Every finding on record at Waldron Rehabilitation and Healthcare Center

Based on interview and record review, the facility failed to treat residents with dignity and respect for 3 of 6 resident's reviewed for dignity (Residents F, H, and L).Findings include: 1. The clinical record for Resident F was reviewed on 5/13/26 at 10:00 a.m. The resident's diagnosis included, but was not limited to, high blood pressure (elevated above normal range blood pressure). An admission Minimum Data Set (MDS) Assessment, completed 2/7/26, indicated Resident F was cognitively intact. During an interview on 5/13/26 at 10:28 a.m., Resident F indicated on the evening, of 5/8/26, the Director of Nursing (DON) had come to his room to tell him not to curse at the nursing staff. The DON had screamed at him and told him to get the h*ll out. The DON had cursed at him and was disrespectful. The resident had informed the Executive Director (ED) about the incident on Monday 5/11/26. On 5/13/26 at 12:05 p.m., the ED provided a copy of the Reportable Incident Report, dated 5/11/26, indicated Resident F had alleged the DON had screamed at the resident during an interaction. The resident was assessed and had no injuries. A thorough investigation had been initiated. The investigation file for the Reportable Incident included a statement from the DON that indicated on 5/8/26 at around 6:00 p.m., the DON entered Resident F's room to discuss the resident's request for the aides to put his penis in the urinal. When the DON entered the room, the resident was lying in bed. The DON advised the resident to not yell and cuss out (insulting language) the girls (Certified Nursing Assistants) when they offer to help you. The Certified Nursing Assistants were to encourage the resident to do things for himself. During an interview on 5/14/26 at 10:31 a.m., Registered Nurse (RN) 4 indicated she had worked the evening shift on 5/8/26. RN 4 heard the DON and Resident F discussing something in Resident F's room. Both Resident F and the DON's voices had been raised, but the DON had not been screaming. The DON had a voice that carries. RN 4 was unable to hear what was being discussed. During an interview on 5/14/26 at 10:47 a.m., Resident D and Resident J indicated they were outside in the smoking area on 5/8/26 at around 6:00 p.m. Resident D and Resident J had heard Resident F and the DON yelling at each other. Resident F's room was right by the smoking area and Resident F's window had been cracked. Resident D indicated Resident F was hard to get along with sometimes, but the DON should not have yelled at Resident F. During an interview on 5/14/26 at 1:11 p.m., Resident L indicated he was outside in the smoking area on 5/8/26 at around 6:00 p.m. Resident L had heard the DON going off on Resident F. The DON was mad and Resident L had never heard the DON yell like that before. Resident F could push everyone's buttons. During an interview on 5/14/26 at 2:33 p.m., the DON indicated she had a discussion with Resident F on 5/8/26 at around 6:00 p.m., the DON had been firm with Resident F but had not screamed at him during the discussion. Resident F had screamed and cursed at the DON. During an interview on 5/14/26 at 2:33 p.m., the ED indicated that the DON had informed the ED of the interaction between the DON and Resident F on 5/8/26. The DON had been stern with Resident F about his behaviors of cursing at the staff and toileting issues. 2. During an interview on 5/14/26 at 1:11 p.m., Resident L indicated some of the staff were mad at him because he had reported a CNA for being disrespectful to him. The CNA had told Resident L that he had *******[cuss word] peed his pants. Resident L had reported the CNA to the DON about three weeks ago. The CNA that Resident L had reported was not allowed in his room anymore but would walk by when the resident's call light was on and stare. Since Resident L had reported the CNA, some of the other CNA's would not come into his room to answer his call light. 3. During an interview on 5/13/26 at 1:53 p.m., Resident H indicated he had completed a grievance form earlier in the week because one of the staff had accused the resident that sh*t his pants. Resident H felt that was very disrespectful and it upset the resident. On 5/14/26 at 1:19 p.m., the ED provided the Resident Rights Policy, effective 11/1/2021, that read .Residents have the right to a dignified existence, self-determination, and communication with persons and services inside and outside the facility .Residents have the right to be treated with consideration, respect, and recognition or their dignity and individuality . This citation relates to Intake 3011627 410 IAC (Indiana Administrative Code) 16.3.1-3(a)

Based on interview and record review, the facility failed to ensure staff timely reported allegation of abuse to the Executive Director for 1 of 4 residents reviewed for abuse (Resident F). Findings include:The clinical record for Resident F was reviewed on 5/13/26 at 10:00 a.m. The resident's diagnosis included, but was not limited to, high blood pressure (elevated above normal). An admission Minimum Data Set (MDS) Assessment, completed 2/7/26, indicated Resident F was cognitively intact. During an interview on 5/13/26 at 10:28 a.m., Resident F indicated on the evening of 5/8/26, the Director of Nursing (DON) had come to his room to tell him not to curse at the nursing staff. The DON had screamed at him and told him to get the h*ll out. The DON had cursed at him and been very disrespectful. The resident had informed the Executive Director (ED) about the incident on Monday 5/11/26. A confidential interview was conducted during the course of the survey. The confidential interview indicated they had been told by Resident F that the DON had yelled at him. They had not reported it to the ED because Resident F had indicated he had reported it. During an interview on 5/14/26 at 2:33 p.m., the ED indicated she had been at the facility on Saturday 5/9/26. The ED had not heard anyone talking about the incident between Resident F and the DON. The ED had not been informed of the incident by any staff while she was at the facility on Saturday. The ED would have wanted to have known about what was being said about the incident and the staff should have reported it to her. On 5/13/26 at 12:15 p.m., the ED provided the Abuse and Incident Report Policy, dated 4/8/24, that read .The facility will ensure that all alleged violations involving mistreatment or exploitation, neglect, or abuse, including injuries of unknown origin and misappropriation of resident property are reported immediately to the administrator and to other officials in accordance with state and federal regulations. Any incident or accident that meets the requirement of reportable incident as outlined in the policy must be immediately reported to the Administrator or Director of Nursing .Types of Incidents Reportable under Federal and State Regulations: I. ABUSE: a) Staff to Resident Abuse: All allegations of staff to resident abuse must be reported. Staff may receive allegations from any source, including other staff, residents, family members, or otherhealth care providers. Also, each occurrence must be reported. If staff are aware of or witness any abuse that occurs, it must be reported .This citation relates to Intake 3011627.410 IAC (Indiana Administrative Code) 16.3.1-28(c)

Based on interview and record review the facility failed to assess pain level prior to administering as needed pain medications and to implement non-pharmacological pain interventions for 1 of 1 resident reviewed for pain ( Resident F).Findings include:The clinical record for Resident E was reviewed on 5/13/26 at 10:00 a.m., the resident's diagnosis included, but was not limited to, inguinal hernia (tissue that has protruded through the lower abdominal muscles and caused a bump in the groin). A care plan, initiated 1/27/26, indicated Resident F had chronic conditions and risk for discomfort, complications, or decline. The goal was for him to attain or maintain his highest practicable level of well-being and to minimize risks of complications. The interventions included, but were not limited to, assess for verbal and non-verbal signs and symptoms related to pain such as grimace, guarding, crying, moaning, and increased anxiety. Monitor Resident F for signs and symptoms of discomfort and reports of pain. Attempt non-pharmacological interventions and provide medications, as ordered, if not effective. Offer pharmacological and non-pharmacological interventions to relieve pain as needed. Activity level as tolerated by the residents; encourage rest periods to avoid fatigue. A physician's order, dated 2/5/26, indicated staff were to observe the resident for pain every shift. An admission Minimum Data Set (MDS) assessment, completed 2/7/26, indicated Resident F was cognitively intact, required substantial assistance of staff for toilet hygiene, and had no pain. A nurse's note, dated 4/23/26 at 9:44 p.m., indicated Resident F had returned from an acute care hospital after having his inguinal hernia repaired. The resident had a new physician's order for Ultram (narcotic-like pain medication) 50 milligram (mg) every 8 hours, as needed, for pain. The April 2026 Medication Administration Record (MAR) indicated Resident F had received Ultram 50 mg at the following days and times: on 4/23/26 at 10:45 p.m., for a pain level of 9 (using pain scale of 1 to 10 with 10 being the extreme pain); on 4/24/26 at 8:57 a.m., for a pain level of 10; on 4/27/26 at 9:38 a.m., for a pain level of 6; on 4/28/26 at 8:58 a.m., for a pain level of 8; and on 4/28/26 at 8:22 p.m., for a pain level of 7.The facility Capsus (emergency drug dispensing machine) record indicated four doses of Ultram 50 mg had been obtained for Resident F on 4/24/26 at the following times: 12:28 a.m., 12:45 a.m., 8:58 a.m., and 9:04 a.m. The April 2026 MAR did not include documentation that two of the four doses of Ultram, pulled from the Capsus machine, had been administered to Resident F, what his pain level was upon administration, or if the medication was effective. The clinical record did not include what non-pharmacological interventions had been attempted to assist with Resident F's pain control. A nurse's progress note, dated 4/26/2026 at 1:33 p.m., indicated Resident F had been offered education about the post-surgical period and post-surgical healing. The resident's surgical incision was assessed and was clean, dry, and intact. Resident F was unsatisfied with education and requested to speak to a doctor who can tell me what the h*ll is going on. A Nurse Practitioner Visit Note, dated 4/27/26, indicated Resident F had multiple complaints and indicated he was having a lot of pain from his surgery. He indicated he was unable to do anything for himself due to pain. The resident was unhappy with staff who were trying to force him to get up. The facility staff reported behaviors such as rolling over to the side of the bed to urinate on the floor. The resident indicated he was unable to use the urinal because his testicles were too swollen. The Nurse Practitioner had encouraged the resident to get out of bed for at least for meals. The resident's genitals had mild scrotal edema (swelling). The resident was encouraged to use a urinal to void (urinate). During an interview on 5/13/26 at 10:28 a.m., Resident F indicated he had a lot of pain when he returned from his hernia surgery. The nursing staff did not assist him with controlling his pain. During an interview on 5/14/26 at 1:40 p.m., the Director of Nursing indicated the nursing staff should have documented each dose of Ultram given on the Medication Administration Record and included a pain assessment. The nursing staff should have documented the non-pharmacological pain interventions attempted. On 5/14/26 at 1:33 p.m., the Executive Director provided the Pain Clinical Protocol, revised April 2025, that read .The provider will order appropriate non-pharmacologic and medication interventions to address the individual's pain .The staff will reassess the individual's pain and related consequences at regular intervals, at least each shift for acute pain or significant changes in levels of chronic pain, and at least weekly in stable chronic pain. a. Review should include frequency, duration, and intensity of pain, ability to perform activities of daily living [ADLs], sleep pattern, mood, behavior, and participation in activities. b. The staff will evaluate and report on the resident/patient's use of standing and PRN [as needed] analgesics .This citation relates to Intake 3011627.410 IAC (Indiana Administrative Code) 16.3.1-37(a)

Based on interview and record review, the facility failed to completely and accurately reconcile admission orders and failed to timely input and initiate physician orders for a resident with a change of condition for 1 of 6 residents reviewed for medication management and 1 of 1 resident reviewed for hospitalization (Resident 18 and 5).Findings include: 1. The clinical record for Resident 18 was reviewed on 12/4/2025 at 11:30 a.m. The medical diagnoses included pulmonary disease, osteoporosis, and heart disease. The admission Minimum Data Set, dated [DATE], indicated Resident 18 was cognitively intact and rejected care one to three of the last seven days. Resident 18 received anticoagulant, antiplatelet, and anticonvulsant medication. The Medication Review did not find any issues. A Nursing admission Assessment, dated 11/20/2025, indicated Resident 18 did not receive medications. During an interview on 12/3/2025 at 10:09 a.m., Resident 19 indicated she was not receiving her medications as she should be. She has concerns about multiple medications, including medication for pain control and arthritis. admission orders for Resident 18, dated 11/17/2025, indicated physician orders for 35 medications and orders to hold two additional orders. The facility's Medication Administration Record (MAR), dated for November 2025, was reviewed on 12/5/2025 at 10:57 a.m. Reconciliation from the physician order to the admission MAR indicated eight medications were not transcribed to the facility MAR. These medications included: as needed Flexeril for muscle spasms, three injections for osteoporosis, a meal supplement, an oral vitamin B-12, an antibiotic used two times a week, and twice daily eye drops. During an interview on 12/05/2025 at 12:15 p.m., the DON confirmed she spoke with the physician about the eight medications at admission but did not document the conversation or discontinuation orders. She indicated some medications were not prescribed based on a pre-admission agreement (the three injections), and others were not prescribed because Resident 18 indicated she did not want to take them. 2. The clinical record for Resident 5 was reviewed on 12/3/25 at 9:50 a.m. The resident's diagnosis included, but was not limited to, obstructive uropathy (inability to urinate). A care plan, last revised 9/9/24, indicated he was at risk for activities of daily living self-care level of functioning to the extent deficits and continence needs and risk for functional declines related to obstructive uropathy and catheter. The interventions included, but were not limited to, observe for signs and symptoms of urinary tract infection such as pain, abnormal urine color, mental status changes, and toileting hygiene may fluctuate throughout the day, but usual performance is maximal assistance. A nurse's note, dated 10/09/25 10:49 p.m., indicated Resident 5's urinary output was 800 milliliters (ml) of coffee-tinged urine. Resident 5 had no complaints of pain or discomfort in his bladder. Resident 5 was encouraged to drink plenty of water. A nurses note, dated 10/29/25 at 3:15 a.m., indicated Resident 5 was observed to be supported in the sit to stand (type of mechanical lift) sling, but limp and non-responsive. A radial pulse was unable to be located. Resident 5 was lowered to the floor and there was an immediate return of his radial pulse. He remained unresponsive with flaccid extremities. His respirations were shallow with notable use of accessory muscles. His pupils were fixed and dilated. He was transferred to bed with the use of a Hoyer (full body mechanical lift). Resident 5 spontaneously opened his eyes and spoke during the transfer. He was slightly alert with slow verbal responses and oriented x 3. The on-call provider (physician) and family member were notified. The October 2025 Medication Administration Record (MAR) indicated on 10/29/25 at 10:26 a.m., Resident 5 had received acetaminophen (Tylenol) 650 milligram (mg) for a temperature of 102.6. The acetaminophen had been ineffective. He had received another dose on 10/29/25 at 4:55 p.m., for a temperature of 99.8, that was effective. A physician's nursing home visit note, dated 10/29/25, indicated the Nurse Practitioner (NP) had seen Resident 5 due to fever and chills. The physical exam indicated he had a suprapubic catheter that was draining cloudy, amber colored urine. The plan indicated he had acute cystitis and was to be empirically treated with Levaquin (antibiotic) 500 mg x seven days. The urine culture was to be monitored, and the antibiotic would be adjusted as indicated by the final culture. He also was to be treated for hypokalemia (low potassium level) and was to receive 40 milliequivalents of potassium daily for three days. A physician's order, dated 10/30/25, indicated he was to receive Levaquin 500 mg daily in the morning related to urinary tract infection. A physician's order, dated 10/30/25, indicated he was to receive potassium oral tablet 40 milliequivalents twice daily for hypokalemia. The October 2025 MAR indicated Resident 5 received the first dose of Levaquin and the first dose of potassium the morning of 10/31/25. A nurse's note, dated 10/31/25 at 10:13 a.m., indicated the NP had been notified of resident 5's change in condition and a new order was received to send him to the emergency room for evaluation and treatment. The clinical record did not contain assessments of Resident 5's urine color, clarity, or characteristics from 10/29/25 through 10/31/25, when he was sent to the emergency room. During an interview on 12/4/25 at 2:08 p.m., NP 5 indicated she had seen Resident 5 on 10/29/25 because of his elevated temperature and not feeling well. Resident 5 refused treatment at the emergency room on [DATE]. She had ordered the Levaquin and potassium on 10/29/25. She expected antibiotics to be started as soon as reasonably possible. She would sometimes enter her own orders into the electronic health record and sometimes the nurses entered the orders. The order for the Levaquin and potassium had not been entered into the electronic health record until 10/30/25. On 12/4/25 at 4:23 p.m., the Executive Director provided the Physician Services and Orders policy, dated 12/1/23, that read .6. A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident's immediate care and needs .8. All physician or other health care professional verbal orders, including telephone orders, will be promptly recorded, dated, and signed by the person receiving the order in the EMR [Electronic Medical Record] . 3.1-37

Based on observation, interview, and record review, the facility failed to ensure a resident was assessed accurately to determine if the resident was able to participate in a smoking activity for 1 of 9 residents reviewed for smoking. (Resident 3)Findings include: The clinical record for Resident 3 was reviewed on 12/2/24 at 1:15 p.m. The diagnoses included but were not limited to: stroke resulting in right side hemiplegia (paralysis on one side) and nicotine dependence. A quarterly Minimum Data Set (MDS) assessment, dated 11/1/25, indicated Resident 3 was moderately cognitively impaired. A care plan, dated 6/30/25, indicated Resident 3 was at risk for falls with safety and injuries due to his diagnoses that included but was not limited to: smoking. A list of residents that smoke was provided by the Administrator on 12/2/25 at 12:11 p.m. It indicated Resident 3 does participate in the smoking activity. An interview was conducted with Resident 3 on 12/2/25 at 1:14 p.m. He indicated he does go outside to smoke. He smokes cigarettes and vapes. A smoking assessment, dated 3/3/25, conducted with Resident 3 indicated the resident did not smoke. A smoking assessment, dated 6/9/25, conducted with Resident 3 indicated the resident did smoke and was able to participate in the activity safely. A smoking assessment, dated 9/9/25, conducted with Resident 3 indicated the resident did not smoke. An interview was conducted with License Practical Nurse (LPN) 2 and Registered Nurse (RN) 1 on 12/4/25 at 2:37 p.m. LPN 2 indicated Resident 3 has been going outside to participate in the smoking activity. An observation was made of a smoking activity on 12/4/25 at 3:00 p.m. Resident 3 was observed participating in the smoking activity with smoking two cigarettes. During and interview with the Administrator and Director of Nursing on 12/4/25 at 3:47 p.m., they indicated Resident 3 was not a consistent smoking resident. There has been times when he had stopped smoking and that may be reflecting why the inconsistent smoking assessments. A smoking policy, dated 1/16/25, was provided by the Administrator on 12/4/25 at 3:10 p.m. It indicated, .All residents who have been assessed and determined to be safe to smoke will smoke with supervision, outside of the facility at the designated area and designated smoking times listed below. All smokers must have direct supervision. No smoker is to be smoking without supervision. No smoking is permitted inside the building, this includes vaping. 3.1-45(a)(1)

Based on observation, interview, and record review, the facility failed to ensure proper hand hygiene was utilized during medication administrations for 4 of 6 residents observed during medication administration. (Resident 1, Resident 7, Resident 19 and Resident 22) Findings include: 1. The clinical record for Resident 22 was reviewed on 12/4/2025 at 1:20 p.m. The diagnoses included, but were not limit to: diabetes and cardiovascular disease. The physician's orders, dated 6/8/2025, indicated for Resident 22 to have insulin 3 units twice a day. The physician's orders, dated 6/23/2025, indicated for Resident 22 to have insulin per sliding scale three times a day. During an observation and interview on 12/4/2025 at 11:49 p.m., RN 1 was observed administering insulin per injection to Resident 22 without the use of gloves. When asked about hand hygiene, RN 1 indicated she used hand sanitizer after administering insulin. No hand hygiene was observed prior to the RN administering the insulin after she touched multiple areas on the medication cart with her bare hands. 2.The clinical record for Resident 1 was reviewed on 12/2/25 at 1:00 p.m. The diagnosis included, but was not limited to: hypertension. An observation was made of a medication administration for Resident 1 with Registered Nurse (RN) 1 on 12/4/25 at 8:52 a.m. RN 1 was observed at the medication cart preparing the resident's medications. RN 1 touched the mouse to the computer, the medication cart drawers, the medication cards, an inhaler medication, a pitcher of water and drinking cups. During that time, RN 1 popped several medications from the medication cards in her bare hand and then placed in a medication cup. After, she went to the resident in the hallway and administered the resident's medications. There was observation of utilizing hand hygiene and donning on gloves prior to touching the pill medications with her hands. 3. The clinical record for Resident 7 was reviewed on 12/2/25 at 1:50 p.m. The diagnosis included, but was not limited to: Paranoid Schizophrenia. An observation was made of medication administration for Resident 7 with RN 1 on 12/4/25 at 8:57 a.m. RN 1 was observed at the medication cart preparing the resident's medications. RN 1 pulled morning pill medications, eye drops and nasal spray from the medication cart. She then knocked on the resident's door and entered the room. During the administration, RN 1 donned gloves and administered eye drops. After, she doffed the gloves and returned back to the medication cart. There was no observation of hand hygiene prior to the donning gloves. 4. The clinical record for Resident 19 was reviewed on 12/2/25 at 2:00 p.m. The diagnosis included, but was not limited to: legal blindness. An observation was made of a medication administration for Resident 19 with RN 1 on 12/4/25 at 9:05 a.m. RN 1 was observed at the medication cart preparing the resident's morning medications. During that time, she was observed popping medications in her bare hands and placing the medications in a medication cup. After, she entered the resident's room; she donned gloves and administered the resident's medications, administered the resident's eye drops and eye ointment. There were no hand hygiene and donning on gloves prior to touching the resident's medication at the medication cart nor hand hygiene prior to donning gloves during the eye medication administrations. An interview was conducted with the Director of Nursing on 12/5/25 at 11:30 a.m. She indicated the staff should utilize hand hygiene prior to donning gloves, don on gloves prior to insulin administrations and should not be touching medications directly with their bare hands. A hand hygiene policy was provided by the Administrator on 12/4/25 at 3:10 p.m. indicated, .This facility considers hand hygiene the primary means to prevent the spread of healthcare associated infections.Indications for hand hygiene.a. immediately before touching a resident. b. before performing aseptic task (for example.or handling an invasive device.) g. immediately after glove use.4. Single-use of disposable gloves should be used: a. before aseptic procedures., when anticipating contact with blood or body fluids.5. The use of gloves does not replace hand washing/hand hygiene. 3.1-18(l)

Based on interview and record review, the facility failed to ensure residents received mail on Saturdays. This had a potential to affect 46 of 46 residents that resided in the facility.Findings include:1. The clinical record for Resident 1 was reviewed on 12/2/25 at 1:00 p.m. The diagnosis included, but was not limited to: hypertension. A quarterly Minimum Data Set (MDS) assessment, dated 10/8/25, indicated Resident 1 was cognitively intact. 2. The clinical record for Resident 15 was reviewed on 12/2/25 at 1:15 p.m. The diagnosis included, but was not limited to: hypertension. An annual MDS assessment, dated 9/19/25, indicated Resident 15 was cognitively intact. 3. The clinical record for Resident 22 was reviewed on 12/2/25 at 1:30 p.m. The diagnosis included, but was not limited to: hypertension. A quarterly MDS assessment, dated 10/17/25, indicated Resident 22 was cognitively intact. 4. The clinical record for Resident 24 was reviewed on 12/2/25 at 2:00 p.m. The diagnosis included, but was not limited to: hypertension. A quarterly MDS assessment, dated 9/15/25, indicated Resident 24 was cognitively intact. 5. The clinical record for Resident 29 was reviewed on 12/2/25 at 2:10 p.m. The diagnosis included, but was not limited to: diabetes mellitus. A quarterly MDS assessment, dated 9/15/25, indicated Resident 29 was cognitively intact. 6. The clinical record for Resident 41 was reviewed on 12/2/25 at 2:20 p.m. The diagnosis included, but was not limited to: hypertension. A quarterly MDS assessment, dated 10/21/25, indicated Resident 41 was cognitively intact. A resident council meeting was conducted on 12/3/25 at 1:04 p.m. The residents that attended the meeting that day were the following: Resident 1, Resident 15, Resident 22, Resident 24, Resident 29, and Resident 41. During the council meeting, the resident council indicated mail was not delivered on Saturdays. They have to wait until Monday to receive the mail that had come in over the weekend. An interview was conducted with the Business Office Manager (BOM) on 12/3/25 at 1:27 p.m. He indicated the receptionist gives him all the mail that was delivered. He pulls out the mail that he needs and then gives the remaining mail that was to be delivered to the residents to the Activities Director (AD). The AD delivers the mail to the residents. The mail was not delivered to the residents on Saturdays. They do have to wait until Monday to receive the mail that had come in over the weekend. He comes in on Mondays, and there usually was a large pile of mail to go through. It piles up.An interview was conducted with the AD on 12/3/25 at 1:35 p.m. She indicated she does not work over the weekends. She was not sure if anyone does pass out the mail to the residents. An interview was conducted with the Administer on 12/3/25 at 3:06 p.m. She indicated the Nurse Manager on duty was to pass out the mail on Saturdays to the residents. She will provide education to the weekend staff about mail delivery on Saturdays. 3.1-3(s)(1)

Based on interview and record review, the facility failed to properly ensure treatment of a urinary tract infection was completed for 1 of 3 residents reviewed for identification and treatments of urinary tract infections. (Resident D)Findings include:The clinical record for Resident D was reviewed on 8/19/2025 at 1:45 p.m. The medical diagnoses included stroke and urinary tract infection.A Quarterly Minimum Data Set assessment, dated 7/20/2025, indicated Resident D was cognitively impaired, always incontinent with bladder, and needed substantial to maximal assistance with toileting hygiene.An activity of daily living care plan, revised 5/21/2025, indicated Resident D had issues with continence status with interventions were to assist with toileting and personal hygiene.Hospital discharge documentation, dated 8/6/2025, indicated Resident D was being treated for a urinary tract infection with Bactrim DS (an antibiotic) by mouth every 12 hours for the next five days. Later in that document, a new prescription was listed as Bactrim DS by mouth every 12 hours with a quantity of ten. A hospital after visit summary, dated 8/6/2025, indicated Resident D was diagnosed with a urinary tract infection, received two doses of intravenous antibiotics, and needed to take .this medication [antibiotic] for the next 5 days.Review of the Medication Administration Record for August 2025 indicated Resident D received eight doses of Bactrim DS over four days.During an interview on 8/19/2025 at 2:30 p.m., the Director of Nursing indicated Resident D had only received four days of antibiotics.A policy entitled, Physician Servers and Orders, was provided by the Administrator on 8/19/2025 at 3:00 p.m. The policy indicated . All physician orders will be followed as prescribed.This citation relates to Complaint 2581246.3.1-41(a)(2)

Based on interview and record review, the facility failed to ensure documentation was complete and accurate, related to care-planned arguing between 2 of 6 residents reviewed for possible abuse allegations and for 1 of 5 residents reviewed for activities programming. (Resident C, Resident D, and Resident H) Findings include. 1. The clinical record of Resident C was reviewed on 5-27-25 at 11:06 a.m. Her most recent Minimum Data Set assessment, dated 4-12-25, indicated she was cognitively intact. An entry in the progress notes, on 5-12-25 at 6:05 p.m., indicated Resident C had fight with Resident H during supper, that brought one of them cussing and walked away. The documentation was unclear regarding what constituted a fight, if it was physical or verbal, who was cursing, the negative impact of the interaction, nor what actions were taken by facility staff during or after the interaction. The clinical record of Resident H was reviewed on 5-28-25 at 10:55 a.m. Her most recent Minimum Data Set assessment, dated 4-15-25, indicated she was cognitively intact. An entry in the progress notes, on 5-12-25 at 6:00 p.m., indicated Resident H had fight with Resident C during supper, that brought one of them cussing and walked away. The documentation was unclear regarding what constituted a fight, if it was physical or verbal, who was cursing, the negative impact of the interaction, nor what actions were taken by facility staff during or after the interaction. During an interview on 5-27-25 at 1:31 p.m. with the Director of Nursing (DON), she indicated the staff member who documented the interaction between Resident C and Resident H was a Registered Nurse (RN) for whom English was not his native language and his charting and wording and English can be a problem at times. The DON provided an example of a charting problem on a different resident where RN 3 was trying to say the resident was annoyed, but he documented the resident was annoying. During an interview with the Executive Director (ED) on 5-27-25 at 2:03 p.m., she indicated RN 3 does have broken English. During a phone interview with RN 3 on 5-28-25 at 11:40 a.m., he indicated English was his second language and sometimes had difficulty with wording in his chart documentation. He indicated on the date in question, the dietary staff had informed him they overheard Resident C and Resident H arguing with each other, as well as these two residents had a history of doing this type of behavior. The management team was aware of this, and it needed to be reported to Social Services. He indicated he sought advice from his co-workers and was informed he needed to report their behaviors to Social Services and document the event in the clinical record. He indicated from what he was aware of with these two residents, the arguing was a common behavior between both residents. During an interview with the DON and the ED on 5-28-25 at 11:40 a.m., the DON indicated she had worked with RN 3 quite a bit in regards to wording of documentation. For example, I addressed with him using the phrase a resident's actions were annoying to him, when what he meant was the resident had been annoyed. He is normally very good to reach out to me or his co-workers for clarification of terminologies. We review all documentation each morning in our morning meeting to review any care or resident issues . I would say the term, 'fight,' would not be the most accurate word to use for their interaction. The ED indicated both residents were care planned for bickering with one another. She indicated when she spoke with Resident C the next day, Resident C indicated Resident H was wanting to become verbal, so she [Resident C] chose to just walk away. She did say that she did mumble curse words while she was walking down the hall, but definitely did not yell or curse out loud. There was no physical contact with anyone. In an interview with Resident C on 5-27-25 at 10:30 a.m., she indicated she had no concerns for abuse of any kind. She added there are times that some people may have words, but then end up being friends again, just like family. In an interview with Resident H on 5-28-25 at 1:50 p.m., she indicated she had no concerns related to any type of abuse at the facility. Resident H indicated there were times that she and a peer have words one day and get upset with each other, just like with family, but the next day, everything is fine. 2. The clinical record for Resident D was reviewed on 5/27/2025 at 1:45 p.m. The medical diagnoses included major depressive disorder and diabetes. A Quarterly Minimum Data Set assessment, dated 3/7/2025, indicated Resident D was cognitively intact and did not reject care. Documented activities for Resident D indicated she did not have documented activities for 7 out of the last 30 days provided. During an interview on 5/27/2025 at 12:01 p.m., Resident D indicated the facility had issues with maintaining activities. Resident D indicated she would attend every activity when it was available. During an interview on 5/28/2025 at 12:15 p.m., the ED indicated the activities staff were responsible for providing and documenting activities to residents. During an interview on 5/28/2025 at 12:45 p.m., the Activities Director indicated residents were provided with passive activities every day and interactive most days. She indicated Resident D comes to almost every activity unless she was out with her family, at an appointment, or not feeling well. It was the responsibility of the activities staff to document activities. A policy entitled, Charting and Documentation, was provided by the ED on 5/28/2025 at 12:56 p.m. The policy indicated . Documentation in the medical record will be objective (not opinionated or speculative), completed and accurate . This citation relates to Complaints IN00459780 and IN00459777. 3.1-50(a)(1) 3.1-50(a)(2)

Based on interview and record review, the facility failed to have a Registered Nurse (RN) 8 hours a day, 7 days a week, for 5 of 5 months of RN coverage reviewed. This had the potential to affect all 47 residents that resided in the facility. Findings include: Review of the schedules provided by the Administrator, on 10/4/24 at 1:00 p.m., indicated there were no RNs in the facility for seven out of 30 days in April 2024, seven out of 31 days in May 2024, four out of 30 days in June 2024, six out of 30 days in September 2024, and two out of eight days in October 2024. During an interview with the Administrator on 10/8/24 at 2:27 p.m., they verified the facility did not have RN coverage in April, May, June, September, and/or October of 2024. During an interview with the Administrator on 10/8/24 at 2:34 p.m., indicated she was not aware of any residents being affected by the facility not having an RN in the building during those months and there were no incomplete tasks that only an RN could do. The sufficient staffing policy provided by the Director of Nursing (DON), on 10/9/24 at 1:50 p.m., indicated the facility would have a Registered Nurse (RN) at least 8 hours a day, and 7 days a week. 3.1-17(b)(3)

Based on observation, interview, and record review, the facility failed to ensure a chemical dishwasher was tested /monitored three times daily per their expectations and to maintain documentation of such monitoring. This had the potential of affect all 47 residents who resided in the facility. Based on observation, interview, and record review, the facility failed to maintain holding temperatures for pureed foods for 5 of 5 residents receiving pureed foods. (Resident 18, 26, 34, 39, and 40) Findings include: 1. A tour of the kitchen was conducted, on 10/3/24 at 12:00 p.m., with the Dietary Manager (DM). During an observation of the chemical dishwasher, the only documentation log for monitoring of the dishwasher was obtaining temperatures only for wash and rinse cycles three times a day. The DM indicated the dishwasher was a chemical/low temperature dishwasher and not a high temperature dishwasher. The DM indicated the facility used a chemical solution for the dishwasher. During an interview with the DM on 10/7/24 at 1:17 p.m., they indicated the facility was testing the chemicals daily on the dishwasher before, but they were not recording them. The dishwasher was changed over from a high temperature to a chemical/low temperature a couple months ago and they continued with the temperature logs only and did not add a chemical log. The DM indicated it was the dietary aid who was responsible for the testing of chemical parts per million (ppm) being conducted on the dishwasher. The Dietary Policy and Procedure Manual provided by the Administrator, on 10/4/24 at 1:00 p.m., indicated the following, . the dishwashing staff will monitor and record dish machine temperatures and Sanitizer PPM to assure proper sanitizing of dishes. The director of food and nutrition services will post a log near the dish machine for the staff to document temperatures and Sanitizer PPM 2. A tour of the kitchen was conducted, on 10/3/24 at 11:15 a.m., with [NAME] 4. During an observation of the pureed food temperatures being obtained, it was noted that pureed mixed vegetables were recorded with a holding temperature of 118 degrees Fahrenheit. The pureed apple butter pork loin had a holding temperature of 118 degrees Fahrenheit and the pureed mashed potatoes had a holding temperature of 118 degrees Fahrenheit. An observation was noted of pureed food containers being stored in a hot water container. [NAME] 4 indicated if they did not have room to store food on the serving line, they held the containers in a separate container off the serving line with hot water on the bottom of it to keep the food warm. [NAME] 4 indicated she would heat the pureed food in the microwave before serving it to the residents. The Dietary Policy and Procedure Manual provided by the Administrator, on 10/4/24 at 1:00 p.m., indicated the following, . the temperatures of all food items will be taken and properly recorded prior to service of each meal. All hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 degrees Fahrenheit 3.1-21(a)(2) 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to have knowledgeable dietary staff regarding a chemical dishwasher for 6 of 6 dietary employees reviewed for kitchen. (Dietary Manager, [NAME] 4, [NAME] 5, Dietary Aid 6, Dietary Aid 7, and Dietary Aid 8) A tour of the kitchen was conducted with [NAME] 4 on 10/3/24 at 11:15 a.m. [NAME] 4 indicated she was not sure what the dishwasher strip testing should read. It was observed [NAME] 4 was using the wrong testing strips to test the chemical dishwasher. She also was unsure of proper temperatures that should be recorded. [NAME] 4 did not know what the temperatures or readings should be for chemical sanitization parts per million (ppm). During an observation of the chemical dishwasher with the Dietary Manager (DM) on 10/3/24 at 12:00 p.m., she was using the wrong chemical testing strips to test the chemical dishwasher. An incorrect reading was being read and the DM did not know why. During an interview with the DM on 10/3/24 at 12:23 p.m., they indicated high temperature logs were being kept for the chemical dishwasher, but chemical testing was not being logged and monitored. She indicated, we test daily, we just did not start a log for chemical monitoring. During an interview with the Administrator on 10/4/24 at 11:00 a.m., they indicated education on the new chemical dishwasher was provided by the service man when he came to install it, but the Dietary Manager could not find the education that was provided to the employees. The Dietary Policy and Procedure Manual provided by the Administrator, on 10/4/24 at 1:00 p.m., indicated, .low temperature dishwasher/spray type dish machines using chemicals to sanitize should have wash temperatures of 120 degrees Fahrenheit and final rinse sanitization should read 50 parts per million (ppm) Hypochlorite 3.1-20(h)

Based on observation, interview, and record review, the facility failed to promote residents' dignity by ensuring privacy for a resident during toileting and providing incontinent care in a timely manner for 2 of 2 residents reviewed for dignity. (Resident 23 and Confidential Resident) Findings include: 1. During an observation on 10/8/24 at 12:13 p.m., Qualified Medication Aide (QMA) 1 and Certified Nurse Aide (CNA) 2 assisted Resident 23 to the toilet in the shower room. QMA 1 and CNA 2 indicated they left Resident 23 in the bathroom alone, because the resident preferred privacy. The shower room had hooks for a privacy curtain, but did not have a privacy curtain hanging to provide privacy to the hallway. QMA 1 and CNA 2 did not know what happened to the privacy curtain. The shower room door was opened four times while the resident was using the restroom, exposing the resident to the hallway. During an interview with the Maintenance Director on 10/8/24 at 12:26 p.m., they indicated it was laundry staff's responsibility to ensure the privacy curtains were in place. During an interview with the Maintenance Director on 10/8/24 at 12:32 p.m., they indicated laundry staff had taken the privacy curtains down, on 10/7/24, to wash them and they were putting the curtains back up at that time. During an interview with the Director of Nursing (DON) on 10/9/24 at 1:09 p.m., they indicated Resident 23 not having the privacy curtain up during toileting could have impacted the resident's dignity. 45291 2. A confidential resident's record was reviewed on 10/8/2024 at 1:30 p.m. The medical diagnoses included depression and anxiety. The most recent Minimum Data Set Assessment indicated the confidential resident was cognitively intact, occasionally incontinent of bowel and bladder, and dependent on staff for assistance with toileting. The most recently revised care plans, last revised in August of 2024, indicated the resident was incontinent of bladder and was at risk for skin break down related to incontinence. An intervention was to provide the resident with scheduled toileting upon rising, before and after meals, and before bed, as well as incontinence care as needed. During a confidential resident interview conducted during the survey, the resident indicated they were made to wait a long time for their call light to be answered, upwards to an hour. They were able to verify they use the wall mounted clock in their room to keep track of the time. The confidential resident indicated they almost always know when they must relieve their bowel and bladder, but they cannot get assistance to the bathroom in a timely manner, resulting them in having incontinence of bladder frequently. They stated they had bladder incontinence episodes due to having to wait for assistance as recently as in the last week, but this was a long-standing issue for the last few months. When the confidential resident had incontinence episodes, they would feel terrible and embarrassed. During a confidential staff interview conducted during the survey, they indicated they attempt to get everything done, but they cannot always get all the residents toileted and showered due to not having enough help. A policy entitled, Resident Rights, was provided by the Director of Nursing on 10/8/2024 at 1:50 p.m. The policy indicated, .Residents have the right to a dignified existence . and .to be treated with considerations, respect, and recognition of their dignity . 3.1-3(t)

Based on interview and record review, the facility failed to hold quarterly care plan meetings for 1 of 3 residents reviewed for care plans. (Resident 8) The clinical record for Resident 8 was reviewed on 10/7/24 at 10:35 a.m. The diagnoses included, but were not limited to, chronic kidney disease, heart failure, and generalized anxiety disorder. During an interview with Resident 8 on 10/4/24 at 11:00 a.m., they indicated they did not have regular care plan meetings. A Quarterly Minimum Data Set (MDS) assessment, dated 8/1/24, indicated Resident 8 was cognitively intact for daily decision making. The electronic health record (EHR) indicated Resident 8 had a quarterly care plan meeting, on 8/4/23, a quarterly care plan meeting, on 2/5/24, and another quarterly care plan meeting, on 7/9/24; indicating no care plan meetings were done for six months, then not again for another five months. During an interview with the Social Service Director (SSD) on 10/7/24 at 1:31 p.m., they indicated care plan meetings were to be held quarterly, and she did not know how the quarterly meetings got missed. A Comprehensive Care Plan Policy provided by the Administrator, on 10/8/24 at 10:15 a.m., indicated, .4. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: a. Participate in the planning process .c. Participate in establishing the expected goals and outcomes of care .5. The resident is informed of his or her right to participate in his or her treatment and provided advance notice of care planning conferences 3.1-35(d)(2)(B)

Based on observation, interview, and record review, the facility failed to utilize an assistive device of a gait belt during a transfer resulting in a fall for 1 of 2 residents reviewed for accidents. (Resident 23) Findings include: During an interview with the Director of Nursing (DON) on 10/8/24 at 11:45 a.m., they indicated Resident 23 was an extensive assist of two people for transfers, on 9/20/24, when she fell . The staff were not utilizing a gait belt during the transfer and the resident did not have any medical condition that would prevent a gait belt being used. During an observation on 10/8/24 at 12:13 p.m., Qualified Medication Aide (QMA) 1 and Certified Nurse Aide (CNA) 2 assisted Resident 23 from her wheelchair to the toilet utilizing a gait belt. The resident was totally dependent of the two staff and gait belt for the transfer and the resident was bent over at the waist. During an interview with the Therapy Manager on 10/8/24 at 12:34 p.m., they indicated gait belts should be used during transfer and ambulation for all residents unless the resident was independent with ambulation and transfer. The Therapy Manager indicated a gait belt should be used for Resident 23. During an interview with the Therapy Manager on 10/8/24 at 12:40 p.m., they indicated the staff should have been utilizing a gait belt when transferring Resident 23, on 9/20/24, when she fell . Review of the record of Resident 23, on 10/9/24 at 1:27 p.m., indicated the diagnoses included, but were not limited to, vascular dementia, anxiety, weakness, unsteadiness on feet, lack of coordination, muscle wasting, and Alzheimer's disease. The plan of care for Resident 23, dated 6/4/24, indicated the resident was at risk for falls related to impaired safety awareness due to dementia, Alzheimer's disease, hypertension, right rotator cuff strain, incontinence and impaired mobility. The State Optional Minimum Data Set (MDS) assessment for Resident 23, dated 7/12/24, indicated the resident was moderately impaired for daily decision making. The resident required extensive assistance of two people with transfers and toileting. The initial occurrence note for Resident 23, dated 9/20/24, indicated the resident had a witnessed fall in the bathroom. The resident was lowered down to the floor on her knees. There were no injuries. The Interdisciplinary (IDT) note for Resident 23, dated 9/23/24, indicated the resident was lowered to the floor in the restroom. There were no injuries or pain. The resident would be evaluated by therapy. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure 2 of 2 residents reviewed for misappropriation of property were not subjected to missing narcotic medications. (Residents B and C) The deficient practice was corrected on 4-4-24, prior to the start of the survey, and was therefore past noncompliance. The facility had immediately began an investigation upon learning of the missing narcotic medication and associated paperwork and begin staff education regarding the correct means to conduct controlled substance counts. Based on resident assessments and interviews, there was not a negative impact to the comfort level of either resident identified as being affected by this deficient practice. Findings include: In an interview with the Executive Director (ED) 5-21-24 at 11:22 a.m., she indicated the facility recently had an issue with diversion of narcotics. She indicated the concern was reported to the Indiana Department of Health's Long Care Division on 3-28-24, the date it was identified, and investigation has continued since that date. In another interview on 5-21-24 at 1:35 p.m., with the ED, she further explained only two residents, Residents B and C, were involved in the misappropriation of property. Once we knew there was an issue, we did an audit of everyone with prn [as needed] narcotics. So, our goal after that was to get any prn narcotics that weren't being used to have them stopped or if they were being used to get something to help them on a routine basis. She indicated 3 staff members were identified as possible suspects, LPN 3, RN 4 and QMA 5, and were each sent for drug testing with the results being negative for all three staff members. Review of the employment records of LPN 3 and RN 4 indicated each began employment after 1-1-24, with QMA 5 beginning employment in the fall of 2022. The ED indicated LPN 3 and RN 4 resigned after this situation and QMA 5 remains employed by the facility. In an interview on 5-22-24 at 9:23 a.m., with the ED, she indicated the manner in which the diversion of narcotics was brought to light was Resident B had requested something for pain from LPN 6 on the evening shift of 3-27-24. She shared LPN 6 inquired about the pain level of the resident's pain and offered Resident B a choice of Percocet or Tylenol; Resident B chose Tylenol. Apparently this got [name of LPN 6] to thinking she could not remember counting the Percocet for the resident at the beginning of her shift, because she recalled she done this earlier in the week when she had done the narcotic counts. This caused her to go and look to see if [name of Resident B]'s Percocet was in the med cart. That's when she couldn't find the med card or the count sheet. [Name of LPN 6] then immediately called the Director of Nursing (DON) to report the discrepancy. The ED indicated the facility was unable to definitely determine exactly who was responsible for the misappropriation of the narcotics, but she was able to view security camera footage from 4-4-24, that was suspicious. She indicated at the time, the camera video captured RN 4 and RN 7 conducting a destruction of Resident C's discontinued hydrocodone. The ED indicated she was able to view RN 4 to place something that appeared small and white into her hand, during the destruction process, and then place her hand into her pocket, then upon removal of her hand from her pocket, the same hand was empty. The ED emphasized she could not say with certainty the object or objects were some of the medication being destroyed, but seemed suspicious, or at the very least, unusual. The ED emphasized that she could say with certainty the facility had several cards of narcotics missing, as well as the paperwork associated with the medications for Residents B and C. The ED added, by the time this video of events of 4-4-24, were viewed, the nursing staff were aware of the situation in which narcotics were being evaluated by the facility management. On 5-22-24 at 8:58 a.m., the ED provided a timeline of the investigation of missing narcotics. The timeline indicated Resident C's medication card for hydrocodone had been discontinued as of 3-29-24. It was noted the drug destruction sheet there was only 1 sheet of 2 in the file. When questioning the 2 nurses, [names of RN 7 and RN 4] destroyed the medication for [name of Resident C]. The camera was reviewed, and it was noted that [name of RN 4] walked around the nurse's station--while talking on the telephone was punching out the medications the 2 nurses were destroying. The camera shows [name of RN 4] punching the card and placing the medication into her palm and slipping her hand into her left pocket. Further review of the camera--it is noted she dropped something--and a while [sic] object was picked up 2 times and put into the cup in her hand--the 3rd white object was picked up and placed in her pocket. In an interview with the DON on 5-22-24 at 12:50 p.m., she indicated she was notified on the evening shift of 3-27-24 by LPN 6 of the missing medications and medication paperwork. We truly looked all over this building for the paperwork. It became apparent pretty quick something was wrong. She indicated an audit of all the controlled substances was conducted and corporate assistance was provided to help with the process. She indicated the following day, 3-28-24, an inservice education was conducted for staff that administer medications on counting of the narcotics and how the process was to be conducted, including changes that were instituted. She indicated the previous day, 5-21-24, additional inservice education was conducted with staff who administer medications to reinforce these concepts. In review of the medication administration records (MAR) for Resident B for January, 2024, the MAR indicated Resident B had received the Percocet nine (9) times, for February, 2024, it indicated she had received Percocet five (5) times, for March, 2024, five (5) times and none for April or May, 2024. The Percocet 10-324 milligrams (mg) had been ordered on 12-27-20, to be administered every 8 hours as needed for pain and was discontinued 3-29-24. A review of the contracted pharmacy records reflected the medication had been re-ordered and received 30 tablets on 12-23-23, 2-6-23, 2-14-24, 2-24-24, 3-3-24, 3-11-24 and 3-19-24. A review of the controlled substance log indicated Resident B had received 30 tablets on 11-6-24 and indicated she was administered 1 tablet as needed with her using the 30 tablet supply by 12-21-23, less than one tablet per day on average. No other controlled substance logs could be located for the for the Percocet delivered by the contracted pharmacy company on 12-23-23, 2-6-23, 2-14-24, 2-24-24, 3-3-24, 3-11-24 and 3-19-24, a total of 210 tablets. In review of the MAR for Resident C for February, 2024, it indicated he was administered hydrocodone 16 times and six (6) times in March, 2024. The hydrocodone-apap 5-325 mg had been ordered on 12-22-23, to be administered 2 tablets every 4 hours as needed for pain and discontinued on 2-18-24. This order was restarted on 2-20-24 and discontinued on 3-27-24. A new order for the hydrocodone 5-325 mg 1 tablet every 4 hours as needed for mild to moderate pain was issued on 3-27-29 and stopped on 3-29-24. A review of the controlled substance log indicated Resident C had received 30 tablets on 2-6-24 and indicated he had been administered the 30 tablet supply by 2-23-24 and was documented as receiving 2 doses of 1 tablet twice and the remainder of the doses were documented as a 2 pill dose fourteen times. The second controlled substance log indicated a supply of 30 tablets on page 1 of 2 was received on 3-21-24. The second page of this order was not located. On page 1 of 2, six 2-pill doses were documented as administered to Resident C, and 16 (sixteen) pills were documented as destroyed on 3-29-24 by RN 4 and RN 7. On 5-22-24 at 2:25 p.m., the ED provided a copies of documents from the contracted pharmacy which indicated the following tablets of hydrocodone-apap 5-325 mg for Resident C were received: -2-6-24, 30 tablets. -3-3-24, 2 orders of 30 tablets for total of 60 tablets. None of the associated medication or associated paperwork were located. 3-21-24, 2 orders of 30 tablets for total of 60 tablets. Only the narcotic log for one of those orders, page 1 of 2, could be located. In random interviews with the ED and DON on 5-22-24, another issue that had been identified with the misappropriation investigation was inconsistent documentation of controlled substance documentation of administration between the controlled substance logs and the medication administration records. Each indicated this topic was identified and is being addressed by placing into the facility's quality improvement process and the facility is continuing audits of this. 1. The clinical record of Resident B was reviewed on 5-21-24 at 12:09 p.m. Her diagnoses included, but were not limited to, recent cholangitis, muscle wasting and atrophy, age-related osteoporosis without pathological fracture, atrial fibrillation, transient ischemic attacks (TIA's) and unspecified osteoarthritis. Her most recent Minimum Data Set assessment, dated 3-31-24, indicated she was cognitively intact and had not received any opioid medications within the previous 7 day look-back period. In an interview with Resident B on 5-22-24 at 11:34 a.m., she indicated she has low-grade pain all the time due to her arthritis, but only requests pain medication when it gets worse. She indicated the staff have always been good to provide her pain medication to her when she requests it. 2. The clinical record of Resident C was reviewed on 5-21-24 at 1:54 p.m. His diagnoses included, but were not limited to, diabetes with neuropathy, muscle wasting and atrophy, right above knee amputation within the last 6 months and age-related osteoporosis. His most recent Minimum Data Set assessment, dated 4-17-24, indicated he was moderately cognitively impaired and had not received any opioid medications within the previous 7 day look-back period. In an interview with Resident C on 5-22-24 at 11:45 a.m., he indicated he had a surgical amputation above his right knee in January or February of this year. He indicated he initially requested pain medication frequently after his surgery, but rarely does at this point. He indicated the facility staff have provided him his pain medication in a timely manner when he has requested it. On 5-22-24 at 10:55 a.m., the ED provided a copy of a policy entitled, Controlled Medication Storage, with a review date of 2-22-22. This policy indicated its purpose as, To ensure the facility provides separately locked, permanently affixed compartments for storage of controlled drugs Schedule II-V and other drugs subject to abuses .and a missing dose can be readily be detected .Regulations require that the facility have a system to account for the receipt, usage, disposition, and reconciliation of all controlled medications .Record of receipt of all controlled medication(s) with sufficient detail to allow reconciliation (i.e., specifying name and strength of medication, the quantity and date received, and resident name.) .Records of all usage and disposition of all controlled medication(s) with sufficient detail to allow reconciliation (i.e., MAR, proof-of-use sheets, or declining inventory sheets) including destruction, wastage, return to pharmacy/manufacturer, or disposal in accordance with applicable State requirements .Periodic reconciliation of records or receipt, disposition, and inventory of all controlled medication(s) monthly or more frequently as defined by the facility's procedures or when loss is identified. If discrepancies are identified during reconciliation, the facility and pharmacist develop and implement recommendations for resolving discrepancies .A controlled medication accountability record is provided by the pharmacy for all Schedule II-V medications .A physical inventory of all controlled medication(s), including emergency supply is completed at each shift change by two (2) licensed nurses and is documented on the controlled medication accountability record per facility procedure. Any discrepancy in controlled medication counts is reported to the DON/designee immediately. The DON/designee investigates and makes every reasonable effort to reconcile all reported discrepancies. The DON/designee documents irreconcilable discrepancies in a report to the administrator and/or state as applicable. Major discrepancy/Pattern of discrepancies/Apparent criminal activity -- the DON/designee notifies the administrator and pharmacy immediately. The administrator, pharmacy, and/or DON/designee determine whether other action(s) are needed (i.e., notification of police or other enforcement personnel, State department of health). The medication regimen of residents using medication(s) that have such discrepancies are reviewed to ensure the resident has received all medication(s) ordered and the goal of therapy is met. As an example, is the resident receiving a pain medication complaining of unrelieved pain. Current controlled medication accountability records are kept in the Narcotic Book (Narc Book). When completed, the accountability records are submitted to the DON/designee and kept on file at the facility .Controlled medication(s) remaining in the facility after the order has been discontinued are destroyed by two(2) licensed nurses, or as otherwise directed by law, in a timely manner. The pharmacist/designee routinely monitors controlled medication storage, records, and expiration dates. This Federal tag relates to Complaints IN00433363 and IN00434334. 3.1-28(a)

Based on interview and record review, the facility failed to implement policies and procedures related to misappropriation of resident property for 2 of 2 residents reviewed for misappropriation of property related to drug diversion. (Residents B and C) The deficient practice was corrected on 4-4-24, prior to the start of the survey, and was therefore past noncompliance. The facility had immediately began an investigation upon learning of the missing narcotic medication and associated paperwork and begin staff education regarding the correct means to conduct controlled substance counts. Based on resident assessments and interviews, there was not a negative impact to the comfort level of either resident identified as being affected by this deficient practice. Findings include: In an interview with the Executive Director (ED) 5-21-24 at 11:22 a.m., she indicated the facility recently had an issue with diversion of narcotics. She indicated the concern was reported to the Indiana Department of Health's Long Care Division on 3-28-24, the date it was identified, and investigation has continued since that date. In another interview on 5-21-24 at 1:35 p.m., with the ED, she further explained only two residents, Residents B and C, were involved in the misappropriation of property. Once we knew there was an issue, we did an audit of everyone with prn [as needed] narcotics. So, our goal after that was to get any prn narcotics that weren't being used to have them stopped or if they were being used to get something to help them on a routine basis. She indicated 3 staff members were identified as possible suspects, LPN 3, RN 4 and QMA 5, and were each sent for drug testing with the results being negative for all three staff members. Review of the employment records of LPN 3 and RN 4 indicated each began employment after 1-1-24, with QMA 5 beginning employment in the fall of 2022. The ED indicated LPN 3 and RN 4 resigned after this situation and QMA 5 remains employed by the facility. In an interview on 5-22-24 at 9:23 a.m., with the ED, she indicated the manner in which the diversion of narcotics was brought to light was Resident B had requested something for pain from LPN 6 on the evening shift of 3-27-24. She shared LPN 6 inquired about the pain level of the resident's pain and offered Resident B a choice of Percocet or Tylenol; Resident B chose Tylenol. Apparently this got [name of LPN 6] to thinking she could not remember counting the Percocet for the resident at the beginning of her shift, because she recalled she done this earlier in the week when she had done the narcotic counts. This caused her to go and look to see if [name of Resident B]'s Percocet was in the med cart. That's when she couldn't find the med card or the count sheet. [Name of LPN 6] then immediately called the Director of Nursing (DON) to report the discrepancy. The ED indicated the facility was unable to definitely determine exactly who was responsible for the misappropriation of the narcotics, but she was able to view security camera footage from 4-4-24, that was suspicious. She indicated at the time, the camera video captured RN 4 and RN 7 conducting a destruction of Resident C's discontinued hydrocodone. The ED indicated she was able to view RN 4 to place something that appeared small and white into her hand, during the destruction process, and then place her hand into her pocket, then upon removal of her hand from her pocket, the same hand was empty. The ED emphasized she could not say with certainty the object or objects were some of the medication being destroyed, but seemed suspicious, or at the very least, unusual. The ED emphasized that she could say with certainty the facility had several cards of narcotics missing, as well as the paperwork associated with the medications for Residents B and C. The ED added, by the time this video of events of 4-4-24, were viewed, the nursing staff were aware of the situation in which narcotics were being evaluated by the facility management. On 5-22-24 at 8:58 a.m., the ED provided a timeline of the investigation of missing narcotics. The timeline indicated Resident C's medication card for hydrocodone had been discontinued as of 3-29-24. It was noted the drug destruction sheet there was only 1 sheet of 2 in the file. When questioning the 2 nurses, [names of RN 7 and RN 4] destroyed the medication for [name of Resident C]. The camera was reviewed, and it was noted that [name of RN 4] walked around the nurse's station--while talking on the telephone was punching out the medications the 2 nurses were destroying. The camera shows [name of RN 4] punching the card and placing the medication into her palm and slipping her hand into her left pocket. Further review of the camera--it is noted she dropped something--and a while [sic] object was picked up 2 times and put into the cup in her hand--the 3rd white object was picked up and placed in her pocket. In an interview with the DON on 5-22-24 at 12:50 p.m., she indicated she was notified on the evening shift of 3-27-24 by LPN 6 of the missing medications and medication paperwork. We truly looked all over this building for the paperwork. It became apparent pretty quick something was wrong. She indicated an audit of all the controlled substances was conducted and corporate assistance was provided to help with the process. She indicated the following day, 3-28-24, an inservice education was conducted for staff that administer medications on counting of the narcotics and how the process was to be conducted, including changes that were instituted. She indicated the previous day, 5-21-24, additional inservice education was conducted with staff who administer medications to reinforce these concepts. In review of the medication administration records (MAR) for Resident B for January, 2024, the MAR indicated Resident B had received the Percocet nine (9) times, for February, 2024, it indicated she had received Percocet five (5) times, for March, 2024, five (5) times and none for April or May, 2024. The Percocet 10-324 milligrams (mg) had been ordered on 12-27-20, to be administered every 8 hours as needed for pain and was discontinued 3-29-24. A review of the contracted pharmacy records reflected the medication had been re-ordered and received 30 tablets on 12-23-23, 2-6-23, 2-14-24, 2-24-24, 3-3-24, 3-11-24 and 3-19-24. A review of the controlled substance log indicated Resident B had received 30 tablets on 11-6-24 and indicated she was administered 1 tablet as needed with her using the 30 tablet supply by 12-21-23, less than one tablet per day on average. No other controlled substance logs could be located for the for the Percocet delivered by the contracted pharmacy company on 12-23-23, 2-6-23, 2-14-24, 2-24-24, 3-3-24, 3-11-24 and 3-19-24, a total of 210 tablets. In review of the MAR for Resident C for February, 2024, it indicated he was administered hydrocodone 16 times and six (6) times in March, 2024. The hydrocodone-apap 5-325 mg had been ordered on 12-22-23, to be administered 2 tablets every 4 hours as needed for pain and discontinued on 2-18-24. This order was restarted on 2-20-24 and discontinued on 3-27-24. A new order for the hydrocodone 5-325 mg 1 tablet every 4 hours as needed for mild to moderate pain was issued on 3-27-29 and stopped on 3-29-24. A review of the controlled substance log indicated Resident C had received 30 tablets on 2-6-24 and indicated he had been administered the 30 tablet supply by 2-23-24 and was documented as receiving 2 doses of 1 tablet twice and the remainder of the doses were documented as a 2 pill dose fourteen times. The second controlled substance log indicated a supply of 30 tablets on page 1 of 2 was received on 3-21-24. The second page of this order was not located. On page 1 of 2, six 2-pill doses were documented as administered to Resident C, and 16 (sixteen) pills were documented as destroyed on 3-29-24 by RN 4 and RN 7. On 5-22-24 at 2:25 p.m., the ED provided a copies of documents from the contracted pharmacy which indicated the following tablets of hydrocodone-apap 5-325 mg for Resident C were received: -2-6-24, 30 tablets. -3-3-24, 2 orders of 30 tablets for total of 60 tablets. None of the associated medication or associated paperwork were located. 3-21-24, 2 orders of 30 tablets for total of 60 tablets. Only the narcotic log for one of those orders, page 1 of 2, could be located. In random interviews with the ED and DON on 5-22-24, another issue that had been identified with the misappropriation investigation was inconsistent documentation of controlled substance documentation of administration between the controlled substance logs and the medication administration records. Each indicated this topic was identified and is being addressed by placing into the facility's quality improvement process and the facility is continuing audits of this. 1. The clinical record of Resident B was reviewed on 5-21-24 at 12:09 p.m. Her diagnoses included, but were not limited to, recent cholangitis, muscle wasting and atrophy, age-related osteoporosis without pathological fracture, atrial fibrillation, transient ischemic attacks (TIA's) and unspecified osteoarthritis. Her most recent Minimum Data Set assessment, dated 3-31-24, indicated she was cognitively intact and had not received any opioid medications within the previous 7 day look-back period. In an interview with Resident B on 5-22-24 at 11:34 a.m., she indicated she has low-grade pain all the time due to her arthritis, but only requests pain medication when it gets worse. She indicated the staff have always been good to provide her pain medication to her when she requests it. 2. The clinical record of Resident C was reviewed on 5-21-24 at 1:54 p.m. His diagnoses included, but were not limited to, diabetes with neuropathy, muscle wasting and atrophy, right above knee amputation within the last 6 months and age-related osteoporosis. His most recent Minimum Data Set assessment, dated 4-17-24, indicated he was moderately cognitively impaired and had not received any opioid medications within the previous 7 day look-back period. In an interview with Resident C on 5-22-24 at 11:45 a.m., he indicated he had a surgical amputation above his right knee in January or February of this year. He indicated he initially requested pain medication frequently after his surgery, but rarely does at this point. He indicated the facility staff have provided him his pain medication in a timely manner when he has requested it. On 5-22-24 at 10:55 a.m., the ED provided a copy of a policy entitled, Controlled Medication Storage, with a review date of 2-22-22. This policy indicated its purpose as, To ensure the facility provides separately locked, permanently affixed compartments for storage of controlled drugs Schedule II-V and other drugs subject to abuses .and a missing dose can be readily be detected .Regulations require that the facility have a system to account for the receipt, usage, disposition, and reconciliation of all controlled medications .Record of receipt of all controlled medication(s) with sufficient detail to allow reconciliation (i.e., specifying name and strength of medication, the quantity and date received, and resident name.) .Records of all usage and disposition of all controlled medication(s) with sufficient detail to allow reconciliation (i.e., MAR, proof-of-use sheets, or declining inventory sheets) including destruction, wastage, return to pharmacy/manufacturer, or disposal in accordance with applicable State requirements .Periodic reconciliation of records or receipt, disposition, and inventory of all controlled medication(s) monthly or more frequently as defined by the facility's procedures or when loss is identified. If discrepancies are identified during reconciliation, the facility and pharmacist develop and implement recommendations for resolving discrepancies .A controlled medication accountability record is provided by the pharmacy for all Schedule II-V medications .A physical inventory of all controlled medication(s), including emergency supply is completed at each shift change by two (2) licensed nurses and is documented on the controlled medication accountability record per facility procedure. Any discrepancy in controlled medication counts is reported to the DON/designee immediately. The DON/designee investigates and makes every reasonable effort to reconcile all reported discrepancies. The DON/designee documents irreconcilable discrepancies in a report to the administrator and/or state as applicable. Major discrepancy/Pattern of discrepancies/Apparent criminal activity -- the DON/designee notifies the administrator and pharmacy immediately. The administrator, pharmacy, and/or DON/designee determine whether other action(s) are needed (i.e., notification of police or other enforcement personnel, State department of health). The medication regimen of residents using medication(s) that have such discrepancies are reviewed to ensure the resident has received all medication(s) ordered and the goal of therapy is met. As an example, is the resident receiving a pain medication complaining of unrelieved pain. Current controlled medication accountability records are kept in the Narcotic Book (Narc Book). When completed, the accountability records are submitted to the DON/designee and kept on file at the facility .Controlled medication(s) remaining in the facility after the order has been discontinued are destroyed by two(2) licensed nurses, or as otherwise directed by law, in a timely manner. The pharmacist/designee routinely monitors controlled medication storage, records, and expiration dates. This Federal tag relates to Complaints IN00433363 and IN00434334. 3.1-28(a)

Based on observation, interview and record review, the facility failed to maintain a safe, clean, sanitary and comfortable environment for a resident shower room and a resident's recliner was observed with a dried brown substance present. These deficient practices have the ability to adversely affect any residents who utilize the shower room and Resident F. (Resident F) Findings include: 1. During an observation of the shower room, located across from the Rehab Hall's Nurse's Station on 1-16-24 at 7:20 p.m., with LPN 3, the tile floor of the shower appeared discolored with brown and tan stains, one wet wash cloth was observed in left back corner of the shower. Behind and adjacent to the wall of the toilet were two balled-up pieces of tissue paper located on the floor. LPN 3 indicated she had heard the facility is planning to be replace the shower floor tile soon, but was unsure of a date. LPN 3 indicated she had noticed the discoloration of the tile and it did not look appealing to her. I don't know that I would want to walk on that shower floor barefoot. LPN 3 indicated she has personally cleaned the shower floor with bleach products and still cannot get rid of the stains. In an interview with Resident J on 1-16-24 at 4:58 p.m., he indicated he does not like to use the shower room located across from the Rehab Nurse's station. It looks dirty to me, maybe just stained, but I won't put my bare feet on that floor. In an interview on 1-17-24 at 2:22 p.m., with the Executive Director, she indicated the tile replacement for this shower room has not been scheduled for replacement at this time. She indicated several treatments have been attempted to clean the tile in the shower in the recent past. In an interview on 1-17-24 at 2:35 p.m., with the Corporate Nurse, she explained she was informed by her superiors the tile replacement is on the schedule to be conducted. I was told the bathroom tile is on the list to be done next. But, I can't tell you an exact date for that. I would guess within the next few months. 45291 2. The clinical record for Resident F was reviewed on 1/17/2024 at 11:00 a.m. The medical diagnosis included stroke. An Annual Minimum Data Set Assessment, dated for 12/11/2023, indicated Resident F needed assistance with activities of daily living. An observation on 1/17/2024 at 1:40 p.m. indicated there was a thick brown substance on the recliner with a wet washcloth laying partially over the area. An interview with Resident F on 1/17/2024 at 1:40 p.m. indicated that they usually clean her room and she would like her recliner cleaned before she got back up. An observation and interview on 1/17/2024 at 2:00 p.m. indicated that there was brown residue on the recliner with a wet washcloth laying partially over the area. Medical Records came to the room and cleaned the area as best she could. She indicated that she would have housekeeping spot clean the recliner. A policy, entitled Homelike Environment, was provided by the Administrator on 1/18/2024 at 10:00 a.m. The policy indicated, .The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include .Clean, sanitary, and orderly environment . This Federal tag relates to Complaints IN00425127 and IN00424182. 3.1-19(f) 3.1-19(g) 5.1-5(a)

Based on interview, observation, and record review, the facility failed to ensure resident specific fall interventions of antiroll back brakes and bright color tape were applied to wheelchair brakes 1 of 3 residents reviewed for falls. (Resident G) Findings include: The clinical record for Resident G was reviewed on 1/17/2024 at 2:51 p.m. The medical diagnosis included Alzheimer's disease. A Quarterly Minimum Data Set Assessment, dated 11/10/2023, indicated that Resident G had multiple falls and was cognitively impaired. A fall care plan for Resident G indicated interventions of anti-roll back to wheelchair, dated 3/7/2023, and bright colored tape to the wheelchair brakes, dated 12/18/2023. An observation on 1/17/2024 at 2:49 p.m. indicated Resident G was laying in bed at this time. She had a wheelchair next to her bed that did not have antiroll back brakes nor had color tape to the wheelchair brakes. An observation and interview on 1/17/2024 at 3:00 p.m. indicated CNA 2 came to Resident G's room. She confirmed that no antiroll back brakes or color tape to her wheelchair brakes. An interview with the Director of Nursing on 1/28/2024 at 12:40 p.m. indicated that the direct care staff are responsible for ensuring fall interventions are in place for each resident. A policy, entitled Fall Management and Fall Risk, was provided by the Administrator on 1/18/2024 at 10:00 a.m. The policy indicated .If falling occurs despite initial interventions, staff will implement additional or different interventions . This Federal tag relates to Complaint IN00425169 and IN00424732. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure 1 of 5 residents reviewed for nutrition had an admission weight obtained in less than 14 days from time of admission. (Resident B) Findings include: The clinical record of Resident B was reviewed on 1-16-24 at 4:06 p.m. It indicated he admitted to the facility on [DATE] with diagnoses that included, but were not to, a recent left femur fracture, muscle wasting and atrophy, cognitive communication deficit, dementia, paranoid schizophrenia and prostate cancer. An admission nursing assessment, dated 12-2-23, indicated his admission weight, dated 5-1-2021, was 175.4 pounds (#). This resident had previously been a resident from 1-29-2021 to 5-10-2021. Current weights for Resident B were documented as 150 # on 12-13-23, and 148.5 # on 1-4-24. A nutrition assessment, dated 12-4-23, 76 yo [years old] M [male] readmit with fracture of L. [left]femur and dx [diagnosis] of cancer of bone, ARF, [acute renal/kidney failure] and anemia. Monthly wt [weight] pending. Previous BMI [body mass index] fo [sic] 27.5, while on the higher side is appropriate for age. Resident is on a regular diet. High protein needs r/t [related to] cancer. Poor intake at this time, will monitor another week and add supplement if warranted. ADL [activities of daily living]-total dependence. No issues with chewing or swallowing noted. Skin intact. Labs reviewed above. New admit will be followed by CAR [clinically at risk team or interdisciplinary team]. Care plan initiated. Will continue to monitor and follow. A nurse practitioner visit note, dated 12-12-23, indicated, [Name of Resident B] is being seen as follow up to [name of facility] on 11-30-2023 .Weekly weights x4 orders, however no admission weight or subsequent weights found. A physician visit note, dated 1-2-2024, indicated, Pt [patient] has had 1 [one] documented weight since admission, that was on 12-15-23. Reported to have poor appetite, for which he does take [brand name of liquid dietary supplement] w/o [without] difficulty. In an interview with Director of Nursing (DON) on 1-18-24 at 11:05 a.m., she indicated she had recently noted the missing admission weight for Resident B. The only thing I can tell you is this is that he came in while we were in the midst of an outbreak of Covid, we had a lot of staff out with Covid, including myself. So, I was not in here to monitor like I would normally have done. He is no longer being followed by IDT [the interdisciplinary team] for his weight or nutrition. His appetite has improved and is doing pretty good in therapy. On 1-18-24 at 9:05 a.m., the Executive Director provided a copy of a policy entitled, Weight Policy, with a review date of 5-1-2022. This policy indicated, New Admission weights [are to be conducted] weekly, for the first 4 weeks after admission .Residents identified as nutritional risk may be weighed weekly or bi-weekly per physician order or IDT recommendations .Weekly weights may be discontinued if weight has remained stable for at least 4 weeks, as determined by the IDT, Dietician [sic] or Physician . This Federal tag relates to Complaints IN00424182 and IN00425127. 3.1-46(a)(1)

Based on interview and record review, the facility failed to ensure follow-up and initiation of treatment to an identified skin impairment that was later identified as an unstageable pressure ulcer that resulted in a wound infection, hospitalization , and surgical intervention for 1 of 3 residents reviewed for pressure ulcers. (Resident B) Findings include: The clinical record for Resident B was reviewed on 7/29/20 at 12:48 p.m. The [DIAGNOSES REDACTED]. An Admission Minimum Data Set (MDS) assessment, dated 5/6/20, indicated a surgical wound was present. There were no pressure or arterial ulcers marked on the admission MDS. He was marked to need extensive assistance with 2 staff person with transfers and bed mobility. A hospital discharge summary, dated 4/30/20, indicated Resident B had surgical wounds to left lower extremity related to the repair of a left femoral fracture. There was no indication of pressure or arterial wounds noted for Resident B upon discharge from the hospital. An admission observation, dated 4/30/20, indicated the following, .left heel .DTI (deep tissue injury) 4cm (centimeters) diam. (diameter) The admission observation was opened with a locked date of 7/29/20. A Braden Assessment, dated 4/30/20, indicated Resident B was at moderate risk for pressure ulcer development. An activities of daily living (ADL) care plan, undated, indicated the following, .I have an ADL self-care performance deficit r/t (related to) recent surgery to hip from fracture (sic) .Interventions .Skin Inspection: The resident requires SKIN inspection. Observe for redness, open areas, scratches, cuts, bruises and report changes to the NURSE A care plan pertaining to skin, undated, indicated the following, .I have a potential for impairment to skin integrity r/t (related to) aging/disease process, decreased mobility, fragile skin, impaired mobility, incontinence .Interventions .Assess/record changes in skin status .Follow facility protocols for treatment of [REDACTED].>There were no indications a care plan specific to pressure ulcers was noted for Resident B. A weekly skin observation, dated 5/8/20, indicated the following, .NO FOOT CONCERNS A weekly skin observation, dated 5/15/20, indicated the following, .NO FOOT CONCERNS A physician order, dated 5/21/20, indicated the following, .Venelex Ointment .Apply to back of left thigh topically two times a day A physician order, dated 5/21/20, indicated the following, .Resident to not wear shoes until area on feet have healed A weekly skin observation, dated 5/22/20, indicated the following, .a. Describe any foot problems: .(checkmark) 10 Open Lesion(s) .left heel redness, pressure area dorsum (area facing upwards while standing) of left foot There were no further description and/or measurements to the skin concerns identified to Resident B's left foot and heel. A Skin & Wound Evaluation, dated 5/28/20, indicated a deep tissue injury was noted to Resident B's left heel that was marked present upon admission. The wound measured 2.6 centimeters x 4.4 centimeters and contained 40 percent of eschar (dead tissue) to the wound bed. A Skin & Wound Evaluation, dated 5/28/20, indicated an arterial wound was noted to Resident B's dorsum left foot that was marked present upon admission. The wound measured 2.3 centimeters x 5.6 centimeters and marked as a scab. A weekly skin observation, dated 5/29/20, indicated the following, .Left heel redness, pressure area to dorsum of left foot All physician orders [REDACTED]. A Skin & Wound Evaluation, dated 6/4/20, indicated a blister to Resident B's dorsum left foot that was in-house acquired and measured 4.0 centimeters x 5.2 centimeters. The wound contained 30% of slough to the wound bed. A Skin & Wound Evaluation, dated 6/4/20, indicated an arterial ulcer was noted to Resident B's left lateral malleolus (bony prominence on the ankle) that was present upon admission. The wound measured 1.8 centimeters x 4.9 centimeters with pink and red tissue marked with a scab. A progress note, dated 6/5/20, indicated the following, .WEEKLY SKIN OBSERVATIONS .Open lesion observed to foot. purulent drainage (a thick and milky discharge from a wound that is often a sign of infection) from left heel. Left heel open area, dorsum of left foot blister, right heel blister A physician order, dated 6/5/20, indicated the following, .[MEDICATION NAME] (antibiotic) .300 MG (milligrams) .Give 1 capsule by mouth every 6 hours for Wound infection for 10 days A physician order, dated 6/8/20, indicated the following, .Santyl Ointment (used to remove damaged tissue from skin ulcers) .Apply to Left heel topically one time a day for DTI (deep tissue injury) to left heel The order was discontinued on 6/25/20. A physician order, dated 6/8/20, indicated the following, .Venelex Ointment .Apply to top L (left) foot, r (right) heel topically one time a day for WOUND CARE There was no indication of a treatment order for Resident B's wound to left foot and heel from 5/22/20 to 6/8/20. A Wound Care Report, dated 6/11/20, indicated the following, .We have been asked to see (Resident B) for bilateral heel ulcers. Today is initial wound evaluation at our clinic .On initial take down of his dressings it was noted he had quite a bit of [MEDICAL CONDITION] and odor is drainage (sic) from his left heel ulcer .Wound Exam .Wound 1. To left calcaneus (heel bone) - area measures 5.6 x 13.0 x 0.1 cm (centimeters). Areas odor is (sic). Area has a moderate level of purulence/sanguineous (bloody) drainage area is primarily eschar with some devitalized tissue .Area was debrided times 50% to remove the devitalized tissue at wound edges and attempt to remove some of the unstable eschar to wound base using scissors and pickups .[DIAGNOSES REDACTED].Unstageable pressure ulcer of left heel A Wound Care Report, dated 6/18/20, indicated the following, .still odor to that left heel .left calcaneus quite a bit smaller .The remaining open areas is thick, adherent and wet and odorous eschar .Wound will be stages (sic) of 4. Wound measures 5.4 x 6.5 x 0.7 cm (centimeters) .Debridement was performed using a blade, scissors, and forceps A Wound Care Report, dated 6/25/20, indicated the following, .still odor to left heel .reports recommendation is for left AKA (above the knee amputation) .Left calcaneal wound remains odor (sic) .Area was debrided of most superficial eschar and slough The records indicated Resident B was sent to the hospital from a wound care appointment, on 7/9/20, related to altered mental status and a low blood sugar level. Hospital records, dated 7/9/20 for admission, indicated the following, .imaging was completed on his left heel which was concerning for soft tissue gas and bony changes in his heel concerning for osteo[DIAGNOSES REDACTED] .Impressions/Status/Plan .Left heel osteo[DIAGNOSES REDACTED] and nonhealing (sic) ulcer .patient left heel wound is not salvageable and would benefit from a left AKA (above the knee amputation), which he went to have this afternoon, 7/13 An interview conducted with the Director of Nursing (DON), on 7/29/20 at 2:05 p.m., indicated the order for Venelex, dated 5/21/20, was supposed to say the back of the left thigh and bilateral heels. The order was only put in for application to the posterior thigh. The heel treatment was not added until later. The DON further indicated, on 7/29/20 at 4:40 p.m., that she believes the left heel wound was present upon admission and she changed the documentation on the admission assessment to reflect that. She doesn't believe the wound was open upon admission but wasn't sure. A policy titled Skin Condition Assessment & Monitoring - Pressure and Non-Pressure, revised 6/8/18, was provided by the DON on 7/29/20 at 4:09 p.m. The policy indicated the following, .Purpose .To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and other non-pressure skin conditions and assuring interventions are implemented .Pressure and other ulcers (diabetic, arterial, venous) will be assessed and measured at least weekly by licensed nurse and documented in the resident's clinical record .A wound assessment will be initiated and documented in the resident chart when pressure and/or other non-pressure skin conditions are identified by licensed nurse .Wound Assessment/Measurement: .6. The resident's care plan will be revised as appropriate, to reflect alteration of skin integrity, approaches and goals for care .7. Physician ordered treatments shall be initiated by the staff on the electronic Treatment Administration Record after each administration. Other nursing measures not involving medications shall be documented in the weekly wound assessment or nurses note 3.1-40(a)(1) 3.1-40(a)(2)

Based on interview and record review, the facility failed to report injuries of unknown origin within two hours to the Director of Nursing (DON) and Executive Director for 1 of 3 resident reviewed for injured of unknown origin. The resident had bruising to the forehead, right side of face and right hand a fracture to the third finger of the right hand and a five day hospitalization , (Resident C) Findings include: During an initial tour of the facility on 1-7-19 at 9:40 a.m. with the MDS (Minimum Data Set) Coordinator, she shared Resident C had been sent out to an area hospital in the last two months related to an altered mental status and an injury of unknown origin of a fractured finger. Resident C's clinical record was reviewed on 1-7-19 at 1:01 p.m. Her [DIAGNOSES REDACTED]. Her most recent MDS assessment, dated 12-31-18, described Resident C as having short-term and long-term memory problems, is severely cognitively impaired; has no speech, requires extensive assistance of one or more persons with dressing, eating, toileting, hygiene and bathing needs, is unable to walk and receives hospice services. Documentation indicated she was admitted to an area hospital on 12-15-18 and returned to the facility on [DATE]. Upon return to the facility on [DATE], Resident C was noted to have new services of hospice care added. Review of the clinical record on 1-7-19 at 1:01 p.m., indicated a progress note, dated 12-15-18 at 10:25 a.m., indicated RN 2 was unable to awaken Resident C while she was seated in a specialty chair and slumped to her right side. Upon repositioning of Resident C in her chair, RN 2 discovered the middle finger on her right hand was bruised and swollen. bruising also observed to the back of right hand, left eye and forehead. V/S (vital signs of blood pressure) 212/104 (elevated), HR (heart rate) 78, O2 (oxygen saturation) 94% on ra (room air), temp 97.5, respirations 14 et (and) shallow, lungs congested. multiple (sic) attempts were administered to arouse resident, including sternal rub were not successful. writer attempted communication with 3rd eye (on-call virtual health care system) to no avail .writer followed up with AHA (local medical care service) as last resort to notify. RN 2's progress note at this time added Resident C's daughter was notified of the change in condition and wished for the resident to be sent to the local emergency room for further evaluation and treatment, as well as notification to the Director of Nursing (DON) and Executive Director (ED). A progress note dated 12-15-18 at 1:20 p.m., indicated Resident C was admitted to the local hospital with a [DIAGNOSES REDACTED]. In an interview on 1-7-19 at 2:40 p.m., with the DON, she specified the facility's investigation, revealed via staff interviews, some of the CNA staff had reported to the nurses on duty a small amount of bruising to Resident C's forehead on 12-14-18, before she went into the hospital on 12-15-18, it was not documented or assessed and was not reported to me. I would have expected the nursing staff would have documented it and they should have notified me about it. Review of the clinical record failed to indicate any documentation of Resident C on the day prior, 12-14-18 or until RN 2's documentation on 12-15-18 at 10:25 a.m., regarding any change in condition or bruising. Review of Resident C's emergency room visit, dated 12-15-18, indicated she was seen by the Physician's Assistant at 11:17 a.m. At baseline patient is nonverbal but awakens spontaneously, will occasionally smile, but otherwise not interactive. Today when nursing staff went to get the patient up the (sic) noted she was more altered than her baseline. She was reportedly unresponsive, but they were able to get up and in her wheelchair. They noted bruising on her forehead, left eye, and right hand. (MONTH) have had an unwitnessed fall, but they are uncertain .Exam Notes .WDWN (well developed well nourished, appropriate, NAD (no acute distress), not anxious, non-toxic appearing .General: Head/neck: Normocephalic. Left periorbital ecchymosis .Muskuloskeletal: Ecchymosis noted over the dorsum of the right hand which is tender to palpation, as well as bruising over the right shoulder which is tender. Spontaneous range of motion. Neurologic: Responsive to painful stimuli. Follows commands with right hand grip, otherwise will not follow commands. Radiology studies conducted at this time reported a CT of the head no evidence of acute intracranial pathology, a CT of the spine indicated no evidence of cervical spinal fractures. Xray films of the right hand indicated a [MEDICAL CONDITION] finger, with severe osteopenia, as well as swelling to the area and other [MEDICAL CONDITION] changes of the right hand. Laboratory studies described Resident C's with a low serum potassium level, otherwise laboratory studies were essentially unremarkable. Resident C was admitted to the hospital with [REDACTED]. In an interview on 1-8-19 at 9:48 a.m., with CNA 3, she reported she had worked with Resident C on Friday, 12-14-18, and Saturday, 12-15-18. On Friday, I noticed 3 small areas on her face, kind of a light color, maybe gray. She added CNA 4 indicated she was going to notify LPN 5 about the bruises. She indicated she and CNA 4 worked together on South Hall, which Resident C resided on. CNA 3 described Resident C as dependent for all care, rarely spoke and has very significant dementia. CNA 3 clarified she worked on a different hall on Saturday, but did see Resident C at breakfast. CNA 3 explained Resident C was not eating or really waking up. She sometimes would sleep like that. They said everyone had tried 3 or 4 times each and couldn't wake her up. The first thing I noticed was she had a black eye and it wasn't there the day before. I asked (name of CNA 4 and CNA 6) what happened and they said they didn't know, but they said the nurse was aware of it. Later, I noticed her hand had a bruise on her finger, when we were trying to get the oximeter on her. Again, I asked what had happened. I said it looked like she had broken her finger. That's when she ended up getting sent out (to the area emergency room ). In a telephone interview on 1-8-19 at 1:32 p.m., with CNA 4, she indicated she had worked with Resident C on Friday, 12-14-18, and Saturday, 12-15-18. She explained on Friday, Resident C seemed like her normal self, doesn't speak, but was able to acknowledge us. Ate okay that day. At breakfast, noticed 3 dots, less than a dime, very small on her forehead. I asked the other aides working that day and asked if they had seen them and they said they hadn't. So after breakfast, I took her to the nurse, (name of LPN 5). She said she was not aware of any bruises. She said it could be where she lays her head on the table or against the chair. I passed this on to the next shift during report. The next morning, (Resident C) was different and did not seem to be responding like normal. I brought this to (name of RN 2)'s attention and she went with me to assess (Resident C) and ended up sending her out to the hospital. In report that morning, I did not get any report about her bruising. That morning, the places on her forehead already were starting to look a little yellow, like they were healing. But, during the assessment of (Resident C) by the nurse, we found the bruising on her right hand when we went to put the oximeter on her hand. (It was) Not as noticeable on the back side of her hand, but more purple on the palm side with slight swelling. She also had some bruising around her left eye, more of a dark purple. On Saturday morning, I'm pretty sure I got her up in her chair. I do not recall seeing any of the new bruising on her when I got her up. I noticed the new bruising right before lunch. That's when I let the nurse know what was going on. In an interview on 1-8-19 at 10:30 a.m., with LPN 5, she recalled working on Friday, 12-14-18, and cared for Resident C. She shared CNA 4 reported to her Resident C had a small bruise above her left eyebrow. Was very tiny. I remember her saying that maybe someone had rolled her over and hit the bedrails. I remember saying that would probably be more linear, not like the dot size it was. I didn't document anything, because it was so small. Honestly, I even wondered why (CNA 4) was even showing it to me, because it was so small. It was after lunch when she told me. (Resident C) did not seem any different as far as her general condition. LPN 5 described Resident C being totally dependent for all care, requiring assistance to eat all meals, a mechanical lift for movement, having advanced dementia with a possible history of [MEDICAL CONDITION]. I did not notice anything else out of the ordinary that Friday for (Resident C). In a telephone interview on 1-8-19 at 12:37 p.m., with LPN 8, she recalled working on the evening shift of Friday, 12-14-18, and provided care to Resident C. I did not get any report at shift change about her having any bruises. That evening, I did notice light, very faint, yellow bruises, like old bruises, on her forehead. None of the staff mentioned anything about any bruises on her. I would guess the place on her forehead was less than 1 centimeter. She seemed more sleepy than usual and more difficult to get her to open her mouth. I gave her meds to her before dinner. No one mentioned anything about her not eating. I assumed, since the small bruise looked like it was in the healing process, it had been charted on before and I did not take the time to look for any previous charting about the bruising. I did not see any other bruising on her. I did not see her undressed, so I didn't see what her shoulders would have looked like. On 1-7-19 at 10:50 a.m., the DON provided a copy of a policy entitled, Incident/Accident Reports. This undated policy was identified to be the current policy utilized by the facility. This policy indicated, The Incident/Accident Report is completed for all unexplained bruises or abrasions, all accidents or incidents where there is injury or the potential to result in injury, allegations of theft and abuse registered by residents, visitor or other, and resident-to-resident altercations. An 'incident' is defined as any happening, not consistent with the routine operation of the facility, that does not result in bodily or property damage .An 'accident' is defined as any happening, not consistent with the routine operation of the facilit that results in bodily injury other than abuse. An incident/accident report will be completed for: 1. All serious accidents or incidents of residents .3. All unusual occurrences .6. All unexpected events that occur that cause actual or potential harm to a resident .An RN or LPN must notify the following if an actual injury occurs: Physician, Legal Representative, or interested family member within 24 hours, the Director of Nursing, Assistant Director of Nursing, or Nursing supervisor must notify the following if an actual injury occurs: The Illinois (sic) Department of Health, by phone, within twenty-four (24) hours of the occurrence .Documentation in nurses' notes is (sic) to include: A description of the occurrence, the extent of injury (if any), the assessment of the resident, vital signs, treatment rendered, and parties notified . On 1-9-19 at 3:25 p.m., the Executive Director provided a copy of a policy entitled, Skin Condition Assessment & Monitoring - Pressure and Non-Pressure. This policy was identified to be currently utilized by the facility, with a revision date of 6-8-18. This policy's purpose was indicated as, To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and other non-pressure skin conditions and assuring interventions are implemented .Pressure and other ulcers (diabetic, arterial, venous) will be assessed and measured at least weekly by licensed nurse and documented in the resident's clinical record. Non-pressure skin conditions (bruises/contusions, abrasions, lacerations, rashes, skin tears, surgical wounds, etc.) will be assessed for healing progress and signs of complications or infection weekly. Bruises: A bruise or contusion is an impact site on the skin's surface over subcutaneous or deeper tissues. On the skin's surface, bruises undergo progressive color changes before they fade away. 0-2 days: Red, Swollen, Tender; 2-5 days: Blue; 5-7 days: Green; 7-10 days: Yellow; 10-14 days: Brown; 2-4 weeks: Clear .A wound assessment will be initiated and documented in the resident chart when pressure and/or other non-pressure skin conditions are identified by licensed nurse. Each resident will be observed for skin breakdown daily .Changes will be promptly reported to the charge nurse who will perform the detailed assessment . On 1-7-19 at 10:50 a.m., the Executive Director provided a copy of a policy entitled, Abuse, Neglect and Misappropriation of Property. This undated policy was identified as the current policy utilized by the facility. It indicated, This facility's policy is that the resident has the right to be free from .abuse by anyone .This policy's purpose is to ensure that resident rights are protected by providing a method for investigation and reporting of allegations of mistreatment, neglect, abuse, including injuries of unknown source .Definitions .Neglect: This occurs on an individual basis when a resident is not cared for in one or more areas. Neglect is also lack of attentiveness, carelessness or the failure to provide timely, consistent, safe, adequate and appropriate services, treatment and care .The absence of reasonable accommodation of individual needs and preferences may result in neglect. And neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. On 1-9-19 at 4:20 p.m., the Executive Director provided an untitled policy regarding Notification of Change of Condition, with a revision date of 3-8-17 and was identified as the current policy utilized by the facility. This policy indicated its purpose as, To ensure that medical problems are communicated to the attending physician or authorized designee and family/responsible party in a timely, efficient and effective manner .The facility will inform the resident; consult with the resident's physician or authorized designee such as Nurse Practitioner; and if known, notify the resident's legal representative or an interested family member when there is: (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status .(C) A need to alter treatment significantly . This Federal tag relates to Complaint IN 929. 3.1-28(c)

Based on record view, observation, and interviews, the facility failed to ensure supervision was provided during the transfer of a resident with a mechanical lift, resulting in the resident falling from the lift and sustaining multiple fractures and a head injury, for 1 of 3 residents reviewed for accidents in a sample of 3. (Resident #B) Findings include: During an interview with Resident #B on 6/14/12 at 1:15 p.m., Resident #B indicated that in the process of being moved with a mechanical lift on 4/12/12 at 8:30 p.m., from her motor scooter to her bed, she fell out of the sling onto the floor beside her bed resulting in a fractured femur, broken ribs and a head injury. She indicated that when the accident occurred, there was only one CNA moving her. She indicated there are usually two people, but the other CNA was helping her roommate. The clinical record of Resident #B was reviewed on 6/14/12 at 2:20 p.m. and indicated the resident had [DIAGNOSES REDACTED]. Resident #B's quarterly Minimum Data Set (MDS) assessment dated [DATE] and significant change MDS dated [DATE], indicated the resident had a BIMS score of "15" which indicated she was independent with cognitive skills for daily decision making. The MDS's also indicated the resident needed extensive assist of two persons for transfers. Review of Occupational Therapy notes dated 02/16/12 at 2:50 p.m. and 04/17/12 at 7:04 a.m., indicated Resident #B had used a walker, then had a decline and a fall, and required a Hoyer lift since sustaining an ankle injury in October of 2011. Resident #B's Activities of Daily Living (ADL) Care Plan indicated a notation dated 2/24/12 that resident is to have a Hoyer lift for all transfers. The resident's Fall Risk Care Plan dated 4/17/12 (after the accident) indicated a mechanical lift be used with two people for all transfers. The record indicated the resident fell during the transfer on 4/12/12, and sustained a head injury, fractured femur and fractured ribs. physician's orders [REDACTED]. Orders dated 04/21/12, indicated a clarification order of two assist with mechanical lift. During an interview with RN #3 on 6/14/12 at 4:45 p.m., by telephone, she indicated that after the accident QMA #4 asked her to come to Resident B's room. She noticed the Hoyer lift was still in the air and the strap that should have been under the resident's right shoulder was not attached to the lift. She indicated CNA #1 and CNA #2 indicated one was putting the resident to bed while the other one was on the other side of the bed. She also indicated she observed the sling was new and all in-tact. She indicated QMA #4 stayed with the resident on the floor until the paramedics arrived. She indicated she also reminded the CNAs about putting the sling on correctly. On 6/15/12 at 11:00 a.m., CNA #1 was interviewed by telephone and indicated she and CNA #2 were both in the room at the time of the accident. She indicated she was across the hall helping another resident when CNA #1 asked her to help with the Hoyer lift of Resident #B. She indicated CNA#1 had already attached the straps from the sling to the lift and she watched CNA #2 lift the resident out of her motorized chair with the sling when she observed the resident fall out of the sling from her right side onto the floor. She indicated she was unable to do anything because she was on the other side of the bed due to lack of space. A record review of an inservice provided by the facility, attended by CNA #1 and #2 conducted by the facility on 2/21/12 indicated the Hoyer Lift must have two people present before using to transfer the resident. During an observation of a Hoyer Lift transfer on 6/14/12 at 4:10 p.m., by other CNAs, it was noted that while one CNA used the controls to mechanically lift the resident from the wheelchair, the other CNA held onto the sling guiding it onto the area of the bed while the CNA at the controls lowered the resident onto the bed safely. Interview with the Administrator on 06/14/12 at 3:35 p.m. indicated the facility did not have manufacturer's recommendations for the Hoyer lift, but the facility used the instructions for mechanical lift out of a book by Briggs Corporation dated 2006 for long term care procedures and it was their policy to use the "Instructions for the mechanical lift" out of this book. The instructions were for an Invacare lift which recommended two assist for transfers to and from, but indicated their equipment will permit proper operation with one assist. This federal tag is related to Complaint IN 595. 3.1-45(a)(2)