However, a re-weight was not completed at the time to confirm weight loss, and the weight loss had not been addressed until this month. On 2/23/26 at 1:00 p.m., the Director of Nursing provided a document titled, Resident weight monitoring dated 9/2024, and indicated it was the policy currently being used by the facility. The policy indicated, .3. Monthly weights will be obtained, verified for accuracy. This deficiency reflects State Findings cited in accordance with 410 Indiana Administrative Code (IAC) 16.2-3.1-46.

Based on record review and interview, the facility failed to ensure the resident received notice of transfer and bed hold policy, and failed to notify the hospital of transfer or condition report for 2 of 24 residents reviewed for hospitalization (Residents 96 and 7). Findings include:1. On 2/23/26 at 9:52 a.m., the medical record of Resident 96 was reviewed. The resident was admitted to the facility on [DATE]. admission diagnoses included, but was not limited to, Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), and congestive heart failure (CHF) (a condition that develops when your heart doesn't pump enough blood for your body's needs). An admission Minimum Data Set Assessment (MDS), dated [DATE], indicated the resident was cognitively intact and required assistance with daily care needs. The medical record, indicated on 1/24/26 at 2:32 p.m., the resident was observed to have extensive swelling of the right side of the face. The physician was notified and an order was received to send the resident to the emergency department for evaluation. The nurse called the hospital on 1/24/26 at 4:44 p.m., to obtain report on the resident's condition. The resident was admitted to the hospital. The medical record lacked evidence of written notice of transfer information and bed hold policy being sent with the resident or transfer report called to the hospital at the time of transfer. On 2/23/26 at 1:00 p.m., during an interview, the Director of Nursing (DON) acknowledged the record lacked documentation to indicate the facility sent the bed hold policy or the notice of transfer information with the resident and failed to call transfer report to the hospital. 2. During a family interview, on 2/18/26 at 9:08 a.m., they indicated Resident 7 had been in and out of the hospital several times since admission. Resident 7's record was reviewed on 2/18/26 at 3:22 p.m. The profile indicated the resident's diagnoses included, but were not limited to, chronic respiratory failure with hypoxia (lungs cannot properly transfer oxygen in the blood, leading to low oxygen levels) and chronic kidney disease, stage 3a (mild to moderate kidney damage). Facility census information indicated Resident 7 was admitted to the facility on [DATE] and was transferred to the hospital on 1/15/26. Review of progress note, dated 1/15/26 at 9:08 a.m., indicated Resident 7 was lethargic and had slurred speech. Vitals were obtained by the nurse, and the nurse practitioner came to evaluate the resident and the nurse practitioner indicated to send the resident to ER (emergency room) for further evaluation and abnormal labs. Emergency Medical Services (EMS) arrived to the facility to transfer the resident to the hospital at 9:48 p.m. The record lacked documentation the hospital was notified of the transfer and the condition of Resident 7 at the time of transfer. During an interview on 2/20/26 at 9:32 a.m., the Director of Nursing (DON) indicated she was unable to find documentation where staff had notified the hospital of the transfer and condition of Resident 7 prior to her leaving the facility. The staff should have called report to the hospital staff and documented it in the record. On 2/20/26 at 10:07 a.m., the DON provided a document with a revised date of 2/19, titled, Hospital Discharge/Transfer, and indicated it was the currently policy being used by the facility. The policy indicated, .Nursing will complete an Emergency transfer observation and attach copies of the following information form the resident medical record:.Notice of Transfer/Discharge, Bed hold policy.Bed hold policy/transfer notification will be reviewed with the responsible party at the time of notification and documented in the medical record.Nursing will provide a thorough report to receiving hospital nurse that will include: head to toe assessment, current skin condition, current medications, when medications last received, any non-compliance or care issues for the resident, and any other pertinent information that will assist admitting facility in how to care for that resident. This deficiency reflects State Findings cited in accordance with 410 Indiana Administrative Code (IAC) 16.2-3.1-12(a)(6)(a).

Based on observation and interview, the facility failed to ensure medications were dated when opened for 1 of 2 medication carts. Findings include:On 2/20/26 at 8:43 a.m., observed the medication cart for 100 hall with Qualified Medication Aide (QMA) 19. Observed an insulin pen, Basaglar insulin100 units, with instructions to administer 15 units at bedtime for Resident 30. The insulin pen had been opened, and label was not dated with an opened date. Observed an insulin pen Lantus insulin 3 milliliter pen with instructions to administer 15 units daily, for Resident 73 opened and not dated with an opened date. On 2/20/26 at 8:50 a.m., during an interview Licensed Practical Nurse (LPN) 18 indicated the insulin pens must be dated when opened and discarded after 30 days. On 2/20/26 at 10:00 a.m., the Director of Nursing provided a document titled, Medication storage and expiration policy, and indicated it was the policy currently being used by the facility. The policy indicated, .9. Facility staff should record the date opened on the primary medication container.c. If a multidose vial of an injectable medication has been opened or accessed (e.g., needle punctured), the vial should be dated and discarded within 28 days. This deficiency reflects State Findings cited in accordance with 410 Indiana Administrative Code (IAC) 16.2-3.1-25(j).

Based on observation, interview, and record review, the facility failed to ensure staff donned (put on) personal protective equipment (PPE-wearable gear and clothing designed to protect individuals from workplace illnesses and infections) when entering a room of a resident who was COVID-19 (a highly contagious respiratory disease) for 1 of 1 hall tray pass observation (Resident 93). Findings include:On 2/17/26 at 12:52 p.m., the Activity Director (AD) was observed entering Resident 93's room to deliver his lunch tray. Through the open door, the AD was observed to set the resident's lunch tray on the overbed table (a table that can be placed over a resident in bed to allow the resident access to items, such as meal trays, etc.) which was set directly in front of the resident. The AD was observed to enter and exit the room without donning or doffing (removing) appropriate PPE. Signage on the resident's room door indicated the resident was in droplet precautions (measures designed to prevent the spread of germs transmitted through large respiratory droplets) and a PPE bin was setting outside of the room. At the same time, the AD indicated she was not aware that the resident was on droplet precautions. During an interview, on 2/17/26 at 12:59 p.m., Registered Nurse (RN) 5, indicated the Regional Clinical Nurse had notified her that Resident 93 had tested positive for COVID-19. She assumed that the information had been passed along to all staff on the hallway. During an interview, on 2/17/26 at 1:08 p.m., the AD indicated she had gone into the room to give the resident his lunch tray. She had set it in front of the resident on the overbed table which was next to his bed. She had not been told that he had COVID-19 and did not put on any PPE prior to entering the room. During an interview, on 2/17/26 at 2:27 p.m., the Executive Director (ED) indicated that the resident had tested COVID-19 positive. He had tested positive earlier that morning. The staff had just messed up, by not wearing PPE when entering the resident's room. She was unsure if all the staff who were passing the lunch trays had been made aware of the resident situation, prior to passing the hall trays. The staff should have worn proper PPE when entering the resident's room. During an interview, on 2/17/26 at 2:34 p.m., Qualified Medication Aide (QMA) 3 indicated she had been notified about the resident testing COVID-19 positive from another staff earlier in her shift. She was not sure if any of the other staff who were assisting with passing the hall trays had been told. During an interview, on 2/17/26 at 2:47 p.m., the Payroll Coordinator indicated she had assisted with hall trays on the hall during the lunch meal. No one had informed her about the resident being COVID-19 positive. She had noticed the signage outside the door and the PPE bin sitting in the hallway. During an interview, on 2/18/26 at 11:00 a.m., the Business Office Manager (BOM) indicated she had assisted with passing the hall lunch trays. She was not told that the resident was COVID-19 positive. She did not observe the signage for droplet precautions until she saw the AD coming out of his room. During an interview, on 2/18/26 at 11:10 a.m., Certified Nursing Assistant (CNA) 8 indicated that she had not been informed that the resident was COVID-19 positive. When she was passing trays, she noticed the droplet precautions signage and had to ask the nurse to find out the reason for the signage. On 2/18/26 at 11:43 a.m., a home healthcare representative was observed in the resident's room standing directly in front of the resident, without any PPE in place. At the same time, the representative was informed that the resident was COVID-19 positive. She indicated no one had made her aware of the resident being positive and she did not observe the signage on the door, prior to entering. 8/26 at 8:17 a.m., the ED provided an undated and untitled document, and indicated it was the policy for infections that required droplet precautions currently in use by the facility. The policy indicated, .Use of Personal Protective Equipment-Mask and face protection in addition to gown and gloves: Anyone who goes into a room should wear a mask/face protection.Remove mask/face protection and dispose of it before leaving room.Perform hand hygiene before leaving the room.Droplet/Contact Precautions.Covid-19 Positive Resident.Use of Personal Protective Equipment: health care personnel (HCP) should wear an N95 or higher-level respirator, eye protection (.that covers the front and sides of the face).when caring for these residents. This deficiency reflects State Findings cited in accordance with 410 Indiana Administrative Code (IAC) 16.2-3.1-18(b).

Based on interview and record review, the facility failed to ensure care plan meetings were conducted quarterly for 4 of 24 residents reviewed for care plan meetings (Residents 24, 28, and 37), and the facility failed to ensure the resident and or the resident representative was present for an initial care plan meeting for 1 of 24 residents reviewed. (Resident 64). Findings include: 1. During an interview, on 1/8/25 at 10:12 a.m., Resident 24 indicated he did not remember being invited to or attending a care plan meeting recently. He thought maybe the last one was 6 months ago. Resident 24's record was reviewed on 1/9/25 at 10:42 a.m. A quarterly Minimum Data Set (MDS) assessment, dated 11/12/24, indicated the resident had no cognitive impairment. Census information indicated the resident was admitted to the facility on [DATE]. A care plan summary note, dated 6/26/24 indicated a care plan meeting was conducted on this day for Resident 24. A care plan summary note, dated 10/30/24, indicated a care plan meeting was conducted on this day for Resident 24. Resident 24's record lacked documentation of quarterly care plan meetings being conducted for the last year, January 2024 to January 2025. 2. During an interview, on 1/7/24 at 11:46 a.m., Resident 28 indicated she did not remember being invited to or attending a care plan meeting. She could not recall when the last one was. Resident 28's record was reviewed on 1/9/25 at 11:42 a.m. A quarterly Minimum Data Set (MDS) assessment, dated 10/29/24, indicated the resident had no cognitive impairment. Census information indicated that the resident was admitted to the facility on [DATE]. A care plan summary note, dated 6/4/24, indicated a care plan meeting was conducted on this day for Resident 28 . Resident 28's record lacked documentation of quarterly care plan meeting being conducted from June 2024 to January 2025. 48226 2. On 1/07/25 at 12:07 p.m., during an interview, Resident 37 indicated she had not attended a care plan meeting. On 1/9/25 at 11:23 p.m., the medical record for resident 37 was reviewed. Diagnosis included but were not limited to nontraumatic intracerebral hemorrhage (bleeding in the brain that occurs without trauma or other known causes), dated 11/29/2023. Parkinsons disease (a brain disorder that causes movement problems, including tremors, stiffness, and difficulty with balance), dated 1/02/2025. A quarterly Minimum Data Set (MDS) assessment, dated 10/29/24, indicated the resident was cognitively intact. The medical record documentation indicated a care plan summaries, dated 5/8/24 and 10/30/24, were completed. The meeting notes indicated the resident attended. The record lacked documentation of any disciplines attending. The record lacked evidence of additional care plan meetings before 5/8/24 or after 10/30/24. 34525 3. Resident 64's record was reviewed on 1/8/25 at 3:01 p.m. The profile indicated the resident had been admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to, type 2 diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high) and adult failure to thrive (a state of decline that is multifactorial and may be caused by chronic concurrent diseases and functional impairments). An admission Minimum Data Set (MDS) assessment, dated 12/19/24, indicated the resident had severe cognitive deficit. A Road to Recovery meeting document (a document that summarizes a person's health conditions, care needs, and treatments), dated 12/16/24, lacked documentation that the resident and/or her representative were present and participated in the meeting or a reason why they had not attended. The document indicated Social Services were the only persons in attendance. A Social Services progress note, dated 1/2/25 at 2:04 p.m., indicated a meeting had taken place to discuss the resident's clinical information, goals, and discharge plan. The document indicated members of the Interdisciplinary Team (IDT-a group of health care professionals with various areas of expertise who work together toward the goals of their residents) and Social Services had attended the meeting. The note lacked documentation that the resident and/or her representative had attended or participated in the meeting or a reason why they had not attended. On 1/9/25 at 9:46 a.m., the Social Services Director (SSD) provided a document, with a postmark date of 12/16/24, and indicated it was a letter that had been sent to the resident's representative. The letter requested that her representative call to schedule a meeting to discuss her plan of care. The resident's record lacked documentation of any return contact from her representative about scheduling a meeting. The record lacked documentation of any follow-up attempt by the facility, to contact the resident's representative regarding the letter. During an interview, on 1/9/25 at 11:55 a.m., the Social Service Director (SSD) indicated he was hired in March 2024 to fill a vacant SSD position and completed his training in May 2024. He indicated the facility did not have a good system in place to keep track of the quarterly care plan meetings and he was now working on that and they had an action plan in place. He was unable to provide documentation that the care plan meetings were conducted quarterly for the above residents. The SSD indicated that a post card was mailed out or handed to the residents and/or resident representatives to remind them to call the facility to schedule a care plan meeting, but he had noticed that they were not calling the facility to schedule the care plan meetings, and they were getting missed. On 1/9/25 at 12:51 p.m., the Executive Director (ED) provided a document, with a revision dated of 8/2023, titled, IDT Comprehensive Care Plan Policy, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure: Care plan review will be interdisciplinary and should include, to the extent possible, nursing, social services, activities, dietary, therapy, pharmacy, physician, direct care staff, and hospice (if indicated). Resident, resident representative, or others as designated by the resident will be invited to the care plan review. The care plan review will be conducted face-to-face, via phone conference, video conference, or through written communication per resident and/or representative preference. Care plan problems, goals, and interventions must be reviewed and revised by the interdisciplinary team periodically and following completion of each MDS assessment 3.1-35(a)(2)(C) 3.1-35(e)

Based on interview and record review, the facility failed to ensure residents who were dependent on staff for shaving facial hair, received the service for 1 of 24 residents reviewed for Activities of Daily Living (ADL) assistance (activities related to personal care). (Resident 65) Findings include: On 1/07/25 at 11:54 a.m., during an observation, Resident 65 was observed in his room with extensive beard growth. The resident indicated he wanted to be shaved. He indicated the staff had shaved him before and needed to do it again. He did not like to have facial hair. On 1/8/25 at 10:45 a.m., observed Resident 65 in his room with facial hair. He indicated the staff had not offered to shave him. On 1/9/24 at 10:30 a.m., observed Resident 65 in the hall with extensive facial hair. On 1/9/25 at 11:35 a.m., during an interview, Certified Nurse Aide (CNA) (15) indicated she shaved residents on their designated shower day. On 1/9/24 at 11:38 a.m., during an interview CNA (13) indicated residents were to be shaved on shower days. On 1/9/24 at 2:30 p.m., during an interview the Director of Nursing Services (DNS) indicated Resident 65 often refused showers and those were the days he would have been shaved. The DON provided shower records indicated the resident had refused showers and records indicated the resident had been shaved on other days. On 1/9/24 at 2:45 p.m., the medical record of Resident 65 was reviewed. The resident was admitted to the facility with diagnoses including but not limited to, Type 2 diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high), with diabetic neuropathy (a type of nerve damage that can occur if you have diabetes), chronic obstructive pulmonary disease (COPD) (a group of diseases that cause airflow blockage and breathing-related problems) and need for assistance with personal care, dated 10/23/24. An admission Minimum Data Set (MDS) assessment, dated 10/29/24, indicated the resident was cognitively intact and required assistance from the staff for activities of daily living (ADL) care. A care plan, dated 10/24/24, indicated the resident required assistance and monitoring for a.m. and p.m., care. Interventions included but were not limited to, a.m. and p.m. care tasks included bathing, dressing, hair combing, and oral care. On 1/9/2025 at 12:51 p.m., the DNS provided a document, titled, AM Care, dated, and indicated it was the policy currently being used by the facility. The policy indicated, .8. Shave resident, if needed or requested 3.1-38(a)(3)

Based on observation, interview, and record review, the facility failed to ensure that 1of 1 residents observed for transfers and reviewed for accidents had adequate assistance devices and interventions in place to prevent potential for accidents (Resident 8). Findings include: On 1/7/25 at 1:00 p.m., observed Certified Nurse Aide (CNA) 16 transfer Resident (8) from bed to chair. CNA failed to apply a gait belt, nor shoes or non-skid socks prior to assisting to transfer from the bed to a chair next to the resident's bed. The CNA assisted the resident by lifting under the resident's left arm, stood and transferred the resident to the chair. The resident required extensive assistance to transfer and was unsteady when standing. On 1/7/25 at 1:07 p.m., during an interview, CNA 16 indicated the resident refused to wear shoes or socks and indicated sometimes she used a gait belt to transfer a resident. On 1/7/25 at 1:10 p.m., during an interview, Resident 8 indicated the staff always made her wear her shoes when transferring her. She could not recall if the CNA had offered to apply shoes or non-skid socks. On 1/9/24 at 11:40 a.m., during an interview, CNA 14 indicated she placed shoes and or non-skid socks on residents before assisting to transfer. On 1/9/25 at 1:00 p.m., the medical record of Resident 8 was reviewed. The resident was admitted with diagnoses including but not limited to vascular dementia, unspecified severity, (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), chronic congestive heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), type 2 diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), and hypertension (high blood pressure). The record indicated the resident had multiple falls since admission and was identified as high fall risk. An annual Minimum Data Set (MDS) assessment, dated 11/5/24, indicated the resident was cognitively intact and required staff assistance with transfers. A care plan, dated 1/30/24, indicated Resident was a high fall risk for falls per a John Hopkins score of 25 points due to: age, one or more falls in the last 6 months, incontinence, on 2 or more high fall risk drugs, unsteady gait, impulsive, lack of understanding of one's physical and cognitive limitations, and requires assist/supervision with mobility/transfers or ambulation. Interventions included but were not limited to, shoes to be placed next to bed and non-skid footwear, dated 12/16/2024. On 1/9/2025 at 12:51 p.m., the Director of Nursing Services (DNS) provided a document, titled, Transfer to Wheelchair, dated 9/2023, and indicated it was the policy currently being used by the facility. The policy indicated, .9. put non-skid footwear on resident and securely fasten .11. Place gait belt around resident's waist. 12. Grab belt securely on both sides. 13. With legs on the outside of the resident's legs, brace resident's lower legs to prevent slipping. 14. Instruct resident on count of three to slowly rise and stand 3.1-45(a)

Based on observation, interview, and record review, the facility failed to ensure it was free of a medication error rate of greater than 5 percent (%) for 1 of 3 residents (Resident 172) observed during the medication pass when 2 medication errors were observed during 29 opportunities for error in medication administration resulting in a medication error rate of 6.9%. Findings include: On 1/10/25 at 8:51 a.m., during an observation of the medication pass, Licensed Practical Nurse (LPN) 17 was observed to prepare medications for Resident 172. The LPN was observed administering Timolol 5% eye drops (a medication used to treat the pressure within the eye caused by glaucoma) one drop into each eye of Resident 172. At 8:52 a.m., the LPN administered Dorzolamide HCL 2% (a medication used to treat the pressure within the eye caused by glaucoma) one drop into each eye. The LPN failed to wait a specific time period between administering the eye drops. On 1/10/25 at 8:55 a.m., during interview LPN 17 indicated she would normally wait five minutes between eye drops but the physician order did not indicate to wait between drops. On 1/10/25 at 9:05 a.m., the medical record of Resident 172 was reviewed. The resident was admitted with diagnosis of Glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of your eye called the optic nerve.) Physician orders included but not limited to, Timolol 5% eye drops administer one drop into each eye two times daily for diagnosis of glaucoma. Dorzolamide HCL 2% administer one drop into each eye two times daily for diagnosis of glaucoma. On 1/10/2025 at 10:41 a.m., the Director of Nursing (DNS) provided a document, titled, Medication Administration (Medication Pass Procedure), dated 07/2023, and indicated it was the policy currently being used by the facility. The policy indicated, .15. Eye drops separated 3 minutes, when using multiple medications to allow proper absorption 3.1-48(c)(1)

Based on observation, interview, and record review, the facility failed to ensure the scoop used to place ice into residents drink glasses was maintained in a safe and sanitary fashion, and to ensure proper hand hygiene was used when assisting residents in eating their meals for 2 of 2 dining observations. Findings include: 1. During an observation in the main dining room, on 1/7/25 at 11:59 a.m., the Activity Director was preparing a drink for a resident. She scooped ice into the glass and returned the scoop into the ice bucket. The Activity Director served the juice to a male resident. The ice scoop remained in the ice bucket until 12:12 p.m., the Marketing and Admission Director walked over to the drinks and prepared a lemonade for a resident. She scooped the ice into a glass and returned the scoop into the ice bucket. She then served the lemonade to a female resident. The ice scoop remained in the ice bucket until 12:20 p.m. During an interview, om 1/13/25 at 8:30 a.m., Registered Nurse (RN) 19 indicated staff were not to leave the ice scoop in the ice bucket. They were to return it to the empty container by the ice bucket. On 1/13/25 at 8:43 a.m., the Executive Director (ED) provided a document, dated 02/10, titled, Passing Fresh Ice Water, and indicated it was the policy currently being used by the facility. The policy indicated, . 4. Replace ice scoop in proper covered container or cover it with a clean towel or plastic bag to prevent contamination 34525 2. During the initial dining observation in the west unit dining room, on 1/7/25 at 12:00 p.m., the following was observed: a. On 1/7/25 at 12:26 p.m., Qualified Medication Aide (QMA) 10 was observed assisting Resident 47 and Resident 27 with their lunch meals. The QMA failed to perform hand hygiene between residents while assisting them. b. On 1/7/25 at 12:27 p.m., Certified Nursing Assistant (CNA) 11 was observed assisting Resident 221, Resident 40, and Resident 63 with their lunch meals. The CNA failed to perform hand hygiene between residents while assisting them. 3. During a follow-up dining observation, on 1/10/25 at 12:15 p.m., Certified Nursing Assistant (CNA) 12 was observed assisting Resident 27 and Resident 221 with their lunch meals. The CNA was observed touching the residents to help them with their positioning while assisting the residents to eat their meal. She was moving back-and-forth between the residents while assisting them. The CNA failed to perform hand hygiene while assisting the residents with their meals. During an interview, on 1/10/25 at 1:45 p.m., the Director of Nursing (DON) indicated the staff should always perform hand hygiene when assisting residents with their meals. If they were assisting more than one resident, hand hygiene should be done between residents. On 1/10/25 at 3:24 p.m., the DON provided a document, with a revised date of 9/2023, titled, Nursing Skills Competency .Feeding a Resident, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure Steps: .17. Perform hand hygiene 3.1-21(i)(3)

Based on record review and interview, the facility failed to ensure timely assessments and treatment for a resident with a change of condition in 1 of 6 residents reviewed for quality of care resulting in delayed treatment and hospitalization (Resident C). Findings include: On 11/26/24 at 10:00 a.m., the medical record of Resident C was reviewed. The most recent admission to the facility was on 7/29/24. Admitting diagnoses included, but not limited to, Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), fracture of lower end of right femur (broken thigh bone), chronic congestive heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), and chronic pain. Physician orders included, but were not limited to, acetaminophen (Tylenol) tablet; 325 milligrams (mg) every 4 hours and as needed (PRN), Occupational therapy (OT) to treat 3 times week for 8 weeks for wheelchair (WC) positioning, generalized weakness, bilateral (both) LE (lower extremity) edema (swelling), physical therapy (PT) to evaluate and treat for transfers. A significant change Minimum Data Set (MDS) assessment, dated 7/13/24, indicated the resident was mildly cognitively impaired and required extensive assistance with daily care needs. A care plan, dated 4/16/2018, indicated the resident was at risk for impaired mobility related to weakness, debility, edema in bilateral lower extremities. Interventions included, but were not limited to, notify therapy of declines in mobility or improvement in mobility, observe for signs of pain. A care plan, dated 4/16/2018, indicated the resident was at risk for pain related to diagnosis of neuropathy (nerve pain). Interventions included, but were not limited to, administer medications as ordered, observe for nonverbal signs of pain, changes in breathing, vocalizations, mood/behavior changes, eyes change, expression, sad/worried face, crying, teeth clenched, and changes in posture. An Indiana State Department of Health (ISDH) Survey Report System report, dated 7/25/24 at 10:01 a.m., indicated Resident C had sustained a fracture of the right femur and the injury had occurred while being transferred with a mechanical lift. On 11/26/24 at 10:40 a.m., during an interview, the Regional [NAME] President of Clinical Services (RNCS) indicated the ISDH report, submitted on 7/25/24 where the facility reported Resident C's injury had occurred during a transfer of Resident C with a mechanical lift, was a statement by the resident's family member. On 7/11/24 and 7/17/24 physical therapy notes indicated treatment was provided to Resident C. The treatment provided, on 7/11/24, indicated the resident was dependent for transfer using a mechanical lift. The physical therapy treatment note, dated 7/17/24, indicated the resident was repositioned in the wheelchair due to resident leaning to the left side, and the right hip was internally rotated. The record lacked documentation the physical therapist had notified the nurse of Resident C's internal rotation of the right leg. A nurse progress note, dated 7/18/24 at 2:55 p.m., indicated the resident's skin was dark with yellowish tint. The resident's right foot was contracted inward, and the right knee was very swollen where knee replacement scars were. Resident C required extensive assistance of two staff during mechanical lift. The record lacked documentation of detailed assessment of the right leg, physician notification of change in condition or additional observations or assessment of the right leg. On 7/25/24 the medical record indicated the resident was transferred to the hospital emergency room (ER) for evaluation and was admitted to the hospital for distal femur fracture. The hospital record indicated the right leg was bruised and swollen. The resident was able to minimally move the toes and foot and unable to actively mobilize any part of the leg. On 11/26/24 at 11:40 a.m., during an interview the RNCS indicated she did not know why there was a delay in resident assessment or notification of rotation of right hip and swollen knee to the physician from 7/17/24 to 7/25/24. On 11/26/24 at 3:35 p.m., during interview, the Physical Therapist indicated if a resident had a physical issue during a therapy treatment, depending on if it would affect the resident's function, she would document it in the therapy note. If there was an abnormality they would report it to the nurse. The therapist indicated she would talk to the nurse personally and record the conversation in the therapy notes. The therapist indicated she did not use a communication form to relay information to the nurse. On 11/26/24 at 3:40 p.m., during an interview, Registered Nurse (RN) 12 indicated if a resident had a swollen ankle or leg the RN would do an assessment and then call the physician and report the change in condition. The employee indicated when assessing for an injury the RN would look for redness and warmth and swelling. On 11/26/2024 at 2:16 p.m., the RDCS provided a document titled, Resident Change of Condition Policy, dated 11/2018, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy .It is the policy of this facility that all changes in resident condition will be communicated to the physician and family/responsible party, and that all appropriate, timely, and effective intervention takes place .2. Acute Medical Change .a. Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician .d. All nursing actions/interventions will be documented in the medical record as soon as possible after resident needs have been met .3. Non-Urgent Medical Change .a. All symptoms and unusual signs will be documented in the medical record and communicated to the attending physician promptly b. The nurse in charge is responsible for notification of physician .prior to end of assigned shift .g. The licensed nurse responsible for the resident will continue assessment and documentation in the medical record every shift until the resident's condition has stabilized This citation relates to Complaint IN00445095. 3.1-37

Based on interview and record review, the facility failed to ensure that a care plan was implemented for 1 of 2 residents reviewed for activities (Resident 14). Finding includes: During an interview on 11/13/23 at 11:14 a.m., Resident 14 indicated he did not come out of his room for group activities and the facility has an activity person come into his room once a week for one of one (1:1) activities. Resident 14's record was reviewed on 11/15/23 at 10:30 a.m. The profile indicated the resident's diagnoses included, but were not limited to, Type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), contracture of left knee (causes the envelope of the knee to stiffen and become rigid so the knee can no longer move the way it used to), and contracture of left hip (develops when the normally elastic connective tissues in the hip are replaced by inelastic fiber like tissue). A quarterly Minimum Data Set (MDS) assessment, dated 10/3/23, indicated the resident was cognitively intact and required 2 persons assist for transfers, bed mobility, and toilet use. A Care plan, dated 9/13/22, indicated the resident enjoys the following types of activities: watching television and movies, playing games, listening to music, etc. The resident will be receiving 1:1 engagement due to not being able to participate in group activities. Interventions included but were not limited to, resident would be seen 3 times per week for 1:1 activities. During an interview, on 11/16/23 at 2:30 p.m., the Director of Nursing Services (DNS) indicated she was unable to provide documentation of 1:1 activities were provided to resident 14 as care planned for three times a week. During an interview, on 11/17/23 at 8:30 a.m., the Administrator indicated the facility was unable to provide documentation of 1:1 activities being completed for Resident 14 as care planned. On 11/17/23 at 10:54 a.m., the Administrator provided a document, dated 1/2006, titled, Activities, and indicated it was the policy currently being used by the facility. The policy indicated, .It is the policy of this facility to provide an ongoing program of activities designed to meet the interests and the physical, mental and psychosocial well-being of each resident in accordance with the comprehensive assessment 3.1-35(a)

Based on observation, record review, and interview, the facility failed to ensure proper handling of the glucometer (small portable machine that's used to measure how much glucose [type of sugar] is in the blood) meter during medication administration pass for 2 of 4 residents reviewed during medication administration (Residents 38 and 35). Findings include: 1. During a medication administration observation, on 11/16/23 at 11:06 a.m., RN 4 had a glucometer meter on top of the medication cart, no barrier was placed under the machine. The nurse entered Resident 38's room and placed the glucometer onto her side table, no barrier was placed under the meter. The nurse did not clean the side table prior to placing the glucometer on it. RN 4 cleaned off the glucometer with a disinfectant wipe and placed the wipe on a paper towel. The nurse obtained the resident's blood sugar and exited the room. The nurse wiped the glucometer with the same wipe that she had used in the resident's room, once she wiped the meter down, she placed it on top of the medication cart with no barrier underneath the meter. Resident 38's record was reviewed on 11/16/23 at 2:15 p.m. The profile indicated the resident diagnosis included, but were not limited to, Type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). 2. During a medication administration observation, on 11/16/23 at 11:09 a.m., RN 4 entered Resident 35's room with a glucometer meter, this was the same meter as used in the above encounter. The nurse placed the glucometer on the resident's bedside table with no barrier underneath the meter. The nurse did not clean the side table prior to placing the glucometer on it. RN 4 obtained the resident's blood sugar and exited the room with the meter, she placed the glucometer on the medication cart, no barrier was placed underneath the meter. Resident 35's record was reviewed on 11/16/23 at 2:30 p.m. The profile indicated the resident diagnosis included, but were not limited to, Type 2 diabetes mellitus. A physician order, dated 5/26/23 indicated obtain an Accu check (quantitatively measures glucose in whole blood) four times a day at 8:00 a.m., 12:00 p.m., 5:00 p.m., and 8:00 p.m. During an interview, on 11/16/23 at 11:37 a.m., the Director of Nursing Services (DNS) indicated nursing staff should place a barrier down underneath the glucometer machine when placing it on a surface. The machine should be cleaned in between residents, and they should allow 3 minutes to dry after a disinfectant wipe is used on the glucometer. On 11/16/23 at 2:05 p.m., the DNS provided a document dated 7/2011, titled, Blood Glucose Meter Cleaning/Disinfecting and Testing, and indicated it was the policy currently being used by the facility. The policy indicated, .6. Wipe extern surface of the blood glucose meter with wipe and allow the surface of the meter to remain wet for 3 minutes .7. Place cleaned meter on paper towel, in plastic cup, or on clean barrier. 8. Allow meter to completely dry .1. Perform hand hygiene .16. Place glucometer on paper towel, plastic cup, or other barrier that was left on the mediation cart 3.1-18(b)(1)

Based on observation, interview, and record review, the facility failed to ensure expired medications were disposed of for 1 of 2 medication carts reviewed (Resident 38 & 35). Finding includes: 1a. On 11/16/23 at 9:57 a.m., the 100-hall medication cart contained an insulin (medication used to lower blood sugar) vial that had an open date of 10/14/23. The vial contained a label that indicated it was for Resident 38. During an interview, on 11/16/23 at 9:57 a.m., Registered Nurse (RN) 4 indicated insulin was good for 30 days once opened. She further indicated Resident 38's insulin vial should have been discarded. Resident 38's record was reviewed on 11/16/23 at 11:45 a.m. The profile indicated the resident's diagnosis included, but were not limited to, Type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). A physician order, dated 6/29/23, insulin lispro (insulin medication) 100 unit/ml (milliliter), by subcutaneous (under the skin) injection. Inject 30 units three times a day. 1b. On 11/16/23 at 9:57 a.m., the 100-hall medication cart contained a NovoLog (insulin medication) pen with an open date of 9/22/23. The insulin pen contained a label that indicated it was for Resident 35. During an interview, on 11/16/23 at 9:57 a.m., RN 5 indicated the insulin pen for Resident 35 was expired and should have been discarded. Resident 35's record was reviewed on 11/16/23 at 12:00 p.m. The profile indicated the resident's diagnosis included, but were not limited to, Type 2 diabetes mellitus with ketoacidosis without coma (a condition develops when the body can't produce enough insulin). A physician order, dated 5/25/23, with a discontinue date of 10/31/23, Novolog pen 100 unit/ml, by subcutaneous inject. Inject 35 units at bedtime. During an interview, on 11/16/23 at 10:12 a.m., Licensed Practical Nurse (LPN) 5 indicated insulin was good for 30 days once it had been opened. On 11/16/23 at 2:05 p.m., the Director of Nursing Services (DNS) provided and identified a document as a current facility policy, titled, Storage and Expiration Dating of Medications, Biologicals, with a revised date of 7/21/22. The policy indicated, .5.3 If a multi dose vial of an injectable medication has been opened or accessed, the vial should be dated and discarded within 28 days On 11/16/23 at 2:05 p.m., the DNS provided an undated document and identified it as the currently facility policy titled, Insulin Vials and Pens. The policy indicated, .discard after 28 days 3.1-25(j)

Based on observation, record review, and interview, the facility failed to ensure proper handling of oral medications during the medication administration pass and failed to ensure expired insulin medication was not administered to a resident resulting in a medication error rate of greater than 5 percent (Residents 46, 38, and 35). Findings include: 1a. During a medication administration observation, on [DATE] at 9:20 a.m., Registered Nurse (RN) 4 was preparing oral medications for Resident 46. The nurse dropped a Sertraline (anti-depressant medication) pill onto the top of the medication cart from the pill pack, she picked up the pill with her bare hand and placed it into the medication cup to be administered. RN 4 administered the Sertraline pill along with other medications to the resident. Resident 46's record was reviewed on [DATE] at 2:00 p.m. The profile indicated the resident's diagnosis included, but were not limited to, major depressive disorder (mental health condition that causes a persistently low or depressed mood and loss of interest in activities that once brought joy). A physician order, dated [DATE], indicated Sertraline 50 milligram (mg) give one tablet orally once a day. 1b. During a medication administration observation, on [DATE] at 9:40 a.m., RN 4 was preparing oral medications for Resident 38. The nurse dropped a Tradjenta (anti-diabetic medication) pill onto the top of the medication cart from the pill pack, she picked up the pill with her bare hand and placed it into the medication cup to be administered. RN 4 administered the Tradjenta pill along with other medications to the resident. Resident 38's record was reviewed on [DATE] at 2:15 p.m. The profile indicated the resident diagnosis included, but were not limited to, Type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). A physician order, dated [DATE], indicated Tradjenta 5mg, give one tablet orally once a day. 1c. During a medication administration observation, on [DATE] at 11:10 a.m., RN 4 was preparing oral medications for Resident 35. The nurse placed a Midodrine (medication used to treat low blood pressure) tablet into her bare hand from the pill pack and placed it into the medication cup. The nurse placed a Linzess (a medication used to treat irritable bowel syndrome with constipation) pill into her bare hand from the pill pack and placed it into the medication cup. The nurse dropped a Protonix (relieves symptoms such as heartburn, difficulty swallowing, and cough) pill onto the top of the medication cart from the pill pack, she picked up the pill with her bare hand and placed it into the medication cup. The nurse placed a Norco (pain medication) pill into her bare hand from the pill pack and placed it into the medication cup. RN 4 administered all the above medications to the resident along with other medication in the med cup. Resident 35's record was reviewed on [DATE] at 2:30 p.m. The profile indicated the resident diagnoses included, but were not limited to, Gastro esophageal reflux disease (GERD) (a digestive disease in which stomach acid and or bile irritates the food pipe lining), heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), and Type 2 diabetes mellitus. A physician order, dated [DATE], indicated Midodrine 5mg give one tablet three times a day. A physician order, dated [DATE], indicated Linzess 145 micrograms (mcg) give one capsule once a day. A physician order, dated [DATE], indicated Protonix 40mg give one tablet once a day. A physician order, dated [DATE], indicated Norco 5mg-325mg give one tablet three times a day. 2. During a medication administration observation, on [DATE] at 9:40 a.m., RN 4 was preparing insulin medication to administer to Resident 38. The lispro (anti-diabetic medication) insulin vial was dated [DATE]. The nurse administered the insulin to the resident. A physician order, dated [DATE], insulin lispro (insulin medication) 100 unit/ml (milliliter), by subcutaneous (under the skin) injection. Inject 30 units three times a day. During an interview, on [DATE] at 11:37 a.m., the Director of Nursing Services (DNS) indicated nursing staff should not touch oral medications with their bare hands. The DNS indicated if a pill was dropped onto the medication cart, then the nurse should destroy the medication and should not be given to the resident. She further indicated nursing staff should not administer expired insulin medication. On [DATE] at 2:05 p.m., the DNS provided a document with a revised date of [DATE], titled, General Dose Preparation and Medication Administration, and indicated it was the policy currently being used by the facility. The policy indicated, .3.4 Facility staff should not touch medication when opening a bottle or unit dose package. 3.5 If a mediation which is not in a protective container is dropped, facility staff should discard it according to facility policy .4.1.3 check the expiration date on the medication On [DATE] at 2:05 p.m., the DNS provided an undated document and identified it as the currently facility policy, titled, Insulin Vials and Pens. The policy indicated, .discard after 28 days 3XXX,d+[DATE](c)(2)

Based on observation, record review, and interview, the facility failed to ensure proper storage of respiratory equipment for 2 of 4 residents reviewed for respiratory care (Residents 45 and 63). Findings include: 1. On 11/13/23 at 11:12 a.m., Resident 45's unbagged nebulizer mouthpiece and tubing were observed on the resident's nightstand table next to the nebulizer machine along with an unbagged CPAP (continuous positive airway pressure) mask and it was on lying top of the CPAP machine. On 11/14/23 at 11:47 a.m., Resident 45 was observed sitting up in his wheelchair in his room. An unbagged nebulizer mouthpiece, tubing, and CPAP mask were observed on his nightstand table. The nebulizer mouthpiece was sitting next to the nebulizer machine and the CPAP mask was on top of the CPAP machine. On 11/15/23 at 9:45 a.m., Resident 45 was sitting up in his wheelchair asleep in his room. An unbagged nebulizer mouthpiece, tubing, and CPAP mask were observed on his nightstand table. The nebulizer mouthpiece was sitting next to the nebulizer machine and the CPAP mask was next to the CPAP machine. On 11/17/23 at 8:48 a.m., Resident 45 was sitting up in his wheelchair eating breakfast in his room. An unbagged nebulizer mouthpiece, tubing, and CPAP mask were observed on his nightstand table. The nebulizer mouthpiece was sitting next to the nebulizer machine and the CPAP mask was next to the CPAP machine. Resident 45's record was reviewed on 11/14/23 at 2:07 p.m. The profile indicated the resident diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD- a group of diseases that cause airflow blockage and breathing-related problems) and acute and chronic respiratory failure with hypoxia ( acute or chronic impairment of gas exchange between the lungs and the blood causing hypoxia [ inadequate supply of oxygen] with or without hypercapnia [too much carbon dioxide in your blood]). A significant change Minimum Data Set (MDS) assessment, dated 10/30/23, indicated the resident was cognitively intact and received oxygen therapy. A care plan, dated 7/19/23, indicated resident has potential for impaired gas exchange related to shortness of breath while lying flat secondary to COPD, chronic diastolic congestive heart failure (a condition in which your heart's main pumping chamber becomes stiff and unable to fill properly), and OSA (obstructive sleep apnea). Interventions included but were not limited to CPAP as ordered, administer oxygen as ordered, and administer meds as ordered. A physician order, dated 10/25/23, indicated ipratropium-albuterol solution (a medication that can help people with lung problems, like asthma or obstructive pulmonary disease, breathe easier) 0.5 milligrams (mg) - 3mg/3 milliliters (ml) 1 ampule via inhalation twice daily. A physician order, dated 10/27/23, indicated CPAP to be set a 20 twice daily. On at bedtime and off upon waking. During an interview, on 11/16/23 at 9:55 a.m., Registered Nurse (RN) 4 indicated nebulizer mouthpiece and tubing should be placed in a bag when not in use. During an interview, on 11/17/23 at 9:31 a.m., Infection Preventionist Nurse indicated the CPAP masks should be bagged when not in use. 34525 2. During the initial pool observation, on 11/13/23 at 10:39 a.m. Resident 63's nebulizer (an electrically powered machine that turns liquid medication into a mist so that it can be breathed directly into the lungs through a face mask or mouthpiece) was observed sitting on top of the resident's bed side table and was un-bagged. During a random observation, on 11/13/23 at 2:15 p.m., Resident 63's nebulizer was observed sitting on top of the resident's bed side table and was un-bagged. Resident 63's record was reviewed on 11/15/23 at 9:21 a.m. The profile indicated the resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD-a group of diseases that cause airflow blockage and breathing-related problems). A significant change Minimum Data Set (MDS) assessment indicated the resident had a diagnosis of COPD and was short of breath (SOB) when lying flat. A care plan, dated 9/21/23, indicated the resident required hospice (end of life) services related to the diagnosis of COPD. A physician's order, dated 11/7/23 and discontinued (DC'd) on 11/14/23, indicated ipratropium-albuterol solution (a class of medication called bronchodilators-relaxes the muscles in the lungs and widening the airways [bronchi]) for nebulization; 0.5 (milligrams) mg-3 mg (2.5 mg base)/3 (milliliters) mL inhalation, three times daily. A physician's order, dated 11/7/23 and DC 'd on 11/15/23, indicated ipratropium-albuterol solution for nebulization; 0.5 mg-3 mg (2.5 mg base)/3 mL inhalation, as needed. A physician's order, dated 11/15/23, indicated ipratropium-albuterol solution for nebulization; 0.5 mg-3 mg (2.5 mg base)/3 mL inhalation, every 4 hours as needed. During an interview, on 11/17/23 at 9:33 a.m., Infection Preventionist (IP) 7 indicated nebulizer masks should be stored in a bag when not being used. On 11/15/23 at 11:57 a.m., the Director of Nursing Services (DNS) provided an undated document titled, Aerosolized Medication Therapy, and indicated it was the policy currently used by the facility. The policy indicated, .Procedure: .16) When finished, place the nebulizer in a labeled bag with patient name and date. 17) Change the nebulizer equipment weekly or according to your company's policy On 11/17/23 at 10:10 a.m., the IP provided an undated document titled, Cleaning Nebulizer, and indicated it was the policy currently being used by the facility. The policy indicated, .5. Shake off excess water and lay on clean paper towel or towel dry. 6. Once dry reassemble and place in clear labeled bag. 3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to ensure a resident's indwelling urinary catheter (a semi-flexible plastic tube with one end inserted into the bladder) attached to a urinary drainage bag (a bag that collects urine) did not touch the floor for 1 of 1 resident reviewed for catheter care (Resident 75). Findings include: On 11/13/23 at 9:33 a.m., Resident 75 was observed lying in bed with a foley catheter drainage bag attached under the wheelchair next to the bed. The drainage bag was uncovered and was touching the floor. On 11/15/23 at 9:56 a.m., Resident 75 was observed sitting in wheelchair asleep. The foley catheter bag was in a dignity bag (a urinary drainage bag holder which restores the dignity of catheterized patients by concealing urinary drainage bags from public view) which was attached to the underside of the wheelchair. The bag and catheter tubing were touching the floor. On 11/15/23 at 10:00 a.m., Licensed Practical Nurse (LPN) 5 indicated the foley drainage bag and tubing should not be touching the floor. On 11/15/23 at 12:36 p.m., Resident 75 was observed sitting in a wheelchair while being transported toward the dining area. The foley drainage bag was inside of a dignity bag attached to the underside of the wheelchair. The bag and tubing were dragging on the floor while the resident was being transported. On 1/15/23 at 12:17 p.m., LPN 8 indicated the catheter bag should not be attached to the wheelchair while the resident was in bed. The LPN indicated the resident transfers himself to bed at times. The LPN acknowledged the resident should have a leg bag to prevent trauma, and the drainage bag which was attached to the wheelchair should be placed into a dignity bag and it should not be touching the floor. On 11/15/23 at 11:16 a.m., clinical record review of Resident 75. Diagnoses include, but are not limited to paroxysmal atrial fibrillation (an irregular heart rhythm that begins in the upper atria of your heart), urinary tract infection (includes cystitis, infection of the bladder/lower urinary tract), ischemic cardiomyopathy (refers to heart weakening caused by reduced blood flow to your heart), ventricular fibrillation (a type of arrhythmia, or irregular heartbeat, that affects your heart's ventricles), hypotension (low blood pressure), muscle weakness (generalized) and difficulty in walking. Physicians Orders included but are not limited to, up as needed in wheelchair with assistance, change foley catheter, and urinary drainage bag as needed for dislodgement, leakage, or occlusion. Foley catheter care, catheter securement device in place (a device to secure the catheter to the leg, preventing displacement of the tube), nurse to record output every shift, foley catheter size 16 French (Fr) with 10 milliliter (ml) bulb. A significant change, Minimum Data Set (MDS) a standardized assessment tool that measures health status in nursing home residents), dated 11/6/23, indicated the resident had an indwelling foley catheter during the assessment period. A care plan, dated 10/10/23, indicated the resident required an indwelling urinary catheter related to urinary retention (a condition in which you are unable to empty all the urine from your bladder). The goal was the resident will have catheter care managed appropriately as evidenced by not exhibiting signs of urinary tract infection or urethral trauma. A nursing intervention, dated 10/10/2023, indicated do not allow tubing or any part of the drainage system to touch the floor. On 11/16/23 at 3:45 p.m., the Director of Nursing Services (DNS) provided a document, titled, Nursing dated 02/2012, 06/2023, and indicated it was the policy currently being used by the facility. The policy indicated, .COMPONENTS/GUIDELINES .2. RESIDENT CARE EQUIPMENT .b. Urinary catheters should have a catheter bag cover over them or a wash basin underneath them as a barrier to prevent catheter bag or tubing from touching the ground 3.1-41(a)(1)

Based on record review and interview, the facility failed to ensure pain assessments were completed for residents who were administered pain medication for 4 of 5 residents reviewed for unnecessary medication (Residents 34, 58, 59, and 24). Findings include: 1. Resident 34's record was reviewed on 8/16/22 at 1:08 p.m. The record indicated the resident had been admitted to the facility on [DATE]. The profile indicated the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission Minimum Data Set (MDS) assessment, dated 4/21/22, indicated the resident had no cognitive deficit, reported frequent moderate pain, received as needed (PRN) opioid (substances that act on opiod receptors to produce [MEDICATION(S)]-like effects) pain medications. A care plan, dated 4/18/22, indicated the resident was at risk for pain related to trimalleolar fracture with surgical repair and history of low back pain. Interventions included, but were not limited to, administer medications as ordered. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Schedule IV tablet (drugs with a low potential for abuse and low risk of dependence), 50 milligrams (mg). Administer 50 mg, by mouth, every 4 to 6 hours, PRN, for mild to moderate pain. Review of the April 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the May 2022 MAR, indicated the medication had been administered 30 times: 26 administrations lacked documentation of the pain intensity and 12 administrations lacked documentation of the location of the pain. Review of the June 2022 MAR, indicated the medication had been administered 5 times: 4 administrations lacked documentation of the pain intensity and 1 administration lacked documentation of the location of the pain. Review of the July 2022 MAR, indicated the medication had been administered 7 times: 2 administrations lacked documentation of the pain intensity and 4 administration lacked documentation of the location of the pain. Review of the August 2022 MAR, indicated the medication had been administered 2 times. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Resident 58's record was reviewed on 8/17/22. The profile indicated diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 7/25/22, indicated [MEDICATION(S)] 50 milligrams (mg) (medication used to relieve moderate to moderately severe pain) by mouth routinely twice a day. Review of the July and August 2022, Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The record lacked documentation of effectiveness and no documentation of severity of pain for the doses administered. During an interview, on 8/19/22, the Director of Nursing (DON) indicated that the pain assessments should have been ordered but got missed and were not done. 3. Resident 24's record was reviewed on 8/16/22 at 1:23 p.m. A quarterly Minimum Data Set (MDS) assessment, dated 6/9/22, indicated the resident had a severe cognitive impairment, received scheduled and as needed (PRN) pain medication, and reported occasional mild pain during the assessment period. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, initiated 9/7/21, indicated the resident was at risk for pain related to right hip hemiarthroplasty (surgical fracture repair). Interventions included, but were not limited to, administer medications as ordered, notify the physician if pain was unrelieved or worsening, and observe for non verbal signs of pain. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A MAR, dated August 2022, indicated the resident received 8 administrations of [MEDICATION(S)]-acetaminophen 5-325 mg one tablet: 6 administrations lacked documentation of the location and severity of the resident's pain at the time of the medication administration. 4. Resident 59's record was reviewed on 8/17/22 at 11:06 a.m. A significant change Minimum Data Set (MDS) assessment, dated 7/15/22, indicated the resident had a moderate cognitive impairment, received scheduled and as needed (PRN) pain medication, and reported occasional moderate pain during the assessment period. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A MAR, dated August 2022, indicated the resident received 5 administrations of [MEDICATION(S)]-acetaminophen 5-325 mg one tablet: 3 administrations lacked documentation of the location and severity of the resident's pain at the time of the medication administration. During an interview, on 8/17/22 at 9:35 a.m., the Director of Nursing (DON) indicated documentation on intensity, location of the resident's pain, and the effectiveness of the pain medication, should be completed, whenever a pain medication was administered. On 8/17/22 at 10:24 a.m., the DON provided a document titled, Pain Management, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure: 1. Residents are assessed for pain upon admission, weekly and during medication administration as outlined below .3. Interviewable Resident-Pain medications will be prescribed and given based upon the intensity of the pain as follows using the verbal descriptive, numerical scale (1-10) or Wong-Baker FACES Scale .No-Interviewable Resident-Pain medications will be prescribed and given based upon nursing assessment of the following .6. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 7. Residents receiving routine pain medication should be assessed each shift by the charge nursing during rounds and/or medication pass .9. Additional information including, but not limited to reasons for administration, and effectiveness of pain medication will be documented on the Medication Administration (MAR), or on the facility specific pain management flow sheet 3.1-48(a)(3)

Based on record review and interview, the facility failed to ensure concerns expressed by the Resident Council were addressed by the facility administration for 2 of 4 months of resident council minutes reviewed for grievance responses. Findings include: Resident Council minutes were provided by the Activity Director (AD) on 8/18/22 at 12:01 p.m. The AD indicated she took minutes for the Resident Council meetings. The meeting minutes included the months of May, June, July, and August 2022 and indicated the following concerns by the Resident Council: 1. On 5/5/22 - Staff were coming into the residents' rooms, turning off the call lights and saying they would be right back and then they did not return. 2. On 6/6/22 - Residents' call lights being turned off and staff expressed they would return but did not return. 3. On 7/11/22 - Residents' call lights being turned off and staff expressed they would return but did not return. The food did not look and taste good and was not served at the appropriate temperature. 4. On 7/26/22 - Staff continued to turn off Residents' call lights and say they will be back. Resident council indicated that the staff did not return. The food did not look and taste good and was not served the appropriate temperature. 5. On 8/8/22 - Staff continued to turn off residents' call lights and say they will be back. Resident council indicated that the staff did not return. The food was not served at the appropriate temperature. On 8/22/22 at 3:34 pm., the Executive Director (ED) indicated she was the grievance official for the facility and had handwritten the responses for the resident council concerns for the June and July 2022 meetings on the resident council meeting minutes form. She had not responded to the resident council concerns on the minutes form for the months of May and August 2022 meeting minutes. The ED indicated she had addressed the following concerns: 1. Regarding the residents' call lights being turned off. Response was Spoke with staff and memo placed about this concern asking the staff to leave the light on if they cannot address the residents' needs themselves immediately. 2. Regarding the temperature of the food. The response was Memo sent out to the staff to close the cart door between tray service. Trays leave the kitchen hot, cooling off during service. Meals served in the dining room will be served hot right off the serve line. Everyone was welcome to come down to the dining room for meals. On 8/18/22 at 1:15 p.m., the AD provided and a identified a document as a current facility policy, titled Resident Council, dated 2/2020. The policy indicated, .Policy: .The facility will promote and support the residents' right to participate and organize resident council. The council will be used to communicate concerns, give suggestions for future programming and events, and otherwise participate in and guide facility life .Procedure: .Concerns or suggestions from the meeting will be addressed by the appropriate department. The Executive Director will review all minutes and concern to ensure thorough resolution of concerns 3.1-7(a)(2)

Based on interview, observation, and record review, the facility failed to ensure the temperature and palatability of food served for 1 of 1 test tray reviewed for temperature and palatability (Residents 59, 47, and 27). Findings include: During an interview, on 8/15/22 at 10:24 a.m., Resident 59 indicated she ate meals in the dining room and the food, at times, was not good and was cold. During an interview, on 8/15/22 at 10:36 a.m., Resident 47 indicated she ate meals in her room and the food was often cold, when her meal came to her room. During an interview, on 8/15/22 at 11:21 a.m., Resident 27 indicated she ate meals in her room. The food was lousy, their combinations were not good, and often the food temperatures were not good. On 8/18/22 at 12:01 p.m., the Activity Director (AD) provided 4 months of Resident Council meeting minutes. The minutes from the 7/11/22 meeting indicated the food did not look nor taste good and the temperature of the food was not appropriate. The minutes from the 7/26/22 Resident Council meeting indicated the temperature of the food was not appropriate. The Executive Director (ED) had responded on the minutes and indicated a memo was sent out to staff to close the cart door between tray service. The trays leave the kitchen hot and are cooling off during service. Meals served in the dining room would be served hot right off the serving line. Everyone was welcome to come to the dining room to eat. The 8/8/22 Resident Council minutes indicated the food looked fine but tasted terrible and was not the appropriate temperature. The ED had responded on the minutes and indicated had been reviewing with hall staff to keep food cart door closed between trays as much as possible. During an interview, on 8/22/22 at 10:48 a.m., Dietary Manager (DM) indicated food temperatures would be taken when food came out of the oven, after being placed onto the steam table, and prior to being plated. Hall trays would be placed into the hall carts and covered with insulated lids and heated bases. During a random kitchen observation, on 8//22/22 at 11:04 a.m., food temperatures were taken after placement onto the steam table. The chicken patties temperatures measured at 155 degrees Fahrenheit and the sweet potatoes temperatures measured at 160 degrees Fahrenheit. On 8/22/22 at 12:39 p.m., test tray food temperatures were measured by the DM. The chicken patty temperature measured at 116 degrees Fahrenheit and the sweet potatoes temperature measured at 117 degrees Fahrenheit. DM indicated the food temperatures should be between 115 degrees Fahrenheit to 140 degrees Fahrenheit. On 8/22/22 at 3:08 p.m., DM provided an email correspondence document, dated 8/22/22, between herself and the Sr. Regional Dietician, which indicated, .Hey guys have a question. Where is or do, we have a policy on what temp the food can or should be for hall trays/after leaves the kitchen? Like a test tray .of the end of the hall The Sr. Regional Dietician had responded, .Hi there! There is no set temperature other than palatable which is determined by the resident eating the food. The food needs to be at hot and cold holding temps before leaving tray line On 8/22/22 at 3:30 p.m., the DM provided and identified a document as a current facility policy, titled Food Temperatures, dated 06/21. The policy indicated, .Procedure: .Hot food will be held at or above 135 degrees Fahrenheit. If the minimum temperature requirements are not maintained, food will need to be reheated to a minimum of 165 degrees Fahrenheit before serving 3.1-21(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident at high risk for falls was free of accidents for 1 of 3 residents reviewed in yellow zone (unknown COVID-19 diagnosis) quarantine with high fall risk assessment (Resident B ) when the door to their room was closed during an isolation quarantine upsetting the resident and resulted in a fall with fracture that required hospitalization . Finding includes: During initial tour on 12/2/20 at 10:10 a.m., Resident B was observed through a door slightly opened, sleeping in a low bed with a fall matt on the floor at the side of the resident's bed. During the observation Registered Nurse (RN) 10 was interviewed. She identified Resident B as confused with history of a fall. On 12/2/20 at 10:25 p.m., Certified Nursing Assistant (CNA) 4 was interviewed. She indicated today was the first day doors to residents' rooms could be opened. This made it a lot easier to check on residents, especially those who were fall risks. Resident B's clinical record was reviewed on 12/3/20 at 2:00 p.m. A quarterly Minimum Data Set assessment, dated 10/12/20, coded the resident with severe cognitive impairment, required extensive assistance of two for bed mobility, transfers, and extensive assistance of one for locomotion. The assessment indicated the resident had two or more falls without major injury since prior assessment. A fall risk assessment, dated 10/12/20, indicated the resident was a high fall risk. An update to a care plan that addressed falls, on 11/25/20, indicated the resident's door may be kept open for closer observation while in isolation related to fall with injury. Nursing progress notes, dated 11/23/20 at 5:25 p.m., indicated, Resident was placed in droplet plus precautions following contact tracing as facility received notification today that a member from an outside agency completing their clinical training tested positive for COVID 19 A progress note, on 11/24/20 at 10:54 a.m., indicated, Resident is having difficulty understanding current isolation precautions. Resident currently yelling out and screaming r/ t (related to) door having to be shut because of isolation. Writer has asked resident not to scream out. Will continue to monitor resident. On 11/24/20 at 12:28 p.m., a progress note included, Resident was found on floor face down in room. Resident had large hematoma (collection of blood outside of blood vessels) to forehead that was bleeding. Resident has laceration to nose also that was also bleeding. Resident was moved from floor to bed. Writer notified MD (medical doctor) and received orders to send to hospital A progress note, dated 11/25/20 at 8:49 a.m., indicated an update from the hospital included resident had a nasal fracture, otherwise was stable. Documentation indicated the resident returned from the hospital on [DATE] at 5:45 p.m. The return assessment included the resident's face was bruised, bilateral eyes swollen, a large hematoma to the center of her forehead with sutures, both eyes, forehead, face with black blue purplish red bruising. Resident medicated with Tylenol (pain medication) for complaint of pain. An Interdisciplinary Team (IDT) fall review, dated 11/25/20 at 5:30 p.m., included but was not limited to, Staff standing outside resident's room responded to loud noise in room, opened door and found resident lying face down on the floor in front of closet with blood noted on wall and floor as well as resident's hands During the exit conference on 12/3/20 at 3:50 p.m., the Director Of Nursing indicated they had kept the doors of residents' rooms in the yellow isolation rooms closed in an effort to prevent residents from exiting their rooms and potentially spreading the COVID-19 virus. The facility policy titled, Standard and Transmission-Based Precautions (Isolation) Policy, with most recent revision date of November 2020, provided by the Administrator on 12/4/20 at 3:28 p.m., included but was not limited to, .DROPLET PLUS PRECAUTIONS: is used to designate transmission-based precautions beyond droplet precautions for residents with unknown COVID-19 status under 14-day observation, COVID-19 suspected or positive residents, and the use of N-95 or approved KN95 mask. The door may remain open except during an aerosol generating procedure unless a resident's safety dictates otherwise (i.e. fall risk, bedbound who are in critical need of observation). This Federal tag relates to Complaint IN 395. 3.1-45(a)