Every finding on record at Stonebrooke Rehabilitation Center

Based on interview and record review, the facility failed to ensure a resident was free from mental abuse by a staff member obtaining a photograph of the resident's genitalia without the resident's permission and showing other staff members resulting in unauthorized photographs taken for 1 of 4 residents reviewed for abuse. (Resident B) Using the reasonable person concept, it is likely this would lead to humiliation, confusion, anxiety, and embarrassment for Resident B. Findings include:The clinical record for Resident B was reviewed on 6/12/26 at 10:26 a.m. The diagnoses included, but were not limited to, morbid (severe) obesity, Alzheimer's disease (progressive, irreversible brain disorder that slowly destroys memory and thinking skills) with late onset, major depressive disorder, and anxiety. A physician's order, dated, 2/3/26, indicated Resident B had Dakin's Solution (a diluted hospital-grade bleach formula used as an antiseptic to cleanse wounds) with special instructions to cleanse scrotal abscess with NS (Normal Saline), pat dry, pack open area with Dakin's Solution, and cover with pad. A Facility reported incident, dated 2/8/26 at 8:55 a.m. indicated staff member took unauthorized photo of a resident. A phone interview with Certified Nursing Assistant (CNA) 2, dated 2/8/26 at 10:23 a.m., indicated she did take a picture of Resident B's wound earlier in the week of 2/2/26. CNA 2 indicated she was unsure what day she took the picture or what nurse she showed it to and was unsure if she had shown any other staff members as well. During an interview with Qualified Medical Assistant (QMA) 5/Family Member on 6/12/26 at 1:20 p.m., indicated CNA 6 called her the morning of 2/8/26, and told her she needed to tell her something about her father. CNA 6 indicated CNA 2 had walked up to her at work and took out her cell phone and said, here, look at Junior's balls. QMA 5/Family Member indicated she did not tell her father or any family members that a photo had been taken of his genital area because of how upset they would have been. QMA 5/Family Member indicated she never wanted to see any photographs of Resident B's wound let alone his genitalia. During an interview with CNA 3 on 6/12/26 at 5:30 p.m., indicated on 2/2/26 she and CNA 2 were providing incontinent care to Resident B after a bowel movement. CNA 3 indicated Resident B had an extensive wound to his scrotal area and she had asked CNA 2 to take out her flashlight on her phone so that she could make sure that she got all of the stool off of Resident B. CNA 3 indicated CNA 2 stated, we should take a picture to show QMA 5/Family Member. CNA 3 indicated she told CNA 2 not to take a photo and that QMA 5/Family Member did not want to see a picture of the wound and she did not know that she did take a picture until she was later questioned by the facility. CNA 3 instructed CNA 2 that if she thought Resident B's wound needed to be looked at, then she should have Licensed Practical Nurse (LPN) 4 look at it. During an interview with LPN 4 on 6/15/26 at 8:14 a.m. indicated back in February, CNA 2 had come up to her on shift and indicated she had taken a photograph of Resident B's wound if she wanted to look at it. LPN 4 informed CNA 2 that she did not want to see a photo of Resident B's wound and would see the wound when she did her assessment. LPN 4 indicated she explained HIPPA (Health Insurance Portability and Accountability Act) laws to CNA 2 and explained there was a very thin line between that and abuse. LPN 4 encouraged CNA 2 to delete the photograph and to her knowledge she did, until she was later questioned by staff about it. During an interview with CNA 6 on 6/16/26 at 10:59 a.m., indicated they were working with CNA 2 on 2/3/26, when CNA 2 pulled out her cell phone and said, hey, look at this.look at what was on his balls? CNA 6 questioned CNA 2 why she had the photograph, and she indicated to show the nurse his wound. CNA 6 then asked why CNA 2 still had the photograph, and she indicated she did not know, she just thought it was weird. CNA 6 indicated the picture was of Resident B's genitalia and wound. CNA 6 indicated she told QMA 5/Family Member because it was bothering her and she did not feel right about it. A written statement interview, completed by the Social Services Director (SSD) on 2/11/26, indicated Resident B was unaware of anyone taking photos of him and when asked he said, not that I know of. The Abuse Prohibition, Reporting, and Investigation policy was provided by Executive Director 8 on 6/10/26 at 4:34 p.m. It indicated .Policy:.Will prohibit employees from taking pictures or recordings in any manner which would demean or humiliate a resident(s) and/or from taking unauthorized photos.Definitions:.Mental abuse includes what is facilitated or caused by staff taking or using photographs or recordings in any manner that would demean, humiliate, or dehumanize a resident(s). This includes any type of equipment (cameras, smart phones, or any other electronic device) to take, keep, or distribute photographs or recordings.Demeaning or humiliating photographs or videos include nudity.exposed body parts.provision of incontinent care exposing perineal/rectal areas and/or fecal matter on body parts. This Citation relates to intake 2737919410 IAC (Indiana Administrative Code) 16.2-3.1-27(a)(1)

Based on interview and record review, the facility failed to report an allegation of mental abuse of a resident by a staff member taking a picture of the resident's genitalia in a timely manner to the Indiana Department of Health (IDOH) for 1 of 4 residents reviewed for abuse. (Resident B) Finding include: The clinical record for Resident B was reviewed on 6/12/26 at 10:34 a.m. The diagnoses included, but were not limited to, muscle weakness, Alzheimer's disease (progressive, irreversible brain disorder that slowly destroys memory and thinking skills) with late onset, and anxiety. A facility reported incident, dated 2/8/26 at 8:55 a.m., indicated a staff member took unauthorized photo of resident. A phone interview with Certified Nursing Assistant (CNA) 2, dated 2/8/26 at 10:23 a.m., indicated she did take a picture of Resident B's wound earlier in the week of 2/2/26. CNA 2 indicated she was unsure what day she took the picture or what nurse she showed it to and was unsure if she had shown any other staff members as well. During an interview with Qualified Medical Assistant (QMA) 5/Family Member on 6/12/26 at 1:20 p.m., indicated CNA 6 called her the morning of 2/8/26, and told her she needed to tell her something about her father. CNA 6 indicated CNA 2 had walked up to her at work and took out her cell phone and said, look at Resident B's balls. QMA 5/Family Member indicated she did not tell her father or any family members that a photo had been taken of his genital area because of how upset they would have been. QMA 5/Family Member indicated she never wanted to see any photographs of Resident B's wound let alone his genitalia. QMA 5/Family Member indicated she notified Executive Director (ED) 8 the morning of 2/8/26 to inform her of what she was told and indicated ED 8 did not think it was a reportable event at that time. During an interview with CNA 3 on 6/12/26 at 5:30 p.m., indicated on 2/2/26 she and CNA 2 were providing incontinent care to Resident B after a bowel movement. CNA 3 indicated Resident B had an extensive wound to his scrotal area and she had asked CNA 2 to take out her flashlight on her phone so that she could make sure that she got all of the stool off of Resident B. CNA 3 indicated CNA 2 stated, we should take a picture to show QMA 5/Family Member. CNA 3 indicated she told CNA 2 not to take a photo and that QMA 5/Family Member did not want to see a picture of the wound and she did not know that she did take a picture until she was later questioned by the facility. CNA 3 instructed CNA 2 that if she thought Resident B's wound needed to be looked at, then she should have Licensed Practical Nurse (LPN) 4 look at it. During an interview with LPN 4 on 6/15/26 at 8:14 a.m. indicated back in February, CNA 2 had come up to her on shift and indicated she had taken a photograph of Resident B's wound if she wanted to look at it. LPN 4 informed CNA 2 that she did not want to see a photo of Resident B's wound and would see the wound when she did her assessment. LPN 4 indicated she explained HIPPA (Health Insurance Portability and Accountability Act) laws to CNA 2 and explained there was a very thin line between that and abuse. LPN 4 encouraged CNA 2 to delete the photograph and to her knowledge she did, which is why she did not report anything to the facility, until she was later questioned by staff about it. During an interview with CNA 6 on 6/16/26 at 10:59 a.m., indicated they were working with CNA 2 on 2/3/26, when CNA 2 pulled out her cell phone and said, hey, look at this.look at what was on his balls? CNA 6 questioned CNA 2 why she had the photograph, and she indicated to show the nurse his wound. CNA 6 then asked why CNA 2 still had the photograph, and she indicated she did not know, she just thought it was weird. CNA 6 indicated the picture was of Resident B's genitalia and wound. CNA 6 indicated she did not know how to report it, so she did not report the photo right away. CNA 6 indicated she was written up by the facility for reporting knowledge of the photograph late. During an interview with the Director of Nursing (DON) on 6/16/26 at 1:16 p.m., indicated anyone who knew about the photo should have notified the (ED) immediately so that it could be investigated. The Indiana Department of Health Long-Term Care and Incident Reporting policy, effective 12/8/22, indicated .Procedures and responsibilities: Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse. Staff treatment of residents.(c) The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, are reported immediately to the administrator of the facility. This Citation relates to intake 2737919410 IAC (Indiana Administrative Code) 16.2-3.1-28(c)

Based on interview and record review, the facility failed to timely report an incident of alleged verbal abuse to the Executive Director for 1 of 1 resident reviewed for reporting abuse. (Resident C) Findings include:The clinical record for Resident C was reviewed on 10/22/25 at 1:45 p.m. The diagnoses included, but were not limited to, chronic pain syndrome, major depressive disorder, and hypertension.The annual Minimum Data Set (MDS) assessment, dated 9/25/25, indicated Resident C was cognitively intact.During an interview with Certified Nursing Assistant (CNA) 2 on 10/23/25 at 11:30 a.m., they indicated Resident C was upset and tearful on 10/15/25 after receiving incontinent care from CNA 9. CNA 2 indicated CNA 9 had hushed Resident C when she was apologizing for being wet, making hand gestures for her to shut her mouth and stop talking, and throwing dirty linens on the floor and saying in front of Resident C, great, now I'm covered in piss. CNA 2 indicated she wrote out a statement of the incident and placed it under every director's door the night of 10/15/25, so they received the report on 10/16/25. CNA 2 indicated she should have notified the Executive Director (ED) sooner.During an interview with the Occupational Therapist (OT) on 10/23/25 at 10:26 a.m., they indicated they did a therapy treatment in Resident C's room on 10/15/25 and Resident C was tearful and indicated CNA 9 had rushed in and out of her room earlier that day, hushed her during care and made hand gestures for her to shut her mouth when she was apologizing for being wet. The OT indicated she told the Social Service Director (SSD) that Resident C had some care concerns, and she needed to talk to someone. The OT indicated the Social Service Director (SSD) was in a family meeting at the time and told the OT she would notify the ED once she was done.During an interview with the SSD on 10/23/25 at 11:00 a.m., they indicated the OT informed her on 10/15/25 that Resident C had been crying and to check in on her. The SSD indicated during an interview with Resident C on 10/15/25, she had not indicated to her what had happened that morning with CNA 9. The SSD indicated Resident C did not tell her about CNA 9's care until 10/16/25.During an interview with the Director of Nursing (DON) on 10/23/25 at 1:40 p.m., she indicated she did not know anything about this incident until she came to work the morning of 10/16/25 and there was a statement under her door from CNA 2 explaining the care concerns for Resident C from 10/15/25. The DON indicated once she read CNA 2's statement, she notified the ED who was off of work, who then reported the incident to IDOH (Indiana Department of Health) reporting care concerns.During an interview with the ED on 10/23/25 at 1:30 p.m., she indicated she was not at work when this concern came in and did not know it was an alleged abuse allegation until she began investigating the incident and spoke with Resident C.The Abuse policy was provided by the ED on 10/22/25 at 2:20 p.m. It indicated,.Resident Abuse-Staff member:.2. Any individual who witnesses abuse, or has suspicion of abuse, shall immediately notify the charge nurse of the unit, which the resident resides and to the Executive Director.3.1-28(c)

Based on interview and record review, the facility failed to provide dignified incontinent care for 1 of 3 residents reviewed for dignity (Resident D). Finding include:During an interview with Resident D on 10/22/25 at 1:00 p.m., the resident indicated the facility staff treated her with dignity except CNA 3. CNA 3 was rough during incontinence care and it made her sore. The resident had told CNA 3 to go easy and he would say ok, but did not. CNA 3 was rushing with care and the resident felt it was disrespectful to her. Resident D indicated other than CNA 3 rushing, he was a good guy. The resident had reported this to a nurse and some of the other CNA's about Resident 3 being rough and rushing during care, but did not know their name. The staff have not fill out a grievance for her related to this matter. Review of the clinical record of Resident D on 10/23/25 at 11:31 a.m., indicated the resident's diagnoses included, but were not limited to, acute and chronic diastolic (congestive) heart failure, acute respiratory failure with hypoxia, Chronic obstructive pulmonary disease with (acute) exacerbation, paroxysmal atrial fibrillation, atherosclerotic heart disease of native coronary artery without angina pectoris, iron deficiency anemia, unspecified, Essential (primary) hypertension, type 2 diabetes mellitus with hyperglycemia, mixed hyperlipidemia, pulmonary hypertension, generalized anxiety disorder, major depressive disorder, recurrent, unspecified, obstructive sleep apnea (adult) (pediatric), morbid (severe) obesity due to excess calories, difficulty in walking, not elsewhere classified and Pleural effusion. The admission Minimum Data Set (MDS) assessment for Resident D, dated 10/1/25, indicated the resident was cognitively intact for daily decision making. The resident was reasonable and consistent. The resident had no behavior. The resident was frequently incontinent of urine and always incontinent of bowels. The resident right policy provided by the Executive Director on 10/22/25 at 2:20 p.m., indicated the resident had the right to be treated with dignity and respect. Each resident shall be treated with consideration, respect and full recognition of dignity and individuality, including care of personal needs. The resident had the right to a dignified existence. This citation relates to Intake 2646099.3.1-3(t)

Based on interview and record review, the facility failed to protect the residents' right to be free of verbal abuse for 2 of 4 residents reviewed for abuse. (Resident C and Resident F). Findings include:1. During an interview with Resident C on 10/22/25 at 1:05 p.m., they indicated Certified Nursing Assistant (CNA) 9 had come onto shift one morning to assist CNA 2 with incontinence care. Resident C indicated CNA 9 was upset with her upon entering the room and asked rudely, didn't they change you already?, and indicated she apologized for being wet and she couldn't control her bladder and CNA 9 kept saying hush it and using hand gestures for her to shut her mouth when she was trying to speak. The clinical record for Resident C was reviewed on 10/22/25 at 1:45 p.m. The diagnoses included, but were not limited to, lymphedema (swelling in the body's tissues due to blockage in the lymphatic system), hypertensive heart disease, and post-traumatic stress disorder. An admission Minimum Data Set (MDS) assessment, dated 9/25/25, indicated Resident C was cognitively intact, dependent with toileting hygiene, required substantial/maximal assistance with rolling right/left, and was frequently incontinent of bowels and bladder. An incident report was provided by the Executive Director (ED) on 10/22/25 at 1:30 p.m. It indicated Resident C reported concerns with care on 10/16/25. During an interview with CNA 2 on 10/23/25 at 11:30 a.m., they indicated on the morning of 10/15/25 around shift change (5:55 a.m.) Resident C had called out indicating she was dirty and needed cleaned up. CNA 2 indicated CNA 9 had just come onto shift when CNA 2 asked for CNA 9's help to get Resident C cleaned up. CNA 2 indicated CNA 9 entered Resident C's room to assist with incontinence care with CNA 9 told the resident to be quiet, this was not how she wanted to start her day, hushing the resident when she was speaking and made hand gestures for her to shut her mouth. CNA 2 indicated CNA 9 then said, great, now I'm covered in piss. CNA 2 indicated Resident C was crying after the incident. During an interview with the Occupational Therapist (OT) on 10/23/25 at 10:26 a.m., they indicated Resident C was tearful during therapy on 10/15/25 and informed her that CNA 9 had rushed in and out of her room and hushed her during care that morning. During an interview with the Social Service Director (SSD) on 10/23/25 at 11:00 a.m. she indicated Resident C told her on 10/16/25 that on 10/15/25 CNA 9 had hushed her during care and made hand gestures for her to shut her mouth and stop talking. The SSD indicated Resident C was tearful during the conversation. 2. Review of the record of Resident F on 10/23/25 at 2:15 p.m., indicated the resident's diagnoses included, but were not limited to, bipolar disorder, behavioral disturbance, major depressive disorder, anxiety, traumatic brain injury, muscle weakness and hemiplegia affecting the left and right side. The annual Minimum Data Set (MDS) assessment for Resident F, dated 8/29/25, indicated the resident was moderately impaired for daily decision making. The resident had no behaviors. The resident utilized a wheelchair for mobility. The resident was dependent on staff for toileting needs and transfers. The progress note for Resident F, dated 7/18/25 at 10:52 a.m., indicated the resident was resting in bed with no signs of distress noted. The resident was pleasant and smiling, talkative with this writer. Denied any concerns. Skin assessment completed with no abnormal findings. Denied any pain or psychosocial distress/changes. The physician and Executive Director made aware of the alleged incident with a staff member this morning. The incident report and investigation for Resident F, dated 7/18/25, indicated CNA 4 used a harsh tone with speaking with Resident F. CNA 4 was suspended during the investigation. An interview with CNA 5 indicated on 7/18/25 Resident F became upset because there was not a mechanical lift to assist him out of bed and started cussing at the CNA 4 and CNA 5. CNA 4 was cursing at Resident F, but was unsure exactly what was said. CNA 5 heard CNA 4 use the words F--- and S---. CNA 5 reported the incident to the nurse. The employee communication form for CNA 4, dated 7/23/25, indicated the CNA was terminated for resident abuse or neglect or intentional violation of resident rights. The abuse policy provided by the Executive Director on 10/22/25 at 2:20 p.m., indicated each resident would be provided with an environment free of abuse. Abuse included, but were not limited to, verbal abuse and mental abuse. Verbal abuse was the use of oral, written, and/or gestured language that willfully included disparaging and derogatory terms to residents. Mental abuse included, but were not limited to, mocking, insulting, ridiculing and yelling. This citation relates to Intake 2646099. 3.1-27(b)

2. Review of the clinical record of Resident B, on 5/16/25 at 11:51 a.m., indicated the diagnoses included, but were not limited to, diabetes mellitus, major depressive disorder, anxiety disorder, primary open-angle glaucoma, age-related cataract, unspecified hearing loss, and anorexia. The Significant Change MDS assessment, dated 3/26/25, indicated the resident was severely impaired for daily decision making and was dependent on the staff for showers. The preference for customary routine for Resident B, dated 3/26/25, indicated it was very important for the resident to have a shower. The plan of care for Resident B, dated 4/8/25, indicated the resident required assistance with ADLs related to Alzheimer's disease. The interventions included, but were not limited to, offer showers two times a week. Resident B's profile, dated 4/28/25, indicated to provide assistance with bathing as needed per resident preference and offer showers two times per week with a partial bed bath in between. The shower report for Resident B, dated March 2025, indicated the resident received a complete bed bath instead of a shower on 3/4/25, 3/7/25, 3/18/25 and 3/28/25. The shower report for Resident B, dated April 2025, indicated the resident received complete bed bath instead of a shower on 4/4/25, 4/8/25, 4/25/25 and 4/29/25. The shower report for Resident B, dated 5/15/25, indicated the resident received a complete bed bath instead of a shower. During an interview with the Director of Nursing Services (DNS) on 5/19/25 at 2:30 p.m., she indicated the staff were informed of what resident preferences were by the resident profile. The preferences for daily routine provided by the Executive Director, on 5/19/25 at 1:51 p.m., indicated the purpose was to identify and develop a plan of care that reflects a resident's past and current daily customary routines. This citation relates to Complaint IN00459386. 3.1-3(u)(1) Based on observation, interview, and record review, the facility failed to provide showers as preferred for 2 of 3 residents reviewed for activities of daily living (ADLs). (Resident B and Resident E) Findings include: 1. During an interview with Resident E's daughter on 5/14/25 at 1:00 p.m., she indicated she did not think her mother was receiving her showers as regularly as she preferred. The clinical record for Resident E was reviewed on 5/16/25 at 9:42 a.m. The diagnoses included, but were not limited to, dementia, chronic kidney disease, repeated falls, and chronic pain syndrome. The admission Minimum Data Set (MDS) assessment, dated 4/17/25, indicated the resident was severely cognitively impaired for daily decision making. The resident was dependent on the staff for showering. The plan of care for Resident E, dated 4/4/25, indicated the resident required assistance with ADLs related to a mobility deficit, recent right hip fracture, and dementia. The interventions included, but were not limited to, assistance with bathing as needed per resident preference and to offer showers two times per week. The preference for customary routine and activities for Resident E, dated 4/15/25, indicated the resident preferred to have a shower. The shower report for Resident E, dated April 2025, indicated the resident received a bed bath instead of a shower on 4/3/25, 4/7/25, 4/14/25, 4/17/25, 4/22/25, 4/25/25, and 4/29/25. The shower report for Resident E, dated May 2025, indicated the resident received a bed bath instead of a shower on 5/3/25, 5/7/25, and 5/14/25.

Based on observation, interview, and record review, the facility failed to ensure a chair cushion was in place for a resident with stage 2 pressure ulcers (partial thickness skin loss) for 1 of 1 resident reviewed for pressure ulcers. (Resident E) Findings include: The clinical record for Resident E was reviewed on 5/16/25 at 9:42 a.m. The diagnoses included, but were not limited to, dementia, repeated falls, and chronic pain syndrome. During an observation on 5/14/25 at 1:25 p.m., Resident E had a chair cushion laying on the floor beside a chair. An interview with Resident E's daughter at that time indicated she had soiled the cushion the day before. So, the staff took the cover off for washing and put the cushion on the floor. During an observation on 5/15/25 at 10:26 a.m., Resident E was sitting in a wheelchair with no cushion in the seat. The cushion was lying on the floor beside a chair. The admission Minimum Data Set (MDS) assessment, dated 4/17/25, indicated Resident E was severely cognitively impaired, was at risk for pressure ulcers, and used a pressure reducing device for her chair. A wound management detail report, dated 4/28/25, indicated Resident E had stage 2 pressure ulcers to her right and left buttocks. A plan of care for Resident E, dated 4/4/25, indicated the resident was at risk for skin breakdown due to weakness, decline in mobility, and incontinence of bowel and bladder with moist skin. The interventions included, but were not limited to, have a Roho cushion in chair/wheelchair. During an interview with the Executive Director (ED) on 5/19/25 at 2:30 p.m., he indicated it was nursing's responsibility to ensure a cushion was in Resident E's wheelchair. A Skin Management Program policy was provided by the ED on 5/19/25 at 11:27 a.m. The policy indicated .Procedure for Wound Prevention . 3. Interventions to prevent wounds from developing and or promote healing will be initiated based upon the individual's risk factors to include but no limited to the following . All residents who utilize a wheelchair will have a pressure redistribution cushion in chair . 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to ensure proper infection control measures were maintained during incontinence care for 1 of 1 resident observed for pressure ulcers. (Resident E) Findings include: The clinical record for Resident E was reviewed on 5/16/25 at 9:42 a.m. The diagnoses included, but were not limited to, dementia, repeated falls, and chronic pain syndrome. The admission Minimum Data Set (MDS) assessment, dated 4/17/25, indicated Resident E was severely cognitively impaired, was at risk for pressure ulcers, and was dependent on staff for toileting needs. During an observation of Resident E on 5/16/25 at 9:51 a.m., Certified Nurse Aide (CNA) 2 and CNA 3 entered Resident E's room to clean her up after being incontinent of bowel and bladder while lying in bed. CNA 2 and CNA 3 both donned gowns and gloves due to the resident being in Enhanced Barrier Precautions (EBP) due to wounds on the right and left buttock and labia. CNA 3 was cleaning Resident E's peri-area (area between the anus and the genitals) with a soapy wet washcloth. Each dirty washcloth used was then placed on Resident E's fitted sheet at the end of the bed. After cleaning Resident E's peri-area, the soiled pad underneath her was removed, placed in the trash, and a clean pad was placed underneath the resident. CNA 3 then took the soiled washcloths off the bed and placed them into a plastic bag. The fitted sheet was not changed, and Resident E was then covered with a clean sheet. During an interview with CNA 3 on 5/16/25 at 10:14 a.m., CNA 3 indicated the soiled linens/washcloths should have been placed into a plastic bag after each use to be disposed of and not placed directly onto Resident E's bed. During an observation of Resident E on 5/16/25 at 12:15 p.m., Resident E's daughter pointed out that there was a washcloth with dried up stool laying in Resident E's windowsill and smears of dry stool on the right side of Resident E's fitted bed sheet. An interview was conducted with Registered Nurse (RN) 4 on 5/16/25 at 12:27 p.m. RN 4 indicated the soiled washcloth should have been placed into a plastic bag after use and the soiled sheet should have been changed, bagged, and both taken to the soiled utility room. A Nursing Skills Competency: Perineal Care checklist was provided by the Executive Director (ED) on 5/19/25 at 11:27 a.m. It indicated to gather supplies including plastic bag at foot of bed or on chair for soiled linens. 3.1-18(b)(4)

Based on observation, interview, and record review, the facility failed to ensure a resident was weighed, as ordered, and a resident was provided with an adaptive drinking device, as ordered, for 2 of 6 residents reviewed for nutrition. (Resident 50 and Resident 59) Findings include: 1. The clinical record for Resident 59 was reviewed on 5/15/25 at 12:39 p.m. His diagnoses included, but were not limited to, hemiplegia and hemiparesis and malnutrition. He was admitted to the facility on [DATE]. The 5/6/25 ADL (activities of daily living) care plan indicated he required assistance with eating with an intervention to assist with eating and drinking, as needed. The vitals section of the clinical record indicated a weight of 100 pounds and a BMI (body mass index) of 16.64 (less than 18.5 was considered underweight) on 5/5/25. The 5/5/25 Malnutrition Criteria assessment indicated he met the criteria for malnutrition. The physician's orders indicated, Regular, Honey Thick/Moderately Thick, Pureed, Special Instructions: magic cup with breakfast and lunch; nosey cup, effective 5/14/25. An observation of Resident 59 was conducted on 5/15/25 at 12:40 p.m. He was in bed in his room with his lunch meal in front of him on his bedside table. His food was pureed, and he had what appeared to be vomit on the cloth napkin placed over his chest. His drink was in a regular cup, not a nosey cup. Resident 59 attempted to take a drink from the cup. Some of the liquid from the cup went into his mouth, but most of it ran out of the underside of the cup onto his chin and onto the napkin. LPN (Licensed Practical Nurse) 5 was retrieved for observation at that time. An interview was conducted with LPN 5, on 5/15/25 at 12:46 p.m., after the above observation. He indicated Resident 59 did not have a nosey cup, and it was not on his meal ticket for him to have one. The 5/15/25 lunch meal ticket for Resident 59 did not reference a nosey cup. The Adaptive Eating Devices policy was provided by the Executive Director on 5/19/25 at 1:05 p.m. It indicated Adaptive eating devices are available for those who need them . The type of adaptive equipment needed will be listed on the tray ticket and culinary will provide as ordered. 2. The clinical record for Resident 50 was reviewed on 5/16/25 at 9:27 a.m. The diagnoses included, but were not limited to, Alzheimer's disease and atrial fibrillation. A physician's order, dated 2/12/25, indicated Resident 50 was to have bi-weekly weights, on the 1st and 3rd Monday of the month. A Quarterly Minimum Data Set (MDS) assessment, dated 3/5/25, indicated Resident 50 was severely cognitively impaired and had weight loss of 5% or more in the last month. A follow-up nutrition review, dated 3/5/25, indicated Resident 50 had a weight loss of 10.2% in 17 days. The Electronic Health Record (EHR) for Resident 50 recorded the following weights: 2/4/25- 147 pounds, 2/21/25- 132 pounds, 4/7/25- 126 pounds, 4/23/25- 121 pounds, and 5/7/25- Weight not obtained due to refusal. The Treatment Administration Record (TAR), for March 2025, indicated Resident 50 did not have any weights recorded for the month or refusals of weights documented. The plan of care for Resident 50, dated 5/1/24, indicated the resident was at a nutritional risk, related to weight loss. The interventions included, but were not limited to, monitoring weight. During an interview with the Director of Nursing Services (DNS) on 5/19/25 at 2:36 p.m., she indicated it was nursing's responsibility to obtain weights and to document any refusals of weight in the EHR. The DNS indicated she did not know why Resident 50's weights were not obtained in March 2025. A Resident Weight Monitoring policy was provided by the Executive Director (ED) on 5/19/25 at 1:53 p.m. It indicated .to weigh residents no less than monthly or per physician orders .4. Bi-Monthly Weights will be obtained at a minimum for the following residents: Residents who may be at risk for insidious weight loss .Residents who have experienced a significant weight loss of 5% in 30 days, 7.5% in 90 days or 10% in 180 days . 3.1-21(h) 3.1-46(a)(1)

Based on observation, interview, and record review, the facility failed to implement interventions when residents were kissing in the common area on the memory care unit for 1 of 1 observation of behaviors (Resident 35 and Resident 53). Findings include: During an observation on 5/14/25 at 1:22 p.m., Resident 35 was sitting at a dining room table when Resident 53 bent down and kissed Resident 35 on the lips. This was reported to Registered Nurse (RN) 7. Certified Nurse Aide (CNA) 6 attempted to separate the residents and was unable to. Resident 35 and Resident 53 were holding hands, going up and down the hallway, and into their shared bedroom with the door shut unsupervised. CNA 6 indicated she attempted to separate them, but they were roommates and there was nothing she could do. CNA 6 indicated the residents were care planned for behaviors, but she was unsure what the interventions were. RN 7 was unsure what the interventions were and was looking them up on the computer. The Memory Care Coordinator indicated she had not seen this behavior of them kissing before and only previously noted the residents' holding hands. During an observation at 1:43 p.m., Resident 35 and Resident 53 continued to walk down the hallway while holding hands and going into their bedroom unsupervised with the door shut. When queried at 1:47 p.m., what the Memory Care Coordinator was going to do about this behavior, she indicated she did not know what to do because she had not dealt with this type of behavior before. The Memory Care Coordinator indicated she would talk to someone about it and probably would have to separate them. During this observation, no staff attempted to intervene between Resident 35 and Resident 53 for 25 minutes. Review of the record of Resident 35, on 5/16/25 at 11:20 a.m., indicated the diagnoses included, but were not limited to, Alzheimer's disease, dementia, major depressive disorder, anxiety, and psychotic disorder with delusion. The Significant Change Minimum Data Set (MDS) assessment for Resident 35, dated 3/16/25, indicated the resident was severely impaired for daily decision making. The resident had wandering that significantly intruded on the privacy of other residents. Review of the record of Resident 53, on 5/19/25 at 11:48 a.m., indicated the diagnoses included, but were not limited to, Alzheimer's disease, dementia, and major depressive disorder. The Annual Minimum Data Set (MDS) assessment for Resident 53, dated 3/18/25, indicated the resident was severely impaired for daily decision making. The resident had wandering that significantly intruded on the privacy of other residents. A progress note for Resident 53, dated 5/15/25 at 10:02 a.m., indicated the resident was found kissing a peer. The staff attempted to redirect the resident. The potential root cause was unmet affection. After lunch staff were cleaning up and the environment was noisy and busy. The resident had a cognitive decline and had dementia. The staff were to redirect the resident from others and into an activity. The resident was also moved to another room. During an interview with the Executive Director on 5/19/25 at 11:28 a.m., he indicated the facility did not have a dementia care policy. During an interview with the Director of Nursing Services (DNS) on 5/19/25 at 2:27 p.m., she indicated the nurses had access to the care plans and CNAs had access to the resident's profile. The dementia care training provided by the facility would also help staff with knowledge on what interventions to utilize for behaviors. 3.1-37(a)

Based on interview and record review, the facility failed to routinely document the meal intakes for 1 of 3 residents reviewed for resident assessment. (Resident B) Findings include: The clinical record of Resident B was reviewed on 4-9-25 at 10:55 a.m. Her diagnoses included, but were not limited to, vascular dementia, heart failure and moderate protein-calorie malnutrition. Her most recent Minimum Data Set (MDS) assessment, a significant change assessment, dated 2-18-25, indicated she was severely cognitively impaired, required supervision or touching assistance for meal consumption, had been identified for weight loss within the last six months, and received a therapeutic and mechanically altered diet. In an interview with Certified Nurse Aide (CNA) 4 on 4-9-25 at 12:35 p.m., she indicated Resident B had a big decline in eating and drinking abilities, prior to being sent out to an area hospital on 3-11-25. In an interview with the Assistant Director of Nursing (ADON) on 4-9-25 at 12:45 p.m., she indicated in the weeks prior to Resident B being sent out to an area hospital, one of the biggest problems we had was getting her to eat or drink. To be honest, I think she was just in a decline and wanted us to leave her alone. She needed to be fed in the last week or two before she left here and even with that, she just didn't seem to take much in. The ADON recalled Resident B would swat at the staff trying to help her with her meals and her intake was minimal, at best. The ADON indicated the Nurse Practitioner was made aware of her decline and the Nurse Practitioner attributed this to her advanced dementia. A review of Resident B's progress notes indicated she was being monitored for weight loss by the facility's interdisciplinary team. An entry, dated 2-26-25, from the Registered Dietitian (RD), identified a significant weight loss within the last 30 days. An entry, dated 2-21-25, from the Certified Dietary Assistant, identified Resident B had a significant weight loss of 6.9 % (percent) in the last 30 days. A review of Resident B's meal intakes was reviewed for February and March 2025, which indicated the following inconsistent meal intake documentations: -2-4-25: lack of documentation for breakfast and lunch. -2-5-25: lack of documentation for breakfast and lunch. -2-7-25: lack of documentation for breakfast, lunch and dinner. -2-9-25: lack of documentation for breakfast, lunch and dinner. -2-12-25: lack of documentation for lunch. -2-13-25: lack of documentation for breakfast and lunch. -2-17-25: lack of documentation for breakfast and lunch. -2-20-25: lack of documentation for lunch. -2-21-25: lack of documentation for lunch and dinner. -2-22-25: lack of documentation for breakfast and lunch. -2-24-25: lack of documentation for lunch. -2-26-25: lack of documentation for dinner. -2-27-25: lack of documentation for breakfast, lunch and dinner. -2-28-25: lack of documentation for lunch. -3-3-25: lack of documentation for breakfast and lunch. -3-4-25: lack of documentation for breakfast and lunch. -3-6-25: lack of documentation for breakfast and lunch. -3-7-25: lack of documentation for lunch. -3-8-25: lack of documentation for breakfast and lunch. -3-9-25: lack of documentation for breakfast and lunch. -3-10-25: lack of documentation for dinner. On 4-9-25 at 2:39 p.m., the Director of Nursing provided a copy of a procedure entitled, Food and Fluid Intake Record-EMR [electronic medical record], with a revision date of 2/2015. This procedure indicated its purpose as, To accurately document intake of food and fluids. It indicated, Upon completion of the meal a member of nursing staff (CNA, QMA or Licensed Nurse) will document the percentage of food .consumption for the meal . This citation relates to Complaint IN00457172. 3.1-50(a)(1) 3.1-50(a)(2)

Based on observation, interview, and record review, the facility failed to ensure to maintain a clean, sanitary kitchen, ensure the holding refrigerator didn't contain unlabeled and/or expired foods, ensure bread was discarded that contained a fuzzy green, yellow substance, and ensure a cup was not present in the bulk storage bin. This had the potential to affect all 72 residents who receive food from the kitchen. Findings include: A kitchen tour was conducted on [DATE] at 10:45 a.m. with Cook 2. The holding fridge had a container of diced ham with a date of [DATE] and a use by date of [DATE]. Cook 2 indicated she wasn't sure why they would make the use by date 10 days after the preparation date. The date was usually 7 days after the preparation date. There was prepared salad that contained cubed ham that did not have a date. There was a container of bacon bits underneath the cubed ham that was not dated. Cook 2 indicated she would add the label on the bacon bits due to them being prepared over the weekend. There were multiple boxes stored on the floor of the main freezer. The dry storage room had 11 boxes observed to be stacked while placed directly on the floor. Cook 2 indicated the food shipments come on Tuesdays and Fridays and the boxes were stacked from the delivery this past Friday. There were not enough staff to put the items away. There was a bulk storage bin that contained a food substance along with a plastic cup located inside the bin and contacting the food substance. Outside of the kitchen was a rack that contained bread and buns. A total of 3 packages each containing 8 buns was noted to have a green, yellow fuzzy substance on all 3 packages of buns. Another kitchen observation was conducted on [DATE] at 5:20 p.m. The plastic cup remained in the bulk storage container, the boxes continued to be stacked on the floor in the dry storage room, boxes were stacked on the floor of the main freezer, and the buns were still present on the rack and noted with the yellow, green fuzzy substance. Another kitchen observation was conducted on [DATE] at 4:30 p.m. The plastic cup was no longer located in the bulk storage bin, there were no stacked boxes along the floor of the dry storage room, and there were still boxes stacked on the floor of the main freezer. An interview conducted with the Dietary Manager (DM), on [DATE] at 2:53 p.m., indicated that she was at the facility on [DATE] and put away the food shipment that came on Friday, [DATE]. The bulk storage bin contained oats, but the facility was in the process of getting rid of it since they now receive their oats in a smaller bag that doesn't require the need for a bulk storage bin. She was unaware that the buns were moldy. The bread is stored on the rack located outside of the kitchen due to the environment in the dry storage room making the bread become moldy quicker. The freezer does not have enough room to store the delivered food without it being placed on the floor. They are working on a plan to have the space, so items don't have to be stored in boxes, on the floor of the freezer. A policy titled Food Storage, revised ,d+[DATE], was provided by the Administrator on [DATE] at 9:08 a.m. The policy indicated the following, .Procedure .3. Food items will be stored on shelves, with heavier and bulkier items stored on the lower shelves 7. Scoops must be provided for flour, sugar, cereals, dried vegetables, and spices. Scoops are not stored in the food containers, but may be kept covered in a protected area near the containers .10. Food is stored a minimum of 6'' above the floor and 18'' below the sprinkler heads on clean racks or other clean surfaces, and is protected from splash, overhead pipes, or other contaminations .12. Leftover prepared foods are to be stored in covered containers or wrapped securely. The food must clearly be labeled with the name of the product, the date it was prepared and marked to indicate the date by which the food shall be consumed or discarded. Leftover foods can be held at 41 [symbol for degrees] or less for nor more than 3 days .13. Refrigerated, ready-to-eat, potentially hazardous food purchased from approved vendors, shall be clearly marked with the date the original container is opened and the date by which the food shall be consumed or discarded. This opened food can be held at 41 [symbol for degrees] or less for no more than 7 days and the date marked may not exceed the manufacturer's use-by-date 3XXX,d+[DATE](i)(2) 3XXX,d+[DATE](i)(3)

Based on observation, interview, and record review, the facility failed to ensure resident rooms were in good repair related to the walls, headboard, and cove base (soft flexible material along the bottom part of the wall) in a bathroom for 6 of 72 residents reviewed for environment. (Resident 283, 40, 18, 44, 11, and 28) Findings include: An observation conducted on 3/19/24 at 9:38 a.m. noted Resident 283's room with the cove base peeling in the bathroom. An observation conducted on 3/18/24 at 12:23 p.m. noted Resident 40's room with missing paint alongside the wall behind the headboard. An observation conducted on 3/18/24 at 12:34 p.m. noted Resident 18's room with missing paint and drywall behind the headboard. An observation conducted on 3/19/24 at 9:46 a.m. noted Resident 44's room with a flexible strip of material hanging down her headboard and onto her bed. She was lying in bed during the observation. An observation conducted on 3/19/24 at 1:07 p.m. noted Resident 11's room with missing paint alongside the wall behind the headboard. An observation conducted on 3/18/24 at 12:19 p.m. noted Resident 28's room with missing paint alongside the wall behind the headboard. An environmental tour was conducted on 3/21/24 at 3:44 p.m. with the Maintenance Director and Housekeeping Supervisor. Resident 40, Resident 18, Resident 44, and Resident 283's room were noted with the same observations of missing paint, headboard, and cove base. The Maintenance Director indicated that it has been on ongoing issue with getting the walls repaired. He just repaired 5 walls on the Moving Forward Unit and when he returned the following week there were 2 rooms, previously repaired, noted with the same issues again. It appeared the nursing staff had been pushing the bed or recliner towards the wall and causing the missing paint along the walls. The Maintenance Director indicated they have implemented a training program for the staff regarding the beds going alongside the walls but it's a work in progress. He was waiting for approval to conduct such repairs due to only having a limited amount of work to conduct monthly. They have a system to where the nursing staff and housekeeping can input work orders if they were to see any environmental concerns. The work orders go to the Maintenance Director. 3.1-19(f)(5)

Based on interview and record review the facility failed to have an ongoing activity program on the dementia care unit for 2 of 3 residents reviewed for activities (Resident C and Resident D). Findings include: 1.) During an interview with CNA 3 on 3/20/24 at 11:58 a.m., indicated she normally worked the dementia care unit. CNA 3 indicated there was not enough activities on the dementia care unit until recently when an activity assistant started working. The dementia unit went a long time without activity staff. During an interview with the Dementia Care Coordinator on 3/20/24 at 12:21 p.m., indicated the facility had not had an activity assistant since June 2023. The Dementia Care Coordinator was working in three different roles on the dementia care unit, the Dementia Care Coordinator, Social Services and activities. The facility did hire someone the end of February 2024 for activities. The staff did the best they could with activities, providing self initiated packets and coloring. During an interview with CNA 4 on 3/20/24 at 12:30 p.m., indicated she normally worked the dementia care unit. The staff did the best they could with activities without having an activity assistant. The staff were happy to have an activity assistant now. During an interview with LPN 6 on 3/21/24 at 1:08 p.m., indicated it was tough for the dementia care unit to go without activity staff. The staff did the best they could to provide some activities, but ultimately resident care had to come first. The dementia care unit had a lot residents who required assistance with their care. During an interview with Resident C's family member on 3/20/24 at 3:50 p.m., indicated the dementia care unit did not have any activities. The residents would sit around in the dining room with nothing to do. Review of the record of Resident C on 3/22/24 at 10:47 p.m., indicated the resident's diagnoses included, but were not limited to, dementia, anxiety, mood disturbance, major depressive disorder psychotic disturbance. The Significant Change Minimum Data Set (MDS) assessment for Resident C, dated 4/7/23, indicated the resident was severely cognitively impaired for daily decision making. It was very important for the resident have books, newspapers, magazines, listen to music, be around animals, keep up with the news, do things in groups of people, attend her favorite activity, go outside to get fresh air, participate in religious services The plan of care for Resident C, dated 5/17/24, indicated the resident exhibited severe cognitive impairment related to dementia. The interventions included, but were not limited to, encourage participation in daily activities particularly regarding orientation, socialization and stimulation and encourage social interaction. The plan of care for Resident C, dated 5/17/24, indicated the resident enjoyed the following activities, spending time with family, sewing, bingo and socialization. The interventions were encourage activities of interest such as spending time with family, sewing, bingo, socialization, verbal reminders of activities and may participate in therapeutic structured work activities. 2.) During an interview with Resident D's family member on 3/18/24 at 11:50 a.m., indicated the facility was dishonest with him when he admitted his family member to the dementia care unit in August 2023. The family member indicated they were told the facility would provide lots of activities such as bingo etc. The facility did no activities for the resident and she would sit around all day until recently. The resident enjoyed cards, board games, bingo, being outside and live music. The resident was a [NAME] when she was younger. Review of the record of Resident D on 3/22/24 at 11:10 a.m., indicated the resident's diagnoses included, but were not limited to, Alzheimer's disease, dementia, anxiety and major depressive order. The plan of care for Resident D, dated 8/25/23, indicated the resident was severely cognitively impaired related to dementia. The interventions included, but were not limited to, encourage to participate in daily activities particularly regarding orientation, socialization and stimulation and encourage social interaction. The plan of care for Resident D, dated 8/25/23, indicated the resident enjoyed the following type of activities: cooking, sitting outside, playing with her dog, spending time with family. The interventions included, but were not limited to, give verbal reminders to activities of interest and provide assistance to activities as needed. The Significant Change MDS assessment for Resident D, dated 1/23/24, indicated the resident was severely cognitively impaired for daily decision making. It was somewhat important to have books, newspapers and magazines, keep up with news, do things in groups of people It was was very important to listen to music, be around animals and attend her favorite activity, go outside and get fresh air and participate in religious services. During an interview with the Administrator on 3/21/24 at 11:41 a.m., indicated the facility had no documentation of Resident C and Resident D participating in any activities for the past 3 months. During an interview with the Administrator on 3/21/24 at 1:47 p.m., indicated the facility did not have a dementia care policy. The facility followed the State guidelines with dementia training. The activity policy provided by the Director Of Nursing on 3/21/24 at 12:30 p.m., indicated the facility would provide an ongoing program of activities designed to meet the interests and the physical, mental and psychosocial well-being of each resident. This Federal tag relates to Complaint IN00430463. 3.1-37(a)

Based on interview and record review, the facility failed to ensure a dietary staff member did not work while experiencing signs and symptoms of a gastrointestinal illness and ensure 48 hours had passed since symptoms started. Findings include: A kitchen tour was conducted on 3/18/24 at 10:45 a.m. with Cook 2. Cook 2 indicated the Dietary Manager was out ill. An interview conducted with the Dietary Manager (DM), on 3/20/24 at 2:53 p.m., indicated that she was having symptoms of a gastrointestinal illness while at work on 3/18/24 and so she went home. She did return to work on 3/19/24 and was putting away the food shipment that came on Friday, 3/15/24. A policy titled Employee Illness, revised 12/2023, was provided by the Administrator on 3/21/24 at 3:30 p.m. The policy indicated the following, .Purpose of Policy: Resident(s) will not be exposed to employee(s) who show signs and symptoms of illness or infectious disease .Employees returning to duty after an infectious illness will consult the DNS [Director of Nursing Services], Infection Preventionist/designee before returning to work. If the absence has been related to an infectious illness, a physician's statement of fitness to return to work is required A Centers for Disease Control and Prevention (CDC) document, titled Norovirus, reviewed 5/10/23, indicated the following, .Prevention .Do not prepare and handle food or care for others when you are sick .You should not prepare food for others or provide healthcare while you are sick and for at least 2 days (48 hours) after symptoms stop. This also applies to sick workers in restaurants, schools, daycares, long-term care facilities, and other places where they may expose people to norovirus 3.1-18(b)(6)

Based on interview and record review, the facility failed to complete a Minimum Data Set (MDS) Assessment for a resident discharged from hospice services (Resident 78) for 1 of 3 resident reviewed for timeliness of significant change assessments. Findings include: The clinical record for Resident 78 was reviewed on 3/21/2024 at 1:45 p.m. The medical diagnosis included dementia. A payor census for Resident 78 indicated she discharged from hospice services on 10/12/2023. A physician note, dated 10/12/2023, indicated that Resident 78 was .hospice is releasing her soon . No significant change MDS Assessment was completed for Resident 78 in October of 2023. A policy entitled, Significant Change in Status Assessments (SCSA), was provided by the Administrator on 3/22/2024 at 10:00 a.m. The policy indicated, .SCSA is required to be performed when a terminally ill resident enrolls or revokes hospice program . An interview with the MDS Coordinator on 3/22/2024 at 11:15 a.m. indicated that she coded to the Resident Assessment Instrument Manual for accuracy and timeliness of assessments. She stated that the Significant Change Assessment for Resident 78 was missed. 3.1-31(d)(1)

Based on interview and record review, the facility failed to accurately indicate the use of hospice services (Resident 43) and failed to accurately code oxygen therapy (Resident 10 and 65) for 3 of 16 resident reviewed for MDS accuracy. Findings include: 1. The clinical record for Resident 43 was reviewed on 3/21/2024 at 2:30 p.m. The medical diagnosis included Alzheimer's disease with late onset. An Annual MDS Assessment for Resident 43, dated 2/18/2024, did not indicate the resident had a 6-month prognosis or received hospice services. A hospice certification, dated 1/30/2024, indicated that Resident 43 was terminally ill, elected the hospice benefit with a start of care date of 1/30/2024, and had a life expectancy of less than six months. An interview with MDS nurse on 3/21/2024 at 3:10 p.m., indicated that Resident 43 did not have a significant change completed due to not being sure when she was going to hospice because of the payor source confusion. 15909 2. On 3/19/24 at 2:06 p.m., Resident 10 was observed lying in bed, and received oxygen through a nasal cannula that was looped around her ears and connected to an oxygen concentrator. Resident 10's record was reviewed, on 3/21/24 at 1:49 p.m., and indicated diagnoses that included, but were not limited to, pneumonia, chronic respiratory failure with low oxygen in the blood, emphysema, and high blood pressure. A physician's order, dated 2/13/24, indicated oxygen at 4 liters per nasal cannula every shift. On 3/22/24, at 10:48 a.m., Resident 10 was observed lying in bed with her oxygen in place via nasal cannula. An Admission MDS assessment, dated 2/16/24, indicated Resident 10 was cognitively intact, was at risk for pressure ulcer development, and did not receive oxygen therapy. 3. Resident 65's record was reviewed, on 3/21/24 at 10:18 a.m., and indicated diagnoses that included, but were not limited to, dementia, high blood pressure, anemia, and atrial fibrillation. On 3/21/24 at 3:10 p.m., Resident 65 was observed in bed with her eyes closed, and oxygen was in use at 2 liters per minute with a nasal cannula. A Quarterly MDS assessment, dated 1/19/24, indicated Resident 65 did not receive oxygen therapy. A care plan, with a start date of 9/27/23, indicated an approach for as needed oxygen at 2 liters. An interview with the MDS Coordinator, on 3/22/2024 at 11:15 a.m., indicated that she coded to the Resident Assessment Instrument Manual for accuracy of assessments. She stated she would enter a modification of record for Resident 43's assessment dated [DATE] to reflect the hospice benefit and 6-month prognosis, and for Resident 10 and 65 for oxygen therapy.

Based on interview and record review, the facility failed to ensure continuation of treatment for a resident with pressure ulcers for Resident 55, and failed to ensure Resident 10 and 136's interventions were in place for pressure ulcer prevention and treatment. This affected 3 of 4 residents reviewed for pressure ulcers. Findings include: 1. The clinical record for Resident 55 was reviewed on 3/19/24 at 2:35 p.m. The diagnoses included, but were not limited to, cerebral infarction (or stroke, is a brain lesion in which a cluster of brain cells die when they don't get enough blood), hemiplegia (total or nearly complete paralysis on one side of the body), dementia, glaucoma, and weakness. A pressure ulcer care plan, dated 1/3/24, indicated Resident 55 had pressure ulcers to the left and right heel, right hip, left intergluteal cleft, and left buttock. The approaches included, but were not limited to, treatments as ordered. A physician order, dated 3/5/24, indicated the utilization of Medihoney (sterile, hydrocolloidal dressing with 100% active Leptospermum honey that supports the removal of necrotic tissue and aids in wound healing) to the right heel and left buttock daily. The order was discontinued on 3/6/24. A physician order, dated 3/12/24, indicated the utilization of Medihoney to the left buttocks daily. The order was current. A physician order, dated 3/12/24, indicated the utilization of Medihoney to the right heel daily. The order was current. The electronic treatment administration record (ETAR) for March of 2024 indicated there were no treatment orders to Resident 55's right heel or left buttock from 3/6/24 until 3/12/24. An interview conducted with the Director of Nursing (DON), on 3/21/24 at 3:25 p.m., indicated she could not find any orders for Resident 55's pressure ulcer treatment of the right hip and left buttocks for the period of 3/6/24 to 3/12/24. Resident 55 was put on hospice effective 3/2/24 and they, hospice, were conducting a comprehensive review of Resident 55's orders. 15909 2. On 3/19/24 at 2:06 p.m., Resident 10 was observed in bed, and received oxygen through a nasal cannula that was looped around her ears, and connected to an oxygen concentrator. Resident 10's record was reviewed, on 3/21/24 at 1:49 p.m., and indicated diagnoses that included, but were not limited to, pneumonia, chronic respiratory failure with low oxygen in the blood, emphysema, and high blood pressure. A physician's order, dated 2/13/24, indicated oxygen at 4 liters per nasal cannula every shift. A physician's order, dated 2/13/24, indicated Ear protectors to O2 (oxygen) tubing, special instructions: check placement q (every) shift, every shift. On 3/22/24, at 10:48 a.m., Resident 10 was observed lying in bed with her oxygen in place via a nasal cannula. The tubing around her ears was not padded and Resident 10 indicated her right ear was sore when it rubs and stated it just got sore a couple of days ago. On 3/22/24 at 11:03 a.m., LPN 5 assessed Resident 10's ears and said the right ear was reddened and not open, and placed a folded tissue on the ear crease, then placed the oxygen tubing on the ear. She said she would get ear pads and place them on the tubing. An assessment of the right ear was completed by LPN 5 and a copy provided on 3/22/24 at 12:28 p.m. The assessment indicated Resident 10 had a reddened area on the back of the right eat, at the top, that was not present on admission, measured 0.05 by 0.05 cm and no depth, and was a dark/dull red in color. There was no drainage or odor and a new intervention was to ensure ear pads were on the oxygen tubing at all times. A care plan with a start date of 2/18/24, indicated a problem for Resident is at risk for skin breakdown or further skin breakdown due to: decreased mobility, incontinence, poor nutrition, declining health, COPD, oxygen use, sliding down in bed, sliding during transfers, refuses to get out of bed 3. During an interview, on 3/18/24 at 2:34 p.m., Resident 136 indicated she had developed pressure areas on both heels after she was admitted , and said she didn't move around very much. Both heels were observed to touch the bed, and the resident said the pillow was slick and slides, and her heels will touch the bed. Resident 136's record was reviewed, on 3/21/24 at 2:30 p.m., and indicated diagnoses that included, but were not limited to, type 2 diabetes mellitus with diabetic neuropathy, infection and inflammatory reaction due to internal right hip prosthesis, generalized muscle weakness, and right artificial hip joint. On 3/21/24, at 2:52 p.m., LPN 6 indicated Resident 136 should be checked every 2 hours as she will slide down in the bed, and she does get out of her bed every day, and gets therapy daily. LPN 6 said there was a blister there, and it gets monitored for the left heel, it is changed every Friday and as needed. It is done with the wound doctor. The right heel didn't have any issues, it was just soft. A care plan with a start date of 3/14/24, indicated a problem for dissipated blister to bilateral heels: chronic pain, and recent surgical repair to right hip. The interventions included Heel offloading pillow. A policy titled Skin Management Program, revised 5/22, was provided by the DON on 3/21/24 at 3:24 p.m. The policy indicated the following, .PROCEDURE FOR ALTERATIONS IN SKIN INTEGRITY - PRESSURE AND NON-PRESSURE .2. Treatment order will be obtained from MD/NP 3.1-40(a)(2)

Based on interview and record review, the facility failed to ensure fall interventions were in place after a fall had occurred for 1 of 2 residents reviewed for accidents. (Resident 55) Findings include: The clinical record for Resident 55 was reviewed on 3/19/24 at 2:35 p.m. The diagnoses included, but were not limited to, cerebral infarction (or stroke, is a brain lesion in which a cluster of brain cells die when they don't get enough blood), hemiplegia (total or nearly complete paralysis on one side of the body), dementia, glaucoma, and weakness. A care plan for fall risk, dated 4/6/23, indicated Resident 55 was at risk for falls due to history of falls, medication usage, incontinence, and weakness. The approach included, but were not limited to, a bedside mat while resting in bed that was started on 11/20/23. A fall event, dated 2/15/24 at 11:42 p.m., indicated Resident 55 fell out while sleeping and the [NAME] [sic] not at bedside. A progress note, dated 2/15/24 at 11:52 p.m., indicated the following, .This nurse alerted to resident's room per roommate yelling for help, Resident found lying on his L [left] side at bedside wearing gown and socks .2 s/t [skin tears] noted 5x3cm [centimeters] to L [left] hand and 1x1cm to R [right] pinky finger .Matt [sic] now at bedside A policy titled Fall Management Policy, revised 8/2022, was provided by the Administrator on 3/21/24 at 9:08 a.m. The policy indicated the following, .3. A care plan will be developed at time of admission with specific care plan interventions to address each resident's fall risk factors 3.1-45(a)(1) 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure a resident identified with non-pressure-related skin concerns had timely and routine assessments and documentation of the same conducted of their skin concerns for 1 of 3 residents reviewed for skin issues. (Resident D) Findings include: The clinical record of Resident D was reviewed on 9-25-23 at 3:45 p.m. Her diagnoses included, but were not limited to a history of acute respiratory failure, COPD (chronic obstructive pulmonary/lung disease), diabetes, neuromuscular dysfunction of bladder, morbid obesity, high blood pressure, hyperlipidemia, depression, occlusion and stenosis of bilateral carotid arteries, IBS, fatty liver disease, weakness, anxiety, general muscle weakness, spinal stenosis of lumbar region, knee pain, unspecified osteoarthritis and nutritional anemia. Her most recent Minimum Data Set assessment, dated 5-18-23, indicated she was cognitively intact, had mood issues related to tiredness, depression and sleep, was dependent of 1 or more staff for activities of living, such as bed mobility, transfer, bathing and locomotion and required extensive assistance of 1 or more staff for toileting and hygiene services. It indicated she was non-ambulatory and used a wheelchair for mobility and was incontinent of bowel and bladder. It indicated she was at risk for pressure ulcers, but did not have any pressure ulcers or any other type of non-pressure areas to her skin. It indicated she was provided with pressure-reducing devices to her bed and wheelchair. A review of Resident D's progress notes included a notation she had a newly identified area of MASD (moisture-associated skin damage) to her unspecified gluteal fold. A New Skin Event was entered into the electronic health record on 5-16-23, identifying the MASD as a bright red rash, measured as 4 centimeters (cm) by 0.5 cm. to the gluteal folds, with no drainage or odor. It indicated the Nurse Practitioner was notified of this area, as well as the family and/or responsible party. A review of Resident D's progress and medication/treatment administration records, related to the gluteal MASD, indicated treatments were conducted as ordered, with some notes addressing continuation of redness of the area. The 6-2-23 note indicated there was no improvement of the MASD. The resident discharged to another nursing facility on 6-22-23. No additional assessment, including measurements of the area could be located in the clinical record. In an interview on 9-26-23 at 10:45 a.m. with the Wound Nurse, she indicated she located the nursing progress note of 5-16-23 about MASD, but did not locate any follow-up charting for this. The Wound Nurse shared for a resident with MASD, the Wound Nurse typically will monitor the area for several days and then would transition to become part of the hot charting for the floor nurse to monitor the MASD. She added she had no recall at all of any blister-like areas to Resident D's buttocks or leg area, but was aware she had a history of edematous legs. She indicated it is normal practice for the wound nurse/team to monitor any resident with skin issues at least weekly and document their findings. In a subsequent interview on 9-26-23 at 12:02 p.m., with the Wound Nurse, she indicated, I take the blame for the confusion on the skin problems. I took over the wound nurse position not all that long ago and am learning things all the time. She shared she has learned that with the MASD, she should have opened up a wound management [event in the electronic health record], in addition to the event that had been opened up for hot charting, related to Resident D's MASD. The progress notes for Resident D also included an identification of a new open area to the 2nd toe of her left toe on 5-23-23, measuring 1.5 cm. by 1.5 cm. A Documentation Guidelines/Hot Charting event was initiated in the electronic health record on 5-23-23 at 11:08 a.m., specific to area to 2nd toe on left foot. It indicated the attending physician and resident representative were notified of the new area on 5-23-23 at 11:11 a.m. Treatment orders were received from the nurse practitioner on 5-23-23 at 11:23 a.m. It indicated the event was closed, effective 5-25-23. No additional documentation was located, specific to this area. An IDT (interdisciplinary team) meeting note, dated 5-24-23, indicated the new area of trauma to rt [right] gt [great] toe was reviewed. It described the area as redness and slight swelling to rt gt toe medially .caused by bumping foot on therapy machine. An observation note by the Wound Nurse, dated 5-24-23 at 3:24 p.m., indicated Resident D had dried red drainage to the left great toe, measuring 1.2 cm. by 2.0 cm., with the toenail cleansed with no exudate being removed. A second observation note by the Wound Nurse, dated 5-24-23 at 3:24 p.m., indicated Resident D had a bruise [to the] left big toe. Subsequent documentation was conducted at least daily by the nursing staff of the left great toe, until it was identified as healed on 6-14-23. In an interview with the Wound Nurse on 9-26-23 at 10:45 a.m., she queried if there had been a mistaken entry regarding which toe was affected with the entries dated 5-23-23 and 5-24-23. She indicated she was able to locate a skin/hot charting event that was opened in the electronic health record for the second toe by another nurse and she had opened one for the great toe. She added she had found treatment orders from the nurse practitioner, dated 5-24-23, for the great toe, but was unable to locate any treatment orders for the second toe. In a second interview with the Wound Nurse 9-26-23 at 12:02 p.m., she indicated I take the blame for the confusion on the skin problems. I took over the wound nurse position not all that long ago and am learning things all the time. I found out that not only does a skin event have to be opened up in the computer [electronic health record], but also [a] wound management [event] has to be opened up. She recalled when she went to do the evaluation for the second toe, she found some blood on that left second toe from the problem on the left great toe. She recalled after cleansing the old blood off of the second toe, she found no skin issue as it appeared the actual problem was the great toe. I should have documented all of this, but I didn't. I should have closed out the second toe issue when I opened up the event for the great toe. On 9-26-23 at 4:07 p.m., the Director of Nursing provided a copy of a policy entitled, Skin Management Program, with a revision date of 5-2022. This policy indicated, It is the policy of American Senior Communities to ensure that each resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing .Residents identified at risk for pressure ulcer/injury and those with pressure ulcer/injury will have an individualized care plan developed with specific risk factors and contributing factors including preventative measures. Direct care givers will be notified of the resident specific prevention interventions. The Interdisciplinary Team (IDT) will review risk factors upon admission, quarterly and with changes in condition and update plan of care as indicated. Any skin alterations noted by direct care givers during daily care and/or shower days must be reported to the licensed nurse for further assessment, to include but not limited to bruises, open areas, redness, skin tears, blisters, and rashes. The licensed nurse is responsible for assessing all skin alterations by the direct care caregivers on the shift reported. Facility skin sweeps (head-to-toe assessments) are conducted monthly to assess all residents' current skin conditions and to ensure appropriate preventative measures are in place .All newly identified areas after admission will be documented on the New Skin Event [in the electronic health record]. The wound nurse/designee will be notified of alterations in skin integrity. The wound nurse/designee is responsible for communicating to IDT on a weekly basis for pressure and non-pressure wounds. The wound nurse/designee will complete further evaluation of the wounds identified and complete the appropriate evaluation on the next business day. The 'observed date indicated on the Wound Management document is the date the wound was assessed, including, but not limited to measurements, staging, condition of tissue, and drainage .Wound management entries will be completed for non-ulcers (bruises, skin tear, abrasion, rashes). If no signs of complications or worsening in condition of skin altercation and doesn't meet the guideline for IDT Weekly Wound Review, the wound management entry can be closed after 72 hours. (select discontinue documentation) .IDT will review residents with alterations in skin integrity weekly, if applicable, based on the IDT initial and Weekly Wound Documentation Policy. This federal tag relates to Complaint IN00411770. 3.1-37(a)

Based on interview and record review, the facility failed to ensure the use of a gait belt with the assisted ambulation of a resident which resulted in a fall in which a resident sustained [REDACTED]. (Resident #B) Findings include: Resident #B's clinical record was reviewed on 6-13-12 at 3:15 p.m. Her [DIAGNOSES REDACTED]. The clinical record indicated she was admitted to the facility on [DATE]. The most recent quarterly Minimum Data Set (MDS) assessment, dated 4-24-12, indicated she was moderately cognitively impaired. This same MDS assessment indicated she required extensive assistance of 2 or more persons for bed mobility and transfers from one surface to another, such as rising from a seated position to standing. It indicated she required minimal assistance of one person with ambulation in her room, but did not ambulate out in the hallway. It indicated she required extensive assistance to total dependency of one person for mobility outside of her room. It indicated she required extensive assistance of one person with activities such as routine hygiene, but of two persons with toileting needs. It indicated she used a wheelchair or walker for ambulation or mobility and that she was unsteady with movement. It indicated she was actively involved in physical therapy (PT) services, which began on 11-4-11. In interview with CNA #1 on 6-14-12 at 2:45 p.m., she indicated she had responded to a call light in Resident #B's room. She indicated the resident wanted to go to the bathroom. She indicated several visitors were present at the time for Resident #B. She indicated she placed the walker in front of Resident #B and she stood up and began to walk. She indicated she had one hand on the walker and one hand around the resident. She indicated she was "kind of behind her." She indicated at this time, some of the visitors were leaving, "so I moved in front of her to allow them through. At this time, she reared back, she stiffened up and reared back (sic). Didn't have time to catch her. The visitors were behind her and couldn't catch her either. (I) did not have a gait belt on (her.) I didn't realize if she got up by herself I had to use a gait belt. The policy says to use (a gait belt) on everyone with transfer or ambulation...Had worked with her previously with no problems with balance...Had not used a gait belt with her previously." In review of the "ASC Fall Event" document, dated 5-25-12 at 8:05 p.m., it indicated Resident #B was standing up transferring to the bathroom with her walker at the time of the fall. It indicated the fall was witnessed by CNA #1, the resident's daughter, the roommate and the roommate's daughter. It indicated the witnesses indicated the resident stiffened up and reared backwards prior to falling, then struck her head on the side table and fell on to her right hip. The document indicated the resident was assessed and the right hip was stabilized while still on the floor. The physician was notified of the fall and ordered for the resident to be sent to the local emergency room . The resident was transported to the emergency room by the local emergency services. The facility was made aware of the right hip fracture later the same evening. Review of Resident #B's "CNA Assignment Sheet," prior to the fall on 5-25-12, indicated she was "At risk for falls," and was to have the assistance of 1 staff member with the use of her walker or wheelchair. On the back of the "CNA Assignment Sheet," was indicated in large font and all capitalized, "GAIT BELTS MUST BE USED WITH ALL TRANSFERS". The back of the assignment sheet was provided on 6-14-12 at 3:05 p.m. by the Assistant Director of Nursing (ADON). The ADON indicated this statement regarding gait belts is on the backside of all CNA assignment sheets. Review of CNA #1's employee information on 6-15-12 at 11:19 a.m., indicated she had signed an acknowledgement of the facility's "Gait Belts" employee information upon hire on 4-19-12 which indicated, "I understand that I am to use a gait belt when transferring any resident that requires my assistance." At an inservice education on 5-29-12, CNA #1 signed a document entitled "Gait Belt Policy and Procedure." The Staff Development Coordinator provided a policy entitled, "Gait Belt Policy and Procedure," on 6-13-12 at 2:45 p.m. It indicated, "Gait belts are to be used at all times for transfers or mobility with the exception of recent surgical sites in the abdominal area...Any staff found not using gait belts as directed will result (sic) in disciplinary action up to and including termination." This Federal tag relates to Complaint IN 136. 3.1-45(a)(2)

A. Based on observation, record review and interview, the facility failed to treat unrelieved pain, causing inability to sleep and carry out activities of daily living, for 1 of 3 residents reviewed for pain of 4 who met the criteria for pain recognition and management. (Resident #6) B. Based on observation, record review and interview, the facility failed to treat a resident's mouth sores, causing her pain and inability to eat, for 1 of 3 residents reviewed for nutrition of 8 who met the criteria for nutrition. (Resident #20) Findings include: A.) The record of Resident #6 was reviewed on 2/9/12 at 1:45 p.m. Resident #6's [DIAGNOSES REDACTED]. Resident #6's most recent MDS (Minimum Data Set), assessment, dated 12/7/12 indicated the following: "- BIMS (brief interview for mental status), 15, a score of 13 to 15 indicates cognitively intact - pain, on scheduled pain medication, yes - received PRN (as needed) pain medication, yes - interventions other than medication, yes - pain presence, yes - how often experiencing pain, frequently - verbal description of pain scale, moderate" Resident #6's care plan dated 12/15/11, indicated "Problem, resident has pain related to decreased mobility and [MEDICAL CONDITION] and a history of rhabdomyolysis. Goal, will have relief of pain within 30 to 60 minutes of intervention. Approach, administer medications as ordered, non medication interventions such as rest, quiet environment, therapies as ordered and notify physician if pain is unrelieved and/or worsening." Resident #6's most recent "Pain Assessment (interviewable resident)", dated, 11/29/11, indicated the following "- is the resident currently on routine pain medications, yes - are you currently experiencing pain, yes - have you had pain or hurting at any time in the last 5 days, yes - over the past 5 days, has pain made it hard for you to sleep at night, yes - over the past 5 days, have you limited your day-to-day activities because of pain, yes - what is the location of your pain, left shoulder - please rate the intensity of your worst pain over the last 5 days, (this question not marked) - how much of the time have you experienced pain or hurting over the last 5 days, frequently - type of pain, aching - what causes your pain to increase, movement." Resident #6's physician order [REDACTED]." Resident #6's physician's "history and physical examination Past History" included, but was limited to, "addiction to pain medication." Resident #6's "Nurse's Medication" with documentation of PRN medications indicated "2/14/12, medication, [MEDICATION NAME], reason, general body ache, results/response, (left blank)." Interview with Resident #6 on 2/9/12 at 1:45 p.m., indicated she was having left arm and shoulder pain. Resident #6 indicated she receives [MEDICATION NAME] for her left arm pain and the Tylenol helps very little. Resident #6 also indicated she receives Tylenol everyday and the Tylenol does not help her pain at all. She indicated she has told the nurses because it keeps her awake at night, it hurts too bad for her to try to hold onto the walker to walk and she just does not feel like doing anything. On 2/14/12 at 9:45 a.m., Resident #6 was observed in bed. Resident #6 was pointing with her right hand to her left arm and hand and stated "my left arm hurts so bad and it kept me awake most of the night last night." During interview with 2/14/12 at 9:50 a.m., indicated she was having a pain in her left arm and hand right now and she indicated on a pain scale of 0-10 it her pain was an 8. She stated "the [MEDICATION NAME] does not help, I had it this morning and it just didn't help that much if any. I try not to think about the pain but it is hard to not think about it when it is hurting. I did not sleep much last night because of the pain." During interview on 2/14/12 at 10:40 a.m., the Assistant Director of Nursing (ADON) indicated Resident #6's pain has not been reported to the physician that she is aware of, but the pain medication had not been changed because Resident #6 had a history of [REDACTED]. During interview on 2/12/12 at 10:58 a.m., staff Physical Therapist #9 indicated Resident #6 is receiving physical therapy at this time and does experience pain in her left arm. Staff Physical Therapist #9 also indicated a splint had been ordered for Resident #6 to help with her mobility and pain. A document titled "Pain Management" dated 3/10, provided by the Administrator on 2/14/12 at 1:55 p.m., and indicated by the Administrator to be the most current policy, indicated "Policy, it is the policy of American Senior Communities to provide, mental, and psychosocial well being, including pain management. It is the responsibility of the facility to ensure that each resident is assessed for pain, and the efficacy of pain medication, while keeping the resident as comfortable and pain free as possible. Procedure, residents are assessed for pain upon admission, quarterly, and with a significant change in the resident's condition and/or new onset of pain. The following guidelines will be used when assessing pain, using the specific pain assessment. Interviewable resident, the pain management program will be determined based upon the resident's verbal response to the questions on the pain assessment/interviewable resident. Pain medications will be prescribed and given based upon the intensity of the pain as follows: mild, moderate, severe, very severe, horrible. B.) During interview with Family member #1 and Family member #2 of Resident #20 on 2-9-12 at 2:09 p.m., the family indicated they had talked with the facility numerous times about the resident losing weight and having mouth sores. The family members indicated the resident had been sent to the hospital and was treated for [REDACTED]. The family members indicated when the resident returned to the facility, the resident's mouth started getting bad again. The family member indicated they insisted the facility treat the resident's mouth sores. The family members indicated the resident had not been able to eat due to the mouth sores. The family members indicated the resident was little and weak now because she had been unable to eat. The family members indicated the facility does not give the resident assistance with oral hygiene and they felt the poor oral hygiene also contributed to the resident's sore mouth. Family member #1 indicated the resident's dentures were "a mess" when they came to the facility today. Family member #1 indicated they cleaned the dentures for the resident. During observation and interview on 2-13-12 at 9:06 a.m., Resident #20 was lying in bed with her dentures in her mouth. The resident's dentures appeared dirty and had a film on them. The resident's tongue was bright red and swollen. The resident indicated she had thrush and was unsure how long she had it. The resident indicated she had lost a lot of weight because her mouth had been sore and she was unable to eat. The resident indicated she did not feel like there were any other contributing factors to her weight loss; her mouth was too sore to eat. The resident indicated the facility gives her something to swish in her mouth, and it helps. The resident indicated her mouth was still sore and she also had sores on her gums. The resident indicated she had sour kraut the other day, and it was the first food she could really taste since having thrush. The resident indicated ever since she had thrush, nothing tastes right. The resident indicated food does not have any taste. The resident indicated the last time the facility weighed her, she weighed 108 pounds. The resident indicated she usually weighed a lot more than that. The resident indicated she hoped she did not lose any more weight. Resident #20 indicated her dentures had not been cleaned since Family member #1 cleaned them last week. Resident #20 indicated the facility was supposed to take the dentures out and soak them over night. During observation of the resident's denture cup, it was dated 1-22-12 and marked with the resident's name. The denture cup was completely dry. Resident #20 indicated she had been sleeping in her dentures since Family member #1 cleaned them on Thursday. This indicated the resident had not had her dentures cleaned or taken out of her mouth for three days. During observation, CNA #2 came into Resident #20's bedroom and asked if the resident was ready to get up, the resident indicated no she was not ready to get up yet. Interview with CNA #2 on 2-13-12 at 9:25 a.m., indicated she cleans resident's dentures daily. CNA #2 indicated Resident #20 had not ate breakfast today. CNA #2 indicated she did not know when resident's dentures should be soaked; she thought evening shift should take them out at night and soak them. CNA #2 indicated Resident #20's dentures had not been cleaned today. CNA #2 indicated a lot of residents already have their dentures in when she starts work in the morning. CNA #2 indicated some residents sleep with their dentures in. CNA #2 indicated the facility did not have tablets to soak the residents' dentures in; the residents' families had to provide the cleaning tablets for the residents. CNA #2 indicated denture cups should be changed every three days. During observation with CNA #2 at this time, there were three boxes of cleaning antibacterial with baking soda [MEDICATION NAME] single tablet boxes with 40 tablets per box in the storage room. CNA #2 stated " I guess we do have them." Review of Resident #20's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Interview with CNA #2 on 2-13-12 at 9:40 a.m., indicated the information about Resident #20's dentures not being in her mouth should have been on the CNA assignment sheet. Review of the CNA assignment sheet with CNA #2 did not indicate any information about the resident not having her dentures in except when she was eating. CNA #2 indicated she did not know how information like that was supposed to be communicated to the CNAs. CNA #2 indicated she did not know Resident #20 had false teeth. Interview with LPN #5 on 2-13-12 at 9:53 a.m., indicated the reason Resident #20 was not have dentures in except while eating was because the resident's mouth got sore easy and she had thrush. LPN #5 indicated it was also to ensure the resident's dentures were cleaned. LPN #5 provided a copy of the CNA assignment sheet and there was no documentation for Resident #20 to have her dentures out of her mouth. Review of the record of Resident #20 on 2-13-12 at 9:54 a.m., indicated the resident's [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment for Resident #20 dated 1-17-12, indicated the following: cognitive status summary score was 15- cognitively intact and personal hygiene (including brushing teeth) was extensive assistance of one person. The local hospital discharge note for Resident #20 dated 1-10-12, indicated the resident complained of sores in her mouth, this was most likely secondary to the steroids she inhales. She was started on Mary's magic mouthwash (treatment for [REDACTED]. The resident was being discharged back to the facility with a prescription for this. The discharge medication list from the local hospital for Resident #20 dated 1-10-12, indicated the resident was ordered Mary's magic mouthwash 5 milliliters every six hours, and the last dose was given on 1-10-12 at 10:00 a.m. The facility's physician orders [REDACTED]. The orders were signed by LPN #9. The physician orders [REDACTED]. The progress note for Resident #20 dated 1-10-12 at 3:45 p.m., indicated Resident #20 had returned from the hospital. The doctor orders were noted from hospital and faxed to the pharmacy and the doctor. The progress note for Resident #20 dated 1-25-12 at 6:39 p.m., indicated the resident's mouth was sore again. This was reported to the doctor without getting an answer back about what to do. The progress note for Resident #20 dated 1-25-12 at 7:11 p.m., indicated a call was placed to resident's family. The resident's family requested the resident to have Mary's magic mouthwash. The family member was notified that the physician was out of the office and there would be a follow up in the morning with the office. The fax sent to the physician for Resident #20 dated 1-26-12 at 7:50 a.m., indicated the resident complained of a sore throat and mouth. The resident's family was requesting Mary's magic mouthwash. May we have an order? The physician response was, ok one teaspoon four times a day for 10 days. The progress note for Resident #20 dated, 1-26-12 at 6:36 p.m., indicated the received an order for [REDACTED]. Review of the MAR for Resident #20 dated 1-10-12 through 1-31-12, indicated the resident received her first dose of Mary's magic mouthwash 5 milliliters on 1-27-12 at 6:00 a.m. This indicated the resident went 17 days without treatment for [REDACTED]. The weights for Resident #20 indicated on 10-1-11, the resident weighed 122 pounds, and on 2-13-12 the resident weighed 107 pounds. The ER (emergency room ) record for Resident #20 dated 2-8-12, indicated the resident had a [MEDICAL CONDITION] episode shortly after choking on a large pill. The resident stated she felt very weak. The resident had weight loss in last several months and was thin. The resident had a decrease in appetite since severe episode of thrush. The physician order [REDACTED]. Interview with RN #10 on 2-14-12 at 10:16 a.m., indicated the procedure for when a resident returned from the hospital, was the discharge medication orders were usually faxed to the physician or the physician was called with the list of discharge medications. RN #10 indicated the physician had not signed the physician orders [REDACTED]. 3.1-37(a)

Based on observation, interview and record review, the facility failed to thoroughly assess a resident's pain, failed to consistently attempt to obtain a hip x-ray for a resident experiencing pain and failed to have a physician evaluate a resident's pain, resulting in the resident experiencing unrelieved pain, for 1 of 3 residents sampled for fractures in a total sample of 4 (Resident #A). Finding include: The record of Resident #A reviewed on 8-18-11 at 11:00 a.m., indicated the resident's [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment for Resident #A dated 5-9-11, indicated the following: functional limitation of range of motion- no impairment. The MDS assessment for Resident #A dated 8-3-11, indicated the following: making self understood- usually understood, ability to understand others- usually understands others, cognitive skills for daily living- severely impaired, bed mobility- total dependence of two people, transfer- total dependence of two people, walk in room- did not occur, toilet use- total dependence of two people, functional limitation in range of motion- impairment on one side of the lower extremity. The physician recapitulation for Resident #A dated July 2011, indicated the resident had a routine pain medication ordered of [MEDICATION NAME] 5-500 milligrams at 8 a.m. and 6 p.m. The original date the pain medication was ordered was March 2011. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Tylenol was not signed as given to the resident in the month of July 2011. The resident progress note for Resident #A dated 6-18-11 at 1:50 p.m., indicated the resident was calling out for help. When asked what was wrong the resident indicated her "bottom hurts." The nurse attempted to place resident in a proper placement in the wheelchair to help alleviate the pain. The nurse requested occupational therapy to provide a new pad for the chair to help the resident. The resident progress note for Resident #A dated 6-18-11 at 9:21 p.m., indicated the resident was leaning forward and tipping the wheelchair and trying to get out. The resident progress note for Resident #A dated 6-19-11 at 3:10 p.m., indicated the resident continues to complain of her bottom being sore. There were no open areas noted, but the buttocks was reddened. The resident progress note for Resident #A dated 6-29-11 at 2:27 p.m., indicated the resident complained of her bottom hurting. The area was inspected and an small open area found. The physician was notified and a treatment ordered. The resident progress note for Resident #A dated 7-3-11 at 9:09 p.m. indicated the resident was leaning forward in the wheelchair and putting her legs under the wheelchair. The resident progress note for Resident #A dated 7-5-11 at 10:53 a.m., indicated the open area to coccyx was almost closed. The area was red and blanchable, and the resident complained at times that it hurts. The resident progress note for Resident #A dated 7-6-11 at 2:52 p.m., indicated the resident had been very restless while in the wheelchair. The resident was leaning forward to take the pressure off of the coccyx. The resident progress note for Resident #A dated 7-6-11 at 12:24 p.m., indicated the resident continues to complain of pain in the area of the coccyx while sitting in the wheelchair. The resident was squirming, trying to stand and leaning forward and over the arm rest to get relief from pain. Therapy was called to have resident reviewed for a new chair or pad to allow comfortable sitting. The resident progress note for Resident #A dated 7-7-11 at 10:44 a.m., indicated the resident was complaining of pain in the area of the wound, but it did not appear to be related to the wound. The physician was notified of complaints of pain and waiting for a response. The resident progress note for Resident #A dated 7-7-11 at 1:37 p.m., indicated the resident was occasionally complaining of discomfort in the buttock area. The physician was faxed again about the pain and a request for an x-ray was requested. No return fax at that time. The resident progress note for Resident #A dated 7-7-11 at 7:20 p.m., indicated the physician on call was called to obtain an order for [REDACTED]. Will continue to monitor for increase signs and symptoms of pain. The resident progress note for Resident #A dated 7-8-11 at 10:12 a.m., indicated the staff talked with the Nurse Practitioner (NP) and informed her that the resident was having discomfort while sitting and the pain appeared to be in the buttocks area. The NP gave an order for [REDACTED]. The resident progress note for Resident #A dated 7-8-11 at 10:30 a.m., indicated the NP called back the facility and discontinued the order for the x-ray of the sacrum and coccyx. The NP ordered lab work and for the resident to be off the buttocks as much as possible. The resident progress note for Resident #A dated 7-9-11 at 1:45 a.m., indicated the resident was in wheelchair awake until 12:00 a.m., due to restlessness. The resident was leaning forward until chair alarm sounded. The resident progress note for Resident #A dated 7-9-11 at 9:28 a.m., indicated the resident continued to complain of sacral area hurting when up in wheelchair. The resident progress note for Resident #A dated 7-9-11 at 5:15 p.m., indicated the resident was getting upset and squirming in the chair. The resident progress note for Resident #A dated 7-9-11 at 10:15 p.m., indicated the resident was sitting in the wheelchair yelling out "help me, I can't walk" repetitively. The resident was also squirming in the wheelchair. The resident progress note for Resident #A dated 7-11-11 at 8:54 p.m., indicated the resident was trying to stand up out of wheelchair. The resident progress note for Resident #A dated 7-12-11 at 7:00 p.m., the resident took off a piece of her wheelchair and began hitting nursing staff. The resident was trying to tip her wheelchair back and rocking back and forth. The resident was attempting to pull the printer on the nurses desk. The on call physician was called and an order received to send the resident for a psychiatric evaluation. The resident progress note for Resident #A dated 7-13-11 at 12:44 p.m., indicated the resident's family wished to increase the resident's antianxiety medication before sending the resident to a psychiatric unit. The resident progress note for Resident #A dated 7-15-11 at 11:57 p.m., indicated the resident was standing up in the chair. The resident progress note for Resident #A dated 7-16-11 at 10:04 p.m., indicated the resident was sitting in the wheelchair at the nursing station. The resident continues to rock back and forth. The resident progress note for Resident #A dated 7-17-11 at 5:59 a.m., indicated the resident had been rocking back and forth and pushing herself into other residents. The resident progress note for Resident #A dated 7-17-11 at 9:25 a.m., indicated the resident had attempted to climb out of bed several times. The resident progress note for Resident #A dated 7-20-11 at 7:12 a.m., indicated the resident had been up all night. The resident was standing up in her chair and leaning over in the chair, touching the floor almost tipping the chair over. The resident was placed in bed, but kept getting out of bed. The resident sat up in wheelchair all night in front of the nursing station. The resident had to be redirected multiple times to sit up in the chair. The resident progress note for Resident #A dated 7-21-11 at 7:01 a.m., indicated the resident kept getting out of bed during the night. The resident was up in the wheelchair and kept leaning forward. The resident progress note for Resident #A dated 7-21-11 at 1:10 p.m., indicated the resident continues to be restless in the wheelchair and attempts to stand up occasionally. The resident progress note for Resident #A dated 7-22-11 at 2:21 a.m., indicated the resident was restless in the wheelchair. The resident repeatedly took off her gown. The resident was leaning forward in the wheelchair attempting to reach her feet. The resident progress note for Resident #A dated 7-22-11 at 9:36 p.m., indicated the resident was standing in the wheelchair all shift. The resident progress note for Resident #A dated 7-23-11 at 11:03 p.m., indicated the resident was standing up in wheelchair and leaning forward in the chair, touching the floor. The resident progress note for Resident #A dated 7-24-11 at 12:05 a.m., indicated the resident was out of the bed four times. The resident was sitting at the nursing station in her wheelchair and kept leaning over, almost tipping the chair over. The resident progress note for Resident #A dated 7-24-11 at 12:25 a.m., indicated the resident was unable to sit in the wheelchair. The resident was standing up and leaning over in the wheelchair. The nurse was holding the resident up in the chair. The resident states "can't sit up". The physician on call was notified and an order was received to send the resident to the emergency room . The resident progress note for Resident #A dated 7-24-11 at 4:30 a.m., indicated the resident returned from the emergency room with a new order for [MEDICATION NAME] (antipsychotic medication) 1-2 milligrams for agitation. The resident progress note for Resident #A dated 7-25-11 at 12:19 a.m., indicated the resident was at the nursing station in the wheelchair rocking back and forth. The resident was attempting to stand. The resident was asking for someone to take her home and yelling for help. The resident progress note for Resident #A dated 7-25-11 at 3:00 a.m., indicated the resident was standing up in her wheelchair. The resident also was leaning over in the chair and holding the bottom of the wheelchair. The resident progress note for Resident #A dated 7-25-11 at 5:50 a.m., indicated the resident had been up all night sitting in wheelchair in front of the nursing station. The resident had been rocking back and forth and attempting to stand up. The resident progress note for Resident #A dated 7-25-11 at 9:35 a.m., indicated the physician was in to see the resident and ordered an x-ray of the coccyx. The physician progress notes [REDACTED]. The resident had been up and down, throwing things, wont stay in bed. Sundown's about 1:00 p.m. everyday. The resident does hit. This had been going on for one month, but was worse for the past two weeks. The resident was sent to the emergency room and was given [MEDICATION NAME]. The resident complained of tail bone pain. "Coccyx films". The resident progress note for Resident #A dated 7-25-11 at 3:43 p.m., indicated the resident had been tearful and crying off and on. The resident had been moving all day. The resident was trying to stand up and rocking back and forth. The resident progress note for Resident #A dated 7-26-11 at 1:15 a.m., indicated the x-ray results showed a displaced intertrochanteric [MEDICAL CONDITION] hip with superior displaced of the femur. An order was received to send the resident to the emergency room . The local emergency room record for Resident #A dated 7-26-11, indicated the had left hip pain for one month. The pain was worse when the resident was up and with movement. The [DIAGNOSES REDACTED]. The radiology report for Resident #A dated 7-26-11, indicated the indication was in pain for one month; fall. The discussion was displaced [MEDICATION NAME] left femoral neck fracture (left [MEDICAL CONDITION]). Osteopenia or [MEDICAL CONDITION] is suggested. The orthopedic staff initial consult for Resident #A dated 7-26-11, indicated the resident was seen for an orthopedic assessment concerning a fractured left hip. There was some shortening of the left lower limb on comparison to the right. There was mild external rotation. Review of the x-ray showed subacute to chronic [MEDICAL CONDITION] hip. "It is obviously old." The recommendation was that management be focused on pain management. During observation on 8-18-11 at 10:35 a.m., CNA #1 and CNA #2 transferred Resident #A with a hoyer lift from and geri chair to the bed. Interview with CNA #1 at this time indicated the resident was transferred with two people and a gait belt before she fractured her hip. CNA #1 indicated Resident #A could stand good before the [MEDICAL CONDITION]. CNA #1 indicated Resident #A's family came in all the time every day to see the resident. Interview with Resident #A's family on 8-18-11 at 12:05 p.m., indicated she was told the facility did not know how Resident #A's left [MEDICAL CONDITION] happened. The family member indicated the orthopedic doctor told the family the fracture was at least 6 weeks old. The family member indicated the resident had been complaining of pain and the nurse tried to order an x-ray, but the physician did not feel it was necessary to get an x-ray. The family member indicated the resident had been crying with pain for weeks, approximately 1 month. The family member indicated when the resident's doctor came to see the resident, a family member asked the doctor to get an x-ray and then the facility did. Interview with LPN #3 on 8-18-11 at 12:35 p.m., indicated she was the nurse who called the on call physician on 7-7-11 to obtain an x-ray order for Resident #A. LPN #3 indicated the resident had been having pain. LPN #3 indicated the facility had attempted to call and fax the doctor and did not get any response. LPN #3 indicated she told the on call physician that the resident was in pain and the resident needed an x-ray. LPN #3 indicated the physician on call would not give her an order to do the x-ray. LPN #3 indicated the resident was up in a wheelchair and leaning over. LPN #3 indicated the resident seemed in pain and was leaning over like her back or tail bone hurt. LPN #3 indicated the resident was fidgety. LPN #3 indicated the resident was acting different from her normal. LPN #3 indicated the facility had not told her what to do in this type of situation, LPN #3 indicated she didn't know if she could call someone else or not. Interview with the Assistant Director of Nursing (ADON) on 8-18-11 at 1:00 p.m., indicated the Nurse Practitioner called her on 7-8-11 in the morning and wanted to know what happened the night before and why was the nurse calling the physician on call. The ADON indicated initially the Nurse Practitioner gave her an order for [REDACTED]. The ADON indicated the facility did not have a Director of Nursing (DON) at the time either. The ADON indicated there was a RN acting as DON at the time, but she was working her regular shift as normal. Interview with LPN #4 on 8-18-11 at 1:40 p.m., indicated she was the nurse on 7-7-11 during the day. LPN #4 indicated Resident #A was complaining her bottom hurt and doing a lot of fidgeting. LPN #4 indicated the resident was lifting herself up off the wheelchair a lot trying to relieve pressure. LPN #4 indicated Resident #A had been exhibiting signs of pain for a few days. LPN #4 indicated she had called and faxed the physician and did not get any response. LPN #4 indicated she told the nurse on the next shift. Interview with the DON on 8-19-11 at 9:40 a.m., indicated the hospital told the facility, Resident #A's left [MEDICAL CONDITION] was at least 6 weeks old. The DON indicated she did not think the physician on call had assessed Resident #A. The DON indicated the first physician progress notes [REDACTED]. Interview with the physician on call on 8-19-11 at 11:20 a.m., indicated the facility called him on 7-7-11 at 8:30 p.m. The physician on call indicated the nurse told him Resident #A had been having pain for 3 days. The physician on call indicated he felt like it was something that could have been dealt with in the morning. The physician on call indicated he called the facility the next morning and asked how Resident #A was doing. The physician on call indicated he was told that the resident was not having any problems. The physician on call indicated he could not remember who he talked with. The physician on call indicated he did not want to ignore other problems the resident may have been having such as [MEDICAL CONDITION]. The "Pain Management" policy provided by the DON on 8-18-11 at 2:40 p.m., indicated it was the facility's policy to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being, including pain management. It is the responsibility of the facility to ensure that each resident is assessed for pain, and the efficacy of pain medication, while keeping the resident as comfortable and pain free as possible. The residents are assessed for pain upon admission, quarterly, and with significant change in the resident's condition and/or new onset of pain. The non-interviewable resident pain management program will be determined based upon staff observation of non-verbal signs of pain as follows: non- verbal sounds (crying, whining, gasping, moaning, or groaning), vocal complaints of pain (that hurts, ouch, stop), facial expressions (grimacing, winces, wrinkled forehead, furrowed brow, clenched teeth) and protective body movements or postures (bracing, guarding, rubbing or massaging a body part, clutching or holing a body part during movement). This federal tag relates to Complaint IN 307. 3.1-37(a)